Association Between Buprenorphine Dose and the Urine "Norbuprenorphine" to "Creatinine" Ratio: Revised.

Background: Utilizing a 1-year chart review as the data, Furo et al. conducted a research study on an association between buprenorphine dose and the urine "norbuprenorphine" to "creatinine" ratio and found significant differences in the ratio among 8-, 12-, and 16-mg/day groups with an analysis of variance (ANOVA) test. This study expands the data for a 2-year chart review and is intended to delineate an association between buprenorphine dose and the urine "norbuprenorphine" to "creatinine" ratio with a higher statistical power. Methods: This study performed a 2-year chart review of data for the patients living in a halfway house setting, where their drug administration was closely monitored. The patients were on buprenorphine prescribed at an outpatient clinic for opioid use disorder (OUD), and their buprenorphine prescription and dispensing information were confirmed by the New York Prescription Drug Monitoring Program (PDMP). Urine test results in the electronic health record (EHR) were reviewed, focusing on the "buprenorphine," "norbuprenorphine," and "creatinine" levels. The Kruskal-Wallis H and Mann-Whitney U tests were performed to examine an association between buprenorphine dose and the "norbuprenorphine" to "creatinine" ratio. Results: This study included 371 urine samples from 61 consecutive patients and analyzed the data in a manner similar to that described in the study by Furo et al. This study had similar findings with the following exceptions: (1) a mean buprenorphine dose of 11.0 ± 3.8 mg/day with a range of 2 to 20 mg/day; (2) exclusion of 6 urine samples with "creatinine" level <20 mg/dL; (3) minimum "norbuprenorphine" to "creatinine" ratios in the 8-, 12-, and 16-mg/day groups of 0.44 × 10-4 (n = 68), 0.1 × 10-4 (n = 133), and 1.37 × 10-4 (n = 82), respectively; however, after removing the 2 lowest outliers, the minimum "norbuprenorphine" to "creatinine" ratio in the 12-mg/day group was 1.6 × 10-4, similar to the findings in the previous study; and (4) a significant association between buprenorphine dose and the urine "norbuprenorphine" to "creatinine" ratios from the Kruskal-Wallis test (P < .01). In addition, the median "norbuprenorphine" to "creatinine" ratio had a strong association with buprenorphine dose, and this association could be formulated as: [y = 2.266 ln(x) + 0.8211]. In other words, the median ratios in 8-, 12-, and 16-mg/day groups were 5.53 × 10-4, 6.45 × 10-4, and 7.10 × 10-4, respectively. Therefore, any of the following features should alert providers to further investigate patient treatment compliance: (1) inappropriate substance(s) in urine sample; (2) "creatinine" level <20 mg/dL; (3) "buprenorphine" to "norbuprenorphine" ratio >50:1; (4) buprenorphine dose >24 mg/day; or (5) "norbuprenorphine" to "creatinine" ratios <0.5 × 10-4 in patients who are on 8 mg/day or <1.5 × 10-4 in patients who are on 12 mg/day or more. Conclusion: The results of the present study confirmed those of the previous study regarding an association between buprenorphine dose and the "norbuprenorphine" to "creatinine" ratio, using an expanded data set. Additionally, this study delineated a clearer relationship, focusing on the median "norbuprenorphine" to "creatinine" ratios in different buprenorphine dose groups. These results could help providers interpret urine test results more accurately and apply them to outpatient opioid treatment programs for optimal treatment outcomes.

Telemedicine in Southeast Asia: A Systematic Review.

