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Understaffed and overworked: The stark reality of acute care surgeon staffing in the United States, an Eastern Association for the Surgery of Trauma multicenter study
No full textObjectives: Rightsizing the workforce to clinical demand requires a balance of work intensity, productivity, and a definition of clinical full-time equivalent (cFTE). We hypothesized a shortage of acute care surgeons based on a 204-shift per year (average, 17 per month) definition of a 1.0 cFTE established in our prior mixed-methods study (two service weeks plus five calls per month).
Methods: This multicenter study used mixed methods, integrating clinical schedules (CY2022), work relative value units, and qualitative insights from semistructured interviews (July 2023 to June 2024). Schedules were converted to shifts (8-14 hours). Hospitals were short-staffed when shift demand exceeded supply based on each surgeon\u27s cFTE. Interviews explored clinical demand and staffing challenges. Descriptive analysis and a deductive-inductive thematic analysis were performed.
Results: Forty Level I/II hospitals representing 412 acute care surgeons (287 cFTEs) from 25 states were included. Seventy-nine percent of hospitals were short-staffed. Compared with well-staffed hospitals, short-staffed hospitals had fewer cFTEs (6.5 [interquartile range (IQR), 3] vs. 8.6 [IQR, 3], p \u3c 0.05), a higher demand for clinical work (1,889 [IQR, 933] vs. 1,388 [IQR, 674] shifts, p = 0.05) and a higher work relative value unit/cFTE (8,779 vs. 7,456, p = 0.12). The aggregate clinical demand exceeded available surgeon capacity by 21% overall. Based on volume, a 1.0 cFTE is needed for every 285 (IQR, 169) trauma admissions. There was a deficit of 75 cFTEs across the centers. Key themes identified were related to the value of acute care surgery and balancing unpredictable demand, intensity, and efficiency.
Conclusion: There appears to be a shortage of acute care surgeons in the United States when a definition of 204 shifts per year cFTE is applied. Hospitals face significant financial and administrative barriers to workforce expansion despite the overabundance of clinical volume. Future research is needed to ascertain the effects of expanding the existing workforce on both clinical outcomes and surgeon well-being.
Level of evidence: Mixed-Methods Study; Level III.
Keywords: Acute care surgery; FTE; full-time employment; shortage
Assessment of Salivary Biomarkers as Predictors of Periodontal Disease Severity in Smokers and Nonsmokers
No full textBackground: Inflammatory periodontal disease exists as a chronic condition in which multiple elements including smoking act to affect. Noninvasive salivary biomarkers represent tools that professionals now utilize to evaluate the severity of periodontal disease.
Materials and methods: A sample of 100 individuals with an equal number of smokers (50) and nonsmokers (50) having chronic periodontitis participated in the study. The enzyme-linked immunosorbent assay method examined saliva biomarkers, including interleukin-1β (IL-1β), tumor necrosis factor-alpha (TNF-α), and matrix metalloproteinase-8 (MMP-8) from obtained saliva specimens. The clinical measurements included probing pocket depth (PPD) and clinical attachment loss (CAL) together with bleeding on probing. The statistical evaluation used SPSS software 22.0. (IBM Corp., Armonk, NY, USA) along with P \u3c 0.05 as the critical significance threshold.
Results: The saliva of smokers contained elevated levels of IL-1β (225.6 ± 30.4 pg/mL) and TNF-α (184.3 ± 22.1 pg/mL) as well as MMP-8 (310.5 ± 45.7 ng/mL) in comparison to nonsmokers whose levels were IL-1β: 158.2 ± 25.6 pg/mL, TNF-α: 120.8 ± 18.4 pg/mL, MMP-8: 215.6 ± 38.2 ng/mL. Results indicated that smokers demonstrated poorer clinical characteristics since their PPD measurements averaged 4.9 ± 0.8 mm and their CAL levels reached 5.2 ± 1.1 mm, which exceeded the values of nonsmokers (PPD: 3.6 ± 0.7 mm, CAL: 4.0 ± 0.9 mm) at P \u3c 0.05.
