Evaluation of coagulopathy in cirrhotic patients: A scoping review of the utility of viscoelastic testing.

BACKGROUND: Cirrhosis causes significant coagulopathy. Traditional coagulation tests may not accurately measure coagulopathy in well-compensated patients with cirrhosis. Viscoelastic tests are functional tests that may better assess coagulopathy in cirrhotic patients. METHODS: We searched PubMed, ScienceDirect, Google Scholar, and grey literature using terms meaning viscoelastic testing and cirrhosis. After reviewing over 500 titles and abstracts, 40 full-text papers met inclusion criteria. RESULTS: Twenty-two papers found viscoelastic testing was a better indicator of baseline coagulation than traditional testing in cirrhosis. Nineteen additional papers evaluated the utility of peri-procedural viscoelastic testing and found they led to a reduction in blood product administration without increasing risk of hemorrhage, thrombotic events, or other complications. CONCLUSIONS: The usage of viscoelastic testing in patients with cirrhosis allows for better assessment of coagulopathy, resulting in improved outcomes. Educating physicians to optimize care of this high-risk group is necessary to further improve their treatment.

New legislation in New Jersey reduced opioid use among trauma patients.

PURPOSE: In New Jersey, politicians have emphasized the need to attenuate the ongoing opioid epidemic as opioid use disorder can lead to addiction and, in many cases, mortality. New legislation (New Jersey Senate Bill 3) was enacted in 2017 to reduce opioid prescription from 30 days to 5 days for acute pain in both inpatient and outpatient healthcare settings. Therefore, we sought to evaluate if the enactment of the bill influenced the consumption of opioid pain medication at an American College of Surgeons-verified Level I Trauma Center. METHODS: Patients from 2016 to 2018 were compared for differences in average daily inpatient morphine milligram equivalents (MMEs) consumption and injury severity score (ISS), among other parameters. To ensure that changes in pain medication did not affect the quality of pain management, we compared their average pain ratings. RESULTS: Although the average ISS in 2018 was higher than that in 2016 (10.6 ± 0.2 vs 9.1 ± 0.2, p < 0.001), opioid consumption decreased in 2018 without increasing the average pain rating for patients with an ISS of 9 and 10. More specifically, the average daily inpatient MMEs consumption dropped from 14.1 ± 0.5 in 2016 to 8.8 ± 0.3 in 2018 (p < 0.001). Even among patients with an average ISS >15, the total MMEs consumed per person decreased in 2018 (116.0 ± 14.0 vs 59.4 ± 7.6, p < 0.001). CONCLUSION: Overall, opioid consumption was lower in 2018 without negatively affecting the quality of pain management. This suggests that the implementation of the new legislation has successfully reduced inpatient opioid use.

Clinical Application of Thromboelastography in Patients With Cirrhosis: A Single Center Experience.

INTRODUCTION: Thromboelastography (TEG) is a functional test of coagulation used to guide transfusions. Despite literature supporting its utility, its use remains limited to select populations. In patients with cirrhosis, conventional coagulation tests are notoriously inaccurate, and TEG may be a better measure of coagulopathy. We aimed to assess the utilization of TEG in patients with cirrhosis to steward blood transfusions in this high-risk group. METHODS: A single-center retrospective chart review of all patients ≥18 y old with a diagnosis of liver cirrhosis who had TEG results documented in the electronic medical record from January 1 to November 1, 2021. RESULTS: There were 277 TEG results on 89 patients with cirrhosis. Overall, 91% of the TEGs performed were associated with a clinical indication for transfusion. However, of the patients who were transfused, abnormal TEG values, including elevated R time and reduced maximum amplitude, did not correspond to transfusion of indicated blood products (fresh frozen plasma and platelets). A reduction in alpha angle showed a statistically significant association with transfusion of cryoprecipitate (P < 0.05). When assessing conventional coagulation tests, abnormal values were not significantly associated with transfusion (P = 0.07). CONCLUSIONS: Despite TEG suggesting that transfusions could be avoided in many cirrhotic patients, patients are still being transfused platelets and fresh frozen plasma in the absence of evidence of coagulopathy on TEG. Our finding suggests the need for education about appropriate utilization of TEG. More research is needed to understand the role of these tests to guide transfusion practices in patients with cirrhosis.

Dexmedetomidine only regimen for long-term sedation is associated with reduced vasopressor requirements in septic shock patients: A retrospective cohort study from MIMIC-IV database.