Introduction: Telemedicine is an effective means of delivering health care in Southeast Asian (SEA) countries. This systematic review explored the use of telemedicine systems for delivering health care services in SEA countries during the past 10 years. Methods: Literature searches were conducted in PubMed, Embase, Medline, Global Health, and CENTRAL (Cochrane Central Register of Controlled Trials). The inclusion criteria were as follows: (1) studies published between 2010 and 2021; (2) study settings located in SEA countries; (3) articles published in English; and (4) availability of a full-text version of the article. Information was extracted and evaluated for each study based on quality and risk of bias. Results: Thirty-seven of 6,554 records were eligible for inclusion. Studies included based on percentage were descriptive (29.73%), cost-effective (8.11%), randomized controlled trials (5.41%), and mixed methods (2.7%). Teleophthalmology and teleconsultation were the major reasons for using telemedicine, representing 21.62% of all studies. A hub-and-spoke and store-and-forward models were used. Free messenger applications supported communication modalities in or out of the systems. Discussion: The COVID-19 (coronavirus disease 2019) pandemic increased research studies on telemedicine, with most studies occurring in Singaporean hospitals (49%). Descriptive studies predominated, followed by retrospective and cross-sectional studies. Conclusions: Our findings demonstrated that telemedicine was a powerful tool. It is feasible, safe, effective, and less expensive than traditional methods. However, robust research is needed to fully investigate telemedicine systems in SEA countries.

Buprenorphine Dosage and Urine Quantitative Buprenorphine, Norbuprenorphine, and Creatinine Levels in an Office-Based Opioid Treatment Program.

BACKGROUND: Treatment progress is routinely monitored by urine testing in patients with opioid use disorder (OUD) undergoing buprenorphine medication-assisted treatment (MAT). However, interpretation of urine test results could be challenging. This retrospective study aims to examine the results of quantitative buprenorphine, norbuprenorphine, and creatinine levels in urine testing in relation to sublingual buprenorphine dosage to facilitate an accurate interpretation of urine testing results. METHODS: We reviewed the medical charts of 41 consecutive patients, who were residing in halfway houses where their medication intake was closely monitored and who had enrolled in an office-based MAT program at an urban clinic between July 2018 and June 2019. The patients' urine testing results were reviewed, and demographic variables were recorded. We focused on the patients treated with 8-, 12-, or 16-mg/day of buprenorphine, examining their urine buprenorphine, norbuprenorphine, and creatinine levels. Analysis of variance tested the statistical association between the dosage and urine testing results on the norbuprenorphine-to-creatinine ratio. RESULTS: A total of 240 urine samples from 41 patients were included for this study. The 41 patients received a mean buprenorphine dose of 10.5 ± 3.7 mg/day (range, 4-20 mg/day). Then, this study examined the distribution of the 240 urine samples and then focused on 184 urine samples that came from the 33 patients who were treated with 8-, 12-, and 16-mg/day of buprenorphine, the 3 most common dosages. All of the 184 urine samples had a creatinine level of >20 mg/dL and buprenorphine-to-norbuprenorphine ratio <50:1. The average norbuprenorphine-to-creatinine ratio in the 8 mg/day dosage group was 3.85 ± 2.24 × 10-4 (n = 66; range, 0.44-11.12). The respective ratios in the 12- and 16-mg dosage groups were 5.64 ± 3.40 × 10-4 (n = 83; range, 1.55-22.72) and 6.23 ± 4.92 × 10-4 (n = 35; range, 1.37-27.12). The 3 dosage groups differed significantly in the mean ratios (P < .01), except when the 12- and 16-mg dosage groups were compared (P = .58). The results of this study thus suggest that prescribers should pay attention to the following features: (1) unexpected substance(s) in urine testing, (2) creatinine level under 20 mg/dL, (3) buprenorphine-to-creatinine ratio over 50:1, (4) buprenorphine dosage over 24 mg/day, and (5) norbuprenorphine-to-creatinine ratio consistently under 0.5 × 10-4 in patients treated with 8 mg/day or 1.5 × 10-4 in patients treated with 12 mg/day or more. CONCLUSION: This study suggested parameters for interpreting quantitative urine test results in relation to buprenorphine intake dose in office-based opioid treatment programs.

Current Approaches and Trends in Graduate Public Health Informatics Education in the United States: Four Case Studies from the Field.

