Treatment patterns, survival, and healthcare utilisation and costs in patients with locally advanced and metastatic bladder cancer in Denmark 2015-2020.

BACKGROUND: Treatment patterns in locally advanced and metastatic urothelial bladder cancer (La/mUBC) is changing, but little is known about current treatment patterns, survival, and costs of these patients. Our aim was to describe treatment patterns, survival, and healthcare utilisation/costs in Danish La/mUBC patients in a routine clinical care setting. METHODS: Registry-based nationwide cohort study including all bladder cancer patients aged 18 years or older with a La/mUBC tumour in the pathology register and a concomitant bladder cancer diagnosis in the Danish National Patient Registry in the period 2015-2020. We categorised the patients according to (1) La/mUBC at time of first bladder cancer diagnosis (de novo La/mUBC) and (2) non-invasive or localised muscle-invasive bladder cancer at time of diagnosis which had progressed to La/mUBC. All patients were included at date of pathology-confirmed La/mUBC. Follow-up ended 30 September 2022. RESULTS: We identified 1278 patients (69% men) with La/mUBC and no other previous cancer. Of these, 212 (17%) had de novo La/mUBC, while 1066 (83%) had progressed to La/mUBC. Median age was 72 years. Patients were followed for a median of 13.0 months (interquartile range 4.7;32.0). During follow-up, 651 (51%) patients started first-line treatment, of these, 285 progressed to second-line treatment, and 112 also started third-line treatment. Median survival was 13.0 months from La/mUBC diagnosis, 12.1 months from start of first-line treatment, 9.8 months from start of second-line treatment, and 8.6 months from start of third-line treatment. The mean number of days admitted to hospital was 3.47, 3.97, and 4.07 per month following initiation of first-line, second-line, and third-line treatment, respectively. CONCLUSION: Patients with La/mUBC have a poor prognosis, and in routine clinical care only around half of the patients received systemic anti-cancer treatment suggesting an unmet need for novel treatments. The overall costs only increased slightly from first to third-line treatment.

The accuracy and clinical impact of intraoperative frozen section in determining the extent of surgical intervention in patients with early stage endometrial cancer.

The aim of this study was to compare intraoperative frozen section (FS) with the final pathology (FP), and determine its clinical impact in clinically apparent early stage endometrial cancer (EC) at the American University of Beirut Medical Center (AUBMC). Data for patients 18 years or older, with clinically apparent early stage, grade 1 or 2, endometrioid EC, who underwent hysterectomy ± lymph node dissection (LND) at AUBMC between January 1st 1996 and June 30th 2016 were retrospectively reviewed. 70 patients were included. The overall concordance between FS and FP was 92.3% for histological subtype, 77% for tumour grade, 82% for Myometrial invasion (MI) and 100% for tumour size. At a median follow up of 30 months, 8 recurrences (11.4%) were noted, with a 5-year PFS and OS of 76 and 84% respectively, with a trend towards lower recurrence and improved survival in patients who underwent FS or LND.Impact statementWhat is already known on this subject? Hysterectomy and bilateral salpingo-oophorectomy is the standard surgery for stage I endometrial cancer (EC). Intraoperative frozen section (FS) facilitates the decision on performing lymph node dissection (LND). However, its accuracy and clinical impact have been questioned.What do the results of this study add? Our objective is to compare FS with the final pathology (FP), and determine its clinical impact in clinically apparent early stage EC at the American University of Beirut Medical Center (AUBMC). There is a lack of standardisation regarding FS use and reporting at AUBMC.What are the implications of these findings for clinical practice and/or further research? The strong correlation between FS and FP can serve as a tool to guide decision to perform LND in patients with apparent early stage disease, where use of sentinel LN biopsy technique is not available.

Association between duration of anticoagulant thromboprophylaxis and revision rate in primary total hip arthroplasty: a Danish and Norwegian nationwide cohort study.

