More isn't always better: antibiotic duration after surgical decortication in pleural empyema.

Background: While ample high-level evidence supports the limited use of antibiotics post-source control in intraabdominal infections, there is a paucity of available data in guiding antibiotic duration for intrathoracic infections. This study aims to analyze patient outcomes among those who have undergone surgical decortication for parapneumonic pleural empyema, comparing cases managed with infectious disease (ID) specialists against those without, and to identify predictive factors influencing antibiotic duration post-source control. We hypothesized that antibiotic duration would vary depending on the involvement of ID specialists. Methods: A retrospective chart review was completed on patients with parapneumonic pleural empyemas who underwent surgical decortication at a single tertiary center from January 2011 to March 2021. Differences in patient characteristics and outcomes for those whose antibiotics were managed by ID or not were compared with Wilcoxon two-sample tests and Fisher's exact tests. Linear regression was used to evaluate for significant factors predictive of antibiotic duration. Results: A total of 116 patients underwent surgical decortication for pleural empyema of parapneumonic etiology. ID specialists were involved with antibiotic management in 62 (53.4%) cases, while the remaining cases were not managed by ID. Demographics and patient comorbidities were similar between both groups. Growth of preoperative fluid cultures was higher in patients managed by ID (40.3% vs. 20.4%, P=0.03). Postoperatively, patients managed by ID had longer durations of antibiotics (28.7 vs. 20.9 days, P<0.001) and were more likely to be on IV antibiotics than patients not managed by ID (59.7% vs. 38.9%, P=0.04). However, postoperative outcomes were similar, including rates of disease recurrence, readmission, and 30-day mortality. Linear regression revealed length of antibiotics was significantly dependent on preoperative ventilator status [estimate: 16.346; 95% confidence interval (CI): 6.365-26.326; P=0.002], growth of preoperative pleural fluid cultures (estimate: 10.203; 95% CI: 2.502-17.904; P=0.01), and ID involvement (estimate: 8.097; 95% CI: 1.003-15.191; P=0.03). Conclusions: Antibiotic duration for pleural empyema managed with surgical decortication is significantly dependent on ID involvement, preoperative growth of cultures, and preoperative ventilator status. However, outcomes, including disease recurrence and 30-day mortality, were similar between patients regardless of ID involvement and longer length of antibiotics, raising the question of what the adequate duration of antibiotics is for patients who receive appropriate source control for pleural empyema. Further study with randomized control trials should be conducted to provide high-level evidence regarding length of antibiotics in this patient population.

Disparities in postoperative outcomes among diverse patient groups with inflammatory bowel disease.

Background: Inflammatory bowel disease (IBD) represents a significant burden in the United States. We aim to evaluate disparities in postoperative outcomes among diverse patients undergoing surgery for IBD. Methods: The National Inpatient Sample (NIS) (2016-2018) was used to calculate national estimates for a number of postoperative complications in patients with IBD. Statistical analyses were performed using SAS survey procedures when calculating the national estimates. Results: A majority of the 107,375 patients (weighted) undergoing surgery for IBD were White (81.7%), rather than Black (10.1%) or Hispanic (8.2%). Black patients had higher rates of postoperative infections compared to White or Hispanic patients (4.2% vs. 3.1% vs. 2.7%, P=0.0137). There was a significant difference in morbidity and mortality, with higher rates in Black patients (20.1% vs. 17.1% vs. 17.9%, P=0.0029). Black patients experienced longer average hospital stays compared to White or Hispanic patients (12.6 vs. 9.6 vs. 11.2 days, P<0.001), despite suffering fewer comorbidities (Modified Charlson Index 1.9 vs. 2.3 vs. 2.0, P<0.001). Conclusions: This study demonstrated racial disparities in postoperative outcomes, with Black patients experiencing significantly higher rates of postoperative infections, overall morbidity and mortality, and length of stay, despite suffering from fewer comorbidities. This suggests an opportunity to improve equity of care for all patients with IBD by further examining social determinants of health that have not been traditionally studied.