Background:Public Health Informatics (PHI) has taken on new importance in recent years as health and well-being face a number of challenges, including environmental disasters, emerging infectious diseases, such as Zika, Ebola and SARS-CoV-2, the growing impact of the Influenza virus, the opioid epidemic, and social determinants of health. Understanding the relationship between climate change and the health of populations adds further complexity to global health issues. Objectives: To describe four examples of curricula that exist in U.S. based graduate-level public and population health informatics training programs. Methods: Biomedical informatics educators are challenged to provide learners with relevant, interesting, and meaningful educational experiences in working with and learning from the many data sources that comprise the domain of PHI. Programs at four institutions were reviewed to examine common teaching practices that stimulate learners to explore the field of public health informatics. Results: Four case studies represent a range of pedagogical approaches to meeting the requirements of three established accreditation/certification agencies relevant to PHI education. Despite their differences, each program achieved the established learning objectives along with a substantive record of student learning achievements. Conclusion: The overarching goal of empowering learners to serve an active and dynamic role in enhancing preventive measures, informing policy, improving personal health behaviors, and clarifying issues such as quality, cost of care, and the social determinants of health, are essential components of PHI education and training, and must receive additional consideration now and in the future by educators, policy makers, administrators, and government officials.

Risk Factors for Opisthorchis Viverrini Infection: A Systematic Review.

Opisthorchis viverrini (O. viverrini) infection is the primary cause of cholangiocarcinoma (CCA) and a major public health challenge along the Mekong River in Thailand, Vietnam, Laos PDR, Cambodia, China and Myanmar. This systematic review appraised the risk factors for O. viverrini infection. Literature searches were conducted using Medical Subject Headings (MeSH) and keywords, without date or language restriction, in PubMed, EMBASE, Global Health, and Thai Journals Online. References from relevant papers also were reviewed to expand the scope of the search. The inclusion criteria were human subjects. The primary outcome was O. viverrini infection. The exclusion criteria were in vitro, animal, genetic research, and systematic reviews. All included studies were summarized and reported as follows: study design, age, sample size, setting, data collection and fecal examination methods, adjusted odds ratio and 95% confidence interval, significant risk factors, and other findings. The search results show that across all databases 1,098 records were identified. Twenty-four articles were included in the systematic review, consisting of cross-sectional studies (79.2%), cohort studies (12.5%), and case-control studies (8.3%). The majority of study settings were in Thailand (75%). The People's Democratic Republic of Laos (Lao PDR) accounted for the second greatest number of studies (20.8%), and 4.2% of the studies originated in Vietnam. Key findings included demographic, environmental, geographic, health behavior, treatment with praziquantel, and a history of O. viverrini infection that was significantly associated with O. viverrini infection. Health professionals should investigate the potential risk factors for the disease and should seek and develop innovative methods for prevention and control of O. viverrini infection in these countries.

Context and Meaning in EHR Displays.

Many Electronic Health Record (EHRs) data displays are insensitive to their settings, contexts, and to clinicians' needs. Yet, the contexts in which the data are displayed critically affect EHR usability and patient safety. Medication prescribing is a complex task; especially sensitive to contextual variation in EHR displays as vast variations in formats and logic are often unnecessarily confusing, leading to unwanted cognitive burdens and medical errors. With examples of EHR screenshots, we illustrate contextual variations in medication and allergy displays across different EHR systems and implementations-noting often seemingly haphazard differences that can lead to misunderstandings and misinterpretations.

A Systematic Review of Computational Drug Discovery, Development, and Repurposing for Ebola Virus Disease Treatment.

Ebola virus disease (EVD) is a deadly global public health threat, with no currently approved treatments. Traditional drug discovery and development is too expensive and inefficient to react quickly to the threat. We review published research studies that utilize computational approaches to find or develop drugs that target the Ebola virus and synthesize its results. A variety of hypothesized and/or novel treatments are reported to have potential anti-Ebola activity. Approaches that utilize multi-targeting/polypharmacology have the most promise in treating EVD.

