S157-a structured early intervention program in patients with predicted poor long-term outcome following bariatric surgery: a prospective randomized study.

BACKGROUND: Early postoperative weight loss can be predictive of one-year outcomes. It is unclear if poor performers identified in the first post-operative month can have improvement in outcomes with additional support and education. PURPOSE: To evaluate the impact of a structured targeted support program for patients with lower-than-average early post-operative weight loss on 1-year outcomes. METHODS: This was a prospective randomized study of bariatric surgery patients who experienced less than 50th percentile excess body weight loss (%EWL) at 3 weeks. Subjects with EWL < 18% were randomized into two groups: an intervention (IV) arm or a control (NI, no intervention) arm. The IV arm was offered a program with 7-weekly behavioral support sessions, while the NI patients received routine post-operative care. RESULTS: A total of 128 patients were randomized: 65 NI and 63 IV. In the IV group, 20 attended all sessions, 7 attended < 4, and 36 did not participate. There was no difference in baseline demographics, procedure type, or BMI. At 1 year, there was no difference in %EWL (ratio 0.993, 95% CI 0.873, 1.131), %EBMIL (ratio 0.997, 95% CI 0.875, 1.137), and %TWL (ratio 1.016, 95% CI 0.901, 1.146) between groups. A subgroup analysis including only the subjects who participated in all seven sessions showed similar results. CONCLUSION: Patients who present with suboptimal weight loss early after bariatric surgery do not experience a significant weight loss improvement with a structured behavioral support program. Importantly, despite being alerted to their poor early weight loss, patients demonstrated poor adherence to the proposed interventions.

Conversion of Adjustable Gastric Banding to Stapling Bariatric Procedures: Single- or Two-stage Approach.

OBJECTIVE: The aim of this study was to compare the safety of single- versus two-stage conversion of adjustable gastric band (AGB) to gastric bypass (RYGB) or sleeve gastrectomy (SG). SUMMARY BACKGROUND DATA: AGB patients often present for conversion to RYGB or SG. The impact of single- or two-stage approach of such conversion remains unclear. METHODS: A statewide database was used to identify all patients who underwent AGB removal and concurrent (single-stage) or interval (two-stage) RYGB or SG. Propensity score matching schemes were constructed to account for differences in baseline comorbidities and demographics, allowing for matched pairs available for comparisons. RESULTS: A total of 4330 patients underwent AGB conversion. Complications, readmissions, and ED visits were noted in 394 (9.1%), 278 (6.42%), and 589 (13.6%) patients, respectively. Three hundred sixty-seven matched pairs underwent RYGB; single-stage patients experienced shorter length of stay (LOS) (median difference -1 d, P < 0.0001), less complications [risk difference (RD): -8.4%, 95% confidence interval (CI), -13.4% to -3.5%], readmissions (RD: -5.2%, 95% CI, -9.6% to -0.8%), and ED visits (RD: -5.7%, 95% CI, -11.3% to -0.2%). Eight hundred seventy-five matched pairs underwent SG; single-stage patients experienced improved outcomes in all measures examined. For single-stage procedures (809 pairs), RYGB was associated with longer LOS, and more complications (RD: 3.3%, 95% CI, 0.9%-5.8%), with similar readmissions, and ED visits. CONCLUSIONS: AGB conversion procedures have low morbidity. Single-stage conversion is associated with lower morbidity compared with the two-stage approach. Conversion to SG seems to be safer than RYGB.

Clinical course of patients presenting to the emergency department with small bowel obstruction in New York State.

