Trends and seasonality in hospitalizations for acute alcohol-related and biliary pancreatitis in the USA.

BACKGROUND: The incidence of acute pancreatitis (AP) is characterized by circannual and geographical variation. The aim of this study was to describe seasonal variation and trends in hospitalizations for AP in the USA with respect to AP etiology. METHODS: The Nationwide Inpatient Sample data (2000-2016) from the Healthcare Cost and Utilization Project were used. The study population included all primary hospitalizations for AP. Biliary AP (BAP) and alcohol-induced AP (AAP) were distinguished by diagnostic and procedural ICD codes. Seasonal trend decomposition was performed. RESULTS: There was a linear increase in annual incidence (per 100 000 population) of AAP in the USA (from 17.0 in 2000 to 22.9 in 2016), while incidence of BAP, equaled 19.9 in 2000, peaked at 22.1 in 2006 and decreased to 17.4 in 2016. AP incidence demonstrated 18% annual incidence amplitude with summer peak and winter trough, more prominent in AAP. In 2016, within AAP, the highest incidence (per 100 000 population) was noted among African-Americans (up to 50.4), followed by males aged 56-70 years (26.5) and Asians of low income (25.5); within BAP, above the average incidence was observed in Hispanic (up to 25.8) and Asian (up to 25.0) population. The most consistent and rapid increase in AP incidence was noted in males aged 56-70 years with an alcoholic etiology (average 6% annual incidence growth). CONCLUSIONS: The incidence and annual trends of AP vary significantly among demographic and socioeconomic groups and this knowledge may be useful for the planning of healthcare resources and identification of at-risk populations.

Detecting accidental punctures and lacerations during cholecystectomy in large datasets: Two methods of analysis.

BACKGROUND: After the Institute of Medicine (IOM) report To Err Is Human highlighted the impact of medical errors, the Agency for Healthcare Research and Quality (AHRQ) developed Patient-Safety Indicators (PSI) to improve quality by identifying potential inpatient safety problems. PSI-15 was created to study accidental punctures and lacerations (APL), but PSI-15 may underestimate APLs in populations of patients. This study compares PSI-15 with a more inclusive approach using a novel composite of secondary diagnostic and procedural codes. METHODS: We used Nationwide Inpatient Sample (NIS) data (2000-2012) from AHRQ's Healthcare Cost and Utilization Project (H-CUP). We analyzed PSI-15-positive and -negative cholecystectomies. Cross tabulations identified codes that were significantly more frequent among PSI-15-positive cases; these secondary diagnostic and procedural codes were selected as candidate members of a composite marker (CM) of APL. We chose cholecystectomy patients for study because this is one of the most common general operations, and the large size of NIS allows for meaningful analysis of infrequent occurrences such as APL rates. RESULTS: CM identified 1.13 times more APLs than did PSI-15. Patients with CM-detected APLs were significantly older and had worse mortality, comorbidities, lengths of stay, and charges than those detected with PSI-15. Further comparison of these two approaches revealed that time-series analysis for both APL markers revealed parallel trends, with inflections in 2007, and lowest APL rates in July. CONCLUSIONS: Although CM may yield more false positives, it appears more inclusive, identifying more clinically significant APLs, than PSI-15. Both measures presented similar trends over time, arguing against inflation in PSI-15 reporting. While arguably less specific, CM may increase sensitivity for detecting APL events during cholecystectomies. These results may inform the interpretation of other large population studies of APLs following abdominal operations.

Clues to predict incidental gallbladder cancer.