Health Sciences Library Closings; A Context Sensitive Pilot Study.

A significant number of U.S. health sciences libraries have closed since the mid-1990's. A pilot study was conducted with academic physicians to understand the impact of closing the health sciences library in the teaching hospital with which they were affiliated. A brief survey was designed and distributed to fourteen faculty members with thirteen useable responses received. The study elicited a context-sensitive perspective on the closing of the library with the most noteworthy outcome being the additional time required by attending physicians and trainees to perform the work that previously was performed by library staff. The loss of the expert literature search, instructional services, journal request, and interlibrary loan services had the most significant impact on study participants. Further research is needed to understand the long term consequences of closing hospital-based health sciences library on the education of physicians.

Barriers, Facilitators, and Solutions to Optimal Patient Portal and Personal Health Record Use: A Systematic Review of the Literature.

Patient portal and personal health record adoption and usage rates have been suboptimal. A systematic review of the literature was performed to capture all published studies that specifically addressed barriers, facilitators, and solutions to optimal patient portal and personal health record enrollment and use. Consistent themes emerged from the review. Patient attitudes were critical as either barrier or facilitator. Institutional buy-in, information technology support, and aggressive tailored marketing were important facilitators. Interface redesign was a popular solution. Quantitative studies identified many barriers to optimal patient portal and personal health record enrollment and use, and qualitative and mixed methods research revealed thoughtful explanations for why they existed. Our study demonstrated the value of qualitative and mixed research methodologies in understanding the adoption of consumer health technologies. Results from the systematic review should be used to guide the design and implementation of future patient portals and personal health records, and ultimately, close the digital divide.

Use of Bronchoscopy in Percutaneous Dilational Tracheostomy.

IMPORTANCE: A modified percutaneous dilational tracheostomy (PDT) is a relatively new alternative method of performing PDTs in which tissues overlying the trachea are dissected, but needle entry is still performed blindly. Many centers use bronchoscopy-assisted PDT, but the necessity of bronchoscope assistance for modified PDTs has not been examined. Discontinuing bronchoscopy for this procedure could potentially decrease cost and increase efficiency with similar outcomes compared with bronchoscopy-assisted PDT. OBJECTIVE: To evaluate the necessity of bronchoscopy in placement of PDT. DESIGN, SETTING, AND PARTICIPANTS: A single-center, retrospective cohort study of 149 patients who underwent PDT, with or without bronchoscope assistance, was conducted between May 1, 2007, and February 1, 2015, in a tertiary care facility. Data analysis was performed from April 15, 2015, to May 1, 2015. INTERVENTIONS: Modified PDT with or without bronchoscopy. MAIN OUTCOMES AND MEASURES: The primary outcomes of interest were postprocedural complications and length of stay during the hospitalization at which the tracheostomy was placed. RESULTS: Of the 149 patients who underwent modified PDT during the study period and met the inclusion criteria, 107 were in the no-bronchoscope cohort (66 [61.7%] were men; mean [SD] age, 56.0 [18.7] years) and 42 were in the bronchoscope-assisted cohort (26 [61.9%] were men; mean [SD] age, 58.0 [15.7] years). Complications with PDT were significantly associated with use of a bronchoscope (odds ratio, 6.7; 95% CI, 1.3-43.4; P = .04). The rate of complications was 1.9% in the no-bronchoscope cohort and 11.9% in the bronchoscope-assisted cohort (P = .05). The mean (SD) length of hospital stay was not significantly different between the 2 groups (51.4 [49.4] days in the no-bronchoscope cohort vs 46.9 [28.6] days in the bronchoscope-assisted cohort; P = .58). CONCLUSIONS AND RELEVANCE: Percutaneous dilational tracheostomy can be performed with similarly low complication rates with or without the use of bronchoscopy. Discontinuing the use of bronchoscopy in these procedures appears to be a safe, cost-effective alternative with reassuring outcomes and low complication rates.

