Study protocol of a systematic review and metaanalysis of stress and burnout among general surgery residents.

Introduction: Chronic workplace stress and burnout are impediments to physicians' professional fulfillment, healthcare organizations' efficiency, and patient care quality/safety. General surgery residents are especially at risk due to the complexity of their training. We report the protocol of a metaanalysis of chronic stress and burnout among Accreditation Council for Graduate Medical Education (ACGME)-affiliated general surgery residents in the era after duty-hour reforms, plus downstream effects on their health and clinical performance. Methods: The proposed systematic review and metaanalysis (PROSPERO registration CRD42021277626) will synthesize/pool data from studies of chronic stress and burnout among general surgery residents at ACGME-affiliated programs. The timeframe under review is subdivided into three intervals: (a) after the 2003 duty-hour restrictions but before 2011 reforms, (b) after the 2011 reforms but before the coronavirus pandemic, and (c) the first 3 years after the pandemic's outbreak. Only studies reporting outcomes based on validated instruments will be included. Qualitative studies, commentaries/editorials, narrative reviews, and studies not published in English will be excluded. Multivariable analyses will adjust for sample characteristics and the methodological quality of included studies. Conclusions: The metaanalysis will yield evidence reflecting experiences of North American-based general surgery residents in the years after ACGME-mandated duty-hour restructuring.

Protecting Our Own: A Method for Reducing Breast Radiation Exposure in Healthcare Workers.

ABSTRACT: Standard lead aprons do not protect the female breast adequately from radiation exposure, which has been associated with breast cancer in healthcare workers. A novel lead shield was designed to reduce radiation to the breast, axilla, and thyroid (BAT). A procedure room was simulated with an anthropomorphic phantom representing the operator. Dosimeters were positioned on the outer quadrant of each breast, the chest, the thyroid, and deep inside of a phantom acrylic female torso with neck and head. Standard lead vest plus a thyroid shield was used as control and compared to standard lead vest plus BAT shield. Three operator and two image receptor positions were tested. The reductions in radiation exposure were calculated. The standard vest plus BAT shield provided significant reductions in radiation exposure for all anatomic locations compared to control. When averaging all operator positions, the BAT provided reductions of 91% (p < 0.0001) for near breast. Reductions for far breast, chest, thyroid, and deep tissues were 76% (p = 0.016), 94% (p < 0.0001), 52% (p = 0.026), and 60% (p = 0.004). With operator 90° to the table using a cross-table lateral beam, the BAT provided a 97.7% reduction in radiation to the near breast and significant reduction in radiation to the chest, thyroid, and deep tissues. The BAT shield reduces radiation exposure to the breast, chest, thyroid and deep hematopoietic tissues. Such shields could benefit healthcare workers to reduce the risk of breast cancer and other radiation-associated cancers.

Predictability of magnetic sphincter augmentation device explantation: a nomogram-based scoring tool from an experienced quaternary center.

BACKGROUND: Magnetic sphincter augmentation (MSA) explantation is an uncommon occurrence, and there are limited studies characterizing factors predictive of MSA explantation. This study aimed to create a nomogram to aid in determining the probability of explantation in patients before MSA implantation. METHODS: An institutional review board-approved, prospectively maintained database was retrospectively reviewed for all patients undergoing antireflux surgery between February 2015 and May 2023. All patients who underwent MSA-related procedures were included. Patients were divided into 2 groups, explant group and nonexplant group, and differences were analyzed. A multivariable logistic regression model was fitted to identify independent risk factors for predicting MSA explantation, and a nomogram-based scoring tool was developed. RESULTS: There were 227 patients (134 females and 93 males) with a mean age of 51.4 years. The explant group included 28 patients (12.3%), whereas the nonexplant group included 199 patients (87.7%). Patient sociodemographic characteristics, medical comorbidities, preoperative testing results, and surgical history were included in the analysis. The multivariable regression model resulted in 4 significant variables that were included in the nomogram. These included preoperative DeMeester score, preoperative gastroesophageal reflux disease health-related quality of life score, preoperative distal contractile integral value on manometry, and body mass index. Based on these variables, a scoring nomogram was developed with values ranging from 0 to 18. CONCLUSION: Our data were used to develop a scoring calculator capable of predicting the probability of MSA explantation. This scoring tool can guide preoperative patient selection and treatment decisions.

The impact of COVID-19 on surgical cases at a large quaternary referral hospital.