Race and Ethnicity Impacts Overall Survival of Patients with Appendiceal Cancer Who Undergo Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

Appendiceal cancer treatment may include cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). We investigated whether patient race/ethnicity influences outcomes and overall survival for patients with appendiceal cancer who undergo CRS/HIPEC. We queried the National Cancer Database for adult patients with appendiceal cancer treated with CRS/HIPEC from 2006 to 2018. Patients were stratified by race/ethnicity: non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and Other. Sociodemographics and outcomes were compared using descriptive statistics. Kaplan-Meier survival analysis and Log-rank tests assessed differences in overall survival (OS). Cox Multivariate Regression evaluated factors associated with OS. In total, 2532 patients were identified: 2098 (82.9%) NHW, 186 (7.3%) NHB, 127 (5.0%) Hispanic, and 121 (4.8%) Other patients. The sociodemographics were statistically different across groups. The perioperative and postoperative outcomes were similar. OS was significantly different by race/ethnicity (p = 0.0029). NHB patients compared to Hispanic patients had the shortest median OS (106.7 vs. 145.9 months, p = 0.0093). Race/ethnicity was independently associated with OS: NHB (HR: 2.117 [1.306, 3.431], p = 0.0023) and NHW (HR: 1.549 [1.007, 2.383], p = 0.0463) patients compared to Hispanic patients had worse survival rates. Racial/ethnic disparities exist for patients with appendiceal cancer undergoing CRS/HIPEC. Despite having similar tumor and treatment characteristics, OS is associated with patient race/ethnicity.

Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review.

BACKGROUND: Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days). METHODS: Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0. RESULTS: For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia. CONCLUSION: In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Socioeconomic Disparities in Neoadjuvant Chemotherapy for Early-Stage Breast Cancer.

BACKGROUND: Neoadjuvant chemotherapy (NCT) is often used for patients with early-stage breast cancer. Disparities in the use of NCT based on clinical, demographic, and socioeconomic factors have not been evaluated. METHODS: Data from the National Cancer Database was analyzed for patients with T1-2, N0-1 breast cancer from 2006 to 2015. Univariate and multivariate analysis determined which factors predicted for the receipt of NCT. RESULTS: We found 159 946 eligible patients. Factors associated with receipt of NCT included T2 vs. T1 disease, N1 vs. N0, and treatment at an academic facility. Race itself was not significant; however, a higher level of education amongst Black populations correlated with the receipt of NCT. DISCUSSION: Clinical factors are the greatest determinants for receipt of NCT in early-stage breast cancer. Disparities exist that cannot be explained by race alone; socioeconomic and demographic factors are important. Cancer care should be evaluated in the context of the intersectionality of these health determinants.

The Impact of Preoperative Breast Volume on Development of Mastectomy Skin Flap Necrosis in Immediate Breast Reconstruction.

BACKGROUND: Mastectomy skin flap necrosis (MSFN) can significantly impact outcome after immediate breast reconstruction. Several techniques exist to predict MSFN, but these may require additional testing and information, and they are often not available before surgery. We aim to identify whether breast volume, as calculated from preoperative mammography, can be used as a preoperative predictor of MSFN. METHODS: A retrospective chart review from 2010 to 2020 resulted in 378 patients who underwent immediate implant-based breast reconstruction. Complete imaging data were available for 278 patients and 441 reconstructed breasts. Demographic, perioperative, and outcomes data were collected. Measurements from preoperative diagnostic mammograms were used to calculate breast volume. Univariate and multivariate analyses were used to evaluate the association of variables available preoperatively, including breast volume from mammogram and MSFN. Secondary analyses were performed for need for reoperation and loss of reconstruction. RESULTS: On univariate analysis of MSFN development, demographic variables found to be significantly associated with MSFN included body mass index (P = 0.04), diabetes (P = 0.03), and breast volume calculated from routine mammography (P ≤ 0.0001). Average preoperative breast volume via mammography without and with MSFN was 970.6 mL (95% confidence interval [CI], 908.9-1032.3) and 1298.3 mL (95% CI, 1140.0-1456.5) (P < 0.0001), respectively. Statistically significant intraoperative variables for MSFN development included prolonged operative time (P = 0.005), greater initial tissue expander fill volumes (P ≤ 0.001), and prepectoral implant location (P = 0.02). Higher initial tissue expander fill volumes in implant-based reconstructions were associated with increased rates of MSFN, 264.1 mL (95% CI, 247.2-281.0) without MSFN and 349.9 mL (95% CI, 302.0-397.8) in the group with MSFN, respectively (P < 0.001). On multivariate analysis, preoperative imaging volume (P = 0.02) was found to be significant, whereas body mass index and diabetes lost significance (P = 0.40) in association with MSFN. CONCLUSIONS: The results of this study establish an association between larger breast volume on preoperative imaging and development of MSFN. This may be useful as a tool for more appropriate patient selection and guidance in the setting of immediate breast reconstruction.

