Surgical Outcomes in Patients With Preoperative Anemia Undergoing Colectomy for Colon Cancer.

INTRODUCTION: Preoperative anemia is relatively common in colon cancer patients; however, its impact on short-term surgical outcomes is not well established. The aim of our study was to evaluate short-term surgical outcomes in colon cancer patients with preoperative anemia undergoing colectomy. METHODS: We performed a 4-year analysis of the ACS-NSQIP and included all adult patients who underwent colectomy for colon cancer. Patients were stratified into two groups based on preoperative anemia (Preop Anemia, No Preop Anemia). Our outcome measures were 30-day complications, 30-day unplanned readmissions, and 30-day mortality. RESULTS: A total of 35,243 colon cancer patients who underwent colectomy were included in the analysis, of whom 50.4% had preoperative anemia. The mean age was 65 ± 13 years and the mean hemoglobin level was 12 ± 2 g/dL. Patients in the anemia group were more likely to be African American, have higher ASA class ≥3, and were more likely to receive at least 1 unit of packed red blood cells preoperatively (7.1% versus 0.3%, P < 0.01). Patients in the anemia group had higher rates of 30-day complications (34.5% versus 16.6%, P < 0.01), 30-day readmission related to the principal procedure (11.7% versus 8.7%, P < 0.01), and 30-day mortality (3.1% versus 1%, P < 0.01). On regression analysis, preoperative anemia was independently associated with higher odds of 30-day complications (P < 0.01), but not 30-day readmission, or 30-day mortality (P = 0.464 and P = 0.362 respectively). CONCLUSIONS: Preoperative anemia appears to be associated with postoperative complications. Preoperatively optimizing hemoglobin levels may lead to improved outcomes.

Two MicroRNAs, miR-34a and miR-125a, Are Implicated in Bicuspid Aortopathy by Modulating Metalloproteinase 2.

It has been recognized that wall shear stress plays an important role in the development of Bicuspid Aortopathy (BA), but the intrinsic mechanism is not well elucidated. This study aims to explore the underlying relationship between hemodynamical forces and pathological phenomenon. Total RNA was prepared from aortic wall tissues collected from 20 BA patients. RNA sequencing, bioinformatic analysis and quantitative reverse-transcription PCR validation identified nine miRNAs that were up-regulated in the aortic part exposed to high wall shear stress compared to the low wall shear stress control, and six miRNAs that were down-regulated. Among these candidates, miR-34a and miR-125a, both down-regulated in the high wall shear stress parts, were shown to be potential inhibitors of the metalloproteinase 2 gene. Luciferase reporter assays confirmed that both miRNAs could inhibit the expression of metalloproteinase 2 mRNA in CRL1999 by complementing with its 3' untranslated region. Conversely, immunofluorescence assays showed that inhibition of miR-34a or miR-125a could lead to increased metalloproteinase 2 protein level. On the other hand, both miR-34a and miR-125a were shown to alleviate stretch-induced stimulation of metalloproteinase 2 expression in CRL1999 cells. The results suggested that miR-34a and miR-125a might be implicated in wall shear stress induced aortic pathogenesis due to their apparent regulatory roles in metalloproteinase 2 expression and extracellular matrix remodeling, which are key events in the weakening of aortic walls among BA patients.

Effect of Stocking Density and Dietary Protein Level in Biofloc System on the Growth, Digestive and Antioxidant Enzyme Activities, Health, and Resistance to Acute Crowding Stress in Juvenile Common Carp (Cyprinus carpio).

This study is aimed at evaluating the effects of stocking densities and dietary protein levels in the biofloc system on the performance of common carp. Fish (12.09 ± 0.99 g) were transferred to 15 tanks: fish reared at 10 kg/m3 as medium density and fed 35% (MD35) or 25% (MD25) protein and fish reared at 20 kg/m3 as high density and fed 35% (HD35) or 25% (HD25) protein in the biofloc system and control fish reared at MD and fed 35% protein in clear water. After 60 days, fish were subjected to crowding stress (80 kg/m3) for 24 h. The growth of fish was highest in MD35. The feed conversion ratio was lower in MD35 compared to the control and HD groups. The amylase, lipase, protease, and superoxide dismutase and glutathione peroxidase activities in the biofloc groups were significantly higher than in the control. After crowding stress, cortisol and glucose levels in biofloc treatments were significantly decreased compared to the control. After 12 and 24 h stress, lysozyme activity in MD35 was significantly lower than in the HD treatments. Overall, the biofloc system with MD could improve growth and robustness against acute stress in fish. Also, biofloc could compensate 10% reduction of protein in common carp juvenile diet when reared in MD.

