A pilot randomized controlled trial comparing THUNDERBEAT to the Maryland LigaSure energy device in laparoscopic left colon surgery.

BACKGROUND: The THUNDERBEAT is a multi-functional energy device which delivers both ultrasonic and bipolar energy, but there are no randomized trials which can provide more rigorous evaluation of the clinical performance of THUNDERBEAT compared to other energy-based devices in colorectal surgery. The aim of this study was to compare the clinical performance of THUNDERBEAT energy device to Maryland LigaSure in patients undergoing left laparoscopic colectomy. METHODS: Prospective randomized trial with two groups: Group 1 THUNDERBEAT and Group 2 LigaSure in a single university hospital. 60 Subjects, male and female, of age 18 years and above undergoing left colectomy for cancer or diverticulitis were included. The primary outcome was dissection time to specimen removal (DTSR) measured in minutes from the start of colon mobilization to specimen removal from the abdominal cavity. Versatility (composite of five variables) was measured by a score system from 1 to 5 (1 being worst and 5 the best), and adjusted/weighted by coefficient of importance with distribution of the importance as follow: hemostasis 0.275, sealing 0.275, cutting 0.2, dissection 0.15, and tissue manipulation 0.1. Other variables were: dryness of surgical field, intraoperative and postoperative complications, and mortality. Follow-up time was 30 days. RESULTS: 60 Patients completed surgery, 31 in Group 1 and 29 in Group 2. There was no difference in the DTSR between the groups, 91 min vs. 77 min (p = 0.214). THUNDERBEAT showed significantly higher score in dissecting and tissue manipulation in segment 3 (omental dissection), and in overall versatility score (p = 0.007) as well as versatility score in Segment 2 (retroperitoneal dissection p = 0.040) and Segment 3 (p = 0.040). No other differences were noted between the groups. CONCLUSIONS: Both energy devices can be employed effectively and safely in dividing soft tissue and sealing mesenteric blood vessels during laparoscopic left colon surgery, with THUNDERBEAT demonstrating some advantages over LigaSure during omental dissection and tissue manipulation. CLINICALTRIAL: gov # NCT02628093.

Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients.

OBJECTIVE: Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking. DESIGN: We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%). RESULTS: Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005). CONCLUSION: In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

Delayed laparotomy after selective non-operative management of penetrating abdominal injuries.

BACKGROUND: Main concern during the practice of selective non-operative management (SNOM) for abdominal stab wounds (SW) and gunshot wounds (GSW) is the potential for harm in patients who fail SNOM and receive a delayed laparotomy (DL). The aim of this study is to determine whether such patients suffer adverse sequelae because of delays in diagnosis and treatment when managed under a structured SNOM protocol. METHODS: 190 patients underwent laparotomy after an abdominal GSW or SW (5/04-10/12). Patients taken to operation within 120 min of admission were included in the early laparotomy (EL) group (n =153, 80.5 %) and the remaining in the DL group (n =37, 19.5 %). Outcomes included mortality, hospital stay, and postoperative complications. RESULTS: The median time from hospital arrival to operation was 43 min (range: 17-119) for EL patients and 249 min (range: 122-1,545) for DL patients. The average number and type of injuries were similar among the groups. Mortality and negative laparotomy were observed only in the EL group. There was no significant difference in the hospital stay between the groups. The overall complications were higher in the EL group (44.4 vs. 24.3 %, p =0.026). DL was independently associated with a lower likelihood for complications (OR 0.39, 95 % CI 0.16-0.98, p =0.045). Individual review of all DL patients did not reveal an incident in which complications could be directly attributed to the delay. CONCLUSIONS: In a structured protocol, patients who fail SNOM and require an operation are recognized and treated promptly. The delay in operation does not cause unnecessary morbidity or mortality.

Robotic Off-Pump Totally Endoscopic Coronary Artery Bypass in Patients With Low Ejection Fraction.