Introduction: Coronavirus-19 (COVID) stressed healthcare systems by increasing hospital admissions and in-hospital mortality. The impact of COVID on surgical patients is unknown. The purpose of this study was to evaluate how the COVID pandemic affected surgical patients at a large quaternary referral hospital. Methods: A retrospective review of patients undergoing surgical procedures was performed to evaluate patients undergoing surgery. The impact of COVID on surgical patients was divided into four timeframes based on government regulations: pre-COVID (January 1, 2020 to March 15, 2020), suspended (March 16, 2020 to May 4, 2020), backlogged cases (May 5, 2020 to June 14, 2020), and restoration (June 15, 2020 to September 30, 2020). Differences between patient characteristics and outcomes during these timeframes were evaluated. Results: A total of 21,424 surgical cases were performed between January 1, 2020 and September 30, 2020. During the suspended timeframe (when all elective cases were cancelled), the percentage of surgeries increased in men (53.8% compared to 49.2% pre-COVID; P < 0.01), in Black and Hispanic patients (23.1% and 15.3%, respectively; P < 0.05), and in Medicaid and self-pay patients (16.3% compared to 9.9% pre-COVID; P < 0.01). All service lines experienced similar trends in overall case volume except obstetrics (constant), trauma, vascular, and thoracic (which increased during the suspended timeframe). Conclusions: COVID-19 induced stresses in surgical patients, altering payor mix and impacting minority groups at a large quaternary referral hospital.

Exploring the Association of Metabolic Syndrome with In-Hospital Survival of Older Patients Hospitalized with COVID-19: Beyond Chronological Age.

BACKGROUND: Despite the variability and complexity of geriatric conditions, few COVID-19 reports of clinical characteristic prognostication provide data specific to oldest-old adults (over age 85), and instead generally report broadly as 65 and older. OBJECTIVE: To examine metabolic syndrome criteria in adults across 25 hospitals with variation in chronological age. DESIGN AND PARTICIPANTS: This cohort study examined 39,564 hospitalizations of patients aged 18 or older with COVID-19 who received inpatient care between March 13, 2020, and February 28, 2022. EXPOSURE: ICU admission and/or in-hospital mortality. MAIN MEASURES: Metabolic syndrome criteria and patient demographics were examined as risk factors. The main outcomes were admission to ICU and hospital mortality. KEY RESULTS: Oldest old patients (≥ 85 years) hospitalized with COVID-19 accounted for 7.0% (2758/39,564) of all adult hospitalizations. They had shorter ICU length of stay, similar overall hospitalization duration, and higher rates of discharge destinations providing healthcare services (i.e., home health, skilled nursing facility) compared to independent care. Chronic conditions varied by age group, with lower proportions of diabetes and uncontrolled diabetes in the oldest-old cohort compared with young-old (65-74 years) and middle-old (75-84 years) groups. Evaluations of the effect of metabolic syndrome and patient demographics (i.e., age, sex, race) on ICU admission demonstrate minimal change in the magnitude of effect for metabolic syndrome on ICU admission across the different models. CONCLUSIONS: Metabolic syndrome measures are important individual predictors of COVID-19 outcomes. Building on prior examinations that metabolic syndrome is associated with death and ARDS across all ages, this analysis supports that metabolic syndrome criteria may be more relevant than chronological age as risk factors for poor outcomes attributed to COVID-19.

Achieving fascial closure with preoperative botulinum toxin injections in abdominal wall reconstruction: outcomes from a high-volume center.

Preoperative injection of Botulinum Toxin A (Botox) has been described as an adjunctive therapy to facilitate fascial closure of large hernia defects in abdominal wall reconstruction (AWR). The purpose of this study was to evaluate the impact of Botox injections on fascial closure and overall outcomes to further validate its role in AWR. A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2014 and March 2022. Patients who did and did not receive preoperative Botox injections were analyzed and compared. A total of 426 patients were included (Botox 76, NBotox 350). The Botox group had significantly larger hernia defects (90 cm2 vs 9 cm2, p < 0.01) and a higher rate of component separations performed (60.5% vs 14.4%, p < 0.01). Despite this large difference in hernia defect size, primary fascial closure rates were similar between the groups (p = 0.49). Notably, the Botox group had higher rates of surgical-site infections (SSIs)/surgical-site occurrences (SSOs) (p < 0.01). Following propensity score matching to control for multiple patient factors including age, sex, diabetes, chronic obstructive pulmonary disease (COPD), and hernia size, the Botox group still had a higher rate of component separations (50% vs 26.3%, p = 0.03) and higher incidence of SSIs/SSOs (39.5% vs 13.5%, p = 0.01). Multimodal therapy with Botox injections and component separations can help achieve fascial closure of large defects during AWR. However, adding these combined therapies may increase the occurrence of postoperative SSIs/SSOs.