Early Thromboprophylaxis in Operative Spinal Trauma Does Not Increase Risk of Bleeding Complications.

BACKGROUND: Thromboprophylaxis in patients with spinal trauma is often delayed due to the risk of bleeding and expansion of the intraspinal hematoma (ISH). Our study aimed to assess the safety of early initiation of thromboprophylaxis in patients with operative spinal trauma (OST). METHODS: We performed a 2014-2017 retrospective analysis of our level I trauma registry and included all adult patients with isolated OST who received low-molecular-weight heparin (LMWH). Patients were stratified into early (≤48 h) and late (>48 h) initiation of LMWH groups. Outcomes were a decline in hemoglobin level, packed red blood cell transfusion, and progression of ISH. We performed multivariable logistic regression. RESULTS: We identified a total of 526 patients (early: 332, late: 194). Mean age was 46 ± 22y, and the median spine abbreviated injury scale was 3 [2-4]. After thromboprophylaxis, 1.5% (8) of the patients had progression of ISH and 1% (5) underwent surgical decompression of the spinal canal. There was no difference between the two groups regarding the rate of postprophylaxis ISH progression (1.5% versus 1.6%, P = 0.11) or surgical decompression (0.9% versus 1.1%, P = 0.19). Patients who received LMWH within 48 hrs had a lower incidence of clinically significant deep vein thrombosis (2.4% versus 6.8%, P = 0.02), but no difference in pulmonary embolism (0.6% versus 1.6%, P = 0.33) or mortality (1.2% versus 1.5%, P = 0.41). On regression analysis, there was no difference regarding decline in hemoglobin levels (ß = 0.079, [-0.253 to 1.025]; P = 0.23) or number of packed red blood cell units transfused (ß = -0.011, [-0.298 to 0.471]; P = 0.35). CONCLUSIONS: Thromboprophylaxis with LMWH within the first 48 h in patients with OST is safe and efficacious. Prospective studies are needed to further validate their risk-benefit ratio. LEVEL OF EVIDENCE: Level III therapeutic.

Gallbladder Cancer Surgery in the United States: Lymphadenectomy Trends and Impact on Survival.

BACKGROUND: Gallbladder cancer has a poor prognosis, and surgery is the only curative treatment. However, lymphadenectomy has been underperformed. We evaluate the trend of lymphadenectomy in the United States and its impact on survival. METHODS: This is a cohort study of patients who underwent gallbladder cancer surgery between 2004 and 2016. Trend analysis of the rate of lymphadenectomy and the number of lymph nodes (LNs) removed were examined. The impact of lymph node status and different LN staging systems on survival was examined. RESULTS: Of the 4577 patients identified, 69.9% were female, the mean age was 71.0 (±12.4), 87.2% had ≥ T2, and only 50.3% (n = 2302) received lymphadenectomy. Although the rate of lymphadenectomy and the number of LNs removed increased during the study period, both with P < 0.0001, the rate of patients who received examination of ≥6 LNs remained low, 13.6% in 2016. Adjusted regression analysis showed that patients without LN examination had worse overall survival than patients with LN positive disease, HR: 1.11 (95% CI: 1.01, 1.22). Concordance index analysis revealed that LN ratio (LNR) and Log odds of positive LN (LODDS) did not improve the ability of the American Joint Commission on Cancer (AJCC) staging in predicting 5-y survival rate. CONCLUSIONS: Lack of LN examination is associated with worse survival than LN positive disease. Although the rate of LN examination and number of LNs retrieved have increased from 2004 to 2016, they remained low. LNR and LODDS staging systems added no benefit to AJCC staging ability in predicting a 5-y survival rate.

Protective effects of black seed (Nigella sativa) diet supplementation in common carp (Cyprinus carpio) against immune depression, oxidative stress and metabolism dysfunction induced by glyphosate.