Conclusion: Periodontal disease among smokers produces substantially higher concentrations of IL-1β, TNF-α, and MMP-8 than nonsmoking adults do. The combination of biomarkers acts as a highly effective tool to evaluate the severity of periodontal diseases among risk groups.
Keywords: IL-1β; MMP-8; TNF-α; noninvasive diagnostics; periodontal disease; salivary biomarkers; smoking
Predicting Severe Short-Term Neurologic Outcomes in Human Parechovirus Meningoencephalitis
No full textBackground and objectives: Human parechovirus (PeV) is an increasingly recognized cause of meningoencephalitis (ME) in infants. The US 2022 outbreak provided opportunity to analyze the clinical presentation and predictors of severe disease in affected infants.
Methods: We conducted a multicenter retrospective review of infants diagnosed with PeV ME during the outbreak. We examined demographics, clinical features, laboratory findings, and neuroimaging results. Logistic regression was used to identify predictors of complicated disease and abnormal brain magnetic resonance imaging (MRI). Complicated disease was defined as requiring intensive care or findings of an abnormal brain MRI or electroencephalogram.
Results: 139 infants had PeV ME. The median age was 19 days. Fever was the most common presenting symptom (89.2%) and was associated with uncomplicated disease and normal MRI. A total of 42 (30.2%) infants had complicated disease. Hypothermia (36.5% vs 5.1%), somnolence (38.1% vs 13.4%), poor feeding (76.1% vs 47.4%), hemodynamic instability (28.5% vs 3%), seizures (57.1% vs 4.1%), apnea (40.4% vs 0%), hypoglycemia (16.6% vs 1%), mechanical ventilation (23.8% vs 0%), and inotropic support (11.9% vs 0%) were associated with complicated disease. Younger age and seizures were predictors of abnormal MRI on multivariable analysis (adjusted odds ratio, 0.92 [0.48-0.99] and 40.1 [3.49-460.7], respectively). Laboratory findings, including cerebrospinal fluid indices, were rarely abnormal.
Conclusion: Despite nonspecific symptoms on presentation and normal laboratory values, PeV can cause complicated disease, requiring clinicians to maintain high suspicion for this infection. We suggest PeV evaluation in workup of infant sepsis cases, neuroimaging in patients at high risk, and long-term developmental follow-up
Creation of a telehealth addiction consultation service at a rural hospital: a case study
No full textBackground: Rural communities face significant barriers to accessing substance use disorder (SUD) treatment, resulting in gaps in care and increased rates of opioid-related overdose deaths. Hospital-based Addiction Consult Services (ACS) improve outcomes for patients with SUD, but rural hospitals often lack these services.
Case presentation: The Community Addiction Consult (CAC) service was established at a rural hospital in western Massachusetts to address this gap. CAC was designed by a community coalition comprised of a diverse cross-section of the community in which the hospital is based, using opioid-overdose data from the region to inform their decisions. Using a telehealth model, the CAC provided evidence-based treatments to support hospital staff treating patients with opioid use disorder (OUD) or requiring addiction-related care. From April 2023 through December 2023, the CAC provided 36 consults, facilitating increased access to medications for opioid use disorder (MOUD), and enhancing provider confidence in treating people who use drugs (PWUD) and initiating MOUD. An average of 22 patients received MOUD as inpatients monthly, and 11 emergency department patients received MOUD monthly. The CAC team also implemented training sessions, and an anti-stigma campaign to familiarize hospital staff with harm reduction principles and person-centered care strategies to foster a more supportive treatment environment for PWUD.
Conclusions: The Community Addiction Consult service demonstrates the feasibility and efficacy of a telehealth Addiction Consult Service model. Paired with staff trainings, such a model can bridge the gaps in rural addiction care. By leveraging local expertise and data-driven approaches, this model offers a scalable, equitable solution to improving access to substance use disorder treatment in rural settings.
