Prevalence and Predictors of Barrett's Esophagus After Negative Initial Endoscopy: Analysis From Two National Databases.

BACKGROUND & AIMS: Guidelines suggest a single screening esophagogastroduodenoscopy (EGD) in patients with multiple risk factors for Barrett's esophagus (BE). We aimed to determine BE prevalence and predictors on repeat EGD after a negative initial EGD, using 2 large national databases (GI Quality Improvement Consortium [GIQuIC] and TriNetX). METHODS: Patients who underwent at least 2 EGDs were included and those with BE or esophageal adenocarcinoma detected at initial EGD were excluded. Patient demographics and prevalence of BE on repeat EGD were collected. Multivariate logistic regression was performed to assess for independent risk factors for BE detected on the repeat EGD. RESULTS: In 214,318 and 153,445 patients undergoing at least 2 EGDs over a median follow-up of 28-35 months, the prevalence of BE on repeat EGD was 1.7% in GIQuIC and 3.4% in TriNetX, respectively (26%-45% of baseline BE prevalence). Most (89%) patients had nondysplastic BE. The prevalence of BE remained stable over time (from 1 to >5 years from negative initial EGD) but increased with increasing number of risk factors. BE prevalence in a high-risk population (gastroesophageal reflux disease plus ≥1 risk factor for BE) was 3%-4%. CONCLUSIONS: In this study of >350,000 patients, rates of BE on repeat EGD ranged from 1.7%-3.4%, and were higher in those with multiple risk factors. Most were likely missed at initial evaluation, underscoring the importance of a high-quality initial endoscopic examination. Although routine repeat endoscopic BE screening after a negative initial examination is not recommended, repeat screening may be considered in carefully selected patients with gastroesophageal reflux disease and ≥2 risk factors for BE, potentially using nonendoscopic tools.

Clinical Outcomes After Endoscopic Management of Low-Risk and High-Risk T1a Esophageal Adenocarcinoma: A Multicenter Study.

INTRODUCTION: Endoscopic eradication therapy (EET) is standard of care for T1a esophageal adenocarcinoma (EAC). However, data on outcomes in high-risk T1a EAC are limited. We assessed and compared outcomes after EET of low-risk and high-risk T1a EAC, including intraluminal EAC recurrence, extraesophageal metastases, and overall survival. METHODS: Patients who underwent EET for T1a EAC at 3 referral Barrett's esophagus endotherapy units between 1996 and 2022 were included. Patients with submucosal invasion, positive deep margins, or metastases at initial diagnosis were excluded. High-risk T1a EAC was defined as T1a EAC with poor differentiation and/or lymphovascular invasion, with low-risk disease being defined without these features. All pathology was systematically assessed by expert gastrointestinal pathologists. Baseline and follow-up endoscopy and pathology data were abstracted. Time-to-event analyses were performed to compare outcomes between groups. RESULTS: One hundred eighty-eight patients with T1a EAC were included (high risk, n = 45; low risk, n = 143) with a median age of 70 years, and 84% were men. Groups were comparable for age, sex, Barrett's esophagus length, lesion size, and EET technique. Rates of delayed extraesophageal metastases (11.1% vs 1.4%) were significantly higher in the high-risk group ( P = 0.02). There was no significant difference in the rates of intraluminal EAC recurrence ( P = 0.79) and overall survival ( P = 0.73) between the 2 groups. DISCUSSION: Patients with high-risk T1a EAC undergoing successful EET had a substantially higher rate of extraesophageal metastases compared with those with low-risk T1a EAC on long-term follow-up. These data should be factored into discussions with patients while selecting treatment approaches. Additional prospective data in this area are critical.

Sequential organ failure assessment score improves survival prediction for left ventricular assist device recipients in intensive care.