BACKGROUND: Consequences of incidental gallbladder cancer (iGBC) following cholecystectomy may include repeat operation (depending on T stage) and worse survival (if bile spillage occurred), both avoidable if iGBC were suspected preoperatively. METHODS: A retrospective single-institution review was done. Ultrasound images for cases and controls were blindly reviewed by a radiologist. Chi-square and Student's t tests, as well as logistic regression and Kaplan-Meier analyses were used. A P ≤ 0.01 was considered significant. RESULTS: Among 5796 cholecystectomies performed 2000-2013, 26 (0.45%) were iGBC cases. These patients were older (75.61 versus 52.27 years), had more laparoscopic-to-open conversions (23.1% versus 3.9%), underwent more imaging tests, had larger common bile duct diameter (7.13 versus 5.04 mm) and higher alkaline phosphatase. Ultrasound imaging showed that gallbladder wall thickening (GBWT) without pericholecystic fluid (PCCF), but not focal-versus-diffuse GBWT, was associated significantly with iGBC (73.9% versus 47.4%). On multivariable logistic regression analysis, GBWT without PCCF, and age were the strongest predictors of iGBC. The consequences iGBC depended significantly on intraoperative bile spillage, with nearly all such patients developing carcinomatosis and significantly worse survival. CONCLUSIONS: Besides age, GBWT, dilated common bile duct, and elevated alkaline phosphatase, number of preoperative imaging modalities and the presence of GBWT without PCCF are useful predictors of iGBC. Bile spillage causes poor survival in patients with iGBC.

Minimally invasive and open gallbladder cancer resections: 30- vs 90-day mortality.

BACKGROUND: Minimally invasive surgery is increasingly used for gallbladder cancer resection. Postoperative mortality at 30 days is low, but 90-day mortality is underreported. METHODS: Using National Cancer Database (1998-2012), all resection patients were included. Thirty- and 90-day mortality rates were compared. RESULTS: A total of 36 067 patients were identified, 19 139 (53%) of whom underwent resection. Median age was 71 years and 70.7% were female. Ninety-day mortality following surgical resection was 2.3-fold higher than 30-mortality (17.1% vs 7.4%). There was a statistically significant increase in 30- and 90-day mortality with poorly differentiated tumors, presence of lymphovascular invasion, tumor stage, incomplete surgical resection and low-volume centers (P<0.001 for all). Even for the 1885 patients who underwent minimally invasive resection between 2010 and 2012, the 90-day mortality was 2.8-fold higher than the 30-day mortality (12.0% vs 4.3%). CONCLUSIONS: Ninety-day mortality following gallbladder cancer resection is significantly higher than 30-day mortality. Postoperative mortality is associated with tumor grade, lymphovascular invasion, tumor stage, type and completeness of surgical resection as well as type and volume of facility.

Implications of gallbladder cholesterolosis and cholesterol polyps?

BACKGROUND: The clinical significance of cholesterolosis has not been well established but there are some provocative, if not robust, studies of the role it may play in the pathophysiology of pancreatitis and biliary dyskinesia, as well as hypercholesterolemia. Our aim was to take advantage of a very large cholecystectomy (CCY) database to support or refute these potentially important reported associations. MATERIALS AND METHODS: A retrospective review of 6868 patients who underwent CCY from 2001-2013 was performed. Comparisons were made using the student t-test for continuous and chi-square analysis for categorical, variables. RESULTS: Among patients for whom the CCY was the primary operation, 1053 (18%) had cholesterolosis and 4596 did not. Compared to those without cholesterolosis, those with cholesterolosis were no more likely to have elevated cholesterol levels (P = 0.64) nor low gallbladder ejection fraction (P = 0.2). To evaluate cholesterolosis as a cause of pancreatitis, all patients with gallstones were eliminated, leaving 639 patients. Among these, not only was cholesterolosis not associated with more pancreatitis, but rather there was not a single patient with or without cholesterolosis who had pancreatitis. CONCLUSIONS: Despite prior reports of associations between cholesterolosis and elevated serum cholesterol, depressed ejection fraction, and increased risk of pancreatitis, careful analysis of this current, larger data set does not support these associations. Any patient with stones or sludge, or with biliary dyskinesia, and appropriate symptoms, should be considered for CCY, with or without suspected cholesterolosis.

Adolescent end of life preferences and congruence with their parents' preferences: results of a survey of adolescents with cancer.