BACKGROUND AND PURPOSE: There are concerns that bleeding following primary total hip arthroplasty (THA) contributes to prolonged wound drainage and prosthetic joint infection (PJI). We examined whether short (1-5 days), medium (6-14 days), and extended (≥ 15 days) duration of thromboprophylaxis is associated with the 5-year revision rate after THA due to osteoarthritis. PATIENTS AND METHODS: We performed a cohort study based on data from hip arthroplasty and administrative registries in Denmark and Norway (2008-2014). The outcome was revision surgery due to PJI, aseptic loosening or any cause, and patient mortality. Adjusted cause-specific hazard ratios (HRs) were analyzed with Cox regression analyses. RESULTS: Among 50,482 THA patients, 8,333 received short, 17,009 received medium, and 25,140 received extended thromboprophylaxis. The HRs for revision due to PJI within 5 years were 1.0 (95%CI 0.7-1.3) and 1.1 (CI 0.9-1.3) for short and extended vs. medium treatment, whereas HR for extended vs. medium prophylaxis was 1.5 (CI 1.2-2.0) within 3 months. The HRs for revision due to aseptic loosening within 5 years were 1.0 (CI 0.7-1.4) and 1.1 (CI 0.9-1.4) for short and extended vs. medium treatment. The HRs for any revision within 5 years were 0.9 (CI 0.8-1.1) and 0.9 (CI 0.8-1.0) for short and extended vs. medium treatment. Extended vs. medium prophylaxis was associated with a decreased 0-3 month mortality. The absolute differences at 5 years were ≤ 1%. CONCLUSION: Our data suggests no association between duration of anticoagulant thromboprophylaxis and revision rate within 5 years of primary THA. The extended thromboprophylaxis might be associated with early increased revision rate due to PJI but also with lower mortality; however, the clinical relevance of this finding requires further research.

Could Preoperative Unintended Weight Loss Predispose to Postoperative Thrombosis in Patients Undergoing Colorectal Cancer Surgery? An Analysis of the NSQIP Data.

Objective: A significant portion of colorectal cancer patients lose weight preoperatively. Here we examine the influence of pre-operative significant weight loss on venous thromboembolism (VTE) risk and determine whether pre-operative BMI and albumin could influence VTE outcomes in patients who have lost significant weight prior to surgery.Methods: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and identified 103,455 colorectal cancer patients undergoing major surgery from 2008 to 2012. Patients were assigned to one of two groups based on whether they lost significant weight preoperatively or not. Simple and stepwise multiple logistic regressions were used to evaluate the association between pre-operative unintended weight loss and 30-days postoperative outcomes. The association between weight loss and postoperative thrombosis was further assessed across several strata.Results: The overall prevalence of pre-operative significant weight loss was 6.8%. Significant weight loss prior to surgery was significantly and independently associated with a higher risk of VTE (adjusted OR 1.23, 95% CI 1.06-1.44), mortality (adjusted OR 1.55, 95% CI 1.35-1.78), composite morbidity (adjusted OR 1.52, 95% CI 1.42-1.62), bleeding (adjusted OR 1.78, 95% CI 1.67-1.91) and return to operation room (adjusted OR 1.29, 95% CI 1.16-1.42). The effect of pre-operative significant weight loss on thromboembolic outcome was evident across patients with a BMI <18.5 kg/m2, 18.5 < BMI < 24.99 and BMI >40kg/m2.Conclusions: Significant weight loss and BMI both need to be measured preoperatively to stratify patients who are at a higher risk of VTE.

Performance of the AUB-HAS2 Cardiovascular Risk Index in vascular surgery patients.

The American University of Beirut (AUB)-HAS2 risk index is a recently published tool for preoperative cardiovascular evaluation. It is based on six data elements: history of Heart disease, symptoms of Heart disease (angina or dyspnea), Age ⩾ 75 years, Anemia (hemoglobin < 12 mg/dL), emergency Surgery, and vascular Surgery. This study analyzes the performance of a modified AUB-HAS2 index (excluding the vascular surgery element) in a broad spectrum of vascular surgery procedures. The study population consisted of 90,476 vascular surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database. The performance of the AUB-HAS2 index was studied in seven groups: carotid endarterectomy (CEA), open abdominal aortic aneurysm surgical repair (OAAA), endovascular aortic aneurysm repair, supra-inguinal bypass, infra-inguinal bypass, lower extremity thrombo-endarterectomy, and lower extremity angioplasty. The outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. Each patient was given an AUB-HAS2 score of 0, 1, 2, or > 2 depending on the number of data elements s/he has. The AUB-HAS2 index was able to stratify risk in the majority of patients into low (< 3%, score 0), intermediate (3-10%, score 1-2), and high (> 10%, score > 2) (p < 0.0001). The receiver operating curve had an area of 0.71 in the overall group and it ranged from 0.60 in CEA patients to 0.75 in OAAA patients. In conclusion, the AUB-HAS2 index is a simple tool that can quickly and effectively stratify the risk of patients undergoing a broad spectrum of vascular surgeries into low, intermediate, and high.