Long-term Outcomes of the Kono-S Anastomosis: A Multicenter Study.

BACKGROUND: Postoperative recurrence remains a significant problem in Crohn's disease, and the mesentery is implicated in the pathophysiology. The Kono-S anastomosis was designed to exclude the mesentery from a wide anastomotic lumen, limit luminal distortion and fecal stasis, and preserve innervation and vascularization. OBJECTIVE: To review postoperative complications and long-term outcomes of the Kono-S anastomosis in a large series of consecutive unselected patients with Crohn's disease. DESIGN: Retrospective study of prospectively collected patients. SETTINGS: Four tertiary referral centers. PATIENTS: Consecutive patients with Crohn's disease who underwent resection with Kono-S anastomosis between May 2010 and June 2022. INTERVENTIONS: Extracorporeal handsewn Kono-S anastomosis. MAIN OUTCOME MEASURES: Postoperative outcomes and recurrence defined as endoscopic, clinical, laboratory, or surgical, including endoscopic, intervention. RESULTS: A total of 262 consecutive patients (53.4% male) were included. The mean duration of disease at surgery was 145.1 months. One hundred thirty-five patients (51.5%) had previous abdominal surgery for Crohn's disease. Forty-four patients (17%) were actively smoking and 150 (57.3%) were on biologic therapy. Anastomotic failure occurred in 4 (1.5%), with 2 patients requiring reoperation (0.7%). Sixteen patients had postoperative surgical site infection (6.1%). With a median follow-up of 49.4 months, 20 patients (7.6%) were found to have surgical recurrence. In the multivariate analysis, perianal disease (OR = 2.83, p = 0.001), urgent/emergent surgery (OR = 3.23, p = 0.007), and postoperative use of steroids (OR = 2.29, p = 0.025) were associated with increased risk of overall recurrence. LIMITATIONS: Retrospective study and variability of perioperative medical therapy. CONCLUSIONS: This study showed very low postoperative complication rates despite the complexity of the patient population. There was a low rate of surgical recurrence, likely due to the intrinsic advantages of the anastomotic configuration and the low rate of postoperative septic complications. In experienced hands, the Kono-S anastomosis is a safe technique with very promising short- and long-term results. Randomized controlled trials are underway to validate this study's findings. See Video Abstract . RESULTADO A LARGO PLAZO DE LA ANASTOMOSIS KONOS UN ESTUDIO MULTICNTRICO: ANTECEDENTES:La recurrencia posoperatoria sigue siendo un problema importante en la enfermedad de Crohn y el mesenterio está implicado en la fisiopatología. La anastomosis Kono-S fue diseñada para excluir el mesenterio de una anastomosis amplia, limitar la distorsión luminal y la estasis fecal y preservar la inervación y vascularización.OBJETIVO:Revisar las complicaciones posoperatorias y los resultados a largo plazo de la anastomosis Kono-S en una gran serie de pacientes consecutivos no seleccionados con enfermedad de Crohn.DISEÑO:Estudio retrospectivo de pacientes recolectados prospectivamente.ESCENARIO:Cuatro centros de referencia terciarios.PACIENTES:Pacientes consecutivos con enfermedad de Crohn sometidos a resección con anastomosis Kono-S entre mayo de 2010 y junio de 2022.INTERVENCIONES:Anastomosis Kono-S extracorpórea manual.PRINCIPALES MEDIDAS DE RESULTADO:Resultados posoperatorios y recurrencia definidos como endoscópicos, clínicos, de laboratorio o quirúrgicos, incluida la intervención endoscópica.RESULTADOS:Se incluyeron un total de 262 pacientes consecutivos (53,4% varones). La duración media de la enfermedad al momento de la cirugía fue de 145,1 meses. Ciento treinta y cinco pacientes (51,5%) habían tenido cirugía abdominal previa por enfermedad de Crohn. Cuarenta y cuatro pacientes (17%) eran fumadores activos y 150 (57,3%) estaban en tratamiento biológico. Se produjo filtración anastomótica en 4 (1,5%) y 2 pacientes requirieron reoperación (0,7%). Dieciséis pacientes tuvieron infección postoperatoria del sitio quirúrgico (6,1%). Con una mediana de seguimiento de 49,4 meses, se encontró que 20 pacientes (7,6%) tuvieron recurrencia quirúrgica. En el análisis multivariado, la enfermedad perianal (OR = 2,83, p = 0,001), la cirugía urgente/emergente (OR = 3,23, p = 0,007), el uso postoperatorio de esteroides (OR = 2,29, p = 0,025) se asociaron con un mayor riesgo de recurrencia general.LIMITACIÓN:Estudio retrospectivo. Variabilidad del tratamiento médico perioperatorio.CONCLUSIONES:Nuestro estudio mostró tasas de complicaciones postoperatorias muy bajas a pesar de la complejidad de la población de pacientes. Hubo una baja tasa de recurrencia quirúrgica, probablemente debido a las ventajas intrínsecas de la configuración anastomótica y la baja tasa de complicaciones sépticas posoperatorias. En manos experimentadas, la anastomosis Kono-S es una técnica segura con resultados muy prometedores a corto y largo plazo. Se están realizando estudios randomizados controlados para validar nuestros hallazgos. (Traducción-Dr. Felipe Bellolio ).