BACKGROUND: Little is known about how well family members accurately represent adolescents when making EOL decisions on their behalf. This study reports on surveys given to adolescents with cancer and their parents as part of a larger study facilitating advanced care discussions, as well as the results of a survey for health care providers. PROCEDURE: Trained facilitators administered surveys orally to adolescents and families in the intervention arm of the FAmily CEntered Advance Care Planning (ACP) for Teens with Cancer (FACE-TC) study. In addition, a post-hoc survey was sent to oncology providers. RESULTS: Seventeen adolescent/family dyads completed this survey. Seventy five percent of adolescents believed it was appropriate to discuss EOL decisions early and only 12% were not comfortable discussing death. Most preferred to be at home if dying. There were substantial areas of congruence between adolescents and their surrogates, but lower agreement on the importance of dying a natural death, dying at home and "wanting to know if I were dying." Among providers, 83% felt their patients' participation in the study was helpful to the patients and 78% felt it was helpful to them as providers. CONCLUSIONS: Adolescents with cancer were comfortable discussing EOL, and the majority preferred to talk about EOL issues before they are facing EOL. There were substantive areas of agreement between adolescents and their surrogates, but important facets of adolescents' EOL wishes were not known by their families, reinforcing the importance of eliciting individual preferences and engaging dyads so parents can understand their children's wishes.

Measuring Transition Readiness: A Correlational Study of Perceptions of Parent and Adolescents and Young Adults with Sickle Cell Disease.

Adolescents and young adults (AYAs) often transfer from pediatric to adult care without adequate preparation, resulting in increased morbidity and mortality. The purpose of this descriptive research study of parent/AYA dyads was to measure perceptions of transition readiness. Factors that were found to be associated with perceptions of increased readiness to transition included AYA age, the amount of responsibility AYAs assume for their healthcare and the degree of parent involvement. More attention should be focused on these aspects of care to improve transition from pediatric to adult care for AYAs with sickle cell disease.

Perioperative hypothermia in NICU infants: its occurrence and impact on infant outcomes.

Infants admitted to the neonatal intensive care unit (NICU) often require surgical intervention and maintaining normothermia perioperatively is a major concern. In our preliminary study of 31 normothermic infants undergoing operative procedures in the operating room (OR), 58% (N = 18) returned hypothermic while all 5 undergoing procedures in the NICU remained normothermic (P = .001). To describe perioperative thermal instability (temperatures lower than 36.0°C) and frequency of associated adverse events, support interventions, and diagnostic tests in infants undergoing operative procedures in the OR and the NICU. This prospective, case-control study included 108 infants admitted to the NICU who were sequentially scheduled for an operative procedure in the OR (50.93%; N = 55) or the NICU (49.07%; N = 53). Existing data from the medical record were collected about temperatures and frequency of adverse cardiovascular, respiratory, and metabolic events, associated support interventions, and diagnostic tests during the perioperative period. Analyses examined the relative risks and proportional differences in rates of hypothermia between the OR group and the NICU group and associated adverse events, support interventions, and diagnostic tests between hypothermic and normothermic infants. Hypothermia developed in 40% (N = 43) of infants during the perioperative period. The OR group had a higher rate of perioperative hypothermia (65.45%, N = 36; P < .001) and were 7 times more likely to develop perioperative hypothermia (P = .008) than the NICU group (13.21%, N = 7). Likewise, infants in the OR group were 10 times more likely to develop hypothermia during the intra- and postoperative periods than those in the NICU group (P = .001). The hypothermic group had significantly more respiratory adverse events (P = .025), were 6 times more likely to require thermoregulatory interventions (P < .001), 5 times more likely to require cardiac support interventions (P < .006), and 3 times more likely to require respiratory interventions (P = .02) than normothermic infants. Although infants undergoing operative procedures in the OR experienced significantly higher rates of hypothermia than those undergoing procedures in the NICU, both groups experienced unacceptable rates of clinical hypothermia. Hypothermic infants experienced more adverse events and required more support interventions during the intra- and postoperative periods than normothermic infants, thereby demonstrating the negative sequelae associated with thermal instability. As a result, a translational team of key stakeholders has been created to explore multifaceted strategies based on translation science to implement, embed, and sustain perioperative thermoregulation best practices for the infant, regardless of the operative setting.

