Major Risk Factors of Mortality in Adult and Elderly Patients Emergently Admitted for Intestinal Fistulas, Excluding the Rectum and Anus.

INTRODUCTION: In the United States, intestinal fistulas accounts for $500 million (USD) of healthcare expenditures and 28,000 admissions annually. They are also associated with significant morbidity and mortality. Despite the high prevalence of intestinal fistulas, risk factors of mortality have yet to be fully elucidated. The aim of this study was to identify risk factors of mortality in emergently admitted patients with fistulas of the intestine, excluding the rectum and anus. MATERIALS AND METHODS: Adult and elderly patients emergently admitted with intestinal fistulas, between 2004-2014 were investigated using the National Inpatient Sample Database, ICD-9-CM code 569.81. Clinical outcomes, therapeutic management, demographics, and comorbidities were collected. Associations between mortality and all other variables were established via univariable and multivariable logistic regression models. The final multivariable regression model elucidated the odds ratios (95% confidence interval, p-value) of pertinent mortality risk factors. RESULTS: A total of 7,377 patients were included, of which the average adult and elderly ages were 48.9 and 74.6 years, respectively. Of these patients, 4,241 (57.5%) were female and 3,136 (42.5%) were male. Elderly patients demonstrated a higher mortality rate than adult patients-4.5% and 1.7%, respectively. In the adult group, the odds ratio for mortality was 1.020 for hospital length of stay in days (95% CI: 1.015-1.026, p<0.001), 1.035 for age (95% CI: 1.011-1.060, p=0.004), and 1.033 for days to the first procedure (95% CI: 1.021-1.044, p<0.001), among others. For the elderly group, the odds ratio for mortality was 1.012 for hospital length of stay in days (95% CI: 1.005-1.019, p=0.001), 1.075 for age (95% CI: 1.050-1.101, p<0.001), and 1.026 for days to the first procedure (95% CI: 1.009-1.043, p=0.002), among others. CONCLUSION: In adult and elderly patients emergently admitted for intestinal fistulas, multiple comorbidities were risk factors for in-hospital mortality. In the elderly cohort, increased age and increased days to operation were additional risk factors for in-hospital mortality.

Racial disparities in access to minimally invasive proctectomy for rectal cancer-a National Surgical Quality Improvement Program study.

AIM: The aim of this work was to determine racial disparities in access to minimally invasive proctectomy using a national database. METHOD: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program evaluated for surgical approach (robotic, laparoscopic or open), demographics and comorbidity, and then compared by race. RESULTS: A total of 3511 patients (325 Asian, 2925 White, 261 African American/Black) with cancer who underwent a proctectomy between 2016 and 2020 were included. Both Asians and Whites had significantly higher rates of laparoscopic proctectomy relative to African Americans (38.5%, 33.8% and 28.7%, respectively; p = 0.0001). Asians had the highest rate of robotic proctectomy (38.2%, p = 0.0001). Conversely, Black patients had significantly higher rates of open proctectomy followed by Whites and then Asians (42.1%, 35.4% and 23.4%, respectively; p = 0.0001). In multivariable logistic regression with backward elimination, African Americans were 0.7 times as likely to undergo laparoscopic proctectomy and 1.4 times more likely to undergo open proctectomy than Whites (p = 0.043). Compared with Whites, Asians were 1.8, 1.7 and 1.9 times more likely to undergo minimally invasive, laparoscopic proctectomy and robotic proctectomy, respectively (p = 0.0001, p = 0.001, p = 0.0001). CONCLUSION: Asians had the highest rate of laparoscopic and robotic proctectomy, while Blacks had the highest rate of open proctectomy. African Americans were least likely to undergo laparoscopic proctectomy compared with all races. Race is an independent risk factor for access to minimally invasive proctectomy.

Time to Operation and Mortality Risk in Elderly Patients with Intestinal Fistula: Not Too Early and Not Too Late.