The use of a total bowel length measurement protocol may reduce reoperations and complications after single-anastomosis duodenal switch.

INTRODUCTION: Most surgeons who perform single-anastomosis duodeno-ileal switches (SADI-S) use a pre-determined common channel length without measuring total bowel length (TBL). However, TBL varies between patients, and a standardized common channel length could contribute to malabsorptive complications and reoperations following SADI-S. The purpose of this study was to determine whether using a TBL measurement protocol to individualize common channel length would be associated with reduced reoperations and complications. METHODS: A prospectively maintained data registry was retrospectively reviewed to identify all patients who underwent SADI-S between September 2017 and February 2022. In April 2021, we began using TBL measurements during SADI-S with 40% of the TBL used as the length for the common channel. Outcomes pre-TBL and post-TBL measurement protocol were compared. RESULTS: A total of 119 SADI-S recipients (59 pre-TBL; 60 post-TBL) were included. The pre-TBL group had a higher frequency of reoperations (23.7% vs 1.7%, p < 0.001) and late complications (29.3% vs 3.3%, p < 0.001). The mean time to reoperation was 13.7 months in the pre-TBL group and 6.7 months in the post-TBL group (p = 0.347). Patients in the post-TBL group had significantly higher serum albumin levels at 3 months (4.2 g/dL vs 3.5 g/dL, p < 0.001), 6 months (4.1 g/dL vs 3.6 g/dL, p < 0.001), and 12 months (4.2 g/dL vs 3.8 g/dL, p = 0.023) postoperatively when compared to the pre-TBL group. CONCLUSION: Using TBL measurements to individualize common channel length was associated with a significant reduction in reoperations and late complications following SADI-S.

Impact of an enhanced recovery after surgery program with a multimodal analgesia care pathway on opioid prescribing and clinical outcomes for patients undergoing colorectal surgery.

Background: Opioids are a mainstay for acute pain management, but their side effects can adversely impact patient recovery. Multimodal analgesia (MMA) is recommended for treatment of postoperative pain and has been incorporated in enhanced recovery after surgery (ERAS) protocols. The objective of this quality improvement study was to implement an MMA care pathway as part of an ERAS program for colorectal surgery and to measure the effect of this intervention on patient outcomes and costs. Methods: This pre-post study included 856 adult inpatients who underwent an elective colorectal surgery at three hospitals within an integrated healthcare system. The impact of ERAS program implementation on opioid prescribing practices, outcomes, and costs was examined after adjusting for clinical and demographic confounders. Results: Improvements were seen in MMA compliance (34.0% vs 65.5%, P < 0.0001) and ERAS compliance (50.4% vs 57.6%, P < 0.0001). Reductions in mean days on opioids (4.2 vs 3.2), daily (51.6 vs 33.4 mg) and total (228.8 vs 112.7 mg) morphine milligram equivalents given during hospitalization, and risk-adjusted length of stay (4.3 vs 3.6 days, P < 0.05) were also observed. Conclusions: Implementing ERAS programs that include MMA care pathways as standard of care may result in more judicious use of opioids and reduce patient recovery time.