Developing Sustainable Prehospital Pediatric Care in Rwanda.

OBJECTIVE: Unintentional injury is the leading cause of death in children older than 1 year and disproportionately affects pediatric patients in low- and middle-income countries.Improved prehospital care capacity has demonstrated the ability to improve care and save lives. Our collaboration developed and implemented a sustainable prehospital emergency pediatrics care course (EPCC) for Service d'Aide Medicale Urgente, the public emergency medical service in Rwanda. METHODS: A 1-day context-specific EPCC was developed based on international best practices and local feedback. Two cohorts were created to participate in the course. The first group, EPCC 1, was made of 22 Service d'Aide Medicale Urgente providers with preexisting knowledge on the topic who participated in the course and received training to lead future sessions. After completion of the EPCC1, this group led the second cohort, EPCC 2, which was composed of 26 healthcare providers from around Rwanda. Each group completed a 50 question assessment before and after the course. RESULTS: Emergency pediatrics care course 1 mean scores were 58% vs 98% (pre vs post), EPCC 2 mean scores were 49% vs 98% (pre vs post), using matched-pair analysis of 22 and 32 participants, respectively. When comparing unequal variances across the groups with a 2-tailed paired t test, EPCC 1 and EPCC 2 had a statistically significant mean change in pretest and posttest assessment test scores of 40% compared with 46%, P < 0.0001, with 95% confidence interval. A 1-way analysis of variance mean square analysis for the change in scores showed that regardless of the baseline level of training for each participant, all trainees reached similar postassessment scores (F(1) = 1.45, P = 0.2357). CONCLUSIONS: This study demonstrates effective implementation of a context-appropriate prehospital pediatric training program in Kigali, Rwanda. This program may be effective to support capacity development for prehospital care in Rwanda using a qualified local source of instructors.

Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes.

PURPOSE: Thoracic injury is a major contributor to morbidity in trauma patients. There is limited data regarding practice patterns of video-assisted thoracoscopic surgery (VATS) across trauma-accredited hospitals in the United States. We hypothesized that early VATS remains underutilized affecting patient outcomes. METHOD: We evaluated a cohort of patients who underwent non-urgent thoracic surgical intervention for trauma from the ACS-TQIP database in 2017 excluding patients who were discharged within 48-h or died within 72-h. We selected patients who underwent partial lung resection and decortication to assess the effect of early (day 2-5) versus late VATS. Univariate followed by multivariate regression analyses were utilized to evaluate the independent impact of timing. RESULTS: Over 12 months, 997,970 patients were admitted to 850 trauma-accredited centers. Thoracic injury occurred in 23.5% of patients, 1% of whom had non-urgent thoracic procedures. A total of 406 patients underwent VATS for pulmonary decortication with/out partial resection, 39% were Early VATS (N = 159) compared to 61% late VATS (N = 247). Both groups had comparable demographics and comorbidities with exception of a higher ISS score in the late surgical group (17.9 ± 9.8 vs 14.9 ± 7.6, p < 0.01). The late VATS patients' group had higher rates of superficial site infection, unplanned intubation, and pneumonia. Early VATS was associated with shorter ICU stay and HLOS. Multivariate analysis confirmed the independent effect of surgical timing on postoperative complications and LOS. The conversion rate from VATS to thoracotomy was 1.9% in early group compared to 6.5%, p = 0.03. There was no difference in surgical pattern among participating facilities. CONCLUSION: Despite established practice guidelines supporting early VATS for thoracic trauma management, there is underutilization with less than half of patients undergoing early VATS. Early VATS is associated with improved patient outcomes.

Isolated aortic valve replacement with bio-prostheses in patients age 50 to 65 years: a decade of statewide data on cost and patient outcomes.