Sustainable aquaculture arises as key to increase food production in the coming years. However, the sector still faces many challenges such as the exposure of the cultured animals to pesticide-contaminated water. Pesticides used in agriculture can reach aquaculture systems either directly (integrated-agriculture aquaculture practices) or indirectly (soil leakage) and cause a broad range of ecotoxicological effects on cultured fish and shellfish. Here, we studied how glyphosate affects several haematological, biochemical, and immune parameters in common carp (Cyprinus carpio) fingerlings, the fourth most important cultured fish species worldwide. We also evaluated the potential of dietary supplementation with black seed (Nigella sativa, 0.25, 0.5 and 1%) to lower glyphosate-associated toxicity. Our results showed that 14-day sub-lethal exposure of common carp fingerlings to glyphosate increases oxidative stress, decreases antioxidant defences, affects several metabolic pathways, and induced immune depression. Furthermore, we showed that fish fed with N. sativa-enriched diets at 0.25, 0.5 and 1% for 60 days coped better with glyphosate exposure than control fish and displayed more stable levels of biochemical serum parameters (total protein, albumin, triglycerides, low-density lipoprotein LDL), cholesterol and high-density lipoprotein HDL), higher levels of immune defences (lysozyme and immunoglobulin) and higher antioxidant enzymes (superoxide dismutase SOD, glutathione peroxidase GPx) than control fish. Fish fed with all enriched diets also displayed lower lipid peroxidation (malondialdehyde MDA), lower metabolic enzymes (alanine aminotransferase ALT, aspartate aminotransferase AST and alkaline phosphatase ALP) levels in blood serum and lower cortisol levels than control fish. Altogether, our results show that dietary inclusion of black seed can be used as a sustainable bio-remediation strategy, mitigating many of the negative effects of glyphosate exposure in fish.

Does preoperative neoadjuvant chemotherapy impact short-term surgical outcomes in patients with locally advanced colon cancer?

BACKGROUND: Preoperative neoadjuvant chemotherapy (NAC) for colon cancer in advanced stages is associated with improved outcomes and tumor regression. The aim of our study was to identify outcomes in patients with colon cancer who received preoperative NAC. METHODS: A 4-year analysis of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) was performed. We included patients with locally advanced colon cancer (non-metastatic T3, T4 with or without nodal involvement) who underwent colon cancer resection. Patients were stratified into two groups (NAC and No-NAC). Our outcome measures were anastomotic leaks, hospital length of stay (LOS), 30-day complications, 30-day mortality, and 30-day readmissions. We performed a multi-variable logistic regression analysis. RESULTS: We analyzed 90,055 patients of which 7694 (NAC: 7.8 % (n = 599) and No-NAC: 92.2% (n = 7095)) met the inclusion criteria and included in the analysis. Mean age was 67 ± 13 years, 51% were males, and 72% were whites. Patients in the NAC group were more likely to be younger (60 ± 12 years vs. 68 ± 13 years, p < 0.01) and males (62% vs. 50%, p < 0.01) compared to No-NAC. On regression analysis, preoperative NAC was independently associated with higher odds of anastomotic leak (OR 1.35 [1.05-1.97], p = 0.03) and 30-day readmission (OR 1.54 [1.24-2.05], p < 0.01) in reference to No-NAC. However, no association was found between NAC and 30-day complications and 30-day mortality. CONCLUSIONS: Preoperative NAC might be associated with adverse outcomes of anastomotic leaks and 30-day readmissions, however does not appear to impact 30-day complications nor 30-day mortality.

The role of preoperative anemia in patients undergoing colectomy for diverticular disease: does surgical urgency matter?