Background: Previous studies have shown that dexmedetomidine (DEX) may be associated with reduced vasopressor requirements in septic shock patients, however, long-term DEX-only sedation in reducing vasopressor requirements is still controversial. Methods: A retrospective study was conducted among patients with septic shock on mechanical ventilation using the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The primary outcome was the ratio of norepinephrine equivalent dose to mean arterial pressure (NEq/MAP) in the first 72 h after DEX or other sedatives for sedation. The secondary outcomes were key organ function parameters, 28-day mortality, and 90-day mortality. Univariate, propensity score matching (PSM), and generalized linear mixed model (GLMM) analyses were performed. Results: DEX was associated with decreased NEq/MAP in the first 72 h (difference = 0.05, 95% CI = -0.02-0.08, p = 0.002) after adjusting for confounders in the GLMM analysis. The DEX group was also associated with a lower heart rate, cardiac output (CO), lactate level, aspartate transaminase (AST) level, and higher PaO2/FiO2 ratio (p < 0.0125). Moreover, DEX only sedation was associated with reduced 90-day mortality (OR = 0.60, 95% CI = 0.37-0.94, p = 0.030). Conclusion: DEX may be associated with decreased vasopressor requirements, improved AST and PaO2/FiO2 levels, and reduced 90-day mortality in patients with septic shock, which warrants further study.

The impact of gender on clinical outcomes after sustaining a pelvic fracture.

INTRODUCTION: In trauma care, pelvic fractures contribute to morbidity and mortality. Since men and women have different pelvic structures and hormonal milieu, we studied if these gender differences affect clinical outcomes after pelvic fractures. METHODS: Using the 2016 American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) database, we stratified 24,425 patients with pelvic fractures by gender. Male and female patients were analyzed for differences in comorbidities,  mechanism of injury, complications, and other clinical parameters. RESULTS: Female patients were older (p < 0.001) and had more comorbidities (p < 0.001), such as bleeding disorder, congestive heart failure, chronic obstructive pulmonary disorder, dementia, chronic renal failure, diabetes mellitus, and hypertension. Although female patients were sicker before sustaining pelvic fractures, male patients had higher rates of post-trauma complications (p < 0.001), such as acute kidney injury, deep vein thrombosis, unplanned admission to the intensive care unit (ICU), and unplanned return to the operating room (OR). Multivariate logistic regression further supports this as male gender was independently associated with a 26.1% higher risk of developing at least one complication (p < 0.001), despite having a higher average Injury Severity Score (ISS) (21.91 ± 0.09 versus 20.71 ± 0.11, p < 0.001). Interestingly, male patients also had a longer hospital length of stay than female patients (13.36 ± 0.12 days versus 11.8 2± 0.14 days, p < 0.001). CONCLUSION: Even though female patients were older and had more pre-existing comorbidities, male patients developed more complications and had longer hospital stays. Trial registration number Not a clinical trial.

Vessel Sealant Devices in Thyroidectomies: An ACS-NSQIP Study.

OBJECTIVES: Thyroidectomies involve meticulous dissection of a highly vascularized organ and complications may develop, such as hematoma, hypocalcemia, and even hypoparathyroidism. Because some of these complications may be fatal, we sought to identify the differences in postthyroidectomy outcomes when the use of a vessel sealant device (VSD) such, as LigaSure or Harmonic scalpel, is compared with more traditional techniques, such as ligatures and clips. METHODS: Using the 2016 American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy database, we compared patients who underwent a thyroidectomy using a VSD with patients without a VSD for differences in postoperative complications. RESULTS: A total of 5146 cases were identified and 3452 of those cases used a VSD, whose use was associated with significantly lower rates of hematoma, deep vein thrombosis, and hypocalcemia before discharge, as well as a shorter length of stay and longer operation time. Multivariate logistic regression showed that VSD was associated with 32.27% and 39.15% lower odds of hypocalcemia and hematoma, respectively. VSDs also were used more frequently in cases that had multinodular, severe, or substernal goiter or Graves disease as the primary indication for surgery and in patients with a higher body mass index. There was no significant difference in the incidence of recurrent laryngeal nerve injury between the two groups. CONCLUSIONS: Analysis of the American College of Surgeons National Surgical Quality Improvement Program data indicates that VSDs are associated with a lower risk of complications, such as hypocalcemia, hematoma, and deep vein thrombosis, suggesting that VSDs may be a more effective method of hemostasis than traditional techniques.

Association Between Body Mass Index and Morbidity and Mortality During Hospitalization After Trauma.