BACKGROUND: Guidelines for choice of replacement valve-mechanical versus bio-prosthetic, are well established for patients aged <50 and >65 years. We studied the trends and implications of aortic valve replacement (AVR) with mechanical versus bioprosthetic valve in patients aged 50 to 65 years. METHODS: STS and cost database of 17 centers for isolated AVR surgery were analyzed by dividing them into bioprosthetic valve (BV) or mechanical valve (MV) groups. RESULTS: From 2002 to 2011, 3,690 patients had AVR, 18.6% with MV and 81.4% with BV. Use of BV for all ages increased from 71.5% in 2002 to 87% in 2011. There were 1127 (30.5%) patients in the age group 50-65 years. Use of BV in this group almost doubled, 39.6% in 2002 to 76.8% in 2011. Mean age of patients in BV group was higher (59.2±4.2 years vs. 56.7±4.3 years, P≤0.0001). Preoperative renal failure, heart failure and chronic obstructive pulmonary disease favored use of BV, whereas preoperative atrial fibrillation favored AVR with MV. Mortality (MV 2.2% vs. BV 2.36%) and other postoperative outcomes between the groups were similar. Cost of valve replacement increased for both groups (MV $26,191 in 2002 to $42,592 in 2011; BV $27,404 in 2002 to $44,257 in 2011). CONCLUSIONS: Use of bioprostheses for AVR has increased; this change is more pronounced in patients aged 50-65 years. Specific preoperative risk factors influence the choice of valve for AVR. Postoperative outcomes between the two groups were similar. Long-term implications of this changing practice, in particular, reoperation for bioprosthetic valve degeneration should be examined.

Perioperative outcomes of inpatient laparoscopic Heller myotomy and per-oral endoscopic myotomy in the United States.

BACKGROUND: Per-oral endoscopic myotomy is an alternative to pneumatic dilation and laparoscopic Heller myotomy to treat lower esophageal sphincter diseases. Laparoscopic Heller myotomy and per-oral endoscopic myotomy perioperative outcomes data come from relatively small retrospective series and 1 randomized trial. We aimed to estimate the number of inpatient procedures performed in the United States and compare perioperative outcomes and costs of laparoscopic Heller myotomy and per-oral endoscopic myotomy using a nationally representative database. METHODS: Cross-sectional retrospective analysis of hospital admissions for laparoscopic Heller myotomy or per-oral endoscopic myotomy from October 2015 through December 2018 in the National Inpatient Sample. Patient and hospital characteristics, concurrent antireflux procedures, perioperative adverse events (any adverse event and those associated with extended length of stay ≥3 days), mortality, length of stay, and costs were compared. Logistic regression evaluated factors independently associated with adverse events. RESULTS: An estimated 11,270 patients had laparoscopic Heller myotomy (n = 9,555) or per-oral endoscopic myotomy (n = 1,715) without significant differences in demographics and comorbidities. A concurrent anti-reflux procedure was more frequent with laparoscopic Heller myotomy (72.8% vs 15.5%, P < .001). Overall adverse event rate was higher with per-oral endoscopic myotomy (13.3% vs 24.8%, P < .001), and mortality was similar. Per-oral endoscopic myotomy had higher rates of adverse events associated with extended length of stay (9.3% vs 16.6%, P < .001), infectious adverse events (3.5% vs 8.2%, P < .001), gastrointestinal bleeding (3.4% vs 5.8%, P = .04), accidental injuries (3% vs 5.5%, P = .03), and thoracic adverse events (4.5% vs 9%, P < .01). Rates of adverse events of both procedures remained similar during the years of the study. Per-oral endoscopic myotomy was independently associated with adverse events. Length of stay (laparoscopic Heller myotomy: 3.2 ± 0.1 vs per-oral endoscopic myotomy: 3.7 ± 0.3 days, P = .17) and costs (laparoscopic Heller myotomy: $15,471 ± 406 vs per-oral endoscopic myotomy: $15,146 ± 1,308, P = .82) were similar. CONCLUSION: In this national database review, laparoscopic Heller myotomy had a lower rate of perioperative adverse events at similar length of stay and costs than per-oral endoscopic myotomy. Laparoscopic Heller myotomy remains a safer procedure than per-oral endoscopic myotomy for a myotomy of the distal esophagus and lower esophageal sphincter in the United States.