Objective: Robotic totally endoscopic coronary bypass (R-TECAB) has been shown to be a safe and effective technique with excellent outcomes. The aim of this study is to assess the feasibility of R-TECAB in patients with low left ventricular ejection fraction (LVEF) and to report our midterm outcomes with up to 7-year follow-up. Methods: All patients undergoing R-TECAB at our institution between July 2013 and July 2020 were retrospectively reviewed. A total of 100 patients were identified with low LVEF defined as ≤40%. The preoperative characteristics, perioperative and postoperative outcomes, as well as the midterm results were reviewed. Results: The mean LVEF was 31%, and 62% of all patients had preexisting congestive heart failure. Of the cohort, 59% had 3-vessel disease and 6% underwent previous cardiac surgery. Multivessel TECAB was performed in 54%. Hybrid coronary revascularization occurred in 36 individuals. Two patients required cardiopulmonary bypass, and 35% were extubated in the operating room. No sternotomy conversions were required. One patient underwent reoperation for bleeding. No perioperative stroke, myocardial infarction, or mortality occurred. The left internal mammary artery graft patency was 97% at a mean of 1.6 months in the staged hybrid percutaneous coronary intervention group. At midterm follow-up the cardiac-related mortality was 5%. Heart transplant or left ventricular assist device was required in 4 patients, and 1 patient experienced a myocardial infarction. Freedom from major adverse cardiac events was 89%. Conclusions: Off-pump TECAB can be successfully performed in patients with low LVEF in the setting of an experienced and dedicated robotic cardiac surgery team. Our data demonstrate the feasibility of the technique with excellent perioperative and midterm outcomes.

STS INTERMACS Database: The Key to Conduct Single-Arm Trials in Advanced Heart Failure Patients.

BACKGROUND: Safe introduction of novel mechanical circulatory support (MCS) devices into clinical practice is a challenging process. Single-arm trials using a control arm from existing database is an effective alternative that could be applied for regulatory approval. This study analyzes the capability of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database to establish objective performance criteria and select patient population that could be used for future single-arm MCS trials. METHODS: Patients with INTERMACS profiles IM1-2 and IM3-5, who underwent implantation of isolated left ventricular assist devices between 2014 and 2017, were included. Both cohorts were further stratified into shock and nonshock groups using surrogate markers of shock (extracorporeal membrane oxygenation, temporary ventricular assist device, vasopressor infusions). Survival, transplantation rates, adverse events, 6-minute walk test, and quality-of-life measures were obtained for all 4 groups at 6 and 12 months. RESULTS: Total of 7907 patients were divided into IM1-2 (n = 3909), IM3-5 (n = 3998), shock (n = 3469), and nonshock (n = 3040) groups. Recategorization occurred in 11% of patients from the IM3-5 group into the shock group. Overall, patients in the shock group had similar outcomes to the IM1-2 group (1-year survival: 86% vs 85%; P = .74). Patients in the nonshock group also had similar outcomes to the IM3-5 (1-year survival: 90% vs 90%; P = .43). CONCLUSIONS: The INTERMACS database can successfully establish objective performance criteria and concurrent control group for single-arm trials that could be used to support regulatory approval of new, less invasive MCS. INTERMACS data allow reliable comparisons of outcomes and adverse events.

The Role of Minimally Invasive and Endoscopic Technologies in Morbid Obesity Treatment: Review and Critical Appraisal of the Current Clinical Practice.