COVID-19's impact on family medicine resident training and wellness.

Background: The COVID-19 global pandemic has raised many challenges in training family medicine residents. Family medicine is at the frontline for treating and managing patients with COVID-19. Attention is needed on the critical issue of the effect of the pandemic on resident training, the safety of those performing needed medical services, and the psychological well-being of trainees. Methods: We performed a cross-sectional, 25-question survey-based study to evaluate the perceived effect of the COVID-19 pandemic on family medicine residents' training and residents' well-being in the state of Texas. Results: A total of 250 Texas-based family medicine residents were surveyed with a response rate of 12.8% (n = 32). After the pandemic began, all residents worried about exposing their loved ones to COVID-19, and 65% felt like the COVID-19 pandemic negatively impacted their training overall. Respondents indicated that changes occurred in their respective residency curricula that altered training such as canceling of scheduled lectures (84.3%) and more telemedicine visits (56.25%). There was a significant difference for postgraduate year level and the effect on rotation assignments, with more disruption to the first- and third-year residents (P = 0.03). Conclusions: The COVID-19 pandemic has had a notable impact on the perception of quality of training and mental health within family medicine. Our findings may guide programs in how to proactively target pandemic-related training challenges.

National trends in distribution of underrepresented minorities within United States general surgery residency programs: A longitudinal panel study.

BACKGROUND: Cultural affinity with a provider improves satisfactoriness of healthcare. We examined 2005-2019 trends in racial/ethnic diversity/inclusion within general surgery residency programs. METHODS: We triangulated 2005-2019 race/ethnicity data from Association of American Medical Colleges surveys of 4th-year medical students, the Electronic Residency Application Service, and Accreditation Council for Graduate Medical Education-affiliated general surgery residencies. Temporal trends in minority representation were tested for significance. RESULTS: Underrepresented racial/ethnic minorities in medicine (URiMs) increased among graduating MDs from 7.6% in 2005 to 11.8% in 2019 (p < 0.0001), as did their proportion among surgery residency applicants during 2005-2019 (p < 0.0001). However, proportions of URiMs among general surgery residents (≈8.5%), and of programs without URiMs (≈18.8%), stagnated. CONCLUSIONS: Growing URiM proportions among medical school graduates and surgery residency applicants did not improve URiM representation among surgery trainees nor shrink the percentage of programs without URiMs. Deeper research into motivators underlying URiMs' residency program preferences is warranted.

Enhanced Recovery After Surgery Protocol in Bariatric Surgery Leads to Decreased Complications and Shorter Length of Stay.

PURPOSE: Enhanced recovery after surgery (ERAS) programs have been shown in some specialties to improve short-term outcomes following surgical procedures. There is no consensus regarding the optimal perioperative care for bariatric surgical patients. The purpose of this study was to develop a bariatric ERAS protocol and determine whether it improved outcomes following surgery. MATERIALS AND METHODS: An IRB-approved prospectively maintained database was retrospectively reviewed for all patients undergoing bariatric surgery from October 2018 to January 2020. Propensity matching was used to compare post-ERAS implementation patients to pre-ERAS implementation. RESULTS: There were 319 patients (87 ERAS, 232 pre-ERAS) who underwent bariatric operations between October 2018 and January 2020. Seventy-nine patients were kept on the ERAS protocol whereas 8 deviated. Patients who deviated from the ERAS protocol had a longer length of stay when compared to patients who completed the protocol. The use of any ERAS protocol (completed or deviated) reduced the odds of complications by 54% and decreased length of stay by 15%. Furthermore, patients who completed the ERAS protocol had an 83% reduction in odds of complications and 31% decrease in length of stay. Similar trends were observed in the matched cohort with 74% reduction in odds of complications and 26% reduction in length of stay when ERAS was used. CONCLUSIONS: ERAS protocol decreases complications and reduces length of stay in bariatric patients.

Probability of additional intervention and long-term follow-up of esophagomyotomy.