PURPOSE: Surgery especially in the emergent setting carries higher rates of morbidity and mortality. The aim of our study was to evaluate the impact of preoperative anemia on outcomes for patients undergoing colectomy for acute diverticulitis in both elective and emergent settings. METHODS: We performed a 4-year analysis of the ACS-NSQIP and included adult patients with acute diverticulitis who underwent colectomy. Patients were stratified into two groups based on preoperative hemoglobin levels, preop anemia and no-preop Anemia. Outcome measures were 30-day complications, anastomotic leaks, readmissions, mortality, and intra-/postoperative blood transfusion. We also performed a sub-analysis for patients who underwent emergent colectomy. RESULTS: Six thousand nine hundred sixty-three patients were included in the analysis, of which 37% (n = 2571) had preoperative anemia. Patients in the anemia group were more likely to have higher ASA class and receive blood 72-h preoperatively (5.4% vs. 0.2%, p < 0.01). Patients in the anemia group had higher rates of complications (35.4% vs. 24.7%, p < 0.01), unplanned readmission (9.2% vs 7.2%, p < 0.01), mortality (4.5% vs. 1.8%, p < 0.01), and intra/postoperative transfusion requirement (21% vs. 3.8%, p < 0.01) with no difference in rate of anastomotic leaks. On sub-analysis, 39% of the cases were completed in an emergent setting, 85% of which were due to perforation. Patients with preoperative anemia that underwent colectomy in an emergent setting had higher odds of intra/postoperative blood transfusion (OR 51.6, CI 3.87-6.87, p < 0.01) with no statistical significance in 30-day complications (p = 0.51). CONCLUSION: Preoperative anemia in patients undergoing colectomy for acute diverticular disease is associated with higher odds complications, readmissions, and intra/postoperative blood transfusions.

Opioids After Surgery in the United States Versus the Rest of the World: The International Patterns of Opioid Prescribing (iPOP) Multicenter Study.

OBJECTIVE: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world. SUMMARY OF BACKGROUND DATA: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic. METHODS: Patients ≥16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients. RESULTS: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0-135) and 150 (0-1680) mg for US versus 0 (0-50) and 0 (0-600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 ±â€Š13.9 in US and 183.5 ±â€Š133.7 mg versus 0.8 ±â€Š3.9 and 4.6 ±â€Š27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001). CONCLUSIONS: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.

Metabolic Syndrome Exponentially Increases the Risk of Adverse Outcomes in Operative Diverticulitis.

BACKGROUND: Metabolic syndrome (MS) is defined as the cluster: hypertension, obesity, and diabetes. Operative diverticulitis in the setting of MS can be challenging to manage. The aim of our study was to evaluate the impact of MS on outcomes in operative acute diverticulitis patients. METHODS: We analyzed the (2012-2015) NSQIP database. We identified acute diverticulitis patients who underwent surgery. MS was defined as follows: body mass index (BMI) >30 kg/m2, hypertension, and diabetes. Our primary outcome measure was the occurrence of any adverse events (complications, 30-d readmission, and mortality). Secondary outcome measures were complications, hospital length of stay, 30-d readmission, and mortality. Regression and receiver operating characteristic curve analysis was performed. RESULTS: A total of 4572 patients were identified. Mean BMI was 29 ± 10 kg/m2. 14.6% (275) of obese patients had metabolic syndrome. Adverse events were higher in patients with MS (odds ratio [OR], 8.1; P < 0.001) versus the obese group and the obese and hypertensive group. Patients with MS had higher odds of reintubation (OR 1.9; P = 0.03), >48 h ventilator dependence (OR 3.5; P = 0.01), myocardial infarction (OR 2.3; P = 0.03), and superficial or deep surgical-site infections (OR 2.1; P = 0.01) compared with patients with no MS. MS patients had a longer length of stay (ß = 1.23; P = 0.02), higher 30-d readmissions (OR 1.7; P < 0.01), and mortality (OR 2.1; P < 0.01). The area under the receiver operating characteristic curve of metabolic syndrome for predicting adverse outcomes was 0.797, which was higher than the area under the receiver operating characteristic curve for BMI (0.58), hypertension (0.51), or diabetes (0.64) alone. CONCLUSIONS: Adverse events in patients with MS after surgery for diverticulitis are higher than obesity, hypertension, or diabetes alone. Patients with MS have longer recovery, and higher rates of complications, readmissions, and mortality. LEVEL OF EVIDENCE: Level III Prognostic.

Preinjury Statins Are Associated With Improved Survival in Patients With Traumatic Brain Injury.