Bariatric surgery is the most effective treatment for morbid obesity. Availability of different procedures with low complication rates, performed through a minimally invasive approach, have caused profound positive effect on patient's quality of life and has led to their worldwide, rapid expansion of the field. The laparoscopic revolution has introduced the concept of lowering more and more the treatments' invasiveness, leading to a change in the researchers' mentality. They are now constantly looking for reducing patients' discomfort through new methodologies and devices: aim of this review is to provide an in-depth analysis of the most promising, innovative procedures offering an alternative approach to "classic" laparoscopic procedures. They are described from their original development phases to the most recent experimental and clinical evidence. This review will discuss as well their future perspectives, and includes endoluminal techniques and/or procedures based on alternative concepts, all representing an appealing alternative to surgical approach. We conducted a MEDLINE for articles, clinical trials, and a patent search relating to the minimally invasive management of obesity, excluding intragastric balloons, SILS, and NOTES, and we selected 77 articles. Results are reported for each procedure/device, and discussed both in these paragraphs and in the final, general discussion. The concept of minimally invasive procedures continues to change and evolve over time with novel technologies emerging every year.

Metastatic Epicardial Leiomyoma with uncertain malignant potential.

A 49-year-old female with history of uterine leiomyoma and intermittent shortness of breath presented to the emergency department with new onset of tachycardia and chest pain. Subsequent cardiac work up revealed hypoechoic mass compressing the right ventricle. Computer tomography guided biopsy for tissue characterization revealed a benign spindle cell tumor. Surgical resection of a large epicardial tumor was undertaken. The histologic examination of the tumor was consistent with Estrogen and Progesterone positive leiomyoma of uncertain malignant potential. To the authors' knowledge, this is the first case report of a metastasizing epicardial leiomyoma that exhibits an unknown malignant potential. This case brings together common gynecologic disorder with complex thoracic surgery diagnosis and management. Differential diagnosis of cardiac tumors in patients with history of uterine leiomyoma should include metastasizing leiomyoma. The mainstay of therapy is surgical resection with immediate symptom relieve.

Clinical Outcomes of Inadequate Calorie Delivery and Protein Deficit in Surgical Intensive Care Patients.

BACKGROUND: Adequate nutritional therapy in critically ill patients is integral to optimal outcome. OBJECTIVE: To evaluate the association between cumulative macronutrient deficit and overall morbidity in surgical intensive care unit patients. METHODS: Adult patients receiving enteral nutrition for more than 72 hours were included if they had no previous admission to the surgical intensive care unit, had received no enteral feedings before admission, had no intestinal obstruction or ileus, and survived 72 hours or more after admission. Data on demographics, outcomes, and nutritional intake during the unit stay were collected for up to 14 days until oral intake began, discharge, or death. Outcome variables included lengths of stay in the hospital and intensive care unit, days with no mechanical ventilation, complications, and mortality. RESULTS: Of 94 participants, 71% were men, mean age was 63 years, and mean score on the Acute Physiology and Chronic Health Evaluation II was 14. Patients with high cumulative calorie deficit (≥ 6000 cal) and high protein deficit (≥ 300 g) had significantly fewer days with no mechanical ventilation (P < .001), longer unit stays (P < .001), longer hospital stays (P = .007), more total complications (P = .007), and more infectious complications (P = .009) than other participants. These associations remained significant in multivariable models after adjustments for age, sex, reason for admission, and propensity score of deficit. In-hospital and 30-day mortality did not differ. CONCLUSIONS: Cumulative macronutrient deficits have important clinical outcomes in surgical intensive care patients.

Abscess due to perforated appendicitis: factors associated with successful percutaneous drainage.

BACKGROUND: Percutaneous drainage is the standard treatment for perforated appendicitis with abscess. We studied factors associated with complete resolution (CR) with percutaneous drainage alone. METHODS: Ninety-eight patients underwent percutaneous drainage for acute appendicitis complicated by abscess (October 1990 to September 2010). CR was defined as clinical recovery, resolution of the abscess on imaging, and drain removal without recurrence. Patients achieving CR were compared with patients not achieving CR. RESULTS: The rate of CR was 78.6% (n = 77). Abscess grade was the only radiological factor associated with CR (P = .007). The CR rate was higher with transgluteal drainage (90.9% vs 79.2%) than with other anatomic approaches (P = .018) and higher with computed tomography-guided drainage than with ultrasound-guided drainage (82.7% vs 64.3%, P = .046). CONCLUSION: CR was more likely to be achieved in patients with lower abscess grade, computed tomography-guided drainage, and a transgluteal approach.