INTRODUCTION: Two common surgical procedures used to treat esophageal motility disorders are laparoscopic Heller myotomy (LHM) with partial fundoplication and per-oral endoscopic myotomy (POEM). The difference in frequency of follow-up interventions following these procedures is unknown. This study was designed to report differences in post-surgical interventions as one of the major long-term follow-up expectations. METHODS: An IRB approved registry was used to identify all patients undergoing surgery with LHM or POEM. Following surgery, patients requiring additional interventions with esophageal non-pneumatic dilation, botox injection, or repeat myotomy, as well as persistent proton pump inhibitor (PPI) use were recorded. Multivariable logistic regression analysis was performed to estimate risk factors associated with return for additional post-operative intervention. RESULTS: A total of 203 patients were identified, 139 met inclusion criteria (33 LHM and 106 POEM). There was a higher rate of non-pneumatic EGD dilation (33% vs 15%, p = 0.04), repeat myotomy (18% vs 2%, p < 0.01), and higher rate of overall post-operative intervention in LHM than POEM. With POEM, there was a higher rate of post-operative PPI use (63 vs 29%, p < 0.01). There was no difference in time to post-operative intervention for either group, but if intervention were to occur the median time was within the first year. Patients with a change in pre- to post-operative Eckardt score of 4 or greater decreased their chance of having a post-operative intervention. CONCLUSION: Our results for both LHM and POEM emphasize the importance of long-term follow-up in patients with an esophageal motility disorder. We have found that patients undergoing LHM are more likely to have a post-operative intervention as well as a higher rate of repeat myotomy than POEM. With both interventions, a greater change in Eckardt score decreased the likelihood of reintervention.

Enhanced recovery after surgery (ERAS) decreases complications and reduces length of stay in foregut surgery patients.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs provide a framework for optimal perioperative care to improve post-operative outcomes following surgical procedures. However, there is no consensus regarding an ERAS protocol following foregut surgery. The purpose of this study was to develop an ERAS protocol for these patients and determine whether they improved outcomes. METHODS: An IRB approved prospectively maintained database was retrospectively reviewed for all patients undergoing benign minimally invasive foregut surgery from October 2018 to January 2020. All patients were entered into the ACS risk calculator to determine their predicted rate of complications and length of stay for comparison between the ERAS and control groups. Propensity matching was used to compare post-ERAS implementation to pre-ERAS implementation patients. Firth logistic and Poisson regression analysis were used to assess the rate of complications and length of stay among the different groups of patients. RESULTS: There were 255 patients (60 Post-ERAS, 195 Pre-ERAS) who underwent foregut operations and met inclusion criteria. ERAS was implemented, and patients were then subdivided based on those who completed ERAS (44) and those who deviated from the protocol (16). Propensity matching analysis was performed to compare the different cohorts and showed ERAS patients had 41% decreased odds of complications and 33% reduction in length of stay compared to pre-ERAS patients. Completion of the ERAS protocol resulted in even further reductions in odds of complication and length of stay compared to patients who deviated from the protocol. CONCLUSIONS: ERAS has shown to improve perioperative outcomes, but there is limited literature supporting the use of ERAS in foregut surgery. Usage of an ERAS protocol can decrease complications and reduce the length of stay in patients.

Daily Oxygenation Support for Patients Hospitalized With SARS-CoV-2 in an Integrated Health System.

BACKGROUND: Many COVID-19 studies are constructed to report hospitalization outcomes, with few large multi-center population-based reports on the time course of intra-hospitalization characteristics, including daily oxygenation support requirements. Comprehensive epidemiologic profiles of oxygenation methods used by day and by week during hospitalization across all severities are important to illustrate the clinical and economic burden of COVID-19 hospitalizations. METHODS: This was a retrospective, multi-center observational cohort study of 15,361 consecutive hospitalizations of patients with COVID-19 at 25 adult acute care hospitals in Texas participating in the Society of Critical Care Medicine Discovery Viral Respiratory Illness Universal Study COVID-19 registry. RESULTS: At initial hospitalization, the majority required nasal cannula (44.0%), with an increasing proportion of invasive mechanical ventilation in the first week and particularly the weeks to follow. After 4 weeks of acute illness, 69.9% of adults hospitalized with COVID-19 required intermediate (eg, high-flow nasal cannula, noninvasive ventilation) or advanced respiratory support (ie, invasive mechanical ventilation), with similar proportions that extended to hospitalizations that lasted ≥ 6 weeks. CONCLUSIONS: Data representation of intra-hospital processes of care drawn from hospitals with varied size, teaching and trauma designations is important to presenting a balanced perspective of care delivery mechanisms employed, such as daily oxygen method utilization.