BACKGROUND: Statins have been shown to improve outcomes in traumatic brain injury (TBI) in animal models. The aim of our study was to determine the effect of preinjury statins on outcomes in TBI patients. METHODS: We performed a 4-y (2014-2017) review of our TBI database and included all patients aged ≥18 y with severe isolated TBI. Patients were stratified into those who were on statins and those who were not and were matched (1:2 ratio) using propensity score matching. The primary outcome was in-hospital mortality. The secondary outcomes were skilled nursing facility disposition, Glasgow Outcome Scale-extended score, and hospital and intensive care unit length of stay (LOS). RESULTS: We identified 1359 patients, of which 270 were matched (statin: 90, no-statin: 180). Mean age was 55 ± 8y, median Glasgow Coma Scale was 10 (8-12), and median head-abbreviated injury scale was 3 (3-5). Matched groups were similar in age, mechanism of injury, Glasgow Coma Scale, Injury Severity Score, neurosurgical intervention, type and size of intracranial hemorrhage, and preinjury anticoagulant or antiplatelet use. The overall in-hospital mortality rate was 18%. Patients who received statins had lower rates of in-hospital mortality (11% versus 21%, P = 0.01), skilled nursing facility disposition (19% versus 28%; P = 0.04), and a higher median Glasgow Outcome Scale-extended (11 [9-13] versus 9 [8-10]; P = 0.04). No differences were found between the two groups in terms of hospital LOS (6 [4-9] versus 5 [3-8]; P = 0.34) and intensive care unit LOS (3 [3-6] versus 4 [3-5]; P = 0.09). CONCLUSIONS: Preinjury statin use in isolated traumatic brain injury patients is associated with improved outcomes. This finding warrants further investigations to evaluate the potential beneficial role of statins as a therapeutic drug in a TBI. LEVEL OF EVIDENCE: Level III Therapeutic.

Retrospective Analysis of Low-Molecular-Weight Heparin and Unfractionated Heparin in Pediatric Trauma Patients: A Comparative Analysis.

BACKGROUND: Chemoprophylaxis with either unfractionated heparin (UFH) or Low-Molecular-Weight Heparin (LMWH) are recommended to prevent Venous Thromboembolism (VTE) after trauma. Experimental work has shown beneficial effects of LMWH in animal models, but it is unknown if similar effects exist in humans. We hypothesized that treatment with LMWH is associated with a survival benefit when compared to UFH. METHODS: We performed a retrospective analysis of our level I trauma center database from January 2009 to June 2018. Pediatric patients (age < 18) were included if they received either LMWH or UFH during their stay. Outcome measures included mortality, VTE complications, and hospital length of stay (HLOS). RESULTS: A total of 354 patients were included. Patients who received LMWH had lower mortality compared to those who received UFH. After multivariate logistic regression, LMWH was still independently associated with improved survival. No association was found between LMWH and UFH regarding deep vein thrombosis (DVT) or pulmonary embolism (PE) rates. No association was found between LMWH with HLOS. CONCLUSIONS: LMWH was associated with improved survival compared to UFH in our pediatric trauma patients. This was independent of injury severity or VTE complications. Further studies are required to understand better the mechanisms by which LMWH improves survival. LEVEL OF EVIDENCE: 3.

Multicenter Validation of the Revised Assessment of Bleeding and Transfusion (RABT) Score for Predicting Massive Transfusion.

BACKGROUND: Massive transfusion (MT) is a lifesaving treatment for hemorrhaging patients. Predicting the need for MT is crucial to improve survival. The aim of our study was to validate the Revised Assessment of Bleeding and Transfusion (RABT) score to predict MT in a multicenter cohort of trauma patients. METHODS: We performed a (2015-2017) analysis of adult (age ≥ 18 year) trauma patients who had a high-level trauma team activation at three Level I trauma centers. The RABT was calculated using the 4-point score [blunt (0)/penetrating trauma (1), shock index ≥ 1 (1), pelvic fracture (1), and FAST positive (1)]. A RABT score of ≥ 2 was used to predict MT (≥ 10 units of packed red blood cells within 24 h). The area under the receiver operating characteristic curve (AUROC) was calculated to assess the score's predictive power compared to the Assessment of Blood Consumption (ABC) score. RESULTS: We analyzed 1018 patients: 216 (facility I), 363 (facility II), and 439 (facility III). The mean age was 41 ± 19 year, and the injury severity score (ISS) was 29 [22-36]. The overall MT rate was 19%. The overall AUROC of RABT ≥ 2 was 0.89. The sensitivity of the RABT ≥ 2 was 78%, and the specificity was 91%. The RABT score had a higher sensitivity (78% vs. 69%) and specificity (91% vs. 82%) than the ABC score. CONCLUSION: The RABT score is a valid tool to predict MT in severely injured trauma patients. It is an objective score that aids clinicians in predicting the need for MT to mobilize blood products and minimize the waste of resources.