Patient safety, error reduction, and pediatric nurses' perceptions of smart pump technology.

Patient safety and error reduction are essential to improve patient care, and new technology is expected to contribute to such improvements while reducing costs and increasing care efficiency in health care organizations. The purpose of this study was to assess the relationships among pediatric nurses' perceptions of smart infusion pump (SIP) technology, patient safety, and error reduction. Findings revealed that RNs' perceptions of SIP correlated with patient safety. No significant relationship was found between RNs' perceptions of SIP and error reduction, but data retrieved from the pumps revealed 93 manipulations of the pumps, of which error reduction was captured 65 times.

Pediatric fasting times before surgical and radiologic procedures: benchmarking institutional practices against national standards.

Prolonged preoperative fasting can be associated with adverse outcomes, particularly in children. Our aims were to assess the time pediatric patients fasted prior to surgical or radiologic procedures and evaluate whether fasting (NPO) orders complied with national guidelines. We measured NPO start time, time of last intake, and time test or surgery was scheduled, took place, or was cancelled in 219 pediatric patients. Findings demonstrate that pediatric patients experienced prolonged fasting before procedures and that the majority of NPO orders were non-compliant with national guidelines. We have developed strategies to reduce fasting times and ensure compliance with recommended national fasting standards.

Functional gallbladder disorder: Interim analysis of a prospective cohort study.

BACKGROUND: Functional gallbladder disorder (FGBD) remains a controversial indication for cholecystectomy. METHODS: A prospective cohort study enrolled patients strictly meeting Rome criteria for FGBD, and cholecystectomy was performed. They were assessed pre- and 3 and 6 months postoperatively with surveys of abdominal pain and quality of life (RAPID and SF-12 surveys, respectively). Interim analysis was performed. RESULTS: Although neither ejection fraction nor pain reproduction predicted success after cholecystectomy, the vast majority of enrolled patients had a successful outcome after undergoing cholecystectomy for FGBD: of a planned 100 patients, 46 were enrolled. Of 31 evaluable patients, 26 (83.9 â€‹%) reported RAPID improvement and 28 (93.3 â€‹%) SF12 improvement at 3- or 6-month follow-up. CONCLUSION: FGBD, strictly diagnosed, should perhaps no longer be a controversial indication for cholecystectomy, since its success rate for biliary pain in this study was similar to that for symptomatic cholelithiasis. Larger-scale studies or randomized trials may confirm these findings.

Efficacy of COVID-19 Convalescent Plasma Based on Antibody Concentration.

Background: Convalescent plasma obtained from individuals who have recovered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contains neutralizing antibodies to the virus and has been frequently used as a treatment in hospitalized patients with severe COVID-19. Methods: We conducted a retrospective, observational cohort study involving 96 hospitalized patients with severe COVID-19 who were allocated in a 1 : 1 ratio to having received either high antibody concentration convalescent plasma or low antibody concentration convalescent plasma. Quantitative measurements of IgG to the receptor-binding domain (RBD), the S1 subunit of the spike protein, and the SARS-CoV-2 nucleocapsid (N) protein were determined from donor plasma samples. The primary outcome was all-cause mortality within 30 days following convalescent plasma administration in regard to each of the three antibody domains. Results: Within the nucleocapsid antibody domain, death occurred in 22.2% of patients in the low antibody concentration group versus 23.5% in the high antibody concentration group (p=0.88). Within the RBD antibody domain, death occurred in 22.9% of patients in both the low and the high antibody concentration groups (p=1.0). Within the S1 subunit antibody domain, death occurred in 27.1% of patients in the low antibody concentration group versus 18.8% in the high antibody concentration group (p=0.33). Conclusions: No significant differences were observed between low and high concentration convalescent plasma in regard to overall mortality at 30 days, hospital length of stay, number of ventilator days, and subsequent receipt of invasive mechanical ventilation in patients who were previously not receiving mechanical ventilation. Trial Registration. This study was not associated with a clinical trial due to the retrospective nature of study design.