Military-to-civilian translation of battlefield innovations in operative trauma care.

BACKGROUND: Historic improvements in operative trauma care have been driven by war. It is unknown whether recent battlefield innovations stemming from conflicts in Iraq/Afghanistan will follow a similar trend. The objective of this study was to survey trauma medical directors (TMDs) at level 1-3 trauma centers across the United States and gauge the extent to which battlefield innovations have shaped civilian practice in 4 key domains of trauma care. METHODS: Domains were determined by the use of a modified Delphi method based on multiple consultations with an expert physician/surgeon panel: (1) damage control resuscitation (DCR), (2) tourniquet use, (3) use of hemostatic agents, and (4) prehospital interventions, including intraosseous catheter access and needle thoracostomy. A corresponding 47-item electronic anonymous survey was developed/pilot tested before dissemination to all identifiable TMD at level 1-3 trauma centers across the US. RESULTS: A total of 245 TMDs, representing nearly 40% of trauma centers in the United States, completed and returned the survey. More than half (n = 127; 51.8%) were verified by the American College of Surgeons. TMDs reported high civilian use of DCR: 95.1% of trauma centers had implemented massive transfusion protocols and the majority (67.7%) tended toward 1:1:1 packed red blood cell/fresh-frozen plasma/platelets ratios. For the other 3, mixed adoption corresponded to expressed concerns regarding the extent of concomitant civilian research to support military research and experience. In centers in which policies reflecting battlefield innovations were in use, previous military experience frequently was acknowledged. CONCLUSION: This national survey of TMDs suggests that military data supporting DCR has altered civilian practice. Perceived relevance in other domains was less clear. Civilian academic efforts are needed to further research and enhance understandings that foster improved trauma surgeon awareness of military-to-civilian translation.

Operative delay to laparoscopic cholecystectomy: Racking up the cost of health care.

BACKGROUND: Health care providers are increasingly focused on cost containment. One potential target for cost containment is in-hospital management of acute cholecystitis. Ensuring cholecystectomy within 24 hours for cholecystitis could mitigate costs associated with longer hospitalizations. We sought to determine the cost consequences of delaying operative management. METHODS: The Nationwide Inpatient Sample (2003-2011) was queried for adult patients (≥16 years) who underwent laparoscopic cholecystectomy for a primary diagnosis of acute cholecystitis. Patients who underwent open procedures or endoscopic retrograde cholangiopancreatography were excluded. Generalized linear models (GLMs) were used to analyze costs for each day's delay in surgery. Multivariable analyses adjusted for patient demographics, hospital descriptors, Charlson comorbidity index, mortality, and length of stay. RESULTS: We analyzed 191,032 records. Approximately 65% of the patients underwent surgery within 24 hours of admission. The average cost of care for surgery on the admission day was $11,087. Costs disproportionately increased by 22% on the second hospital day ($13,526), by 37% on the third day ($15,243), by 52% on the fourth day ($16,822), by 64% on the fifth day ($18,196), by 81% on the sixth day ($20,125), and by 100% on the seventh day ($22,250) when compared with the cost of care for procedures performed within 24 hours of admission. Subset analysis of patients discharged 24 hours or earlier from the time of surgery demonstrated similar trends. CONCLUSION: After controlling for patient- and hospital-related factors, we noted significant costs associated with each day's delay in operative management. Cost containment practices for acute cholecystitis justify consideration of same-day or next-day surgery where the diagnosis is straightforward. LEVEL OF EVIDENCE: Economic and value-based analysis, level III.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

National estimates of predictors of outcomes for emergency general surgery.