Similar early mortality risk after cemented compared with cementless total hip arthroplasty for primary osteoarthritis: data from 188,606 surgeries in the Nordic Arthroplasty Register Association database.

Background and purpose - Current literature indicates no difference in 90-day mortality after cemented compared with cementless total hip arthroplasty (THA). However, previous studies are hampered by potential selection bias and suboptimal adjustment for comorbidity confounding. Therefore, we examined the comorbidity-adjusted mortality up to 90 days after cemented compared with cementless THA performed due to osteoarthritis.Patients and methods - Using the Nordic Arthroplasty Register Association database, 2005-2013, we included 108,572 cemented and 80,034 cementless THA due to osteoarthritis. We calculated the Charlson comorbidity index of each patient based on data from national patient registers. The Kaplan-Meier method was used to estimate unadjusted all-cause mortality. Cox regression was used to estimate hazard ratios (HR) with 95% confidence intervals (CI) for 14, 30-, and 90-day mortality comparing cemented with cementless THA, adjusting for age, sex, comorbidity, nation, and year of surgery.Results - Cumulative all-cause mortality within 90 days was 0.41% (CI 0.37-0.46) after cemented and 0.26% (CI 0.22-0.30) after cementless THA. The adjusted HR for cemented vs. cementless fixation was 0.97 (CI 0.79-1.2), and similar risk estimates were obtained for mortality within 14 (adjusted HR 0.91 [CI 0.64-1.3]) and 30 days (adjusted HR 0.94 [CI 0.71-1.3]). We found no clinically relevant differences in mortality between cemented and cementless THA in analyses stratified by age, sex, Charlson comorbidity index, or year of surgery.Interpretation - After adjustment for comorbidity as an important confounder, we observed similar early mortality between the 2 fixation techniques.

Laser enucleation of the prostate versus transurethral resection of the prostate: perioperative outcomes from the ACS NSQIP database.

PURPOSE: To compare the perioperative outcomes associated with laser enucleation of the prostate (LEP) and transurethral resection of the prostate (TURP) using a national database. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for patients who underwent TURP or LEP from 2008 to 2016. Baseline demographics, comorbidities, and predisposition to bleeding were compared between TURP and LEP. The 30-day perioperative outcomes including operative time, length of hospital stay (LOS), return to the operating room (OR), bleeding requiring transfusion, and organ system-specific complications were compared between the procedures. A multivariate logistic regression analysis was performed, adjusting for the type of surgery and other covariates. RESULTS: The series included 37,577 TURP and 2869 LEP procedures. While TURP was associated with a shorter operative time (55.20 ± 37.80 min) than LEP (102.80 ± 62.30 min), the latter was associated with a shorter hospital stay (1.29 ± 2.73 days) than TURP (2.05 ± 5.20 days). Compared to TURP, LEP had 0.52 (0.47-0.58) times the odds of a LOS > 1 day and 0.67 (0.54-0.83) times the odds of developing urinary tract infections. Nevertheless, no difference was found for other postoperative complications, need for transfusion, and return to OR. CONCLUSION: Real-life data from a large national database confirmed that LEP is a safe and reproducible procedure to treat benign prostatic obstruction. Compared to TURP, LEP was associated with a lower rate of infectious complications and a shorter LOS at the expense of an increased operative time.

Short-term surgical morbidity and mortality of distal pancreatectomy performed for benign versus malignant diseases: a NSQIP analysis.