Primary care physician and resident perceptions of gun safety counseling.

A significant public health burden exists related to firearm-related injuries in the United States. Primary care physicians (PCPs) find themselves on the frontline to address it. This study aimed to determine if PCPs feel prepared and responsible for providing firearm safety counseling. Data were gathered via a direct 23-question survey of family medicine, internal medicine, and pediatric physicians and residents in North and Central Texas between May 2019 and January 2020. The survey was delivered to 518 outpatient providers, with a 24% response rate. Associations were assessed by chi-square/Fisher's exact test. A total of 62% agreed that preventable firearm death is an important health issue and PCPs can have a positive effect; 10% felt their residency provided or provides opportunities to learn about firearm safety and how to counsel patients; 55% agreed that a standardized tool to question and counsel patients on firearm safety such as a template in the electronic health record would be useful; and 68% stated they would use a standardized template in their practice if proven to reduce firearm-related injuries. Physicians who had received training in residency felt their knowledge was adequate to be able to provide meaningful counseling to patients (P < 0.001). In conclusion, PCPs are pivotal in addressing firearm safety. A formal curriculum across primary care specialties' graduate education programs should be developed to improve physicians' competency in addressing firearm safety. Further investigation into standardized tools that could be implemented into an electronic health record may help bridge the gap from awareness to implementation of interventions.

Predictability of Endoscopic Success for Foregut and Bariatric Leak in an Experienced Quaternary Center.

BACKGROUND: Leaks of the esophagus and stomach are difficult to manage and associated with significant morbidity and mortality. Endoscopic therapy can manage these leaks without surgical intervention. Our goal is to create a scoring tool to aid in predicting the success of endoscopic therapy in these patients. STUDY DESIGN: An IRB-approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to January 2021, including patients treated for esophageal and stomach leaks. Endpoints include success of leak closure for patients treated solely by endoscopic therapy (ET) compared with surgical therapy as failed endoscopic therapy (FET). A multivariable logistic regression model was fitted to identify independent risk factors for predicting success of endoscopic therapy, and a scoring calculator was developed. RESULTS: There were 80 patients (60 females) with a mean age of 50 years. The ET group included 59 patients (74%), whereas the FET group included 21 patients (26%). Patient demographics, comorbidities, surgical history, and timing of leak diagnosis were used. Multivariable analysis resulted in 4 variables associated with higher probability of successful endoscopic leak management without need for additional surgery. These included increased age, lower BMI, lack of previous bariatric surgery, and quicker identification of the leak. Consequently, a scoring nomogram was developed with values from 0 to 22. CONCLUSION: Our data show the development of a scoring calculator capable of quantifying the likelihood of success treating foregut and bariatric leaks with endoscopic therapies. This can be used clinically to guide treatment decisions.

Overall Complications Following Robotic Heller Myotomy Are Lower Compared With Laparoscopy.

BACKGROUND: The use of robotics in foregut surgery has become more prevalent in the United States over the last 10 years. We sought to find the differences in the clinical outcomes of robotic surgery compared with traditional laparoscopy in patients undergoing Heller myotomy. MATERIALS AND METHODS: A retrospective population-based analysis was performed using the National Inpatient Sample (NIS) database for the span of 2010 to 2015. All patients who underwent laparoscopic or robotic Heller myotomy were included. Weighted multivariable random intercept linear and logistic regression models were used to assess the impact of robotic surgery on patient outcomes compared with laparoscopy. RESULTS: There was a total of 11,562 patients with a median age of 54.2 years. Robotic Heller myotomy has a significantly decreased risk of overall complications for all centers (odds ratio=0.46; 95% confidence interval=0.29, 0.74). A subset analysis was performed looking specifically at high-volume centers (>20 operations per year), and overall complications remained lower in the robotic group. However, in high-volume centers, the robotic cohort did have a higher rate of esophageal perforation (2.7% vs. 0.8%, P<0.001). There was a higher length of stay in the laparoscopic Heller cohort (3.0 vs. 2.6 d, P=0.06) but higher overall charges in the robotic Heller cohort ($42,900 vs. $34,300, P=0.03). CONCLUSIONS: Robotic Heller myotomy is associated with lower overall complications and improved outcomes compared with laparoscopic Heller myotomy, even in high-volume centers. Robotic Heller myotomy is associated with a higher rate of esophageal perforations in high-volume centers despite the reduction in overall complications.