BACKGROUND: Identifying predictors of mortality and surgical complications has led to outcome improvements for a variety of surgical conditions. However, similar work has yet to be done for factors affecting outcomes of emergency general surgery (EGS). The objective of this study was to determine the predictors of in-hospital complications and mortality among EGS patients. METHODS: The Nationwide Inpatient Sample (2003-2011) was queried for patients with conditions encompassing EGS as determined by the American Association for Surgery of Trauma, categorizing them into predefined EGS groups using DRG International Classification of Diseases-9th Rev.-Clinical Modification codes. Primary outcomes considered included incidence of a major complication (pneumonia, pulmonary emboli, urinary tract infections, myocardial infarctions, sepsis, or septic shock) and in-hospital mortality. Separate multivariate logistic regression analyses for complications and mortality were performed to identify risk factors of either outcome from the following domains: patient demographics (age, sex, insurance type, race, and income quartile), comorbidities, and hospital characteristics (location, teaching status, and bed size). RESULTS: This study included 6,712,151 discharge records, weighted to represent 32,910,446 visits for EGS conditions. Mean age was 58.50 (19.74) years; slightly more than half (54.66%) were female. Uninsured patients were more likely to die (odds ratio,1.25; 95% confidence interval, 1.20-1.30), whereas patients in the highest income quartile had the least likelihood of mortality (odds ratio, 0.86; 95% confidence interval, 0.84-0.87). Old age was an independent predictor of mortality for all EGS subdiagnoses. The overall mortality rate was 1.76%; the overall complication rate was 10.03%. Of the patients who died, 62% experienced at least one major complication. Patients requiring resuscitation had the highest likelihood of mortality followed by patients with vascular disease and hepatic disease. CONCLUSION: Death patterns of EGS patients were discerned using an administrative data set. Understanding patterns of mortality and complications derived from studies such as this could improve hospital benchmarking for EGS, akin to trauma surgery's previous success. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Outcomes after emergency general surgery at teaching versus nonteaching hospitals.

BACKGROUND: Previous analyses demonstrate teaching hospitals to have worse outcomes raising concerns for quality of care. The purpose of this study was to compare outcomes between teaching and nonteaching hospitals for emergency surgical conditions in a national sample. METHODS: The Nationwide Inpatient Sample (2005-2011) was queried for patients with emergency general surgery (EGS) conditions as determined by the American Association for Surgery of Trauma. Outcomes of in-hospital mortality, major complications, length of stay (LOS) and hospital cost were compared between patients presenting to teaching versus nonteaching hospitals. Propensity scores were used to match both groups on demographics, clinical diagnosis, comorbidities, and disease severity. Multivariate regression analyses were performed further adjusting for hospital-level factors including EGS volume. Small effect estimates were further tested using standardized differences. RESULTS: A total of 3,707,465 patients from 3,163 centers were included. A majority of patients (59%) (n = 2,187,107) were treated at nonteaching hospitals. After propensity score matching and adjustment, teaching hospitals had a slightly higher odds likelihood of mortality (odds ratio, 1.04; 95% confidence interval, 1.02-1.06), slightly lower rate of major complications (odds ratio, 0.99; 95% confidence interval, 0.98-0.99), slightly decreased LOS (5.03 days [4.98-5.09] vs. 5.22 days [5.16-5.29]), and slightly higher hospital costs [$12,846 [$12,827-$12,865] vs. $12,304 [12,290-12,318]). Although these differences were statistically significant at p < 0.05, the absolute difference was very small. Further testing of these effect estimates using standardized differences revealed an insignificant difference of 0.5% for mortality, 0.4% for major complications, 0.2% for LOS, and 3.1% for hospital cost. CONCLUSION: National estimates of outcomes for EGS conditions demonstrate comparable results between teaching and nonteaching hospitals. Concerns regarding quality of care and higher costs at teaching hospitals may be unfounded. Further research to test for differences by specific EGS conditions, operative management, and hospital costs are warranted.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Cholecystectomy and wound complications: smoking worsens risk.