Cardiopulmonary monitors and clinically significant events in critically ill children.

Cardiopulmonary monitors (CPMs) generate false alarm rates ranging from 85%-99% with few of these alarms actually representing serious clinical events. The overabundance of clinically insignificant alarms in hospitals desensitizes the clinician to true-positive alarms and poses significant safety issues. In this IRB-approved externally funded study, we sought to assess the clinical conditions associated with true and false-positive CPM alarms and attempted to define optimal alarm parameters that would reduce false-positive alarm rates (as they relate to clinically significant events) and thus improve overall CPM performance in critically ill children. Prior to the study, clinically significant events (CSEs) were defined and validated. Over a seven-month period in 2009, critically ill children underwent evaluation of CSEs while connected to a CPM. Comparative CPM and CSE data were analyzed with an aim to estimate sensitivity, specificity, and positive and negative predictive values for CSEs. CPM and CSE data were evaluated in 98 critically ill children. Overall, 2,245 high priority alarms were recorded with 68 CSEs noted in 45 observational days. During the course of the study, the team developed a firm understanding of CPM functionality, including the pitfalls associated with aggregation and analysis of CPM alarm data. The inability to capture all levels of CPM alarms represented a significant study challenge. Selective CPM data can be easily queried with standard reporting, however the default settings with this reporting exclude critical information necessary in compiling a coherent study denominator database. Although the association between CPM alarms and CSEs could not be comprehensively evaluated, preliminary analysis reflected poor CPM alarm specificity. This study provided the necessary considerations for the proper design of a future study that improves the positive predictive value of CPM alarms. In addition, this investigation has resulted in improved awareness of CPM alarm parameter settings and associated false-positive alarms. This information has been incorporated into nursing educational programs.

Is Staple Line Reinforcement Necessary in Conversion From Laparoscopic Adjustable Band to Laparoscopic Sleeve Gastrectomy?

BACKGROUND: Once a common bariatric procedure, laparoscopic adjustable gastric band (LAGB) is more frequently the subject of conversion procedures, particularly to laparoscopic sleeve gastrectomy (LSG), due to failure of weight loss, weight regain, and band intolerance. Staple line reinforcement (SLR) in primary LSG has been studied extensively, but has not been evaluated in revision procedures. The aim of this study is to investigate commonly used SLR techniques and their effects on morbidity and mortality in single-stage bands converted to sleeves. METHODS: The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program (MBSAQIP) Participant Use Data Files (PUF) for 2015-2016 were utilized to assess data for single-stage bands converted to sleeves based on CPT codes, and records were stratified by technique of staple line reinforcement. The database contained all the defined variables utilized for analysis with the exception of leak rate and overall morbidity, which had to be derived. Thirty-day outcomes were analyzed using multiple bivariate analyses and Bonferroni corrections were applied. RESULTS: Of the 6,286 patients who underwent single-stage bands converted to sleeves for whom SLR data is available, 56.9% of surgeons utilized SLR only, 21.3% chose no reinforcement technique (No SLR), 13.4% chose SLR plus over-sewing of the staple line (SLR+OSL), and 8.4% chose OSL alone. There were no statistically significant differences in rates of death, reoperation, readmission, reintervention, number of bleeding events, and staple line leaks across groups. CONCLUSION: Choice of SLR does not affect number of bleeding events or staple line leak rate.

Measured versus Estimated Blood Loss: Interim Analysis of a Prospective Quality Improvement Study.