Keywords: Addiction consult service; Medications for opioid use disorder; Opioid; Overdose; Rural
Inpatient boarding in the emergency departments and clinical outcomes: A propensity-matched study
No full textObjectives: The study evaluated clinical outcomes in patients who experienced inpatient boarding in the ED (boarders) compared to those admitted directly (non-boarders).
Methods: Retrospective propensity-matched study of consecutive adults presented to 22 emergency departments and were subsequently admitted to 17 hospitals across Southeast Minnesota. The exposure variable was ED boarding. ED boarding was defined as patients flagged by ED physicians for admission and awaiting an inpatient bed, regardless of the time to flagging. The primary outcomes were length of hospital stay (LOS) and in-hospital mortality. The secondary outcome was all-cause mortality within 90 days after hospitalization. Boarders were matched to non-boarders using 86 covariates. Poisson, logistic, and Cox regression models were used to assess associations, with subgroup analyses by age, sex, and ED location.
Results: From April 1, 2019, to March 30, 2024, 821,244 ED visits and 151,834 (26.9 %) admissions. Of these, 3173 (1.9 %) were boarders (median time: 4.2 h; IQR, 1.8-9.7). Boarding was not associated with in-hospital mortality (OR, 0.84; 95 % CI, 0.59-1.20; P = 0.340) or LOS (IRR, 1.02; 95 % CI, 0.99-1.04; P = 0.088), but was associated with higher 90-day mortality (HR, 1.30; 95 % CI, 1.15-1.46; P = 0.005). These findings were consistent across age, sex, and ED location.
Conclusions: In this multicenter, propensity score-matched study, ED boarding was not associated with LOS or in-hospital mortality but was associated with a 1.3-fold increase in 90-day mortality, consistent across age, sex, and ED location.
Keywords: Emergency department boarding; Length of hospitalization; Mortality
On the OB Side of Things, It\u27s Completely Disconnected : Early Implementation of Medicaid Accountable Care Organizations and Health Care in the Perinatal Period
No full textObjective: More than 40% of U.S. birthing people are covered by Medicaid. Accountable Care Organizations (ACOs) are increasingly common in state Medicaid programs and may influence maternal health, quality of care, and outcomes. However, there has been limited examination of how Medicaid ACOs operate in the context of perinatal care. Our objective was to explore how individuals in ACO leadership have approached program design to address maternal health and how these programs have shaped health care utilization and maternal health from the perspective of postpartum ACO beneficiaries and clinicians.
Methods: We conducted virtual semi-structured interviews with three key stakeholder groups in Massachusetts (ACO leaders, maternity care clinicians, and Medicaid ACO members who had given birth within the past 6-24 months) between November 2021 and May 2023. Purposive sampling aimed to achieve variation in geographic location (members and clinicians) and race/ethnicity (members). Interviews were recorded, professionally transcribed, and analyzed iteratively using thematic analysis.
Principal findings: Thirty-three interviews were conducted: four with ACO leaders, 15 with maternity care clinicians, and 14 with ACO members. Maternity care clinicians did not perceive that ACO implementation had substantially impacted perinatal health care. Interviews with ACO leadership suggested that the lack of perceived impact may be partially explained by competing priorities; the Massachusetts Medicaid ACOs generally did not focus on maternal health during the initial implementation period. Postpartum ACO members were largely unaware of ACOs.
Conclusions: Lack of explicit attention to the perinatal population in Medicaid financing and delivery system reforms may reduce the potential impact in improving outcomes
Multi-level socioeconomic modifiers of the comorbidity of post-traumatic stress and tobacco, alcohol, and cannabis use: the importance of income
No full textPurpose: Post-traumatic stress (PTS) symptoms are highly comorbid with substance use (i.e., alcohol, tobacco, and cannabis). Few studies have investigated potential individual-, household-, and neighborhood-level socioeconomic effect modifiers of this comorbidity in longitudinal analyses. We aim to examine interactions between this multi-level environment and PTS symptoms on future substance use behaviors.