BACKGROUND/AIM: Distal pancreatectomy (DP) accounts for 25% of all pancreatic resections. Complications following DP occur in around 40% of the cases. Our aim is to analyze short-term surgical outcomes of DP based on whether the indication for resection was benign or malignant pathology, as well as the effect of the surgical approach, open versus laparoscopic on morbidity and mortality. METHODS: We studied all patients undergoing DP from the National Surgery Quality Improvement Program (NSQIP) targeted pancreatectomy participant use file from 2014 to 2016. The patients were divided into 2 groups, those who underwent DP for benign diseases (DP-B) and those who underwent DP for malignant diseases (DP-M). We performed multivariate logistic regression to evaluate the association between benign or malignant distal pancreatectomies and 30-day outcomes. We included clinically and/or statistically significant confounders into the models. We also conducted the same analysis in the subgroups of open and laparoscopic DP. RESULTS: Three thousand five hundred and seventy-nine patients underwent distal pancreatectomy. The most common indication for surgery was malignant disease in 1894 (53%). Thirty-day mortality occurred in 0.4% of DP-B compared to 1.3% DP-M. On multivariate analysis, no significant difference was found in mortality or in the risk of pancreatic fistula between the 2 groups. Bleeding (p = 0.002) and composite morbidity (p = 0.01) were significantly higher in the DP-M group. Among composite morbidities, thromboembolism was significantly associated with DP-M (OR 2.1, p = 0.0004) only when performed with an open approach. CONCLUSION: DP-M is associated with a significantly higher risk of post-operative bleeding, thromboembolism, and sepsis compared to DP-B but no significant increase in mortality. When further analyzing the impact of the operative approach on morbidity, there was an increased rate of post-operative thromboembolic in the DP-M group when the surgery was performed in an open manner and this increased risk was no longer statistically significant if the DP-M was performed using a minimally invasive approach.

Does intraoperative endoscopy decrease complications after bariatric surgery? Analysis of American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Intraoperative endoscopy (IOE) has been proposed to decrease serious complications following bariatric surgeries such as leaks, bleeding, and stenosis. Such complications can lead to sepsis and eventually can be fatal. We aim to compare major postoperative complications in patients with and without IOE. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program database years 2011 till 2016 were used to identify laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) patients. We compared outcomes of IOE and non-IOE using bivariate and multivariate analysis. Thirty-day outcomes included sepsis, organ space infection, unplanned reoperations, unplanned readmissions, prolonged hospital stay, bleeding, and mortality. RESULTS: Out of 62,805 cases of LSG and 50,047 cases of LRYGB, 17.9%, and 19.7% had IOE, respectively. Endoscopy-assisted LSG was associated with a decrease in sepsis [0.37% vs. 0.21%, adjusted odds ratio (AOR) = 0.55 (0.36, 0.84)], unplanned reoperation [0.58% vs. 0.38%, AOR = 0.61 (0.44, 0.85)], prolonged hospital stay [14.9% vs. 14.0%, AOR = 0.87 (0.82, 0.92)], and composite complications [1.43% vs. 1.17%, AOR = 0.78 (0.65, 0.94)]. Outcomes after LRYGB were similar in both groups, except for decreased prolonged hospital stay with IOE [22.4% vs. 20.6%, AOR = 0.89 (0.84, 0.94)]. CONCLUSIONS: IOE is generally underutilized in baraitric procedures. IOE is associated with decreased risk of postoperative complications particularly sepsis, unplanned reoperations, prolonged hospital stay, and composite complications after LSG; and hospital stay after LRYGB. Large multicenter prospective studies are needed to explore the benefits of IOE in bariatric surgery, particularly the intermediate or long-term benefits.

Characteristics and Outcomes of Pediatric Septic Patients With Cancer: A Retrospective Cohort Study.

BACKGROUND: Pediatric oncology patients may be at a higher risk of complications and mortality from sepsis compared with their nononcology counterpart. OBJECTIVES: The aim of this study is to compare characteristics, treatment, and sepsis-related mortality between oncology and nononcology patients presenting to the emergency department (ED). METHODS: This is a retrospective single-center cohort study including patients <18 years old with a diagnosis of sepsis, severe sepsis, septic shock, or bacteremia presenting to an academic ED between January 2009 and January 2015. A total of 158 patients were included with 53.8% having an underlying malignancy. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED vital signs, resuscitation parameters, laboratory work, infection site, general practitioner unit, intensive care unit length of stay, and hospital length of stay. RESULTS: Oncology patients had a higher in-hospital mortality (5.9% vs. 2.7%), however, it did not meet statistical significance (p = 0.45). On presentation, oncology patients had a lower respiratory rate (24.33 ± 9.48 vs. 27.45 ± 7.88; p = 0.04). There was a significant increase in the white blood count in oncology patients (4.011 ± 4.965 vs. 17.092 ± 12.806; p < 0.001) with this cohort receiving more intravenous fluids. In the first 6 hours (33.0 ± 27.7 mL/kg vs. 24.9 ± 16.1 mL/kg; p = 0.029) as well as having a higher percentage of vasopressor administration (15.3% vs. 1.4%; p = 0.002). Antibiotics were initiated at an earlier stage in the oncology cohort (1.25 ± 1.95 vs. 3.33 ± 1.97 hours; p < 0.0001). Cancer-free patients had a significantly higher rate of lung infections compared with cancer patients (68.5% vs. 32.9%; p < 0.0001). In terms of infection characteristics, cancer patients had a higher percentage of bacteremia (27.1% vs. 4.1%; p < 0.001). CONCLUSION: There was no statistical significance regarding mortality between the 2 cohorts. Pediatric cancer patients were found to have a higher incidence of bacteremia and received more aggressive treatment.