Causes and consequences of interrupted enteral nutrition: a prospective observational study in critically ill surgical patients.

BACKGROUND: Malnutrition and underfeeding are major challenges in caring for critically ill patients. Our goal was to characterize interruptions in enteral nutrition (EN) delivery and their impact on caloric debt in the surgical intensive care unit (ICU). MATERIALS AND METHODS: We performed a prospective, observational study of adults admitted to surgical ICUs at a Boston teaching hospital (March-December 2012). We categorized EN interruptions as "unavoidable" vs "avoidable" and compared caloric deficit between patients with ≥1 EN interruption (group 1) vs those without interruptions (group 2). Multivariable logistic regression was used to investigate the association of EN interruption with the risk of underfeeding. Poisson regression was used to investigate the association of EN interruption with length of stay (LOS) and mortality. RESULTS: Ninety-four patients comprised the analytic cohort. Twenty-six percent of interruptions were deemed "avoidable." Group 1 (n = 64) had a significantly higher mean daily and cumulative caloric deficit vs group 2 (n = 30). Patients in group 1 were at a 3-fold increased risk of being underfed (adjusted odds ratio, 2.89; 95% confidence interval [CI], 1.03-8.11), had a 30% higher risk of prolonged ICU LOS (adjusted incident risk ratio [IRR], 1.27; 95% CI, 1.14-1.42), and had a 50% higher risk of prolonged hospital LOS (adjusted IRR, 1.53; 95% CI, 1.41-1.67) vs group 2. CONCLUSIONS: In our cohort of critically ill surgical patients, EN interruption was frequent, largely "unavoidable," and associated with undesirable outcomes. Future efforts to optimize nutrition in the surgical ICU may benefit from considering strategies that maximize nutrient delivery before and after clinically appropriate EN interruptions.

The influence of anesthesia on heart rate complexity during elective and urgent surgery in 128 patients.

BACKGROUND: As an emerging "new vital sign," heart rate complexity (by sample entropy [SampEn]) has been shown to be a useful trauma triage tool by predicting occult physiologic compromise and need for life-saving interventions. Sample entropy may be confounded by anesthesia possibly limiting its value intraoperatively. We investigated the effects of anesthesia on SampEn during elective and urgent surgical procedures. We hypothesized that SampEn is reduced by general anesthesia. METHODS: With institutional review board-approved waiver of informed consent, 128 patients undergoing elective or urgent general surgery were prospectively enrolled. Real-time heart rate complexity was calculated using SampEn through electrocardiogram recordings of 200 consecutive beats in a continuous sliding-window fashion. We recorded SampEn starting 10 minutes before induction until 10 minutes after emergence from anesthesia. The time before induction of anesthesia was categorized as period 1, the time after induction and before emergence as period 2 (intraoperative), and the time after emergence as period 3. We analyzed SampEn changes as patients moved between the different periods and made 3 comparisons: from period 1 with period 2 (comparison A), from period 2 with period 3 (comparison B). We also compared period 1 with period 3 SampEn (comparison C). RESULTS: The mean SampEn value for all patients before induction of anesthesia was 1.55 ± 0.58. In each 1 of the 3, comparisons there was a decline in SampEn. Comparison A had a mean decrease of 0.53 ± 0.55 (P < .0001), comparison B had a decrease of 0.13 ± 0.52 (P < .0051), and the mean SampEn difference for comparison C was 0.66 ± 0.53 (P < .0001). Certain pharmacologics had significant effect on SampEn as did need for urgent surgery and American Society of Anesthesiologists class. CONCLUSION: Sample entropy decreases after induction of anesthesia and continues to decrease even immediately after emergence in patients without any immediately life-threatening conditions. This finding may complicate interpretation low complexity as a predictor of life-saving interventions in patients in the perioperative period.