BACKGROUND: Literature suggests that unhealthy body mass index is a risk factor for adverse clinical outcomes. OBJECTIVES: To study the association between unhealthy body mass index and morbidity and mortality after trauma using the 2016 American College of Surgeons Trauma Quality Improvement Program database. METHODS: A retrospective review was conducted comparing the normal weight control group to the underweight, overweight, obese, severely obese, and morbidly obese groups for differences in demographic factors, injury severity score, comorbidities, length of stay, and complications. RESULTS: Underweight, overweight, obese, severely obese, and morbidly obese body mass indexes, in comparison to normal weight body mass index, were associated with a higher probability of developing at least one complication after trauma. Additionally, we observed a J-shaped curve when analyzing body mass index and mortality, suggesting that both high and low body mass indexes are positively associated with mortality. In fact, morbidly obese patients had the highest mortality rate, followed by underweight patients (p < .001). Interestingly, however, multivariate logistic regression demonstrated that, compared with normal weight body mass index, overweight and obese body mass indexes were independently associated with 9.6% and 10.5% lower odds of mortality, respectively (p < .001 and p = .001). CONCLUSION: Irrespective of preexisting comorbidities, injury severity score, and mechanism of injury, underweight, overweight, obese, severely obese, and morbidly obese body mass indexes were independently associated with higher risks of morbidity, whereas overweight and obese body mass indexes were associated with lower mortality risks. These findings emphasize the complex relationship between body mass index and clinical outcomes for trauma patients.

The impact of BMI on morbidity and mortality after femoral fractures.

PURPOSE: Femur fractures are the result of high energy injury and are associated with life-threatening complications. Therefore, we studied how body mass index (BMI) contributes to complications after femoral fractures. METHODS: Using the 2016 American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) database, we stratified 41,362 patients into groups based on their BMI: Normal Weight (NW), Overweight (OW), Obese (OB), Severely Obese (SO), and Morbidly Obese (MO). We compared each BMI group to the NW cohort for differences in demographic factors, comorbidities, complications, and mechanism of injury. RESULTS: OB, SO, and MO patients sustained higher rates of traumatic injury from high energy mechanisms, such as motor vehicle trauma, in comparison to NW patients, who sustained more injuries from falls (p < 0.05). Correspondingly, obese patients were more likely than NW patients to sustain shaft and distal end fractures (p < 0.05). At hospital admission, obese patients presented with more comorbidities, such as bleeding disorders, congestive heart failure, diabetes mellitus, and hypertension (p < 0.05). Despite these individual findings, patients with OB, SO, and MO BMI, as opposed to NW BMI, were independently associated with a higher probability of developing at least one post-trauma complication. More specifically, MO patients were associated with a 45% higher odds of developing a complication (p < 0.05). CONCLUSION: Irrespective of presenting with more comorbidities and sustaining high energy injuries, OB, SO, and MO patients were independently associated with having a higher risk of developing complications following a femoral fracture. Overall, better clinical outcomes are observed among patients with no underlying conditions and normal BMI.

Analysis of Perioperative Risk Factors for Clostridium difficile Infection After a Colectomy.

Introduction The removal of the terminal ileum may interfere with gut-associated lymphoid tissue function, reduce bile salt reabsorption, and change intraluminal pH, which may contribute to the development of Clostridium difficile infection (CDI) after ileocolic resections. Therefore, we compared CDI incidence among patients who underwent a colectomy with or without removal of the terminal ileum. Methods Using the 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Targeted Colectomy database, we identified 17,962 patients who underwent a left-sided colectomy without removal of the terminal ileum and 5,929 patients who underwent an ileocolic resection involving the removal of the terminal ileum. Patients who underwent an emergency operation or had enterocolitis as the indication for surgery were excluded. Results Patients who underwent an ileocolic resection developed higher rates of postoperative CDI than those who underwent a left hemicolectomy (p<0.001). Multivariate logistic regression analysis demonstrated that removing the ileum was associated with a 50% higher risk of developing CDI than patients who underwent a left-sided colectomy. Additional risk factors for developing postoperative CDI were advanced age (p=0.001) and mechanical bowel preparation (p=0.001). On the other hand, factors independently associated with a lower risk of postoperative CDI were male gender (p<0.001), preoperative oral antibiotics (p<0.001), and preoperative chemotherapy use within 90 days (p<0.013). Conclusion Overall, patients who undergo operations involving the removal of the ileum are at higher risk for developing CDI. To reduce the risk among these patients, we suggest employing preoperative oral antibiotics in part of bowel preparation. Furthermore, it is critical to maintain hygienic measures, such as handwashing and disinfecting surfaces, and attentive care for these patients.