INTRODUCTION: Small Bowel Obstruction (SBO) is a common reason for emergency department (ED) visits in the United States. However, little is known regarding the clinical course of these patients. This study aims to identify all patients presenting to the ED in New York State with SBO and follow their clinical course. METHODS: The New York SPARCS administrative database was used to identify all patients who presented to an ED with the diagnosis of SBO from 2012 to 2014. Patients were followed to identify discharges from the ED, admissions, operations, 30-day readmissions, transfers, and in-hospital death. RESULTS: Between 2012 and 2014, 43,567 ED visits (events) from 35,646 patients were identified, with 2824 (6.5%) resulting in direct discharge from the ED. A majority (n = 31,193; 71.6%) of ED visits were admitted to the presenting institution without surgery, while 7673 (17.6%) were admitted and underwent surgery. A minority (n = 1947; 4.5%) were transferred to a tertiary center. The overall 30-day readmission rate was 17.9%. Those who underwent surgery were more likely to experience in-hospital death but less likely to have 30-day readmission. CONCLUSION: To our knowledge, this is the first study that examines the disposition of all patients presenting to the ED with SBO in a large statewide cohort. The majority of admitted patients underwent non-operative management, with overall low rates of readmission, transfer, and in-hospital death.

Incidence of colon resections is increasing in the younger populations: should an early initiation of colon cancer screening be implemented?

INTRODUCTION: The American Cancer Society recently lowered the recommended age for screening of colorectal cancer (CRC) to age 45 due to recent data showing increased incidence of CRC in younger populations. The purpose of this study was to evaluate if younger patients have increased likelihood of resection for CRC through the use of a statewide longitudinal database. METHODS: The New York SPARCS administrative database was used to identify all patients with diagnosis of colon cancer undergoing colorectal resections from 2000 to 2016. Patients were divided into seven age groups. Patients' characteristics, demographics, co-morbidities, and complications were evaluated. Chi-square test was used to compare patients' characteristics, comorbidities and complications among age groups. The linear trend of colon resection in different age groups over years was examined using log-linear Poisson regression models with year as an explanatory variable, as well as using multivariable logistic regression models after adjusting for patients' gender, race, payment, region, any comorbidity and any complication. RESULTS: There were 73,697 colon resection surgeries extracted from 2000 to 2016. Younger age was significantly associated with increased colorectal cancer resection over time. Patients age 21-70 had a significantly increasing trend over the years (age group 21-30: RR 1.06, p-value < 0.0001; age group 31-40: RR 1.04, p < 0.0001; age group 41-50: RR 1.04, p < 0.0001; age group 51-60: RR 1.02. p < 0.0001); age group 61-70: RR 1.01, p = 0.0012). Patient age > 70 was significantly associated with decreasing trend of colorectal cancer resection over the years (age group 71-80: RR 0.98, p < 0.0001 and age group > 80: RR 0.99, p-value < 0.0001). Such trends also existed after further adjustment for patients' characteristics, any comorbidity and any complication. CONCLUSION: Over the years, younger patients have an increased trend of undergoing colorectal resections for cancer, with up to a 6% yearly increase over the studied period. New screening initiation guidelines should be considered and awareness among clinicians and the general public should be increased.

Evaluating readmissions following laparoscopic cholecystectomy in the state of New York.

INTRODUCTION: Hospital readmissions constitute an important component of associated costs of a disease and can contribute a significant burden to healthcare. The majority of studies evaluating readmissions following laparoscopic cholecystectomy (LC) comprise of single center studies and thus can underestimate the actual incidence of readmission. We sought to examine the rate and causes of readmissions following LC using a large longitudinal database. METHODS: The New York SPARCS database was used to identify all adult patients undergoing laparoscopic cholecystectomy for benign biliary disease between 2000 and 2016. Due to the presence of a unique identifier, patients with readmission to any New York hospital were evaluated. Planned versus unplanned readmission rates were compared. Following univariate analysis, multivariable logistic regression model was used to identify risk factors for unplanned readmissions after accounting for baseline characteristics, comorbidities and complications. RESULTS: There were 591,627 patients who underwent LC during the studied time period. Overall 30-day readmission rate was 4.94% (n = 29,245) and unplanned 30-days readmission rate was 4.58% (n = 27,084). Female patients were less likely to have 30-day unplanned readmissions. Patients with age older than 65 or younger than 29 were more likely to have 30-day unplanned readmissions compared to patients with age 30-44 or 45-64. Insurance status was also significant, as patients with Medicaid/Medicare were more likely to have unplanned readmissions compared to commercial insurance. In addition, variables such as Black race, presence of any comorbidity, postoperative complication, and prolonged initial hospital length of stay were associated with subsequent readmission. CONCLUSION: This data show that readmissions rates following LC are relatively low; however, majority of readmissions are unplanned. Most common reason for unplanned readmissions was associated with complications of the procedure or medical care. By identifying certain risk groups, unplanned readmissions may be prevented.