Self-expanding foam for prehospital treatment of severe intra-abdominal hemorrhage: dose finding study.

BACKGROUND: Noncompressible abdominal bleeding is a significant cause of preventable death on the battlefield and in the civilian trauma environment, with no effective therapies available at point of injury. We previously described the development of a percutaneously administered, self-expanding, poly(urea)urethane foam that improved survival in a lethal Grade V hepatic and portal vein injury model in swine. In this study, we hypothesized that survival with foam treatment is dose dependent. METHODS: A high-grade hepatoportal injury was created in a closed abdominal cavity, resulting in massive noncompressible hemorrhage. After injury, the animals were divided into five groups. The control group (n = 12) was treated only with fluid resuscitation, and four polymer groups received different dose volumes (Group 1, n = 6, 64 mL; Group 2, n = 6, 85 mL; Group 3, n = 18, 100 mL; and Group 4, n = 10, 120 mL) in addition to fluids. Ten minutes after injury, the foam was percutaneously administered, and animals were monitored for 3 hours. RESULTS: Survival with hepatoportal injury was highest in Group 4 (90%) and decreased in a dose-dependent fashion (Group 3, 72%; Group 2, 33%; Group 1, 17%). All polymer groups survived significantly longer than the controls (8.3%). Hemorrhage rate was reduced in all groups but lowest in Group 4 versus the control group (0.34 [0.052] vs. 3.0 [1.3] mL/kg/min, p < 0.001). Increasing foam dose volume was associated with increased peak intra-abdominal pressure (88.2 [38.9] in Group 4 vs. 9.5 [3.2] in the controls, p < 0.0001) and increased incidence of focal bowel injuries. CONCLUSION: The self-expanding foam significantly improves survival in a dose-dependent fashion in an otherwise lethal injury. Higher doses are associated with better survival but resulted in the need for bowel resection.

Self-expanding foam for prehospital treatment of intra-abdominal hemorrhage: 28-day survival and safety.

BACKGROUND: Intracavitary noncompressible hemorrhage remains a significant cause of preventable death on the battlefield and in the homeland. We previously demonstrated the hemostatic efficacy of an in situ self-expanding poly(urea)urethane foam in a severe, closed-cavity, hepatoportal exsanguination model in swine. We hypothesized that treatment with, and subsequent explantation of, foam would not adversely impact 28-day survival in swine. METHODS: Following a closed-cavity splenic transection, animals received either fluid resuscitation alone (control group, n = 6) or resuscitation plus foam treatment at doses of 100 mL (n = 6), 120 mL (n = 6), and 150 mL (n = 2). Foam was allowed to polymerize in situ and was explanted after 3 hours. The animals were recovered and monitored for 28 days. RESULTS: All 18 animals in the 100-mL, 120-mL, and control groups survived to the 28-day endpoint without complications. The 150-mL group was terminated after the acute phase (n = 2). En bloc explantation of the foam took less than 2 minutes and was associated with millimeter-sized remnant particles. All foam animals required some level of enteric repair (imbrication or resection). Excluding the aborted 150-mL group, all animals survived, with no differences in renal or hepatic function, serum chemistries, or semiquantitative abdominal adhesion scores. Histologic analysis demonstrated that remnant particles were associated with a fibrotic capsule and mild inflammation, similar to that of standard suture reaction. In addition, safety testing (including genotoxicity, pyrogenicity, and cytotoxicity) was performed consistent with the ISO-10993 standard, and the materials passed all tests. CONCLUSION: For a distinct dose range, 28-day recovery after foam treatment and explantation for noncompressible, intra-abdominal hemorrhage is not associated with significant physiologic or biochemical evidence of end-organ dysfunction. A foam volume exceeding the maximum tolerable dose was identified. Bowel repair is required to ensure survival.

Complicated intra-abdominal infections worldwide: the definitive data of the CIAOW Study.