INTRODUCTION: This study aimed to ascertain the risk factors contributing to in-patient mortality in elderly patients 65 years and older who were admitted emergently, diagnosed with intestinal fistula, and underwent surgery. MATERIALS AND METHODS: Data were extracted from the National Inpatient Sample (NIS) spanning the years 2005-2014. Multivariable logistic regression and a generalized additive model (GAM) were employed to investigate predictors of mortality. Continuous variables are presented as mean values with standard deviations (SD). RESULTS: The study encompassed 34,853 patients with a mean age of 77.7 years-56.5% were female and 79.4% were White. Patients were categorized into three groups based on the time elapsed between admission and surgery: less than two days (17,761), two to three days (8,407), and more than three days (4,233). Mortality rates were 2.7%, 6%, and 6.1% for patients who underwent surgery within two to three days, within two days, and after more than three days of admission, respectively. Notably, the group that operated more than three days from admission experienced nearly double the hospital length of stay (12 days, SD: 7.2) compared to the other two groups (6.3, SD: 6 and 6.1, SD: 4.8). Furthermore, the association between mortality and time to operation, as indicated by the GAM model, revealed a significant non-linear relationship after adjusting for age, gender, race, zip code, hospital location, and comorbidities (p<0.001). CONCLUSION: Elderly patients diagnosed with intestinal fistula should undergo operative treatment as soon as possible, once they are resuscitated. Delaying the operation more than three days after admission substantially increases the risk of mortality.

Artificial Intelligence and Healthcare: A Journey through History, Present Innovations, and Future Possibilities.

Artificial intelligence (AI) has emerged as a powerful tool in healthcare significantly impacting practices from diagnostics to treatment delivery and patient management. This article examines the progress of AI in healthcare, starting from the field's inception in the 1960s to present-day innovative applications in areas such as precision medicine, robotic surgery, and drug development. In addition, the impact of the COVID-19 pandemic on the acceleration of the use of AI in technologies such as telemedicine and chatbots to enhance accessibility and improve medical education is also explored. Looking forward, the paper speculates on the promising future of AI in healthcare while critically addressing the ethical and societal considerations that accompany the integration of AI technologies. Furthermore, the potential to mitigate health disparities and the ethical implications surrounding data usage and patient privacy are discussed, emphasizing the need for evolving guidelines to govern AI's application in healthcare.

The Prevalence and Risk Factors of Metabolic Syndrome in Patients with Hemodialysis.

Introduction: Metabolic syndrome is a common disorder that puts patients at high risk for cardiovascular disease (CVD) and mortality. To our knowledge, there is no published study in Pub Med which evaluated both lifestyle and metabolic syndrome in hemodialysis patients. This study aimed to estimate the prevalence of metabolic syndrome and investigate the potential risk factors in hemodialysis patients. Methods: This was a cross-sectional study conducted on 204 patients enrolled conveniently. National Cholesterol Education Program Adult Treatment Panel III criteria considered for Metabolic Syndrome. Demographics, lifestyle, and disease characteristics were gathered. The relationship between metabolic syndrome and its severity with independent variables was investigated through multivariable multivariate logistic and linear regressions. Results: The mean (SD) age was 55 (14) years and 42% were women. 42.6% had metabolic syndrome. Low high-density lipoprotein (HDL), high fasting blood sugar, high blood pressure (BP), increased waist circumference (WC), and high triglyceride were observed in decreasing order of frequency in 54.4%, 44.1%, 38.7%, 33.3% 28.9% of patients, respectively. The logistic regression model revealed significant associations between metabolic syndrome and physical activity (OR=0.85, 95% CI : 0.74-0.97), mood (OR=1.04, 95% CI : 1.002-1.078), age (OR=1.023, 95% CI : 1.001-1.046), and missed work (OR=0.86, 95% CI : 0.76-0.97). The linear regression model revealed significant associations between metabolic syndrome severity score and physical activity (B=-0.12, 95% CI : -0.21-0.02) and sleep quality (B=0.017, 95% CI : 0.001-0.033). Conclusion: Poorer sleep quality, lower physical activity, lower mood status, and older age were associated with higher odds of metabolic syndrome/metabolic syndrome severity score in hemodialysis patients.