Examining the underpinnings of loudness dependence of auditory evoked potentials with positron emission tomography.

Loudness dependence of auditory evoked potentials (LDAEP) has long been considered to reflect central basal serotonin transmission. However, the relationship between LDAEP and individual serotonin receptors and transporters has not been fully explored in humans and may involve other neurotransmitter systems. To examine LDAEP's relationship with the serotonin system, we performed PET using serotonin-1A (5-HT1A) imaging via [11C]CUMI-101 and serotonin transporter (5-HTT) imaging via [11C]DASB on a mixed sample of healthy controls (n â€‹= â€‹4: 4 females, 0 males), patients with unipolar (MDD, n â€‹= â€‹11: 4 females, 7 males) and bipolar depression (BD, n â€‹= â€‹8: 4 females, 4 males). On these same participants, we also performed electroencephalography (EEG) within a week of PET scanning, using 1000 â€‹Hz tones of varying intensity to evoke LDAEP. We then evaluated the relationship between LDAEP and 5-HT1A or 5-HTT binding in both the raphe (5-HT1A)/midbrain (5-HTT) areas and in the temporal cortex. We found that LDAEP was significantly correlated with 5-HT1A positively and with 5-HTT negatively in the temporal cortex (p â€‹< â€‹0.05), but not correlated with either in midbrain or raphe. In males only, exploratory analysis showed multiple regions in which LDAEP significantly correlated with 5-HT1A throughout the brain; we did not find this with 5-HTT. This multimodal study partially validates preclinical models of a serotonergic influence on LDAEP. Replication in larger samples is necessary to further clarify our understanding of the role of serotonin in perception of auditory tones.

Early cholecystectomy (< 72 h) is associated with lower rate of complications and bile duct injury: a study of 109,862 cholecystectomies in the state of New York.

INTRODUCTION: The timing of cholecystectomy for acute cholecystitis has been debated with most studies favoring early cholecystectomy (< 72 h of onset). However, most reported studies are from single institution studies with only a few population-based studies. The purpose of this study is to compare clinical outcomes of patients undergoing cholecystectomy within 72 h of emergency department (ED) presentation to patients undergoing cholecystectomy following 72 h in a large statewide database. METHODS: The New York SPARCS administrative database was used to identify all adult patients presenting to the ED with a diagnosis of acute cholecystitis from 2005 to 2016. Patients aged < 18, missing data, or other biliary diagnoses were excluded from the analysis. Early cholecystectomy was defined as within 72 h of presentation to the emergency department. Early vs late groups were compared in terms of overall complications, bile duct injury (BDI), hospital length of stay (LOS), 30-days ED visits and readmissions. The linear trends of yearly early/late cholecystectomies were examined using a log-linear Poisson regression models. Multivariable logistic regression model was used to compare complications, BDI, and 30-day readmission/ED visits after controlling for confounding factors. Multivariable generalized linear regression for a negative binomial distributed count data was used to compare LOS. RESULTS: Following the application of the inclusion/exclusion criteria, there were 109,862 patients who presented to an ED with the diagnosis of acute cholecystitis. The majority of patients underwent early cholecystectomy (n = 93,761, 85.3%), whereas only 16,101 patients underwent late cholecystectomy (14.7%). There was an increasing trend of early cholecystectomy from 2005 (81.1%) to 2016 (87.8%). On multivariable regression, patients with early cholecystectomy were less likely to have complications (OR 0.542, 95% CI 0.518-0.566), had shorter LOS (ratio 0.461, 95% CI 0.458-0.465), were less likely to have 30-day readmission (OR 0.871, 95% CI 0.816-0.928), 30-day ED visits (OR 0.909, 95% CI 0.862-0.959), and bile duct injury (OR 0.654, 95% CI 0.444-0.962) compared to late cholecystectomy patients. CONCLUSION: Early cholecystectomy (< 72 h) is associated with fewer complications, specifically BDI, shorter LOS, and fewer 30-day readmissions and ED visits. For patients presenting to the ED for acute cholecystitis, early cholecystectomy should be preferred.