Could sodium imbalances predispose to postoperative venous thromboembolism? An analysis of the NSQIP database.

BACKGROUND: Hyponatremia is common among patients with pulmonary embolism, while hypernatremia increases the risk of venous thromboembolism (VTE). Our objective was to evaluate the association between sodium imbalances and the incidence of VTE and other selected perioperative outcomes. METHODS: We conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and identified 1,108,704 patients undergoing major surgery from 2008 to 2012. We evaluated 30-day perioperative outcomes, including mortality and cardiac, respiratory, neurological, urinary, wound, and VTE outcomes. Multivariate logistic regressions were used to estimate the odds of 30-day perioperative outcomes. RESULTS: Compared with the normal sodium group, in which VTE occurred in 1.0% of patients, 1.8% of patients in the hyponatremia group (unadjusted odds ratio (OR) 1.84) and 2.4% of patients in the hypernatremia group (unadjusted OR 2.49) experienced VTE. Crude mortality was 1.3% in the normal sodium group, 4.9% in the hyponatremia group (unadjusted OR 3.93) and 8.4% in the hypernatremia group (unadjusted OR 7.01). Crude composite morbidity was 7.1% for the normal sodium group, 16.7% for the hyponatremia group (unadjusted OR 2.63) and 20.6% for the hypernatremia group (unadjusted OR 3.43). After adjusting for potential confounders, hyponatremia and hypernatremia remained significantly and independently associated with an increased risk of VTE (adjusted OR 1.43 and 1.56, respectively), mortality (adjusted OR 1.39 and 1.39, respectively) and composite morbidity (adjusted OR 2.15 and 3.34, respectively). CONCLUSIONS: Pre-operative hyponatremia and hypernatremia are potential prognostic markers for perioperative 30-day morbidity, mortality and VTE.

The Effect of Preoperative Pneumonia on Postsurgical Mortality and Morbidity: A NSQIP Analysis.

BACKGROUND: Currently, only indirect evidence suggests that preoperative pneumonia is a significant risk factor for poor postsurgical outcomes. Although this relationship is clinically intuitive, this is the first study that aims to quantify the extent to which pneumonia impacts morbidity and mortality. The objective of this study was to determine the impact of preoperative pneumonia on 30-day mortality and morbidity among both elective and emergency surgical patients. METHODS: We conducted a retrospective cohort study using 2008-2012 data from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with preoperative pneumonia were matched to controls without preoperative pneumonia. Patient demographics and postoperative outcomes were extracted from the database, including 30-day mortality, specific morbidities (wound, cardiac, respiratory, urinary, central nervous system, thromboembolism and sepsis), composite morbidity, number of blood transfusions and number of patients that returned to the OR. Mortality and composite morbidity were further stratified. RESULTS: We obtained data for 137,174 patients, of whom 6933 (0.50%) had preoperative pneumonia. Overall, 6111 were successfully matched to 24,444 patients with no pneumonia. Postoperative mortality and composite morbidity were both higher in patients with pneumonia than in those without pneumonia, with an odds ratio of 1.37 (95% CI 1.26-1.48) and 1.68 (95% CI 1.58-1.79), respectively. CONCLUSION: Preoperative pneumonia significantly increased the rate of postoperative morbidity and mortality across several surgical settings and patient groups. It is our recommendation that elective surgery be delayed until after the pneumonia resolves.

Ventilator use by emergency medical services during 911 calls in the United States.