Odds of Mortality in Geriatric Patients with Appendicitis is 22 Times Higher than that in Non-Geriatrics: An Analysis of 336,880 Patients from NIS Database.

RESULTS: A total of 336,880 patients were included in the cohort. Mean age was 37.7 and 73.8 years in adult and elderly patients, respectively. 97.3% of adults and 94.2% of elderly patients underwent an operation. The mortality rate in the elderly patients (1.04%, n=402/38,509) was 22 times higher (p<0.0001) than that in adult patients (0.047%, n=144/301,408). Mean (SD) hospital length of stay (HLOS) was 2.6 (2.9) days in adults and 4.9 (5.2) days in elderly patients (p<0.0001). Ninety-nine percent of adult and elderly patients were discharged within 11 and 20 days after emergent hospitalization, respectively. In the final regression model, every one year older in age increased the odds of mortality by 5% (OR=1.05, 95%CI: 1.04-1.06, p<0.001), and for every one day longer, HLOS increased the odds of mortality by 1% (OR=1.01, 95%CI: 1.001-1.02, p<0.001). The multivariable logistic regression model was built on 82,006 patients whose HLOS was ≥4 days, the odds ratio for HLOS was 1.05 (95%CI: 1.04-1.06). This means that for every additional day in hospital after day 4, the odds of mortality increase by 5%.

The Risk of Mortality in Elderly Patients with Acute Vascular Insufficiency of the Intestine is 2.5-Fold Greater than that in Adult Patients: An Analysis of 36,864 Patients.

INTRODUCTION: Vascular insufficiency of the intestine is difficult to diagnose and it has high mortality rates. Our study aimed to identify risk factors for in-hospital mortality of patients emergently admitted with the primary diagnosis of vascular insufficiency of the intestine. MATERIALS AND METHODS: Adult (18-64 years) and elderly (>64 years) patients emergently admitted with the primary diagnosis of vascular insufficiency of the small and large intestine were analyzed using the National Inpatient Sample database from 2005-2014. Using stratified analysis and backward multivariable logistic regression analysis, the relationship between mortality and several risk factors were evaluated. RESULTS: There were 36,864 patients analyzed of which 4,994 died in hospital. Most patients were elderly, making up 23,052 of the total patients (63.4%). The mean (SD) age for adult males, adult females, elderly males, and elderly females were 50.51 (11.18), 52.12 (10.06), 77.00 (7.50), and 78.44 (7.88) years, respectively. When the data was stratified according to outcome, deceased adult patients accounted for 6.9% of all adult patients, while elderly deceased patients accounted for 17.5% of all elderly patients. Elderly patients had a 2.5 times increase in mortality compared to adult patients. When the data was stratified according to operation status, non-operation patients had 58.6% use of gastrointestinal invasive diagnostic procedures, as opposed to the operative patients with 30.3% use. In the final regression model, age (OR=1.03, 95%CI: 1.02-1.04), male sex (OR=1.12, 95%CI: 1.04-1.21), operation (OR=2.73, 95%CI: 2.50-2.97), bacterial infections (OR=3.12, 95%CI: 2.82-3.44), respiratory diseases, (OR=1.84, 95%CI: 1.71-1.99), cardiac diseases (OR=2.78, 95%CI: 2.09-2.48), liver diseases (OR=2.24, 95%CI: 1.99-2.53), genitourinary system diseases (OR=1.40, 95%CI: 1.30-1.51), fluid and electrolyte disorders (OR=1.48, 95%CI: 1.37-1.60), neurological diseases (OR=1.23, 95%CI: 1.13-1.33), and trauma, burns, and poisons (OR=1.57, 95%CI: 1.43-1.73) were the risk factors for mortality. Gastrointestinal invasive diagnostic procedures (OR=0.31, 95%CI: 0.28-0.34) and hospital length of stay (OR=0.91, 95%CI: 0.90-0.92) were protective factors for mortality in all patients. CONCLUSION: For elderly patients emergently admitted for intestinal vascular insufficiency, the odds of mortality were 2.5 times greater than in adult patients. Age, male sex, operation, and several comorbidities were risk factors for mortality; whereas, invasive diagnostic procedures and longer hospital stay were the protective factors against mortality.

