Long-term Outcomes Following Colectomy and Liver Transplantation for Inflammatory Bowel Disease with Primary Sclerosing Cholangitis.

OBJECTIVE: To investigate the long-term outcomes of patients with combined primary sclerosing cholangitis/inflammatory bowel disease (PSC-IBD) undergoing both liver transplantation (LT) and total abdominal colectomy (TAC). SUMMARY BACKGROUND DATA: The fraction of patients with PSC-IBD that require both LT and TAC is small, thereby limiting significant conclusions regarding long-term outcomes. METHODS: Adult and pediatric patients from nine centers from the US IBD Surgery Collaborative who underwent staged LT and TAC for PSC-IBD were included. Long-term outcomes, including survival, were assessed. RESULTS: Among 127 patients, 66 underwent TAC-before-LT, with a median time from TAC to LT of 7.9 yrs, while 61 underwent LT-before-TAC, with a median time from LT to TAC of 4.4 years. Median patient survival post TAC was significantly worse in those undergoing LT-before-TAC (16.0 yrs vs. 42.6 yrs, P=0.007), while post LT survival was not impacted by the order of TAC and LT (21.6 yrs vs. 22.0 yrs, P=0.81). Patients undergoing TAC for medically refractory disease had a higher incidence of recurrent PSC (rPSC) (P=0.02) and biliary complications (0.09) compared to those undergoing TAC for oncologic indications. Definitive TAC reconstruction with either end ileostomy or ileal-pouch anal anastomosis (IPAA) did not impact post-LT or post-TAC outcomes. CONCLUSIONS: Long term survival in PSC-IBD was contingent upon progression to LT and was not impacted by the need for TAC. PSC-IBD patients undergoing TAC for medically refractory disease had a higher incidence of rPSC and biliary complications. The use of IPAA in PSC-IBD was a viable alternative to end ileostomy.

Patterns of firearm related injury in the elderly: A single institution analysis.

BACKGROUND: Firearm-related violence (FRV) is a public health crisis in the United States that impacts individuals across the lifespan. This study sought to investigate patterns of injury and outcomes of firearm-related injury (FRI) in elderly victims and the impact of social determinants of health on this age demographic. METHODS: A retrospective review of the trauma registry at a large Level I center was performed from 2016-2021. Patients over age 18 were included and FRI was defined by ICD 9 and 10 codes. Comparisons were then made between elderly (age > 65 years) and non-elderly (age 18-64 years) victims. The primary outcome was mortality. Secondary outcomes included hospital and intensive care unit length of stay, in-hospital complications and the impact of distressed community index (DCI) and insurance status on discharge disposition. RESULTS: 23,975 patients were admitted for traumatic injury and 4,133 (6 %) were elderly. Of these, 134 had penetrating injuries and 72 (54 %) were FRI. The elderly patients had a median age of 69y and they were predominantly black (50 %) males (85%). Over 75 % had some form of government insurance compared to less than 20% in non-elderly (p<0.001). 33 % of elderly FRIs were self-inflicted compared to only 4 % in the non-elderly cohort and their overall mortality rate was 25 % versus 15 % in non-elderly with FRI (p = 0.038). The median DCI for the non-elderly victims was 72.3 [IQR 53.7-93.1] compared to 63.7 [IQR 33.2-83.6] in the elderly (p < 0.001), however, over 50 % of elderly victims were living in "at risk" or "distressed" communities. CONCLUSION: FRV is a public health crisis across the lifespan and elderly individuals represent a vulnerable subset of patients with unique needs and public health considerations. While many interventions target youth and young adults, it is imperative to not overlook the elderly in injury prevention efforts, particularly self-directed violence. Additionally, given most elderly victims were on government funded insurance and had a higher likelihood of requiring more costly discharge dispositions, new policies should take into consideration the potential financial burden of FRV in the elderly.

Radiofrequency venous ablation for symptomatic relief in postural orthostatic tachycardia syndrome: a case series.