Pediatric Liver Injury: Physical Examination, Fast and Serum Transaminases Can Serve as a Guide.

BACKGROUND: The aim of our study was to determine if the combination of physical examination (PE), serum transaminases along with Focused Assessment with Sonography in Trauma (FAST) would effectively rule out major hepatic injuries (HIs) after blunt abdominal trauma (BAT) in hemodynamically stable pediatric patients. METHODS: We conducted a 9-year retrospective study of pediatric patients (<18 y) with BAT. We collected data on liver enzymes (aspartate transaminase [AST] and alanine transaminase [ALT]), FAST, and PE findings. Definitive diagnosis and staging of HI were based on abdominal CT scanning. The sensitivity and specificity of ALT/AST, FAST, and PE were then calculated individually and in combination. RESULTS: We identified a total of 423 pediatric patients with BAT. Mean age was 11 y, median abdominal Abbreviated Injury Scale was 3 [2-4], and mean ED-SBP was 132 mm Hg. One hundred ninety-eight patients had HI of which 107 were major HI, defined by the American Association for the Surgery of Trauma as ≥grade III. Using ROC curve analysis, optimum ALT and AST thresholds were determined to be 90 U/L and 120 U/L, respectively. The sensitivity of FAST was 50% while that of PE was 40%. Combining PE with AST/ALT and FAST had an overall sensitivity of 97%, a specificity of 95%, a positive predictive value of 87%, and a negative predictive value of 98%. CONCLUSIONS: In hemodynamically stable pediatric blunt abdominal trauma patients, CT scanning can be avoided using a combination of readily available tests thus avoiding unnecessary radiation exposure. However, pediatric patients with positive PE, FAST, and elevated AST/ALT may eventually require CT scan to further evaluate liver injuries.

Chronic Alcohol Consumption and Risk of Deep Venous Thrombosis: A Propensity-Matched Analysis.

BACKGROUND: Alcoholism is associated with variable effects on the coagulation system. Therefore, the aim of our study was to analyze the currently unknown association between chronic alcohol consumption and the risk of venous thromboembolism, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS: We performed a 2-y (2013-2014) analysis of the American College of Surgeons Trauma Quality Improvement Program database. All trauma patients with an Injury Severity Score (ISS) > 16 were included. We excluded patients with acute alcohol intoxication, hematologic disorders, and cancer. Patients were divided into two groups (alcoholic and nonalcoholic) and were matched using propensity score matching (1:1) for demographics, ISS, injury location, and admission vitals. Outcomes measures were the prevalence of venous thromboembolism in each group. RESULTS: Of the 91,066 trauma patients included in our analysis, 35,460 patients were matched (alcoholics: 17,730; nonalcoholics: 17,730). The mean was age 45 ± 18 y, and 81% were males. Matched groups were similar in age (P = 0.32), heart rate (P = 0.31), systolic blood pressure (P = 0.46), location of injury (P = 0.85), ISS (P = 0.76), and Glasgow Coma Scale (P = 0.38). Prevalence of DVT was lower in alcoholics compared with nonalcoholics (2.34% versus 5.12%, P = 0.01). The overall incidence of PE was 1.2%, and there was no difference between the two groups (1.1% versus 1.3%, P = 0.22). Similarly, there was no difference in mortality (14.8% versus 15.4%, P = 0.32) between the groups. CONCLUSIONS: Chronic alcohol consumption is associated with a low risk of DVT in trauma patients. This association warrants further investigation of the possible physiological effects of alcohol in trauma patients. LEVEL OF EVIDENCE: Level III Prognostic.

Can Sarcopenia Quantified by Computed Tomography Scan Predict Adverse Outcomes in Emergency General Surgery?