BACKGROUND: In the United States, approximately 800,000 cholecystectomies are performed annually. We sought to determine the influence of preoperative smoking on postcholecystectomy wound complication rates. MATERIALS AND METHODS: Using the National Surgical Quality Improvement Program database (2005-2011), patients aged ≥18 y who underwent elective open or laparoscopic cholecystectomy (LC) for benign gallbladder disease were identified using current procedural terminology codes. Multivariate regression was performed to determine the association between smoking status and wound complications, by surgical approach. RESULTS: Of 143,753 identified patients, 128,692 (89.5%) underwent LC, 27,788 (19.3%) were active smokers, and 100,710 (70.2%) were females. Active smokers were younger than nonsmokers (mean + standard deviation age: 44.2 (14.9) versus 51.6 (17.9) years); P < 0.001) and had fewer comorbidities. Within 30-d postcholecystectomy, wound complications were reported in 2011 (1.4%) patients. Compared with nonsmokers, active smokers demonstrated increased odds of wound complications after both open cholecystectomy (odds ratio 1.28; P = 0.010) and LC (odds ratio 1.20; P = 0.020) after adjustment for demographic and clinical characteristics. Having wound complications increased the average postoperative length of stay by 2-4 d (P <0.001). CONCLUSIONS: Active smokers are more likely to develop wound complications after cholecystectomy, regardless of surgical approach. Occurrence of wound complications consequently increases postoperative length of stay. Smoking abstinence before cholecystectomy may reduce the burden associated with wound complications.

Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?

BACKGROUND: We hypothesize that lack of access to care results in propensity toward emergent operative management and may be an important factor in worse outcomes for the uninsured population. The objective of this study is to investigate a possible link to worse outcomes in patients without insurance who undergo an emergent operation. METHODS: A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample (NIS) 2005-2011 dataset. Patients who underwent biliary, hernia, and colorectal operations were evaluated. Multivariate analyses were performed to assess the associations between insurance status, urgency of operation, and outcome. Covariates of age, sex, race, and comorbidities were controlled. RESULTS: The uninsured group had greatest odds ratios of undergoing emergent operative management in biliary (OR 2.43), colorectal (3.54), and hernia (3.95) operations, P < .001. Emergent operation was most likely in the 25- to 34-year age bracket, black and Hispanic patients, men, and patients with at least one comorbidity. Postoperative complications in emergencies, however, were appreciated most frequently in the populations with government coverage. CONCLUSION: Although the uninsured more frequently underwent emergent operations, patients with coverage through the government had more complications in most categories investigated. Young patients also carried significant risk of emergent operations with increased complication rates. Patients with government insurance tended toward worse outcomes, suggesting disparity for programs such as Medicaid. Disparity related to payor status implies need for policy revisions for equivalent health care access.

Hypercoagulability after injury in premenopausal females: a prospective, multicenter study.

BACKGROUND: Recent studies suggest there are gender-specific differences in injury response that may be related to coagulation. The objective of this study was to test the hypothesis that rapid thrombelastography (rTEG) coagulation profiles differ by gender. METHODS: Adult trauma patients were prospectively followed at 3 level 1 trauma centers over a 14-month period. rTEG was obtained upon arrival and serially at several time points during the hospital stay. Female patients were stratified into premenopausal (≤50 years) and postmenopausal (>50 years) age groups with age-matched male cohorts. Values were analyzed using a repeated-measures multilevel linear model to evaluate the effect of gender on coagulation. RESULTS: A total of 795 patients had serial rTEG data (24% female and 76% male). Compared with age-matched males, premenopausal females were more hypercoagulable by rTEG on admission (P < .001) and for the first 12 hours after arrival. Gender was an effect modifier for alpha angle (P = .02) and maximum amplitude (P = .04). Controlling for Injury Severity Score and mechanism of injury, age-matched males had a >4-fold increased risk of hypercoagulable complications than premenopausal females (odds ratio, 4.7; P = .038). CONCLUSION: This prospective, multicenter study demonstrates that premenopausal females are relatively hypercoagulable compared with age-matched males early after injury. However, this did not translate into higher thromboembolic complications.