BACKGROUND: Emergency and transport ventilators use in the prehospital field is not well described. This study examines trends of ventilator use by EMS agencies during 911 calls in the United States and identifies factors associated with this use. METHODS: This retrospective study used four consecutive releases of the US National Emergency Medical Services Information System (NEMSIS) public research dataset (2011-2014) to describe scene EMS activations (911 calls) with and without reported ventilator use. RESULTS: Ventilator use was reported in 260,663 out of 28,221,321 EMS 911 scene activations (0.9%). Patients with ventilator use were older (mean age 67±18years), nearly half were males (49.2%), mostly in urban areas (80.2%) and cared for by advanced life support (ALS) EMS services (89.5%). CPAP mode of ventilation was most common (71.6%). "Breathing problem" was the most common dispatch complaint for EMS activations with ventilator use (63.9%). Common provider impression categories included "respiratory distress" (72.5%), "cardiac rhythm disturbance" (4.6%), "altered level of consciousness" (4.3%) and "cardiac arrest"(4.0%). Ventilator use was consistently higher at the Specialty Care Transport (SCT) and Air Medical Transport (AMT) service levels and increased over the study period for both suburban and rural EMS activations. Significant factors for ventilator use included demographic characteristics, EMS agency type, specific complaints, provider's primary impressions and condition codes. CONCLUSIONS: Providers at different EMS levels use ventilators during 911 scene calls in the US. Training of prehospital providers on ventilation technology is needed. The benefit and effectiveness of this intervention remain to be assessed.

Prevalence and predictors of metabolically healthy obesity in adolescents: findings from the national "Jeeluna" study in Saudi-Arabia.

BACKGROUND: Obese children and adolescents may vary with respect to their health profile, an observation that has been highlighted by the characterization of metabolically healthy obesity (MHO). The objectives of this study were to examine the prevalence of MHO amongst obese adolescents in Saudi-Arabia, and investigate the anthropometric, socio-demographic, and lifestyle predictors of MHO in this age group. METHODS: A national cross-sectional school-based survey (Jeeluna) was conducted in Saudi-Arabia in 2011-2012 (n = 1047 obese adolescents). Anthropometric, blood pressure and biochemical measurements were obtained. A multicomponent questionnaire covering socio-demographic, lifestyle, dietary, psychosocial and physical activity characteristics was administered. Classification of MHO was based on two different definitions. According to the first definition, subjects were categorized as MHO based on the absence of the following traditional cardiometabolic risk (CR) factors: systolic blood pressure (SBP) or diastolic blood pressure (DBP) >90th percentile for age, sex, and height; triglycerides (TG) > 1.25 mmol/L; high density lipoprotein-cholesterol (HDL-C) ≤1.02 mmol/L; glucose ≥5.6 mmol/L. The second definition of MHO was based on absence of any cardiometabolic risk factor, according to the International Diabetes Federation (IDF) criteria. RESULTS: The prevalence of MHO ranged between 20.9% (IDF) and 23.8% (CR). Subjects with MHO were younger, less obese, had smaller waist circumference (WC) and were more likely to be females. Based on stepwise logistic regression analyses, and according to the IDF definition, body mass index (BMI) (OR = 0.89, 95% CI: 0.84-0.93) and WC (OR = 0.97, 95% CI: 0.96-0.98) were the only significant independent predictors of MHO. Based on the CR definition, the independent predictors of MHO included female gender (OR = 1.76, 95% CI: 1.29-2.41), BMI (OR = 0.97, 95% CI: 0.94-1.00), and weekly frequency of day napping (OR = 1.06, 95% CI: 1.00-1.12). Analysis by gender showed that vegetables' intake and sleep indicators were associated with MHO in boys but not in girls. CONCLUSION: The study showed that one out of five obese adolescents is metabolically healthy. It also identified anthropometric factors as predictors of MHO and suggested gender-based differences in the association between diet, sleep and MHO in adolescents. Findings may be used in the development of intervention strategies aimed at improving metabolic heath in obese adolescents.

Characteristics of patients presenting post-suicide attempt to an Academic Medical Center Emergency Department in Lebanon.