Novel antibiotic irrigation device versus standard O-ring wound retractor in the prevention of surgical site infection following colorectal resection.

PURPOSE: We sought to compare the effectiveness of a novel antibiotic irrigation device to the standard O-ring wound retractor in preventing surgical site infections (SSIs) following colorectal resections. METHODS: This single-arm clinical trial included patients undergoing colorectal resections utilizing the novel device. A retrospective cohort of patients undergoing the same procedures with the O-ring retractor was selected as the control group. The primary outcome assessed was SSI. Secondary outcomes assessed were overall complications, hospital length of stay (LOS), and 30-day readmission. A univariable and multivariable logistic regression model was built to evaluate the association between SSI as the outcome variable and the use of the novel device as the main independent variable. The model was adjusted for any confounding variables. RESULTS: Eighty-six novel device cases and 170 O-ring retractor cases were enrolled. There were no significant differences between the two groups in terms of demographics and preoperative comorbidities. Cases with the novel device had fewer Pfannenstiel incisions (1.2% vs. 14.6%, p < 0.001). There were no other significant differences in intraoperative variables. SSI rates were significantly lower in the novel device group (1.2% vs. 9.1%, p = 0.014). There were no other significant differences in postoperative complications. Multivariable logistic regression with backward elimination showed that the use of the novel device was significantly more effective against SSI by 92.5% compared to the use of the O-ring retractor. CONCLUSION: The novel device may contribute to lower SSI rates compared to the O-ring retractor following colorectal resection.

Frequency and Characteristics of Depression and Its Association with Diminished Quality of Life in a Cohort of Individuals with Post-Acute Sequelae of COVID-19.

Background: Approximately one-third of COVID-19 survivors will experience persistent symptoms, which may include neurological and psychiatric disturbances. Previous research has suggested that up to 45% of people develop clinically significant depressive symptoms post-COVID. This study sought to determine frequency, symptom profile, and clinical correlates of depression post-COVID. Methods: Seventy-five participants who had recovered from COVID-19 underwent neurocognitive, psychiatric, medical, and cognitive testing/screening. The primary measures of interest in this report included the Patient Health Questionnaire (PHQ-9), a 9-item depression-screening tool, and the Endicott Quality of Life Enjoyment and Satisfaction Questionnaire. Results: One-third of study participants screened as positive on the PHQ-9 for clinically significant depression, with the most commonly reported symptom being fatigue, followed by sleep disturbance and poor concentration. Also reported were decreased satisfaction in employment, sexual life, and mood. Depressed patients described greater illness severity during COVID-19 infection and subjective cognitive impairment, which was not found on neurocognitive testing. The only significant predictor of depression was COVID-19 illness severity. Limitations: A significant portion of participants was a clinical population with specific post-COVID complaints and was predominately comprised of white females. Formal psychiatric evaluation was not performed. Conclusion: Many individuals may experience depression after COVID-19 infection, with symptoms appearing to be predominately somatic in nature and correspond with COVID-19 illness severity.

How Do We Physicians and Surgeons Deal With our Own Disease?

It is a "known secret" that physicians and surgeons do not make good patients and neglect their own health by ignoring early warning signs of physical and psychological problems. Moreover, often, they seek help late. What are the reasons for this self-neglect? Is it because we think we are "super humans," or we think that we will not get sick, cannot get sick, should not get sick, have no "right" to get sick, as we must care for others? Do we ignore ourselves because we must go to one more meeting, do one more thing, write or present one more paper, give one more lecture, or take the call even with a fever, cough, and chills? Why can't we call in sick? Is this the "macho" effect? Is this culture of denial pervasive everywhere, even though we should know better? Yes, it is! Don't we need to remember the advice given by airlines to put on an oxygen mask on yourself first before helping others? Unfortunately, many of us do not do it. In this article, we will present a personal reflection as an example and review how we physicians and surgeons neglect our own health, ignoring the early warning signs of physical and psychological problems, and how we often seek help late. We also discuss potential reasons for this becoming a "norm" for many of us. Lastly, we review measures taken by some healthcare systems to remedy this situation.