Trends of utilization and perioperative outcomes of robotic and video-assisted thoracoscopic surgery in patients with lung cancer undergoing minimally invasive resection in the United States.

Objective: The objective of this study was to evaluate utilization and perioperative outcomes of video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS) for lung cancer in the United States using a nationally representative database. Methods: Hospital admissions for lobectomy or sublobar resection (segmentectomy or wedge resection) using VATS or RATS in patients with nonmetastatic lung cancer from October 2015 through December 2018 in the National Inpatient Sample were studied. Patient and hospital characteristics, perioperative complications and mortality, length of stay (LOS), and total hospital cost were compared. Logistic regression was used to assess whether the surgical approach was independently associated with adverse outcomes. Results: There were 83,105 patients who had VATS (n = 65,375) or RATS (n = 17,710) for lobectomy (72.7% VATS) or sublobar resection (84.2% VATS). Utilization of RATS for lobectomy and sublobar resection increased from 19.2% to 34% and 7.3% to 22%, respectively. Mortality, LOS, and conversion rates were comparable. The cost was higher for RATS (P <.01). Multivariate analyses showed comparable RATS and VATS complications with no independent association between the minimally invasive surgery approach used and adverse surgical outcomes, except for a decreased risk of pneumonia with RATS, relative to VATS sublobar resection (P <.01). Thoracic complication rates and LOS decreased after RATS lobectomy in 2018, compared with previous years (P <.005). Conclusions: The utilization of robotic-assisted lung resection for cancer has increased in the United States between 2015 and 2018 for sublobar resection and lobectomy. In adjusted regression analysis, compared with VATS, patients who underwent RATS had similar complication rates and LOS. The robotic approach was associated with increased total hospital cost. LOS and thoracic complication rates trended down after RATS lobectomy.

Frailty Index associated with postoperative complications and mortality after lower extremity amputation in a national veteran cohort.

OBJECTIVE: Surgical frailty and its assessment have become essential considerations in perioperative management for the modern aging surgical population. The risk analysis index is a validated frailty score that has been proven to predict short-term outcomes and long-term mortality in several surgical subspecialties and high-risk procedures. We examined the association of risk analysis index scores with postoperative outcomes in a retrospective nationwide database of patients who underwent lower extremity amputation in the Veterans Health Administration Health Care System. METHODS: The Veteran Affairs Surgical Quality Improvement Program data was queried across the Veteran Affairs Health Care System with institutional review board approval for lower extremity amputations. Records of above and below knee amputation, Current Procedural Terminology codes 27590, 27591, 27592, 27594, 27596 and 27880, 27881, 27882, 27884, and 27886, respectively, from 1999 to 2018 were obtained. Incomplete and traumatic entries were removed. Risk Analysis Index score was calculated from preoperative variables and patients were separated into five score cohorts (≤15, 16-25, 26-35, 36-45, ≥46). The χ2 test and analysis of variance were used to compare the cohorts. Forward binary logistic regression modeling was used to determine covariate-adjusted odds ratios for outcomes in each cohort (SPSS software; version 25, IBM Corp). RESULTS: A total of 47,197 patients (98.9% male) with an average age of 66.4 ± 10.6 years underwent nontraumatic lower extremity amputation, including 27,098 below knee and 20,099 above knee amputations, during the study period. Frailty was associated with increased rates of deep vein thrombosis, sepsis, cardiac arrest, myocardial infarction, pneumonia, intubation for more than 48 hours, pulmonary embolism, reintubation, acute kidney injury, renal failure, increased length of stay, overall complications, and death. Increases in the frailty score were associated with up to three times the likelihood for the occurrence of a postoperative complication and up to 32 times likelihood to perish within 30 days than those with low frailty scores. CONCLUSIONS: Risk analysis index assessment of frailty was found to be associated with several postoperative outcomes in a dose-dependent manner in patients undergoing lower extremity amputation in the Veterans Health Care System, with higher scores associated with higher rates of death and major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean vent, reintubation), and renal (renal insufficiency, renal failure) complications. We recommend the use of risk analysis index score as a frailty screening tool for patients undergoing lower extremity amputation to enable providers to adequately inform and counsel patients regarding potential significant risks.