Methods: Data were drawn from the Advancing Understanding of RecOvery afteR traumA (AURORA) study, including 2943 individuals who presented to the emergency department (ED) within 72 h of a traumatic event. Frequency of tobacco, alcohol, cannabis use, and PTS symptoms were reported at 6 timepoints. Mixed effect Poisson models, clustered by state, were used to generate incidence rate ratios (IRRs) substance use, both cross-sectionally and prospectively. Moderation analysis of PTS and substance use, stratified by household income and area deprivation index (ADI), was conducted using mixed effect models and parallel process growth curves.
Results: Significant associations were observed between PTS with tobacco, alcohol, and cannabis use frequency cross-sectionally, and for tobacco and alcohol and PTS exposure prospectively. Lower income (P \u3c 0.001) and higher deprivation (P \u3c 0.001) were associated with tobacco use, while higher income (P \u3c 0.001) and less deprivation (P = 0.01) were associated with increased alcohol use. We found modest modification by household income for alcohol and tobacco, and little evidence of modification by neighborhood ADI.
Conclusions: Household income had greater evidence of effect modification for substance use, compared to neighborhood-level ADI. Our findings demonstrate that household indicators of socioeconomic status likely modify the relationship between PTS and substance use.
Keywords: Alcohol; Household income; Neighborhood; Post-traumatic stress disorder; Tobacco
3-minute central apneas: enhanced expiratory rebreathing space to the rescue
No full textThis case report presents an atypical case of central sleep apnea (CSA) treated with continuous positive airway pressure (CPAP), enhanced expiratory rebreathing space (EERS) and oxygen. A 69-year-old female with morbid obesity and congestive heart failure who previously failed multiple positive airway pressure (PAP) modalities for presumed obstructive sleep apnea (OSA) was referred for re-titration with transcutaneous CO2 (TCCO2) monitoring. Titration with CPAP, bilevel PAP, and intelligent volume-assured pressure support resulted in 3-4 minute central apneas with an oxygen saturation nadir of 49%, and an average TCCO2 of 27 mmHg. Subsequent split night polysomnography revealed CSA without OSA. CPAP and adaptive servoventilation alone and CPAP with oxygen were inadequate. Addition of EERS and oxygen supplementation to CPAP led to an improved Epworth Sleepiness Score (12 to 3) and overnight oximetry confirmed a satisfactory oxygen saturation nadir of 92%. This case highlights the use of TCCO2 monitoring in the recognition of hypocapnic CSA leading to successful treatment with CPAP, EERS and oxygen.
Keywords: EERS; central sleep apnea; enhanced expiratory rebreathing space; high loop gain; hypocapnia
Interim Estimates of 2024-2025 Seasonal Influenza Vaccine Effectiveness - Four Vaccine Effectiveness Networks, United States, October 2024-February 2025
No full textAnnual influenza vaccination is recommended for all persons aged ≥6 months in the United States. Interim influenza vaccine effectiveness (VE) was calculated among patients with acute respiratory illness-associated outpatient visits and hospitalizations from four VE networks during the 2024-25 influenza season (October 2024-February 2025). Among children and adolescents aged \u3c18 years, VE against any influenza was 32%, 59%, and 60% in the outpatient setting in three networks, and against influenza-associated hospitalization was 63% and 78% in two networks. Among adults aged ≥18 years, VE in the outpatient setting was 36% and 54% in two networks and was 41% and 55% against hospitalization in two networks. Preliminary estimates indicate that receipt of the 2024-2025 influenza vaccine reduced the likelihood of medically attended influenza and influenza-associated hospitalization. CDC recommends annual receipt of an age-appropriate influenza vaccine by all eligible persons aged ≥6 months as long as influenza viruses continue to circulate locally