Acellular Fish Skin Graft Use in Open Abdomen Management.

INTRODUCTION: Open abdomen (OA) management post damage control laparotomy (DCL) is common in complex abdominal trauma and intra-abdominal catastrophe (IAC). Use of polyglactin 910 mesh (VICRYL™, Johnson & Johnson, New Brunswick, New Jersey) to cover the intra-abdominal contents and wound vacuum-assisted closure (VAC) is current practice in the management of temporary abdominal closure (TAC). This may have complications and requires two to three weeks for granulations to be ready for skin grafting. Acellular fish skin graft (AFSG; Kerecis™, Reykjavik, Iceland), use in wound care management has proven beneficial in the management of both chronic and acute wounds, such as burns, by increasing wound granulation. However, to our knowledge, its utility in OA management has not been reported. OBJECTIVE: The objective of this report is to introduce a novel use of AFSG (Kerecis™) in open abdomen to decrease the time of TACs by accelerating formation of granulation tissue and placement of skin grafts in patients with post damage control laparotomy (DCL) for trauma and IAC when committed to open abdomen management is presented. MATERIALS AND METHODS: Illustration of application of AFSG (Kerecis™) in two patients who underwent DCL for IAC and OA management is presented. RESULTS: Two patients with intra-abdominal catastrophe post-DCL and fistulae were enrolled; one with postoperative enteric fistula and the other with post-anastomotic ileo-colonic fistula breakdown and major intra-abdominal sepsis resulting in multiple organ system failure (MOSF). In both cases, a hostile abdomen was present. The application of AFSG accelerated the placement of skin grafts in both patients and decreased the use of wound VAC and hospital length of stay. CONCLUSION: This report illustrates the use of AFSG (Kerecis™) to accelerate placement of skin grafts in patients post-DCL and OA management. AFSG (Kerecis™) could be considered as part of the OA management strategy.

Predictors of Matching into Anesthesiology and Surgery: Analysis of One Program's Results.

PURPOSE: The objectives of this study were to use a multivariable regression model to determine what application factors made anesthesiology and surgery applicants more or less likely to match into an anesthesiology or surgery residency program. METHODS: Surgery and Anesthesiology applicants listed on the final National Resident Matching Program (NRMP) Rank Order Lists from WMC in the 2020-2021 application cycle were included in analysis. All applicant data were collected through the Electronic Residency Application Service (ERAS). All ERAS and letters of recommendation (LOR) data were deidentified and LOR were subsequently inputted into a linguistics software to analyze the language use in LOR. Descriptive analyses were conducted to compare variables between applicants that matched to a specific residency program and those who matched elsewhere. A multivariable regression model was then used to determine characteristics of anesthesiology and surgery applicants that were indicative of matching to a specific rank of residency program. RESULTS: A total of 116 anesthesiology and 78 surgery applicants were included in final analysis. Analysis of anesthesiology applicants yielded four significant application characteristics that influenced matching to a higher or lower ranked residency program: USMLE Step 2 CK scores, medical school attended, insight category words in LOR, and anger category words in LOR. Similarly, analysis of surgery applicants yielded four significant characteristics: Race, USMLE Step 1 scores, insight category words, and see category words. CONCLUSION: Our results demonstrated that specialties of anesthesiology and surgery considered different metrics regarding the residency application process. Among the many factors that were analyzed, USMLE scores and language in LOR were considered significant in both specialties. As the application process continues to evolve, we may see a shift in what application factors are considered more important than others.

Complex Abdominal Wall Reconstruction with Biologic Mesh for Ventral/Umbilical Hernias in Patients with Cirrhosis: Technique and Outcomes.