The CIAOW study (Complicated intra-abdominal infections worldwide observational study) is a multicenter observational study underwent in 68 medical institutions worldwide during a six-month study period (October 2012-March 2013). The study included patients older than 18 years undergoing surgery or interventional drainage to address complicated intra-abdominal infections (IAIs). 1898 patients with a mean age of 51.6 years (range 18-99) were enrolled in the study. 777 patients (41%) were women and 1,121 (59%) were men. Among these patients, 1,645 (86.7%) were affected by community-acquired IAIs while the remaining 253 (13.3%) suffered from healthcare-associated infections. Intraperitoneal specimens were collected from 1,190 (62.7%) of the enrolled patients. 827 patients (43.6%) were affected by generalized peritonitis while 1071 (56.4%) suffered from localized peritonitis or abscesses. The overall mortality rate was 10.5% (199/1898). According to stepwise multivariate analysis (PR = 0.005 and PE = 0.001), several criteria were found to be independent variables predictive of mortality, including patient age (OR = 1.1; 95%CI = 1.0-1.1; p < 0.0001), the presence of small bowel perforation (OR = 2.8; 95%CI = 1.5-5.3; p < 0.0001), a delayed initial intervention (a delay exceeding 24 hours) (OR = 1.8; 95%CI = 1.5-3.7; p < 0.0001), ICU admission (OR = 5.9; 95%CI = 3.6-9.5; p < 0.0001) and patient immunosuppression (OR = 3.8; 95%CI = 2.1-6.7; p < 0.0001).

Real-time sample entropy predicts life-saving interventions after the Boston Marathon bombing.

PURPOSE: Identifying patients in need of a life-saving intervention (LSI) during a mass casualty event is a priority. We hypothesized that real-time, instantaneous sample entropy (SampEn) could predict the need for LSI in the Boston Marathon bombing victims. MATERIALS AND METHODS: Severely injured Boston Marathon bombing victims (n = 10) had sample entropy (SampEn) recorded upon presentation using a continuous 200-beat rolling average in real time. Treating clinicians were blinded to real-time results. The correlation between SampEn, injury severity, number, and type of LSI was examined. RESULTS: Victims were males (60%) with a mean age of 39.1 years. Injuries involved lower extremities (50.0%), head and neck (24.2%), or upper extremities (9.7%). Sample entropy negatively correlated with Injury Severity Score (r = -0.70; P = .023), number of injuries (r = -0.70; P = .026), and the number and need for LSI (r = -0.82; P = .004). Sample entropy was reduced under a variety of conditions. (Table see text). CONCLUSIONS: Sample entropy strongly correlates with injury severity and predicts LSI after blast injuries sustained in the Boston Marathon bombings. Sample entropy may be a useful triage tool after blast injury.

Complicated intra-abdominal infections in a worldwide context: an observational prospective study (CIAOW Study).

Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high. The World Society of Emergency Surgery (WSES) has designed the CIAOW study in order to describe the clinical, microbiological, and management-related profiles of both community- and healthcare-acquired complicated intra-abdominal infections in a worldwide context. The CIAOW study (Complicated Intra-Abdominal infection Observational Worldwide Study) is a multicenter observational study currently underway in 57 medical institutions worldwide. The study includes patients undergoing surgery or interventional drainage to address complicated intra-abdominal infections. This preliminary report includes all data from almost the first two months of the six-month study period. Patients who met inclusion criteria with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study. 702 patients with a mean age of 49.2 years (range 18-98) were enrolled in the study. 272 patients (38.7%) were women and 430 (62.3%) were men. Among these patients, 615 (87.6%) were affected by community-acquired IAIs while the remaining 87 (12.4%) suffered from healthcare-associated infections. Generalized peritonitis was observed in 304 patients (43.3%), whereas localized peritonitis or abscesses was registered in 398 (57.7%) patients.The overall mortality rate was 10.1% (71/702). The final results of the CIAOW Study will be published following the conclusion of the study period in March 2013.