BACKGROUND: Emergency Department (ED) visits for suicide attempts have been described worldwide; however, the populations studied were predominantly Western European, North American, or East Asian. This study aims to describe the epidemiology of ED patients presenting post-suicide attempt to an academic medical center in Lebanon and to report on factors that affect ED disposition. METHODS: A retrospective cohort study was conducted between 2009 and 2015. Patients of any age group were included if they had presented to the ED after a suicide attempt. Patients with unintentional self-harm were excluded. Descriptive analysis was performed on the demographics and characteristics of suicide attempts of the study population. A bivariate analysis to compare the two groups (hospitalized or discharged) was conducted using Student's t test and Pearson Chi-square where appropriate. A multivariate analysis was then conducted to determine the predictors of hospital admission. RESULTS: One hundred and eight patients were included in the final analysis. Most patients were females (71.4%) and between 22 and 49 years of age. A considerable number of patients were unemployed (43%), unmarried (61.1%), and living with family (86.9%). Most suicide attempts were performed at home (93.5%) and on a weekday (71.3%). The most common mechanisms of injury were overdose with prescription medications (61.3%), overdose with over-the-counter drugs (27.9%), and self-inflicted lacerations (10.1%). The classes of medication most commonly abused were benzodiazepines (39.3%) followed by acetaminophen (27.3%). A large portion of our patients were admitted (70.3%), with the majority going to the psychiatric ward (71.1%). Of note, a quarter (27.5%) of our patients left the ED against medical advice, with 23.5% of admitted patients leaving the hospital before completion of treatment. The main predictors of admission were found to be overdose on prescription medications OR 9.25 (2.12-40.42 CI95%). CONCLUSIONS: The characteristics of our suicide attempters mirror those of international and regional suicide attempters. Further work is required to quantify the effect of voluntary refusal of hospital treatment, the repercussions of family, and financial barriers to healthcare and suicide as a whole in our society.

Trends and Predictors of Limb Tourniquet Use by Civilian Emergency Medical Services in the United States.

BACKGROUND: Tourniquet use by Emergency Medical Services (EMS) can be life saving for severely injured patients. The adoption of this intervention is not well described in civilian settings. This study describes patterns and trends of tourniquet use by civilian EMS and identifies predictors of such use. METHODS: A retrospective study of four consecutive releases of the U.S. National Emergency Medical Services Information System (NEMSIS) public research dataset (2011-14) was conducted. Descriptive analysis was performed to compare two groups of EMS activations for injuries with or without tourniquet application. This was followed by multivariate logistic regression to identify predictors of tourniquet use. RESULTS: A total of 2,048 tourniquet applications were documented among all EMS activations for injured patients (N = 10,366,537) yielding a prevalence of 0.2 per 1,000 EMS activations. Tourniquets were mainly applied in young (mean age 44.0 ± 21.1 years) male patients (76.5%) in urban and suburban EMS activations (86.4%) and by advanced life support (ALS) EMS services (81.6%). Most common complaints reported by dispatch for EMS activations with tourniquet use were Traumatic injury (25.3%), Hemorrhage/laceration (23.5%), and Traffic accident (16.8%) with injuries mainly related to Stabbing/Accidental cutting (20.3%), Falls (17.1%), and Motor vehicle traffic accident (11.5%). Upper extremity injuries (39.6%) were more common than Lower extremity injuries (27.3%). The providers' primary impression was predominantly Traumatic injury (92.8%), and patients' primary symptoms were mainly Bleeding (50.4%) and Wound (28.7%). All prehospital time intervals except on-scene time interval were significantly shorter in the group with tourniquets compared to the group without tourniquets (p < 0.05). Reported prevalence of tourniquet use by EMS (per 1,000 EMS injury activations) increased from 2011 to 2012 then stabilized over the following years (2012-14). Significant predictors of tourniquet use reported by the provider were identified and included demographic characteristics, EMS agency type, specific complaints, injury cause, injury anatomic location, chief complaint organ system, and primary symptom. CONCLUSION: Reported tourniquet use by EMS for injured patients in the U.S. is low. Increasing adoption mainly by urban services was noted. Predictors for tourniquet use in civilian trauma were identified. Establishing the effectiveness of this intervention by comparing patient outcomes is needed. Key words: emergency medical services; prehospital; tourniquet; injury; NEMSIS; hemorrhage.

Impact of intraoperative cholangiography on postoperative morbidity and readmission: analysis of the NSQIP database.