Estimated blood loss (EBL) is an increasingly important factor used to predict outcomes, such as morbidity and mortality, length of stay, and readmissions, after major abdominal operations. However, blood loss is difficult to estimate, with frequent under- and overestimations, consequences of which can be potentially dangerous for individual patients and confounding for scoring systems relying on EBL. We hypothesized that EBL is often inaccurate and have prospectively enrolled consecutive patients undergoing major elective intra-abdominal operations. Actual hemoglobin levels were measured and used to calculate the measured blood loss (MBL), which was compared with the EBL, as estimated both by surgeons (sEBL) and anesthesiologists (aEBL). Of 23 eligible cases at interim analysis, pancreaticoduodenectomy (n = 8) was the most common, followed by colectomy (n = 3), hepatectomy (n = 3) and gastrectomy (n = 2), biliary excision and reconstruction (n = 2), combined gastrectomy + colectomy (n = 1), radical nephrectomy (n = 1), open cholecystectomy (n = 1), pancreatic debridement (n = 1), and exploratory laparotomy (n = 1). aEBL overestimated MBL by 192 mL (143%) on average. The aEBL was significantly greater than the MBL (P = 0.004), whereas the sEBL was significantly less than the MBL (P = 0.009). In conclusion, surgeons significantly underestimate and anesthesiologists significantly overestimate EBL. This finding impacts not only immediate patient care but also the interpretation of scoring systems relying on EBL.

Use of CT Scans for Abdominal Pain in the ED: Factors in Choice.

Overutilization of healthcare resources is a threat to long-term healthcare sustainability and patient outcomes. CT is a costly but efficient means of assessing abdominal pain; however, 97 per cent of ED physicians acknowledge its overutilization. This study sought to understand factors that influence ED providers' decision regarding CT use in the evaluation of abdominal pain. After evaluating a patient for acute abdominal pain, ED providers filled in a form in which the primary diagnosis and index of suspicion were recorded. Bivariate and multivariate analyses were used to identify predictors of outcomes. The CT scan utilization rate was 54.82 per cent. Whereas 34.11 per cent of CT scans were normal, 30 per cent yielded an acute abdominal pathology. Tenderness and rebound tenderness were positive predictors of high index of suspicion [odds ratio (OR) 2.09 and 2.54, respectively]. These variables were also predictive of obtaining a CT scan [OR 2.64 and 3.41, respectively]. Compared with whites, the index of suspicion was 26 per cent and 56 per cent less likely to be high when patients were black [OR 0.73] or Hispanic [OR 0.44] respectively. Blacks and Hispanics were less likely to have CT scans performed than whites [OR 0.58 and 0.48, respectively]. Leukocytosis significantly affected the index of suspicion for acute abdominal pathology, obtaining a CT scan and the acuity of CT scan diagnosis on multivariate analysis. Patients aged ≥60 years had 2.03 odds of acute CT finding compared with those aged <60 years. There is a need for committed efforts to optimize CT scan utilization and eliminate socioeconomic disparities in health care.

Epidemiology of new cases of HIV-1 infection in children referred to the metropolitan pediatric hospital in Washington, DC.

Between 2000 and 2005, 84 HIV-infected children were referred to Children's National Medical Center; 28 were born to immigrant mothers, 89% of whom were of African descent. Rates of antiretroviral prophylaxis were low regardless of maternal origin. Nonimmigrant mothers (30.4%) used illicit drugs (P < 0.001), and 50% of immigrant mothers breast-fed their children (P < 0.001). These data can guide intervention strategies.