INTRODUCTION: Patients with cirrhosis undergoing non-liver transplant surgery have a higher risk or adverse events than those without cirrhosis. The main objectives of this study were to describe characteristics, outcomes, and outcome predictors of cirrhotic patients undergoing complex abdominal wall reconstruction (CAWR) with biologic mesh. MATERIALS AND METHODS: This study had retrospective and prospective components, including all cirrhotic patients at our center with CAWR for ventral/umbilical hernia repair with biologic mesh between December 2016 and November 2021. RESULTS: We studied 37 patients with cirrhosis. Their mean age was 57.2 years, and 64.9% were male. The median body mass index (BMI) was 28.1kg/m2. Ascites was present in 83.3% of patients. The other most common comorbidities were alcohol abuse (67.6%), hypertension (37.8%), and diabetes (24.3%). All complications in aggregate occurred in 11 patients (29.7%). Six patients (16.2%) underwent reoperation. Surgical site infections (SSIs) occurred in five patients (13.5%). Four deaths occurred within 90 days (11.2% cumulative mortality). By 120 days, there were five deaths (14.2% mortality, but none due to the operation). Seven predictor variables achieved an area under the receiver operating characteristic curve (AUROC) for SSI of 0.963, and two predictors yielded an AUROC of 0.825 for 120-day mortality. CONCLUSIONS: Our results suggest that CAWR for ventral/umbilical hernias among cirrhotic patients is feasible given a dedicated CAWR team in collaboration with transplant surgeons and a transplant hepatologist. The rates of adverse outcomes were low or at the midpoint of the range of the study-specific estimates.

Does coffee affect bowel recovery following minimally invasive colorectal operations? A three-armed randomized controlled trial.

PURPOSE: Previous studies have suggested that coffee may shorten the postoperative ileus period. We sought to evaluate the impact of both coffee and caffeine on shortening the return of postoperative bowel function following minimally invasive colectomy. METHODS: This was a single-center, randomized controlled clinical trial conducted in a tertiary hospital. Patients undergoing an elective robotic or laparoscopic small or large bowel operation were included in this study. Patients were randomized into one of three groups: warm water, decaffeinated coffee, and caffeinated coffee. Subjects were assigned to drink a 4-oz cup three times daily starting on postoperative day one. The primary endpoint was time to first bowel movement. Secondary endpoints included time to first flatus, length of hospital stay, and postoperative morbidity. RESULTS: A total of 99 patients were included in this study: 31 warm water, 31 decaffeinated coffee, and 37 caffeinated coffee. The groups were similar in age and sex (p = 0.51 and 0.91, respectively). Mean (SD) time to the first bowel movement in days was 2.94 (1.4), 2.58 (1.2), and 2.86 (1.3), respectively (p = 0.53). There were no significant differences observed in postoperative morbidity (p = 0.52) between groups. Multivariate linear regression analysis did not reveal a statistically significant association between any interventions and time to first bowel movement or length of hospital stay. CONCLUSIONS: Coffee (caffeinated or decaffeinated) does not expedite the return of bowel function following minimally invasive operation. TRIAL REGISTRATION: https://classic. CLINICALTRIALS: gov/ct2/show/NCT02639728 NCT02639728.

Predictive Risk Factors for Childbirth-Associated Breast Infections in the United States: A 10-Year Perspective.

Infectious mastitis is a common condition that affects up to 33% of lactating women. Several risk factors have been suggested to be strongly associated with breast abscess, nipple infection, and non-purulent mastitis associated with childbirth. In this retrospective cohort study, we gathered data from the National Inpatient Sample (NIS) between 2005 and 2014 and utilized data stratification and backward linear regression to analyze the predictive factors associated with patients hospitalized with breast infection after childbirth, with special consideration of risk factors affecting hospital length of stay (LOS). In the ten-year period, 4614 women were hospitalized with a primary diagnosis of breast abscess, nipple infection, or non-purulent mastitis associated with childbirth. Mean (SD) age was 26.75 (6) years. The highest frequency distribution of cases was observed in patients aged 22-30 years (49.82%). Mean (SD) LOS was 2.83 (1.95) days. Mean (SD) LOS in patients with procedure was 3.53 (2.47) days, which was significantly longer than that in those with no procedure (2.39 (1.36) days, p < 0.001). Primary diagnosis of breast abscess and occurrence of a hospital procedure were most significantly associated with prolonged LOS. Factors such as age, socioeconomic position, severity of functional loss, as well as comorbidities were also contributing risk factors to the development of breast infection and increased hospital LOS. Further studies should examine these findings, as they relate to breastfeeding practices and concentrate on establishing best practices for risk reduction and prevention of childbirth-associated breast and nipple infections and hospitalizations.