BACKGROUND: The debate regarding the merits of routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) continues to rage. We aim to analyze the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patterns of utilization of cholangiography during LC as well as its impact on patient outcomes. STUDY DESIGN: This is a retrospective cohort study of patients undergoing LC with or without IOC in the 2012 and 2013 ACS NSQIP database. Only patients without any preoperative biochemical evidence of the CBD stone were included in the analysis. Comparison between two groups and data analysis focused on the following primary outcomes: 30-day mortality, readmission, return to operating room and NSQIP collected morbidity. RESULTS: Twenty-one percentage of patients undergoing LC without any biochemical abnormality are undergoing IOC. There were no statistically significant differences in thirty-day outcomes between two patient populations with regard to mortality, morbidity, cardiac, central nervous system, wound, deep vein thrombosis, sepsis, respiratory and urinary tract complications. Patients undergoing LC plus IOC were found to have statistically significant reduction in the rate of readmission related to the first operation (adjusted odds ratio 0.80, 95 % CI 0.70-0.92; P value = 0.002). Readmissions related to biliary complications including retained CBD following cholecystectomy were 1.61 times more likely in patients who underwent LC without cholangiography. CONCLUSION: The use of IOC at the time of LC appears to be associated with a statistically significant decrease in re-admission rates, especially readmissions related to biliary complications.

Semaglutide (Ozempic®) Use in Denmark 2018 Through 2023 ‒ User Trends and off-Label Prescribing for Weight Loss.

Purpose: A surge in the use of semaglutide injection (Ozempic®) approved to treat type 2 diabetes (T2D) has led to a global supply shortage. We investigated contemporary user rates and clinical characteristics of semaglutide (Ozempic®) users in Denmark, and the extent of "off-label" prescribing for weight loss. Patients and Methods: Nationwide population-based cross-sectional study based on linked health registries January 2018 through December 2023. All adults who received a first prescription of semaglutide once weekly (Ozempic®) were included. We examined quarterly rates of new users and total user prevalences, using other glucagon-like peptide-1 receptor agonists and weight loss medications as comparison. We also investigated user characteristics including T2D, glucose control, comedications, and cardiorenal disease. Results: The new user rate of semaglutide (Ozempic®) remained stable at approximately 4 per 1000 adult person-years between 2019 and 2021 and then accelerated, peaking at 10 per 1000 in the first quarter of 2023 after which it declined sharply. User prevalence increased to 91,626 users in Denmark in 2023. The proportion of semaglutide (Ozempic®) new users who had a record of T2D declined from 99% in 2018 to only 67% in 2022, increasing again to 87% in 2023. Among people with T2D who initiated semaglutide (Ozempic®) in 2023, 52% received antidiabetic polytherapy before initiation, 39% monotherapy, and 8% no antidiabetic therapy. Most T2D initiators had suboptimal glucose control, with 83% having an HbA1c ≥48 mmol/mol and 68% ≥53 mmol/mol despite use of antidiabetic medication, and 29% had established atherosclerotic cardiovascular disease or kidney disease. Conclusion: The use of semaglutide (Ozempic®) in Denmark has increased dramatically. Although not approved for weight loss without T2D, one-third of new users in 2022 did not have T2D. Conversely, most initiators with T2D had a clear medical indication for treatment intensification, and "off-label" use can only explain a minor part of the supply shortage.

Real-World Use of Semaglutide for Weight Management: Patient Characteristics and Dose Titration-A Danish Cohort Study.

OBJECTIVE: To determine patient characteristics and dose titration patterns of real-world semaglutide (Wegovy) users. RESEARCH DESIGN AND METHODS: We used a population-based cohort study including Danish adults who filled semaglutide prescriptions from 12 December 2022 to 31 December 2023. Outcomes were patient characteristics, prescriber type, and dose titration patterns. RESULTS: We identified 110,748 individuals (median age 49 years; 70% female) filling 773,708 prescriptions for semaglutide. General practitioners initiated treatment in 86%. Common comorbidities included hypertension (30%), dyslipidemia (17%), and arthrosis (17%). Only 13% reached the maximum dose of 2.4 mg by their fifth prescription, while 5.7% stopped after the first prescription. Few users (10%) followed recommended dose increases every 4 weeks. Overall, 25% filled at least one prescription of 2.4 mg, while 33-48% continued with the 1.0-mg dosage from the fourth prescription onward. CONCLUSIONS: Real-world semaglutide users generally resembled trial participants, but few follow the dose titration schemes tested in premarket clinical trials.