Preoperative anticoagulation in patients undergoing bariatric surgery is associated with worse outcomes.

INTRODUCTION: Management of patients on chronic anticoagulation (AC) in bariatric surgery may present a challenge, as there is a delicate balance between risks of bleeding and thrombotic events, such as deep vein thrombosis (DVT) and pulmonary embolism (PE). The purpose of this study was to evaluate and compare rates of bleeding, thrombotic events, and outcomes of patients on preoperative AC during bariatric surgery. METHODS: The MBSAQIP data sets for 2015 and 2016 was used to identify all patients undergoing adjustable gastric banding (AGB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB). Clinical outcomes included length of stay, 30-day readmission, 30-day reoperations and interventions, perioperative and 30-day death events, need for transfusion, PE, and DVT. Following univariate analysis, multivariable logistic regression models and generalized linear regression model for a negative binomial distributed count outcomes were used after adjusting for surgery type and other factors related to each outcome. RESULTS: There were 269,243 records extracted, as there were 6541 (2.43%) patients on preoperative AC. Rates of transfusion, DVT, and PE were 0.67%, 0.18%, and 0.11%. Following multivariable logistic regression, patients with preoperative AC had higher risks of bleeding and DVT (OR 2.7, 95% CI 2.3-3.3, p-value < 0.0001 and OR 2.8, 95% CI 1.9-4, p-value < 0.0001, respectively). In addition, patients with pre-op AC had a higher risk of 30-day readmission (OR 2.1, 95% CI 1.9-2.3, p < 0.0001)/reoperation (OR 1.5, 95% CI 1.2-1.7, p < 0.0001)/reintervention (OR 2.1, 95% CI 1.8-2.4, p < 0.0001), mortality (OR 2.9, 95% CI 2.04-4.069, p < 0.0001), and longer LOS (ratio 1.2, 95% CI 1.199-1.241, p < 0.0001). CONCLUSION: Patients with preoperative AC had worse postoperative outcomes. Bariatric surgeons should be aware of the increased morbidity and mortality, and care must be taken to improve outcomes through close attention to postoperative AC protocols in this group of patients.

Does the adoption of an emergency general surgery service model influence volume of cholecystectomies at a tertiary care center.

INTRODUCTION: The purpose of this study was to evaluate the rate of cholecystectomy before and after adoption of an emergency general surgery (EGS) model at our institution. METHODS: A longitudinal, observational study was conducted prior to and following introduction of an EGS model at our institution. Using the New York SPARCS Administrative Database, all adult patients presenting to the emergency department with gallbladder-related emergencies were identified. The rates of laparoscopic and open cholecystectomies performed 3 years prior and 3 years following the adoption of the EGS model were examined. A multivariable logistic regression model was used to compare the incidence of cholecystectomy at initial ED visit at our institution pre- and post-EGS introduction as well as to those in the rest of the state as an external control group, while adjusting for potentially confounding factors. RESULTS: There were 176,159 total ED visits of patients with gallbladder emergencies (154,743 excluding repeat presenters) in the studied period in NY State. Of these, 63,912 patients (41.3%) had a concurrent cholecystectomy in NY State. The rate of cholecystectomy at these institutions remained relatively steady from 38.8% from 2010 to 2013 and 38.6% from 2013 to 2016. At our institution, there were 2039 gallbladder emergencies, and of those 755 underwent cholecystectomy. At our institution, there was an increase from 28.21% 3 years prior to the adoption of the EGS model to 40.2% in the following 3 years (RR = 1.06, 95% CI 1.0164-1.1078, p = 0.0069). CONCLUSION: The initiation of the EGS model at a tertiary center was associated with a significant increase in the number of concurrent cholecystectomies from 28.21 to 40.2% over a 6-year period. This change was accompanied by an increase in the number of patient comorbidities and a lower insurance status.

