Adherence to Extended Venous Thromboembolism Prophylaxis and Outcomes After Complex Gastrointestinal Oncologic Surgery.

BACKGROUND: Clinical guidelines recommend extended venous thromboembolism (VTE) prophylaxis for cancer patients after major gastrointestinal (GI) operations. However, adherence to the guidelines has been low, and the clinical outcomes not well defined. METHODS: This study retrospectively analyzed a random 10 % sample of the 2009-2022 IQVIA LifeLink PharMetrics Plus database, an administrative claims database representative of the commercially insured population of the United States. The study selected cancer patients undergoing major pancreas, liver, gastric, or esophageal surgery. The primary outcomes were 90-day post-discharge VTE and bleeding. RESULTS: The study identified 2296 unique eligible operations. During the index hospitalization, 52 patients (2.2 %) experienced VTE, 74 patients (3.2 %) had postoperative bleeding, and 140 patients (6.1 %) had a hospital stay of at least 28 days. The remaining 2069 operations comprised 833 pancreatectomies, 664 hepatectomies, 295 gastrectomies, and 277 esophagectomies. The median age of the patients was 49 years, and 44 % were female. Extended VTE prophylaxis prescriptions were filled for 176 patients (10.4 % for pancreas, 8.1 % for liver, 5.8 % for gastric cancer, and 6.5 % for esophageal cancer), and the most used agent was enoxaparin (96 % of the patients). After discharge, VTE occurred for 5.2 % and bleeding for 5.2 % of the patients. The findings showed no association of extended VTE prophylaxis with post-discharge VTE (odds ratio [OR], 1.54; 95 % confidence interval [CI], 0.81-2.96) or bleeding (OR, 0.72, 95 % CI, 0.32-1.61). CONCLUSIONS: The majority of the cancer patients undergoing complex GI surgery did not receive extended VTE prophylaxis according to the current guidelines, and their VTE rate was not higher than for the patients who received it.

A closed surgical intensive care unit organization improves cardiac surgical patient outcomes.

Background: Intensive care unit (ICU) organization is a critical factor in optimizing patient outcomes. ICU organization can be divided into "OPEN" (O) and "CLOSED" (C) models, where the specialist or intensivist, respectively, assumes the role of primary physician. Recent studies support improved outcomes in closed ICUs, however, most of the available data is centered on ICUs generally or on subspecialty surgical patients in the setting of a subspecialized surgical intensive care unit (SICU). We examined the impact of closing a general SICU on patient outcomes following cardiac and ascending aortic surgery. Methods: A retrospective cohort of patients following cardiac or ascending aortic surgery by median sternotomy was examined at a single academic medical center one year prior and one year after implementation of a closed SICU model. Patients were divided into "OPEN" (O; n=53) and "CLOSED" (C; n=73) cohorts. Results: Cohorts were comparable in terms of age, race, and number of comorbid conditions. A significant difference in male gender (O: 60.4% vs. C: 76.7%, P=0.049), multiple procedure performed (O: 13.21% vs. C: 35.62%, P=0.019), and hospital readmission rates was detected (O: 39.6% vs. C: 9.6%, P=0.0003). Using a linear regression model, a closed model SICU organization decreased SICU length of stay (LOS). Using a multivariate logistic regression, being treated in a closed ICU decreased a patient's likelihood of having an ICU LOS greater than 48 hours. Conclusions: Our study identified a decreased ICU LOS and hospital readmission in cardiac and ascending aortic patients in a closed general SICU despite increased procedure complexity. Further study is needed to clarify the effects on surgical complications and hospital charges.

Solvent-equilibrated ion pairs from carbene fragmentation reactions.

[R(+) OC Cl(-)] ion pairs were generated in methanol/dichloroethane solutions, with R(+) as the 1-bicyclo[2.2.2]octyl, 1-adamantyl, or 3-homoadamantyl cation. Ion pairs were produced either by the direct fragmentation of alkoxychlorocarbenes (ROCCl), with R = 1-bicyclo[2.2.2]octyl, 1-adamantyl, or 3-homoadamantyl, or by the ring expansion-fragmentation of R'CH(2)OCCl, with R' = 1-norbornyl, 3-noradamantyl, or 1-adamantyl. Correlations of the [ROMe]/[RCl] product ratios as a function of the mole fraction of MeOH in dichloroethane showed that the homoadamantyl chloride ion pairs, produced by either the direct or ring expansion-fragmentations, were identical, solvent- and anion-equilibrated, and precursor independent. Laser flash photolysis experiments gave 20-30 ps as the time required for solvent equilibration and precursor independence. Methanol/chloride selectivities of the (less-stable) 1-adamantyl chloride and 1-bicyclo[2.2.2]octyl chloride ion pairs were not independent of their ROCCl or R'CH(2)OCCl precursors. Computational studies provided transition states for the fragmentations and for the structures of the ion pairs.

Fragmentation of menthyl- and neomenthyloxychlorocarbenes: elimination and substitution reactions of alicyclic oxychlorocarbenes.

Fragmentations of menthyloxychlorocarbene (5) and neomenthyloxychlorocarbene (6) follow distinct pathways to (largely) stereochemically retained substitution products from 5 and elimination products from 6, closely resembling the product distributions from deaminations of the corresponding menthyl- and neomenthylamines.