BACKGROUND: Preoperative risk scores facilitate patient selection, but postoperative risk scores may offer valuable information for predicting outcomes. We hypothesized that the postoperative Sequential Organ Failure Assessment (SOFA) score would predict mortality after left ventricular assist device (LVAD) implantation. METHODS: We retrospectively reviewed data from 294 continuous-flow LVAD implantations performed at Mayo Clinic Rochester during 2007 to 2015. We calculated the EuroSCORE, HeartMate-II Risk Score, and RV Failure Risk Score from preoperative data and the APACHE III and Post Cardiac Surgery (POCAS) risk scores from postoperative data. Daily, maximum, and mean SOFA scores were calculated for the first 5 postoperative days. The area under receiver-operator characteristic curves (AUC) was calculated to compare the scoring systems' ability to predict 30-day, 90-day, and 1-year mortality. RESULTS: For the entire cohort, mortality was 5% at 30 days, 10% at 90 days, and 19% at 1 year. The Day 1 SOFA score had better discrimination for 30-day mortality (AUC 0.77) than the preoperative risk scores or the APACHE III and POCAS postoperative scores. The maximum SOFA score had the best discrimination for 30-day mortality (AUC 0.86), and the mean SOFA score had the best discrimination for 90-day mortality (AUC 0.82) and 1-year mortality (AUC 0.76). CONCLUSIONS: We observed that postoperative mean and maximum SOFA scores in LVAD recipients predict short-term and intermediate-term mortality better than preoperative risk scores do. However, because preoperative and postoperative risk scores each contribute unique information, they are best used in concert to predict outcomes after LVAD implantation.

Hospital discharge hemoglobin values and posthospitalization clinical outcomes in transfused patients undergoing noncardiac surgery.

BACKGROUND: Red blood cell (RBC) transfusion is common in surgical patients, yet optimal transfusion targets are incompletely defined in the perioperative period. Hemoglobin levels at the time of hospital discharge may provide insight into transfusion practices, anemia management, and patient outcomes. STUDY DESIGN AND METHODS: This is an observational cohort study of adults receiving RBC transfusion during noncardiac surgery from 2010 to 2014. Multivariable regression was used to assess the relationships between hospital discharge hemoglobin concentrations, anemia severity (severe: <8 g/dL; moderate: 8-10 g/dL; mild/none: ≥10 g/dL), and clinical outcomes, including a primary outcome of 30-day hospital readmission and secondary outcomes of posthospitalization RBC transfusion, composite stroke or myocardial infarction, and mortality. RESULTS: A total of 3129 patients were included: 165 (5%) with severe discharge anemia, 1962 (63%) moderate, and 1002 (32%) with mild/none. Five hundred ninety-two (19%) were readmitted, with the highest rates observed with severe anemia (26% vs 19% for mild/none). Readmissions were not significantly different after multivariable adjustment (overall P = .216); however, in those receiving postoperative intensive care, severe anemia was associated with increased readmission rates (hazard ratio [HR], 1.72; 95% confidence interval [CI], 1.09-2.71; reference mild/none]. Posthospitalization RBC transfusion rates were highest with severe anemia (25% vs 10% for mild/none; adjusted HR, 2.2; 95% CI, 1.5-3.3; P < .001). There were no significant differences in composite stroke/myocardial infarction, or mortality. RBC transfusion volumes did not modify anemia-outcome relationships. CONCLUSION: Hospital discharge hemoglobin values for transfused surgical patients were not associated with hospital readmission rates except for those receiving postoperative intensive care. Further evaluation is warranted to understand downstream consequences of postsurgical anemia.

Initial Postoperative Hemoglobin Values and Clinical Outcomes in Transfused Patients Undergoing Noncardiac Surgery.