Severity of heterotopic ossification in patients following surgery for hip fracture: a retrospective observational study.

BACKGROUND: Heterotopic ossification (HO) is a relatively common complication following hip surgery treated with open reduction and internal fixation, total arthroplasty or hemiarthroplasty. Development of HO after hip surgery is an important clinical issue as it can affect functional status. We aimed to determine whether there was association between severity of heterotopic ossification about the hip and the interval between the time of hip fracture and surgery. MATERIALS AND METHODS: Our retrospective study included 151 patients (age range 33-95 years) treated for hip fractures by hemiarthroplasty. Medical records were reviewed for time interval to surgery, laterality, surgical approach, and patient age. Patients who had any post-operative complications were excluded. Radiographs were semiquantitatively assessed for the degree of heterotopic ossification based on Brooker Classification (5-point scale). Statistical analysis was performed utilizing Chi-square, Kruskal-Wallis, and Score tests, and also a proportional odds model (significance level set at 0.05). RESULTS: Thirty eight patients had no heterotopic ossification, 43 had class 1, 55 had class 2, and 15 had class 3 or greater heterotopic ossification. The majority of patients (59.6%) had surgery within 2 days of acute injury. Severe heterotopic ossification (HO 3+) was associated with the longer interval between the time of acute hip fracture and surgery (median 6 days) vs. median 2 days in all other groups (HO classes 0-2) (p = 0.0015). The odds ratio and 95% CI for one level higher HO class was 1.296 (1.152, 1.459), which meant that the odds of having HO class one level higher increased by about 29.6% for every one-day increase in the days to surgery. No significant association was found for other variables. CONCLUSION: Class 3 or greater HO was associated with longer time interval between time of acute hip fracture and surgery compared to all other groups (HO class 0-2).

Increasing bile duct injury and decreasing utilization of intraoperative cholangiogram and common bile duct exploration over 14 years: an analysis of outcomes in New York State.

INTRODUCTION: During laparoscopic cholecystectomy (LC), common bile duct (CBD) visualization either directly or with cholangiography (IOC) is less routine. Cholangiography can be used to identify and possibly prevent bile duct injury (BDI), which is a dreaded complication of cholecystectomy. The purpose of our study was to evaluate the trend of IOC/CBD exploration and BDI during LC for benign disease. METHODS: A state-wide database (SPARCS) was used to identify all LC for benign biliary non-obstructive and obstructive disease between 2000 and 2014 in the state of New York. ICD-9 and CPT codes were used to identify IOC/CBD exploration and BDI. Multivariable logistic regression models were used in examining the linear trend in the risk of complication, 30-day readmission, 30-day ED visits, and BDI among all cholangiogram patients after controlling for possible confounding factors. RESULTS: During 2000-2014, 391,945 patients underwent laparoscopic cholecystectomy. The trend of IOC/CBD exploration performed significantly decreased for LC overall (12.37-10.44%, relative risk = 0.98, p <.0001) and particularly, in the outpatient setting (10.77-7.52%, relative risk = 0.96, p value <.0001). Among patients with IOC, overall complication rate, 30-day readmission rate, and 30-day ED visit rates increased. When looking at overall complication rate, there was an increase by about 4% per year (relative risk = 1.04, p value <.0001). After controlling for confounding factors, the complication risk and 30-day ED visit risk increased through years, while the 30-day readmission risk did not have significant change. Risk of BDI also increased significantly (p = 0.03). CONCLUSION: In an era of laparoscopy, the rate of IOC/CBD exploration during LC has significantly decreased, while BDI significantly increased.

What happens to biliary colic patients in New York State? 10-year follow-up from emergency department visits.