Impact of COVID-19 on employment: sociodemographic, medical, psychiatric and neuropsychological correlates.

Introduction: Given the nature of the persistent physical and neuropsychiatric symptoms reported in the literature, among individuals after acute COVID illness; there is growing concern about the functional implications of the Post-Acute Sequelae of COVID-19 (PASC). We aim to evaluate associations of sociodemographic, medical, psychiatric and neuropsychological factors with employment status post COVID-19. Methods: 59 participants were administered a neuropsychiatric assessment and queried about employment status and occupational difficulties months after quarantine. Two levels of comparison were conducted: (1) Those who took time off work (TTO) to those with no time off (NTO); (2) Those who reported occupational performance suffered (PS) to those who did not (PDNS). Results: TTO vs. NTO exhibited extensive differences across medical, psychiatric and neurocognitive domains. PS vs. PDNS differed on subjective measures of physical and cognitive symptoms, but not on objective testing. Conclusion: Individuals who took time off beyond COVID-19 quarantine experience persistent physical, psychiatric, subjective and objective neurocognitive burden. In contrast, occupational impairment appears to reflect subjective complaints, but not objective measures. Clinical implications are discussed.

Predictors of severe lupus flare: a prospective follow-up study.

BACKGROUND: Flare-up of systemic lupus erythematosus (SLE) is a common characteristic that could have deleterious effects on patients' outcome and survival. The aim of this study was to identify the predictors of severe lupus flare. METHODS: 120 patients with SLE were enrolled and followed-up for 23 months. Demographic, clinical manifestations, laboratory parameters and disease activity were recorded at each visit. In addition, presence of severe lupus flare at each visit was evaluated by using the Safety of Estrogens in Lupus Erythematosus National Assessment (SELENA)-SLE disease activity index (SLEDAI) flare composite index. Predictors of severe lupus flare were obtained by backward logistic regression analyses. Predictors of SLEDAI were obtained by backward linear regression analyses. RESULTS: During the follow-up period, 47 patients had at least one episode of severe lupus flare. Mean (SD) age of patients with severe flare versus no flare was 31.7 (7.89) and 38.3 (8.24) years, respectively (P = 0.001). Ten (62.5%) out of 16 males and 37 (35.5%) out of 104 females had severe flare (P = 0.04). History of lupus nephritis (LN) was recorded in 76.5% and 44% of patients with severe flare and no severe flare, respectively (P = 0.001). Thirty-five (29.2%) patients with high anti-double-stranded DNA (anti-ds-DNA antibody) and 12 (10%) with negative anti-ds-DNA antibody had severe lupus flare (P = 0.02). By multivariable logistic regression analysis, younger age (OR = 0.87, 95% CI 0.80-0.94, P = 0.0001), history of LN (OR = 4.66, 95% CI 1.55-14.002, P = 0.006) and high SLEDAI at the first visit (OR = 1.19, 95% CI 1.026-1.38) were the main predictors of flare. When severe lupus flare after the first visit was used as the outcome variable, similar findings were observed but, SLEDAI, although left among the final predictors in the model, was not significant. SLEDAIs in future visits were mainly predicted by Anti-ds-DNA antibody, 24-h urine protein and arthritis at the first visit. CONCLUSION: SLE patients with younger age, history of previous LN or high baseline SLEDAI, may need closer monitoring and follow up.

Hospital Length of Stay Independently Predicts Mortality in Patients Emergently Admitted for Esophageal Hemorrhage: Sex, Frailty, and Age as Additional Mortality Factors.

