Optimizing Hospital Resource Utilization in Bariatric Readmission.

BACKGROUND AND OBJECTIVES: The prevalence of patients with a history of bariatric surgery is climbing. Medical and surgical questions arising in this patient population may prompt them to present to the nearest emergency department (ED), irrespective of that facility's experience with bariatric surgery. The emergency physician is the first to evaluate patients with a history of bariatric surgery who present with abdominal symptoms. As a quality improvement project aimed at reducing resource utilization, we sought to determine which patients presenting to the ED could be treated in an outpatient setting in lieu of hospital admission. METHODS: We conducted a retrospective review of bariatric patients admitted from our ED with abdominal symptoms, including abdominal pain, nausea, vomiting, dysphagia, obstruction, and hematemesis. We collected the following variables: type of bariatric operation, admission and discharge diagnoses, and all interventions performed during admission. RESULTS: One hundred sixty-nine patients (76.1%) had a history of laparoscopic Roux-en-Y gastric bypass. The time from bariatric operation to presentation averaged 42 ± 4.63 (SD) months. The most common symptom was abdominal pain (80.2%). Ninety-four percent of patients underwent invasive management via upper endoscopy, laparoscopy, or laparotomy. The most common postprocedural diagnoses were stricture, bowel obstruction, inflammatory findings, and cholecystitis. CONCLUSION: Most patient encounters resulted in invasive management (204/282; 72.3%). The subset of these patients requiring endoscopic evaluation or therapy (37.7%) may be suitable for outpatient management if appropriate measures are available for rapid follow-up and procedural scheduling.

Delineating the burden of chronic post-operative pain in patients undergoing open repair of complex ventral hernias.

BACKGROUND: After open complex ventral hernia repair (cVHR), chronic pain has a significant impact on quality of life and processes of care. METHODS: Records of 177 patients undergoing cVHR were reviewed in order to characterize the burden of managing postoperative pain in the first post-operative year following open cVHR. RESULTS: In this cohort, 91 patients initiated at least one unsolicited complaint of pain, though phone call (37), unscheduled clinic visit (45) or evaluation in the emergency room (9); among these an actionable diagnosis was found in 38 (41.8%). Among 41 patients who initiated additional unsolicited complaints of pain, an actionable diagnosis was found in only 3 patients. Risk factors for such complaints included pre-operative pain and the use of synthetic mesh. CONCLUSIONS: Even in the absence of an actionable diagnosis, significant resources are utilized in evaluation and management of unsolicited complaints of pain in the first year after cVHR.

Effect of aging on male reproduction in zebrafish (Danio rerio).

The study was designed to test the hypothesis that male aging is associated with a change in reproductive function in the zebrafish. Young (290 ± 37 d) and older (911 ± 48 d) males were combined with females (604 ± 24 d) to test the effect of male age on the number and fertility of eggs laid by their mates. 48% of breeding trials with young males and 25% of the trails with older males resulted in egg deposition. Although young males were associated with significantly more successful breeding attempts than older males, number of eggs laid per clutch, number and percent of fertilized eggs and the number and percent living embryos were not statistically different between young and older males. These data suggest that male aging is associated with altered reproductive behavior and/or female response but not in sperm quality per se. Consistent with this interpretation were the findings that percent motility and sperm motility characteristics did not differ between sperm from young and older males as assessed by computer-assisted sperm analysis. However, older males contained higher quantities of extractable sperm than did young males, perhaps associated with fewer successful breeding attempts. Age-related effects on male reproductive in the zebrafish may therefore be a consequence of behavioral or morphological features that play a role in female mate choice and/ or male sexual response.