BACKGROUND: Sarcopenia (a decline of skeletal muscle mass) has been identified as a predictor of poor postoperative outcomes. The impact of sarcopenia in emergency general surgery (EGS) remains undetermined. The aim of this study was to evaluate the association between sarcopenia and outcomes after EGS. METHODS: A 3-y (2012-15) review of all EGS patients aged ≥45 y was presented to our institution. Patients who underwent computer tomography-abdomen were included. Sarcopenia was defined as the lowest sex-specific quartile of total psoas index (computer tomography-measured psoas area normalized for body surface area). Patients were divided into sarcopenic (SA) and nonsarcopenic. Primary outcome measures were in-hospital complications, hospital-length of stay [h-LOS], intensive care unit-length of stay, adverse discharge disposition, and in-hospital mortality. Our secondary outcome measures were 30-d complications, readmissions, and mortality. RESULTS: Four hundred fifty-two patients undergoing EGS were included. Mean age was 58 ± 8.7 y, and 60% were males. Hundred thirteen patients were categorized as SA. Compared to nonsarcopenic, SA patients had higher rates of minor complications (28% versus 17%, P = 0.01), longer hospital-length of stay (7d versus 5d, P = 0.02), and were more likely to be discharged to skilled nursing facility/Rehab (35% versus 17%, P = 0.01). There was no difference between the two groups regarding major complications, intensive care unit-length of stay, mortality, and 30-d outcomes. On regression analysis, sarcopenia was an independent predictor of minor complications (OR 1.8 [1.6-3.7]) and discharge to rehab/SNIF (OR: 1.9 [1.5-3.2]). However, there was no association with major complications, mortality, 30-d complications, readmissions, and mortality. CONCLUSIONS: Sarcopenia is an independent predictor of minor postoperative complications, prolonged hospital-length of stay, and an adverse discharge disposition in patients undergoing EGS. Identifying SA EGS patients will improve both resource allocation and discussion about the patient's prognosis between physicians, patients, and their families.

Outcomes After Massive Transfusion in Trauma Patients: Variability Among Trauma Centers.

BACKGROUND: Exsanguinating trauma patients often require massive blood transfusion (defined as transfusion of 10 or more pRBC units within first 24 h). The aim of our study is to assess the outcomes of trauma patients receiving massive transfusion at different levels of trauma centers. METHODS: Two-y (2013-2014) retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients who received massive transfusion (MT) of blood. Outcome measures were mortality, hospital length of stay, intensive care unit-free and ventilator-free days, blood products received, and complications. RESULTS: We analyzed a total of 416,957 patients, of which 2776 met the inclusion criteria and included in the study. Mean age was 40.6 ± 20 y, 78.3% were males and 33.1% of the injuries were penetrating. Median injury severity score [IQR] was 29 [18-40], median [IQR] Glasgow Coma Scale 10[4-15]. Mean packed red blood cells transfusion in the first 24 h was 20 ± 13 units and mean plasma transfusion was 13 ± 11 units. Overall in-hospital mortality was 43.5%. Receiving MT in level I trauma center was independently associated with lower rates of mortality (odds ratio [OR]: 0.75 [0.46-0.96], P < 0.001). Higher injury severity score (OR: 1.020 [1.010-1.030], P < 0.001) and increased units of packed red blood cells transfused (OR: 1.067 [1.041-1.093], P < 0.001) were independently associated with increased mortality. However, there was no association between teaching status, age, gender, emergency department vitals, and units of plasma transfused. CONCLUSIONS: Hemorrhage continues to remain one of the most common cause of death after trauma. Almost half of the patients who received massive transfusion died. Patients who receive massive blood transfusion in a level I trauma centers have improved survival compared with level II trauma centers.

Day of Hospital Admission and Effect on Outcomes: The Weekend Effect in Acute Gallstone Pancreatitis.

BACKGROUND: The aim of our study was to evaluate outcomes in patients who are admitted on weekend compared with those admitted on a weekday for acute gallstone pancreatitis. METHODS: We performed a 3-y (2010-2012) analysis of the Nationwide Inpatient Sample database. Patients with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included and were divided into two groups: admission on the weekend versus the weekday. Primary outcome measures were time to ERCP, adverse events, and mortality. Secondary outcome measures were hospital length of stay and total cost. RESULTS: A total of 5803 patients with acute gallstone pancreatitis who underwent ERCP were included in our study; of which 22.6% were admitted on the weekend, whereas 77.4% were admitted on a weekday. Mean age was 57 ± 18 y and 57.1% were female. Within 24 h, the rate of ERCP was higher in patients admitted on the weekday compared with those admitted on the weekend (40% versus 24%; P < 0.001). Similarly, by 48 h, the rate of ERCP was higher in the weekday group (69% versus 49%, P < 0.001). Patients admitted over the weekends had higher complications rate (P = 0.03), hospital length of stay (P < 0.001), and the total cost of hospitalization (P < 0.001) compared with the weekday group with no difference in in-hospital mortality. CONCLUSIONS: Patients admitted on weekends for acute gallstone pancreatitis experience a delay in getting ERCP and have higher complications, prolonged hospital stay, and increased hospital costs compared with those admitted on weekdays.