Gastric Bypass Increases Circulating Bile Acids and Activates Hepatic Farnesoid X Receptor (FXR) but Requires Intact Peroxisome Proliferator Activator Receptor Alpha (PPARα) Signaling to Significantly Reduce Liver Fat Content.

BACKGROUND: We interrogate effects of gastric bypass (RYGB), compared with a low-calorie diet, on bile acid (BA), liver fat, and FXR, PPARα, and targets in rats with obesity and non-alcoholic fatty liver disease (NAFLD). METHODS: Male Wistar rats received a high-fat diet (obese/NAFLD, n=24) or standard chow (lean, n=8) for 12 weeks. Obese/NAFLD rats had RYGB (n=11), sham operation pair-fed to RYGB (pair-fed sham, n=8), or sham operation (sham, n=5). Lean rats had sham operation (lean sham, n=8). Post-operatively, five RYGB rats received PPARα antagonist GW6417. Sacrifice occurred at 7 weeks. We measured weight changes, fasting total plasma BA, and liver % steatosis, triglycerides, and mRNA expression of the nuclear receptors FXR, PPARα, and their targets SHP and CPT-I. RESULTS: At sacrifice, obese sham was heavier (p<0.01) than all other groups that had lost similar weight loss. Obese sham had lower BA levels and lower hepatic FXR, SHP, and CPT-I mRNA expression than lean sham (P<0.05, for all comparisons). RYGB had increased BA levels compared with obese and pair-fed sham (P<0.05, for both), while pair-fed sham had BA levels, similar to obese sham. Compared with pair-fed sham, RYGB animals had increased liver FXR and PPARα expression and signaling (P<0.05). Percentage of steatosis was lower in RYGB and lean sham, relative to obese and pair-fed sham (P<0.05, for all comparisons). PPARα inhibition after RYGB resulted in similar weight loss but higher liver triglyceride content (P=0.01) compared with RYGB alone. CONCLUSIONS: RYGB led to greater liver fat loss than low-calorie diet, an effect associated to increased fasting BA levels and increased expression of modulators of liver fat oxidation, FXR, and PPARα. However, intact PPARα signaling was necessary for resolution of NAFLD after RYGB.

Does Race or Ethnicity Impact Complications After Pulmonary Lobectomy for Patients With Lung Cancer?

BACKGROUND: Racial disparity in surgical access and postoperative outcomes after pulmonary lobectomy continues to be a concern and target for improvement; however, evidence of independent impact of race on complications is lacking. The objective of this study was to investigate the impact of race/ethnicity on surgical outcomes after lobectomy for lung cancer and estimate the distribution of racial/ethnic groups among expected resectable lung cancer cases using a large national database. METHODS: Patients who underwent lobectomy for lung cancer between 2005 and 2016 were identified in the American College of Surgeon National Surgical Quality Improvement Program. Preoperative characteristics and postoperative outcomes were compared between race/ethnicity groups in all patients and in propensity-matched cohorts, controlling for pertinent risk factors. Distribution of each race/ethnicity in the database was calculated relative to estimated numbers of patients with resectable lung cancer in the United States. RESULTS: A total of 10,202 patients (age 67.6 ± 9.7, 46.7% male, 86.4% white) underwent nonemergent lobectomy (46.8% thoracoscopic). Blacks had higher rates of baseline risk factors. In propensity score-matched cohorts of whites, blacks, and Hispanics/Asians (n = 498 each), postoperatively, blacks had higher rates of prolonged intubation and longer hospital stay while whites had a higher rate of pneumonia. Race was independently associated with these adverse outcomes on multivariate analysis. Proportion of blacks and Hispanics in the American College of Surgeon National Surgical Quality Improvement Program was lower than their respective proportion of resectable lung cancer in the United States. CONCLUSIONS: In a large national-level surgical database, there was lower than expected representation of black and Hispanic patients. Black race was independently associated with extended length of stay and prolonged intubation, whereas white was independently associated with postoperative pneumonia.

Statins Protect against Thrombosis of Cannulated Radiocephalic Fistulas in Diabetic Patients.