Current role of staple line reinforcement in 30-day outcomes of primary laparoscopic sleeve gastrectomy: an analysis of MBSAQIP data, 2015-2016 PUF.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a dominant bariatric procedure. In the past, significant leak rates prompted the search for staple line reinforcement (SLR) techniques. Previous analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all LSG suggested a detrimental influence of SLR on leak rates and overall morbidity. OBJECTIVE: To investigate the relationship between various SLR techniques and bougie size with 30-day outcomes. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited bariatric surgery hospitals. METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2016 Participant Use File data, primary LSG cases were divided into study groups based on surgical techniques. All variables were reported in the Participant Use File except leak rate and overall morbidity, which had to be derived. Multiple bivariate analyses were used to analyze the 30-day outcomes. RESULTS: A total of 198,339 primary LSG operations were included and grouped into No SLR (23.0%), SLR (54.2%), oversewn staple line (9.5%), and a combination of SLR + oversewn staple line (13.3%). There were no statistical differences between study groups in mortality, overall morbidity, or leak rate. Bleeding and reoperation rates were statistically higher in the No SLR group. Bougie size was not associated with change in leak rates. CONCLUSION: Primary LSG is a safe procedure with low morbidity and mortality rates. SLR is associated with decreased rates of bleeding and reoperations but does not affect leak rates. The selection of SLR technique should be left to the surgeon's discretion with an understanding of the associated risks, benefits, and costs.

Do patients with higher baseline BMI have improved weight loss with Roux-en-Y gastric bypass versus sleeve gastrectomy?

BACKGROUND: As sleeve gastrectomy (SG) becomes the most common bariatric procedure, it remains unclear for which patients laparoscopic Roux-en-Y gastric bypass (LRYGB) may be advantageous. Some contend that patients with higher initial body mass index (BMI) achieve better weight loss with LRYGB. OBJECTIVES: This study evaluates weight loss in SG versus LRYGB patients based on preoperative BMI. SETTING: Community teaching hospital, Baltimore, Maryland. METHODS: A convenience cohort of 4935 individuals, undergoing bariatric surgery from 2001 to 2015, was studied to examine 5-year postsurgical trends in weight loss stratified by baseline BMI and procedure. Student t tests compared mean weight loss of baseline BMI groups (<45 versus ≥45; <50 versus ≥50; and <55 versus ≥55) and line graphs and plotted 95% confidence intervals of mean weight loss by year were examined to discern differences in percent excess weight loss (%EWL) by procedure type. RESULTS: All patients were more likely to be female (79%) and Caucasian (62.5%). Nearly twice as many patients underwent LRYGB (N = 3236) compared with SG (N = 1699). In patients in the BMI <45, 50, and 55 kg/m2 categories, there was no significant difference in %EWL based on procedure. However, in those patients in the BMI ≥45 and 55 kg/m2 categories, there is significantly higher %EWL in the LRYGB group over SG. CONCLUSION: In conclusion, patients with lower baseline BMI had improved %EWL regardless of procedure, but those patients with higher baseline BMI who underwent LRYGB did have higher %EWL than those undergoing SG at 2 years follow-up. BMI is one of many key factors when selecting a procedure for an individual patient.

Use of Computerized Tomography in Abdominal Pain.

Annually, approximately 70 million computed tomography (CT) scans are performed in emergency department (ED) settings in the United States of America. From 1995 to 2007, there has been a 5.9-fold increase in the use of CT scans nationally. The radiation risks and high costs associated with CT scans underscore the fact that the imaging modality, although necessary, carries a myriad of long-term risks to both patients and providers. For the workup of abdominal pain, most algorithms include the use of CT scan as an early step. To understand better the use of CT scans in our ED, we performed a retrospective review of patients presenting to the ED with abdominal pain. Two main questions were addressed: 1) what were the reasons for scans and how often did the scans reveal pathology related to the presenting symptoms, 2) how often were incidental findings identified. Our results showed that among patients presenting with abdominal pain to the ED, 50 per cent of the scans were normal, about 20 per cent of the patients had findings correlating with acute abdominal pain, whereas the rest (30%) had incidental findings that may have led to further outpatient studies or long standing abdominal pain. Most patients who presented to the ED had nonspecific abdominal pain i.e. 64.4 per cent. There was a low agreement between the presenting quadrant of pain and final pathological diagnosis (9.5-33.3% concordance), with left flank pain presentation having the highest level of agreement with the final pathologic diagnosis.