INTRODUCTION: Upper gastrointestinal bleeding results in greater than $7.6 billion of in-hospital economic burden in the United States yearly. With a worldwide incidence between 40-100/100,000 individuals and a mortality rate of approximately 2-10%, upper gastrointestinal bleeding represents a major source of mortality and morbidity. The goal of this study was to describe mortality risk factors in patients emergently admitted with esophageal hemorrhage, the second most common etiology of upper gastrointestinal bleeding. MATERIALS AND METHODS: Patients emergently admitted with esophageal hemorrhage between 2005-2014 were evaluated using the National Inpatient Sample database. Patient characteristics, clinical outcomes, and therapeutic trends were obtained. Relationships between morality and all other variables were determined via univariable and multivariable logistic regression analyses. RESULTS: In total, 4,607 patients were included, of which 2,045 (44.4%) were adults, 2,562 (55.6%) were elderly, 2,761 (59.9%) were males, and 1,846 (40.1%) were females. The average age of adult and elderly patients were 50.1 and 78.7 years, respectively. The multivariable logistic regression analysis revealed, for every additional day of hospitalization, the odds of mortality for nonoperatively treated adult and elderly patients increased by 7.5% (p=<0.001) and 6.6% (p=<0.001), respectively. Every additional year of age was associated with a 5.4% (p=0.012) increase in mortality odds for nonoperatively managed adult patients. Frailty increased the odds of mortality by 31.1% (p=0.009) in nonoperatively treated elderly patients. Undergoing invasive diagnostic procedures in conservatively treated adults reduced mortality significantly (odds ratio=0.400, p=0.021). Frailty, age, and hospital length of stay demonstrated no significant association with mortality in surgically managed adult and elderly patients. CONCLUSION: Nonoperatively managed patients emergently admitted for esophageal hemorrhage with longer hospital length of stay and higher modified frailty index exhibited higher odds of mortality. Invasive diagnostic procedures were negatively correlated with mortality in nonoperatively treated adult patients. Age is only associated with higher mortality rates in adults, while elderly patients revealed no association between age and mortality.

When Should We Operate on the Elderly with Acute Pancreatitis Requiring Emergency Surgery? A 10-Year Study of a National Inpatient Sample Using a Generalized Additive Model of 110,289 Patients.

INTRODUCTION: Elderly patients with acute pancreatitis have longer hospital length of stay (HLOS) and higher mortality compared to adult patients. We aimed to assess the optimal timing to operate for acute pancreatitis and to evaluate the relationship between HLOS and mortality. MATERIALS AND METHODS: This was a retrospective cohort study of 110,289 elderly patients diagnosed with acute pancreatitis requiring emergency admission using the National Inpatient Sample (NIS) between 2005-2014. The ICD9 code 577.0 was used to select patients with a diagnosis of acute pancreatitis. Stratified analysis was performed to compare male versus female, survived versus deceased, and no operation versus operation. Multivariable logistic regression models were created to assess independent risk factors of mortality. Generalized additive models (GAM) were created to assess the linearity of the relationship between HLOS and in-hospital mortality. RESULTS: The mean age of the cohort was 76 years old, and 56.3% were female. The mean frailty index was 1.65. Twenty-five percent of patients underwent an operation, with a mean time to operation being 3.44 days for females and 3.77 days for males. Overall mortality was 2.3%. For patients who had an operation, each additional day of delay until operation increased the odds of mortality by 8.8%. Each additional point for the modified frailty index increased the odds of mortality by 30.2%. HLOS had a non-linear relationship with mortality, with an estimated degree of freedom of 22.05 and a nadir at three to seven days. Each additional day in hospital after day seven increased the odds of mortality by 6.7%. CONCLUSIONS: In those who required an operation, every day of delay in operation increased the odds of mortality by almost 9%. The lowest mortality for elderly patients with acute pancreatitis occurred with a hospital length of stay of three to seven days. After seven days, each additional day increased the odds of mortality by 6.7%.