BACKGROUND: Radiocephalic arteriovenous fistula (RCAVF) creation is the preferred first line hemodialysis access procedure. Analysis of diabetic rat arteriovenous fistula model indicates improved vascular function with HMG-CoA-Reductase Inhibitor (statin) use. We predict similar outcomes in diabetic patients undergoing primary RCAVF placement. METHODS: A Veterans Administration Hospital dialysis access database over a 15-year period was queried identifying all RCAVF placements in diabetic patients. Patients were stratified into statin medication usage or not at RCAVF creation. Outcomes examined include rate of successful cannulation, functional patency duration, interventions per access, and rates of access thrombosis. Thrombosis-free survival of cannulated RCAVFs were compared using Kaplan-Meier method with log-rank analysis followed by univariate, stepwise logistic regression and ROC curve analysis. RESULTS: Total number of 123 RCAVF cases were performed in 122 diabetic male patients. At the time of RCAVF placement, 92 cases were performed on patients that were taking statin medication and 31 cases were performed on patients that were not taking statin medication. There was no difference in terms of rate of successful cannulation, functional patency duration, and number of interventions per access between the statin and non-statin groups. However, rate of RCAVF thrombosis once accessed was significantly lower in the statin group compared to the non-statin group (P = 0.0005). Kaplan-Meier survival curve for each group were compared using log-rank test to reveal that diabetic patients who were on statin therapy at the time of operation had significantly higher access survival over time against thrombosis once it was cannulated for dialysis treatment compared to those who were not on statin therapy (P = 0.0003). Univariate, stepwise logistic regression model indicated statin use as the only significant factor associated with lack of thrombosis (P = 0.05). CONCLUSIONS: Statins appear to have protective effects against RCAVF thrombosis as predicted in animal models for diabetic patients undergoing primary RCAVF placements. There were similar functional outcomes in terms of rate of successful cannulation, functional patency duration, and number of interventions per access. These data should encourage further investigation of statins and their role in hemodialysis access.

Prehospital emergency obstetric and neonatal care train-the-trainers program in Rwanda.

OBJECTIVE: To improve maternal mortality rates, our collaboration developed and implemented a context-specific, prehospital Emergency Obstetrics and Neonatal Course (EONC) and train-the-trainers program in Rwanda. METHODS: Two cohorts of staff participated in the program-the SAMU emergency medical service and staff from district hospitals. A 2-day course was developed, consisting of skills stations, simulations, and didactics. A 50-question assessment was administered to both cohorts before and after the courses. Student's t test and matched paired t tests were used to evaluate the assessments through retrospective analysis of the data. RESULTS: EONC1 median scores were 60% versus 92% (pre vs post), using matched-pair analysis of 20 participants. EONC2 median scores were 52% versus 96% (pre vs post), using matched-pair analysis of participants. A one-way analysis of variance mean square analysis showed that regardless of the baseline level of training for each participant, all trainees reached similar post-course assessment scores (F(1)  = 8.35, P = 0.0059). CONCLUSION: Optimal prehospital management of obstetric emergencies is essential to prevent needless mortality and morbidity. This study demonstrated that a context-appropriate prehospital obstetric and neonatal training program could be effectively developed and implemented for the SAMU team in Kigali, Rwanda.

Developing sustainable prehospital trauma education in Rwanda.

INTRODUCTION: Every year, >5 million people worldwide die from trauma. In Kigali, Rwanda, 50% of prehospital care provided by SAMU, the public prehospital system, is for trauma. Our collaboration developed and implemented a context-specific, prehospital Emergency Trauma Care Course (ETCC) and train-the-trainers program for SAMU, based on established international best practices. METHODS: A context-appropriate two-day ETCC was developed using established best practices consisting of traditional 30-minute lectures followed by 20-minute practical scenario-based team-driven simulation sessions. Also, hands-on skill sessions covered intravenous access, needle thoracostomy and endotracheal intubation among others. Two cohorts participated - SAMU staff who would form an instructor core and emergency staff from ten district, provincial and referral hospitals who are likely to respond to local emergencies in the community. The instructor core completed ETCC 1 and a one-day educator course and then taught the second cohort (ETCC2). Pre and post course assessments were conducted and analyzed using Student's t-test and matched paired t-tests. RESULTS: ETCC 1 had 17 SAMU staff and ETCC 2 had 19 hospital staff. ETCC 1 mean scores increased from 40% to 63% and ETCC 2 increased from 41% to 78% after the course (p < 0.001 using matched pair analysis). A one-way ANOVA mean square analysis showed that regardless of the baseline level of training for each participant, all trainees reached similar post-course assessment scores, F (1) = 15.18, p = 0.0004. DISCUSSION: This study demonstrates effective implementation of a context-appropriate prehospital trauma training program for prehospital staff in Kigali, Rwanda. The course resulted in improved knowledge for an instructor core and for staff from district and provincial hospitals confirming the effectiveness of a train-the-trainers model. This program may be effective to support capacity development for prehospital trauma care in the country using a qualified local source of instructors.