Background: Hypovolemic postural orthostatic tachycardia syndrome (POTS) is thought to be caused by dysregulated circulating blood volume. Management is mainly limited to symptom-targeted lifestyle changes. Radiofrequency venous ablation (RFA) represents a minimally invasive method of increasing circulating blood volume. The following case series describes a novel application of RFA to successfully target POTS symptoms in patients demonstrating venous insufficiency. The use of RFA in alleviating POTS symptoms has not previously been reported. Case summary: We describe four patients with either a well-established historical POTS diagnosis or dysautonomia symptoms refractory to both medical management and lifestyle modifications. They all demonstrated venous reflux on lower extremity venous ultrasound testing. Upon vascular surgery referral, all underwent great and small saphenous vein RFA. They each subsequently reported subjective improvement in their dysautonomia symptoms and quality-of-life. Two with symptom recurrence years later were found to have new-onset pelvic venous congestion and are being evaluated for pelvic venous insufficiency interventions. Discussion: Lower extremity venous pooling can exacerbate dysautonomia symptoms in POTS patients. Patients refractory to conventional treatment strategies should undergo venous insufficiency workup, and if positive, should be referred for venous pooling intervention evaluation. The success of RFA at treating refractory POTS symptoms in these four patients with lower extremity venous reflux, including no surgical intervention and no adverse effects, are compelling grounds to further explore this therapy and to quantify and standardize symptom improvement assessment in a larger patient population. Future directions include a demonstration of quality-of-life improvement in randomized clinical trials.

Opioid dependency is independently associated with inferior clinical outcomes after trauma.

INTRODUCTION: Increased use of opioids has led to higher rates of overdose and hospital admissions. Studies in trauma populations have focused on outcomes associated with acute intoxications rather than addiction. We hypothesize that clinical outcomes after injury would be inferior for opioid-dependent patients compared to opioid-naïve patients. METHODS: We identified all opioid-dependent adult patients admitted to an academic level I trauma center in 2016 with an Injury Severity Score (ISS) ≥ 5. Patients were further categorized by their pattern of opioid dependency into prescription abuse, illicit abuse, or chronic pain subgroups. Outcome measures included length of stay (LOS), major complications, mortality, non-home discharge, ventilator days, and readmissions. Regression models were adjusted for patient demographics, insurance, ISS, and comorbidities. RESULTS: Of the 1450 patients who met the inclusion criteria, 18% were opioid-dependent. Among opioid-dependent patients, 30%, 27%, and 43% were prescription abuse, illicit abuse, and chronic pain patients, respectively. Compared to opioid-naïve (non-users) patients, opioid-dependent patients had longer LOS, more ventilator days, more non-home discharges, and higher readmission rates. Subgroup analysis revealed significant differences among all cohorts when compared to non-users in LOS, non-home discharge, readmissions, and major complications. Opioid dependency was not associated with mortality. CONCLUSION: Opioid dependency was detected in 18% of trauma patients and was independently associated with inferior outcomes. The impact of opioid dependency affects each opioid subgroup differently with all cohorts demonstrating increased 30-day readmissions. Opioid dependent patients may be targeted for risk interventions to reduce LOS, non-home discharge, complications and readmissions.

The effect of insurance type on access to inguinal hernia repair under the Affordable Care Act.

BACKGROUND: The expansion of Medicaid under the Affordable Care Act extended coverage to any individual with an income up to 138% of the federal poverty level. Our study of surgeon practice management investigated the impact of the type of insurance on access to elective inguinal hernia repair and the disparities in access between Medicaid expansion and nonexpansion states. METHODS: Practices of 240 hernia repair surgeons across 8 states were randomly selected from the American College of Surgeons Find a Surgeon Database. Investigators posed as simulated patients seeking an evaluation for an inguinal hernia. Physician offices were contacted using a standardized script on separate occasions to assess appointment success rates and waiting periods for 3 different insurance types (BlueCross, Medicaid, Medicare). RESULTS: Of 240 surgical practices contacted, 75.4% scheduled appointments for Medicaid patients, compared to 98.8% for Medicare patients and 98.3% for those with private insurance. In states that expanded Medicaid, fewer offices accepted Medicaid patients compared to those in nonexpanded states. No differences in wait times between expanded and nonexpanded states were observed. Surgeons in either solo practices or urban settings were less likely to accept Medicaid patients than those in either group practices or non-urban offices. CONCLUSIONS: Simulated Medicaid patients were less successful at scheduling appointments for surgical consultation than BlueCross or Medicare patients. Fewer surgical practices in expansion states accepted Medicaid patients despite increased coverage due to Medicaid expansion. These findings should be further investigated amidst future changes in Medicaid to understand their impact on access to surgical care.

Scalable synthesis of enaminones utilizing Gold's reagents.

Several Gold's reagents were synthesized from cyanuric chloride and N,N-dialkylformamides. These synthetic equivalents of N,N-dimethylformamide dimethyl acetal were used in an optimized and scalable procedure for the regioselective synthesis of a variety of enaminones from ketone starting materials, whose utility was demonstrated by the stereoselective synthesis of Rawal-type dienes.