Pleural Plaques and the Risk of Lung Cancer in Asbestos-exposed Subjects.

Rationale: Asbestos exposure is associated with a dose-dependent risk of lung cancer. The association between lung cancer and the presence of pleural plaques remains controversial.Objectives: To define the relationship between pleural plaques and lung cancer risk.Methods: Subjects were from two cohorts: 1) crocidolite mine and mill workers and Wittenoom Township residents and 2) a mixed-asbestos-fiber, mixed-occupation group. All subjects underwent annual review since 1990, chest X-ray or low-dose computed tomography scan, and outcome linkage to national cancer and mortality registry data. Cox regression, with adjustment for age (as the underlying matching time variable), was used to estimate hazard ratios (HRs) for lung cancer incidence by sex, tobacco smoking, asbestos exposure, presence of asbestosis, and pleural plaques.Measurements and Main Results: For all 4,240 subjects, mean age at follow up was 65.4 years, 3,486 (82.0%) were male, 1,315 (31.0%) had pleural plaques, and 1,353 (32.0%) had radiographic asbestosis. Overall, 3,042 (71.7%) were ever-smokers with mean tobacco exposure of 33 pack-years. In total, 200 lung cancers were recorded. Risk of lung cancer increased with cumulative exposure to cigarettes, asbestos, and presence of asbestosis. Pleural plaques did not confer any additional lung cancer risk in either cohort (cohort 1: HR, 1.03; 95% confidence interval, 0.64-1.67; P = 0.89; cohort 2: HR, 0.75; 95% confidence interval, 0.45-1.25; P = 0.28).Conclusions: The presence of pleural plaques on radiologic imaging does not confer additional increase in the risk of lung cancer. This result is consistent across two cohorts with differing asbestos fiber exposures and intensity.

Bladder Networking: A Unique Case of Cholecystovesicular Fistula.

We present a case of a 60-year-old woman with chronic lower abdominal pain and green urine. Further workup revealed a cholecystovesicular fistula (CVF), a newly coined term to indicate a fistula between the gallbladder and the urinary bladder. The CVF was treated surgically. The pathophysiology of CVF is thought to result from gallbladder perforation into the liver. Over time, a tract forms inferiorly until it meets another organ, in this case, the urinary bladder. This later complication of the gallbladder disease joins the broader spectrum of cholecystic fistulas. To our knowledge, a CVF has never been reported in the literature.

Analysis of Transport to an American College of Surgeons Level I Trauma Center.

INTRODUCTION: Efficient patient transportation by ground emergency medical services (GEMS) or helicopter emergency medical services (HEMS) to a trauma center is vital for optimal care. We investigated differences between the modes of transport in terms of demographics, injury, scene location, and outcome. SETTING: Morristown Medical Center (MMC), Morristown, NJ METHODS: All 903 trauma admissions in 2016 by advanced life support (ALS) to MMC, a Level I Trauma Center, were retrospectively analyzed. RESULTS: 22% of admissions were HEMS and 78% were GEMS. HEMS patients had higher Injury Severity Scores (ISS) (p<0.001); however, mortality and length of stay were not statistically different. The percentage of pediatric patients transported by HEMS that were discharged home after emergency department evaluation was greater than the older populations (p<0.001). Older age and higher ISS had the largest impact on mortality (p<0.001). CONCLUSION: We believe our current use of HEMS is adequate since patient outcomes between HEMS and GEMS was similar, even though HEMS patients have higher ISS. However, helicopter use in the pediatric population was over-utilized, possibly due to the scarcity of hospitals capable of managing pediatric traumas. Implementation of the Air Medical Prehospital Triage scoring system may also help correct for these unnecessary HEMS transports.

Genes that influence swarming motility and biofilm formation in Variovorax paradoxus EPS.