Biofloc technology improves growth, innate immune responses, oxidative status, and resistance to acute stress in common carp (Cyprinus carpio) under high stocking density.

This study aimed to evaluate the effects of biofloc technology (BFT) on the performance of common carp under high stocking density. Fish (8.41 ±â€¯0.44 g) were stocked into 12 tanks (70 L) in a 2 × 2 factorial design consisting of clear water (CW) and BFT systems at two stocking densities. Fish were divided into four groups according to culture system and stocking density: CW6 (clear water, 6 kg m-3), CW12 (clear water, 12 kg m-3), BFT6 (biofloc, 6 kg m-3), and BFT12 (biofloc, 12 kg m-3). After 49 days, the fish were exposed to acute crowding stress (40 kg m-3) for 7 days to evaluate the fish performance to additional stressors. Total ammonia nitrogen (TAN) concentration was significantly lower in BFT groups at the end of the trial. The growth of fish was significantly higher and the feed conversion ratio was lower in BFT groups. The final density of fish was highest in BFT12 group (25.41 ±â€¯0.48 kg m-3). The amylase and protease activities in BFT groups were significantly higher than the CW12 group. The highest serum catalase, superoxide dismutase, and glutathione peroxidase activities, and malondialdehyde content (3.07 ±â€¯0.16 nmol mg-1 protein) were observed in CW12 group. Serum LDL, cholesterol, triglyceride, total protein, and albumin levels were significantly higher in CW6 and BFT6 groups, followed by BFT12 group, and lowest in CW12 group. Serum globulin level was lowest in CW12 group (0.68 ±â€¯0.06 g dL-1). After 49 days, serum lysozyme, alternative complement (ACH50) and ALP activities were significantly higher and serum cortisol and glucose levels and ALT and AST activities were lower in BFT groups than the CW12 group. After 7 days of acute stress, serum lysozyme activities were significantly lower and ACH50 and ALP activities were higher in BFT groups than the CW12 group. Also, fish in CW12 group were more sensitive to the acute stressor, showing higher cortisol and lower glucose levels. Overall, biofloc had the anti-stress effect, and the culture of common carp in the biofloc system at a stocking density of 12 kg m-3 could be recommended. BFT can also exert beneficial effects on the welfare of fish subjected to acute stress.

Does it matter where you get your surgery for colorectal cancer?

BACKGROUND: The influence of hospital-related factors on outcomes following colorectal surgery is not well-established. The aim of our study was to evaluate the relationship between hospital factors on outcomes in surgically managed colorectal cancer patients. METHODS: We performed a 2-year (2014-2015) analysis of the NIS database. Adult (> 18 years) patients who underwent open or laparoscopic colorectal resection were identified using ICD-9 codes. Patients were stratified based on hospital: volume (low vs. high), teaching status, and location (urban vs. rural). Outcome measures were complications and mortality. Multivariate logistic regression was performed. RESULTS: A total of 153,453 patients with CRC were identified of which 35.3% underwent surgical management. Mean age was 69 ± 13 years, 51.6% were female, and 67% were white. Twenty-seven percent of the patients were managed at a high-volume center, 48% at intermediate-volume center while 25% at a low-volume center. Complications and mortality rates were lower in patients who were managed at high-volume centers and urban hospitals, while no difference was noticed based on teaching status. On regression analysis, patients managed at high-volume centers (OR 0.76 [0.56-0.89]) and urban hospitals (OR 0.83 [0.64-0.91]) have lower odds of complications; similarly, high-volume centers (OR 0.79 [0.65-0.90]) and urban facility (OR 0.87 [0.70-0.92]) were associated with lower odds of mortality. However, there was no association between teaching status and outcomes. CONCLUSION: Hospital factors significantly influence outcomes in patients with CRC managed surgically. High-volume centers and urban facilities have relatively better outcomes. Regionalization of care along with the appropriate availability of resources may improve outcomes in patients with CRC. LEVEL OF EVIDENCE: Level III, Retrospective Observational Study.