Five-Year Experience with VATS Versus Thoracotomy Segmentectomy for Lung Tumor Resection.

OBJECTIVE: Segmentectomy for lung tumors has been performed with either video-assisted thoracoscopic surgery (VATS) or thoracotomy; however, there is a lack of contemporary, multicenter study that compares both approaches. The aim of this study was to compare the 30-day surgical outcomes of VATS versus thoracotomy for segmentectomy using a large national database. METHODS: We performed a retrospective analysis of prospectively maintained American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent segmentectomy for benign or malignant tumors between 2013 and 2017 were included and divided into 2 groups based on whether they received a thoracotomy or VATS approach. All VATS patients were then into 2 subgroups: early (2013 to 2015) and late (2016 to 2017). Propensity-matched analysis was conducted, and the perioperative variables and outcomes were compared. RESULTS: A total of 1,785 patients met the inclusion criteria. VATS segmentectomy was associated with shorter hospital stays (3.9 vs 5.8 days, P < 0.001) and higher rates of home discharge (94% vs 89%, P = 0.002) compared to thoracotomy segmentectomy. VATS was also associated with less postoperative pneumonia (2.8% vs 5.8%, P = 0.007), unplanned intubation (1.5% vs 3.5%, P = 0.016), prolonged intubation (0.6% vs 2.7%, P = 0.001), transfusion requirement (1.7% vs 5.8%, P < 0.001), and deep venous thrombosis (0.1% vs 1.1%, P = 0.03). Compared to the earlier VATS group, the late group was associated with less cardiac arrests (0% vs 0.8%, P = 0.025) and shorter hospital stays (3.3 vs 4.2 days, P < 0.001). CONCLUSIONS: When compared with thoracotomy, VATS segmentectomy is associated with less postoperative complications and shorter hospital length of stay. VATS segmentectomy has been used more frequently and with improved outcomes.

Impact of renal function recovery utilizing left ventricular assist device support.

BACKGROUND: In heart failure (HF) patients with renal insufficiency (RI), we hypothesize that mechanical circulatory support (MCS) with the left ventricular assist device (LVAD) will promote renal function recovery (RR). We sought to quantify RR with LVAD support over 6 months of follow-up. METHODS: RR data at 30, 90, and 180 days were analyzed for all LVAD patients with RI at the time of surgery. RI was defined as either the use of hemodialysis (HD) or a glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 . RESULTS: Between January 2008 and December 2013, 47 of 127 (37%) LVAD recipients had RI at the time of surgery. The mean preoperative GFR was 48 ± 7. We observed RR at each follow-up, with 30-, 90-, and 180-day mean GFRs of 79 ± 33, 71 ± 31, and 63 ± 21, respectively. The absolute increase in GFR at 30, 90, and 180 days was 34 ± 31, 26 ± 29, and 19 ± 20, respectively (All with P < .001). Four patients (8.5%) with RI required HD preoperatively. Of these, three recovered renal function, the fourth patient died. An additional 13 patients (30.2%) that were previously non-HD-dependent required HD postoperatively. Six of these 13 (46%) recovered renal function during the study period, four (30.7%) remain on HD and three (23%) died. CONCLUSIONS: RI improves significantly with LVAD support. Improvements in GFR are marked in the first 30 days. Among those patients requiring either pre- or post-operative HD, a majority recovered renal function.