BACKGROUND: Intraoperative red blood cell (RBC) transfusion is common, yet transfusion strategies remain controversial as pretransfusion hemoglobin triggers are difficult to utilize during acute bleeding. Alternatively, postoperative hemoglobin values may provide useful information regarding transfusion practices, though optimal targets remain undefined. METHODS: This is a single-center observational cohort study of adults receiving allogeneic RBCs during noncardiac surgery from 2010 through 2014. Multivariable regression analyses adjusting for patient illness, laboratory derangements, and surgical features were used to assess relationships between initial postoperative hemoglobin values and a primary outcome of hospital-free days. RESULTS: A total of 8060 patients were included. Those with initial postoperative hemoglobin <7.5 or ≥11.5 g/dL had decreased hospital-free days [mean (95% confidence interval [CI]), -1.45 (-2.50 to -0.41) and -0.83 (-1.42 to -0.24), respectively] compared to a reference range of 9.5-10.4 g/dL (overall P value .003). For those with hemoglobin <7.5 g/dL, the odds (95% CI) for secondary outcomes included acute kidney injury (AKI) 1.43 (1.03-1.99), mortality 2.10 (1.18-3.74), and cerebral ischemia 3.12 (1.08-9.01). The odds for postoperative mechanical ventilation with hemoglobin ≥11.5 g/dL were 1.33 (1.07-1.65). Secondary outcome associations were not significant after multiple comparisons adjustment (Bonferroni P < .0056). CONCLUSIONS: In transfused patients, postoperative hemoglobin values between 7.5 and 11.5 g/dL were associated with superior outcomes compared to more extreme values. This range may represent a target for intraoperative transfusions, particularly during active bleeding when pretransfusion hemoglobin thresholds may be impractical or inaccurate. Given similar outcomes within this range, targeting hemoglobin at the lower aspect may be preferable, though prospective validation is warranted.

Outcomes Following Three-Factor Inactive Prothrombin Complex Concentrate Versus Recombinant Activated Factor VII Administration During Cardiac Surgery.

OBJECTIVE: To compare outcomes following inactive prothrombin complex concentrate (PCC) or recombinant activated factor VII (rFVIIa) administration during cardiac surgery. DESIGN: Retrospective propensity-matched analysis. SETTING: Academic tertiary-care center. PARTICIPANTS: Patients undergoing cardiac surgery requiring cardiopulmonary bypass who received either rFVIIa or the inactive 3-factor PCC. INTERVENTIONS: Outcomes following intraoperative administration of rFVIIa (263) or factor IX complex (72) as rescue therapy to treat bleeding. MEASUREMENTS AND MAIN RESULTS: In the 24 hours after surgery, propensity-matched patients receiving PCC versus rFVIIa had significantly less chest tube outputs (median difference -464 mL, 95% confidence interval [CI] -819 mL to -110 mL), fresh frozen plasma transfusion rates (17% v 38%, p = 0.028), and platelet transfusion rates (26% v 49%, p = 0.027). There were no significant differences between propensity-matched groups in postoperative stroke, deep venous thrombosis, pulmonary embolism, myocardial infarction, or intracardiac thrombus. Postoperative dialysis was significantly less likely in patients administered PCC versus rFVIIa following propensity matching (odds ratio = 0.3, 95% CI 0.1-0.7). No significant difference in 30-day mortality in patients receiving PCC versus rFVIIa was present following propensity matching. CONCLUSIONS: Use of rFVIIa versus inactive PCCs was significantly associated with renal failure requiring dialysis and increased postoperative bleeding and transfusions.

Chronic postthoracotomy pain and health-related quality of life.

BACKGROUND: Pain after thoracotomy is common. The objective of this study was to assess whether pain 3 months postthoracotomy negatively impacts quality of life. METHODS: One hundred ten patients were prospectively assessed using the Medical Outcomes Study 36-Item Short Form Health Survey before and 3 months after elective thoracotomy. Pain and medication use were evaluated by questionnaire. Patients experiencing pain at 3 months were compared with patients who did not have postthoracotomy pain. RESULTS: Seventy-five patients (68%) had pain 3 months postthoracotomy; 12 patients (11%) rated their average pain greater than 3 (out of 10). Eighteen (16%) patients required opioid analgesics. The pain group reported lower SF-36 scores in physical functioning (p = 0.049), bodily pain (p = 0.0002), and vitality (p = 0.044). There were no other significant differences in any SF-36 scale between the pain and non-pain groups. CONCLUSIONS: Pain is commonly reported at 3 months after elective thoracotomy but is generally mild, shows improvement with time, and does not usually require opioid analgesics. Patients who experience postthoracotomy pain at 3 months are at risk for significantly decreased physical functioning and vitality, but are not at risk for significantly decreased social, emotional, or mental health functioning compared with patients who do not experience postthoracotomy pain at 3 months.