Adil H. Haider

Introduction Older populations, being a unique subset of patients, have poor outcomes for emergency general surgery (EGS). In regions lacking specialized medical coverage for older patients, disparities in healthcare provision lead to poor clinical outcomes. We aimed to identify factors predicting index admission inpatient mortality from EGS among sexagenarians, septuagenarians, and octogenarians. Methods Data of patients aged >60 years with EGS conditions defined by the American Association for the Surgery of Trauma at primary index admission from 2010 to 2019 operated and non-operated at a large South Asian tertiary care hospital were analyzed. The primary outcome was primary index admission inpatient 30-day mortality. Parametric survival regression using Weibull distribution was performed. Factors such as patients’ insurance status and surgical intervention were assessed using adjusted HR and 95% CI with a p-value of Results We included 9551 primary index admissions of patients diagnosed with the nine most common primary EGS conditions. The mean patient age was 69.55±7.59 years. Overall mortality and complication rates were 3.94% and 42.29%, respectively. Primary index admission inpatient mortality was associated with complications including cardiac arrest and septic shock. Multivariable survival analysis showed that insurance status was not associated with mortality (HR 1.13; 95% CI 0.79, 1.61) after adjusting for other variables. The odds of developing complications among self-paid individuals were higher (adjusted OR 1.17; 95% CI 1.02, 1.35). Conclusion Lack of healthcare coverage for older adults can result in delayed presentation, leading to increased morbidity. Close attention should be paid to such patients for timely provision of treatment. There is a need to expand primary care access and proper management of comorbidities for overall patient well-being. Government initiatives for expanding insurance coverage for older population can further enhance their healthcare access, mitigating the risk of essential treatments being withheld due to financial limitations. Level of evidence III.

Summary Background/Objective: To describe the current literature regarding long-term physical, mental, and social outcomes of firearm injury survivors in the United States. Methods: We systematically searched the PubMed/MEDLINE and Embase databases for articles published from 2013 to 2019 that involved survivors of acute physical traumatic injury aged 18 or older and reported health outcomes between 6 months and 10 years postinjury. Out of 747 articles identified, seven reported outcomes on United States-based civilian patients whose mechanism of injury involved firearms. We extended our publication date criteria from 1995 to 2020 and expanded the search strategy to include medical subject headings terms specific for firearm injury outcomes. Ultimately, ten articles met inclusion criteria. Results: When studied, a significant proportion of patients surviving firearm injury screened positive for posttraumatic stress disorder (49%–60%) or were readmitted (13%–26%) within 6 months postinjury. Most studies reported worse long-term outcomes for firearm injury survivors when compared both to similarly injured motor vehicle collision survivors and to the United States general population, including increased chronic pain, new functional limitations, and reduced physical health composite scores. Studies also reported high rates of posttraumatic stress disorder, reduced mental health composite scores, lower employment and return to work rates, poor social functioning, increased alcohol, and substance abuse. Conclusions: Research on the long-term health impact of firearm injury is scant, and heterogeneity in available studies limits the ability to fully characterize the outcomes among these patients. A better understanding of the long-term health impact of firearm injury would support systematic change in policy and patient care to improve outcomes.

Background: Despite increasing numbers of women surgeons globally, barriers to career advancement persist. While these barriers have been extensively discussed in high‐income countries (HICs), the topic has received minimal attention in lower–middle‐income countries (LMICs) like Pakistan.Methods: The Association of Women Surgeons of Pakistan (AWSP)—an organization in Pakistan consisting of female surgeons and trainees—carried out this international cross‐sectional study over July–Sept 2019. An anonymous online survey was disseminated via social media platforms and various institutions across Pakistan and internationally.Results: A total of 218 female surgeons responded to the survey, with 146 (67%) from Pakistan and 72 (33%) from HICs. While HIC surgeons were more likely to report gender discrimination/bias (GD/bias) during residency (29.2% vs 11.6%; p = 0.001), more Pakistani surgeons reported that GD/bias negatively affected their job satisfaction (80.7% vs. 64.9%; p = 0.024). GD/bias manifested most commonly as differences in mentoring relationships (72%). A higher percentage Pakistani surgeons reported having experienced a family‐related interruption in their career (24.7% vs. 11.1%; p = 0.019). The vast majority (95%) felt that surgery was perceived as a masculine field, and the majority (56.4%) of respondents reported having been told that they could not be a surgeon because of their gender.Conclusion: Our study highlights keys factors that must be addressed to provide equal career opportunities to women surgeons. It is the responsibility of surgical educators, policy makers, and healthcare organizations to facilitate women surgeons’ career progression by developing systems that support equitable career growth for women surgeons.

Background: Insurance coverage is associated with better cancer outcomes; however, the relative importance of insurance coverage may differ between cancers. This study compared the association between insurance coverage at diagnosis and cancer-specific mortality (CSM; insurance sensitivity) in 6 cancers. Patients and Methods: Using the SEER cancer registry, data were abstracted for individuals diagnosed with ovarian, pancreatic, lung, colorectal, prostate, or breast cancer in 2007 through 2010. The association between insurance coverage at diagnosis and CSM was modeled using a Fine and Gray competing-risks regression adjusted for demographics. An interaction term combining insurance status and cancer type was used to test whether insurance sensitivity differed between cancers. Separate models were fit for each cancer. To control for lead-time bias and to assess whether insurance sensitivity may be mediated by earlier diagnosis and treatment, additional models were fit adjusting for disease stage and treatment. Results: Lack of insurance was associated with an increased hazard of CSM in all cancers (P<.01). The magnitude of the effect differed significantly between cancers (P_interaction=.04), ranging from an adjusted hazard ratio of 1.13 (95% CI, 1.01–1.28) in ovarian and 1.19 (95% CI, 1.11–1.29) in pancreatic cancer to 2.19 (95% CI, 2.02–2.37) in breast and 2.98 (95% CI, 2.54–3.49) in prostate cancer. The benefit of insurance was attenuated after adjusting for stage and treatment (eg, screening/early treatment effect), with the largest reductions in prostate, breast, and colorectal cancers. Conclusions: Greater insurance sensitivity was seen in screening-detected malignancies with effective treatments for early-stage disease (eg, prostate, breast, and colorectal cancers). Given that this differential is significantly reduced after adjusting for stage and treatment, our results suggest that a significant portion (but not all) of the benefit of insurance coverage is due to detection and treatment of certain curable early-stage cancers.