BACKGROUND: Variovorax paradoxus is an aerobic soil bacterium associated with important biodegradative processes in nature. We use V. paradoxus EPS to study multicellular behaviors on surfaces. METHODOLOGY: We recovered flanking sequence from 123 clones in a Tn5 mutant library, with insertions in 29 different genes, selected based on observed surface behavior phenotypes. We identified three genes, Varpa_4665, Varpa_4680, and Varpa_5900, for further examination. These genes were cloned into pBBR1MCS2 and used to complement the insertion mutants. We also analyzed expression of Varpa_4680 and Varpa_5900 under different growth conditions by qPCR. RESULTS: The 29 genes we identified had diverse predicted functions, many in exopolysaccharide synthesis. Varpa_4680, the most commonly recovered insertion site, encodes a putative N-acetyl-L-fucosamine transferase similar to WbuB. Expression of this gene in trans complemented the mutant fully. Several unique insertions were identified in Varpa_5900, which is one of three predicted pilY1 homologs in the EPS genome. No insertions in the two other putative pilY1 homologs present in the genome were identified. Expression of Varpa_5900 altered the structure of the wild type swarm, as did disruption of the chromosomal gene. The swarming phenotype was complemented by expression of Varpa_5900 from a plasmid, but biofilm formation was not restored. Both Varpa_4680 and Varpa_5900 transcripts were downregulated in biofilms and upregulated during swarming when compared to log phase culture. We identified a putative two component system (Varpa_4664-4665) encoding a response regulator (shkR) and a sensor histidine kinase (shkS), respectively. Biofilm formation increased and swarming was strongly delayed in the Varpa_4665 (shkS) mutant. Complementation of shkS restored the biofilm phenotype but swarming was still delayed. Expression of shkR in trans suppressed biofilm formation in either genetic background, and partially restored swarming in the mutant. CONCLUSIONS: The data presented here point to complex regulation of these surface behaviors.

Vaginal vault dehiscence after laparoscopic hysterectomy over a nine-year period at Sydney West Advanced Pelvic Surgery Unit - our experiences and current understanding of vaginal vault dehiscence.

BACKGROUND: A retrospective analysis of all women undergoing hysterectomy at Sydney West Advanced Pelvic Surgery Unit (SWAPS) was performed in the nine-year period from 2001 to 2009. AIMS: To evaluate the incidence, timing and presenting symptoms of vaginal vault dehiscence after hysterectomy, especially via the laparoscopic approach to gain further understanding of patient risk factors and surgical factors that may predispose to this complication. METHODS: Women who presented with vaginal vault dehiscence were identified and possible pre-operative, intra-operative and post-operative risk factors were assessed. A comprehensive literature search was performed to assess the current understanding and incidence of vault dehiscence after laparoscopic hysterectomy. RESULTS: A total of 1224 hysterectomies were performed between 2001 and 2009. 989 (80.80%) were performed laparoscopically of which five women (0.42%) presented with vault dehiscence post-operatively. All had undergone total laparoscopic hysterectomy resulting in a vault dehiscence rate of 1.59% after total laparoscopic hysterectomy specifically. Baseline characteristics included a mean age of 42.8 years (37-51 years), mean BMI of 26.8 kg/m(2) (23.8-32.3 kg/m(2)) and a mean parity of two deliveries (1-3 deliveries). The main presenting symptom of vaginal vault dehiscence was vaginal bleeding. Women with confirmed vaginal vault dehiscence readmitted to hospital at a mean of 18 days (11-28 days) post-operatively. CONCLUSION: Vaginal vault dehiscence is a rare complication after hysterectomy, but more common after a laparoscopic approach. A delayed presentation with vaginal bleeding was the main presenting symptom in this study - a literature review has shown common presenting symptoms to include abdominal pain, vaginal evisceration and vaginal bleeding. Techniques specific to total laparoscopic hysterectomy seem especially important in the increased risk of vaginal vault dehiscence seen after laparoscopic hysterectomy.

Photoassisted Fenton degradation of polystyrene.

Fenton and photoassisted Fenton degradation of ordinary hydrophobic cross-linked polystyrene microspheres and sulfonated polystyrene beads (DOWEX 50WX8) have been attempted. While the Fenton process was not able to degrade these polystyrene materials, photoassisted Fenton reaction (mediated by broad-band UV irradiation from a 250 W Hg(Xe) light source) was found to be efficient in mineralizing cross-linked sulfonated polystyrene materials. The optimal loadings of the Fe(III) catalyst and the H(2)O(2) oxidant for such a photoassisted Fenton degradation were found to be 42 µmol-Fe(III) and 14.1 mmol-H(2)O(2) per gram of the sulfonated polystyrene material. The initial pH for the degradation was set at pH 2.0. This photoassisted Fenton degradation process was also able to mineralize commonly encountered polystyrene wastes. After a simple sulfonation pretreatment, a mineralization efficiency of >99% (by net polymer weight) was achieved within 250 min. The mechanism of this advanced oxidative degradation process was investigated. Sulfonate groups introduced to the surface of the treated polystyrene polymer chains were capable of rapidly binding the cationic Fe(III) catalyst, probably via a cation-exchange mechanism. Such a sorption of the photoassisted Fenton catalyst was crucial to the heterogeneous degradation process.