INTRODUCTION: Biliary colic is a common diagnosis for patients presenting to the emergency department (ED). The purpose of this study is to examine the outcomes of patients coming to the ED with biliary colic. METHODS: The NYS longitudinal SPARCS database was used to identify patients presenting to the ED with biliary colic from 2005 to 2014. Through the use of a unique identifier, patients were followed in NYS across multiple institutions. Patients who were lost to follow-up, with duplicated records, and those that underwent percutaneous cholecystectomy tubes were excluded from the analysis. RESULTS: Between 2005 and 2014, there were 72,376 patients who presented to an ED with biliary colic. The admission rate was 20.7-26.02%. Overall, most patients who presented to the ED did not undergo surgery (39,567, 54.7%), of which 35,204 (89%) had only one ED visit, while 4,363(11%) returned to the ED (≥ 2 visits). Only 3.23-5.51% of patients underwent cholecystectomy at the time of initial presentation. Most subsequent cholecystectomies were performed electively (27.38-52.51%) (See Table 1 in this article). Average time to surgery among patients with elective cholecystectomy was 178.4 days. From the patients who underwent cholecystectomy, 10.35% had cholecystectomy at their first ED visit, 77.7% had cholecystectomy following the first ED visit, and 12% had multiple ED visits prior to surgery. Among patients who were discharged from the ED, 32% had their surgery at a different hospital than index presentation. CONCLUSION: A significant portion of patients (48.6%) who present to the ED with biliary colic will not return or have surgery within 5 years. A third of patients who eventually undergo cholecystectomy will go to another hospital for their surgery.

Academic medicine's glass ceiling: Author's gender in top three medical research journals impacts probability of future publication success.

INTRODUCTION: In December 2017, Lancet called for gender inequality investigations. Holding other factors constant, trends over time for significant author (i.e., first, second, last or any of these authors) publications were examined for the three highest-impact medical research journals (i.e., New England Journal of Medicine [NEJM], Journal of the American Medical Association [JAMA], and Lancet). MATERIALS AND METHODS: Using randomly sampled 2002-2019 MEDLINE original publications (n = 1,080; 20/year/journal), significant author-based and publication-based characteristics were extracted. Gender assignment used internet-based biographies, pronouns, first names, and photographs. Adjusting for author-specific characteristics and multiple publications per author, generalized estimating equations tested for first, second, and last significant author gender disparities. RESULTS: Compared to 37.23% of 2002 - 2019 U.S. medical school full-time faculty that were women, women's first author publication rates (26.82% overall, 15.83% NEJM, 29.38% Lancet, and 35.39% JAMA; all p < 0.0001) were lower. No improvements over time occurred in women first authorship rates. Women first authors had lower Web of Science citation counts and co-authors/collaborating author counts, less frequently held M.D. or multiple doctoral-level degrees, less commonly published clinical trials or cardiovascular-related projects, but more commonly were North American-based and studied North American-based patients (all p < 0.05). Women second and last authors were similarly underrepresented. Compared to men, women first authors had lower multiple publication rates in these top journals (p < 0.001). Same gender first/last authors resulted in higher multiple publication rates within these top three journals (p < 0.001). DISCUSSION: Since 2002, this authorship "gender disparity chasm" has been tolerated across all these top medical research journals. Despite Lancet's 2017 call to arms, furthermore, the author-based gender disparities have not changed for these top medical research journals - even in recent times. Co-author gender alignment may reduce future gender inequities, but this promising strategy requires further investigation.

Metagenomic and bile acid metabolomic analysis of fecal microbiota transplantation for recurrent Clostridiodes difficile and/or inflammatory bowel diseases.

Background: Fecal microbiota transplantation (FMT) is an effective treatment of recurrent Clostridioides difficile infections (rCDI), but has more limited efficacy in treating either ulcerative colitis (UC) or Crohn's disease (CD), two major forms of inflammatory bowel diseases (IBD). We hypothesize that FMT recipients with rCDI and/or IBD have baseline fecal bile acid (BA) compositions that differ significantly from that of their healthy donors and that FMT will normalize the BA compositions. Aim: To study the effect of single colonoscopic FMT on microbial composition and function in four recipient groups: 1.) rCDI patients without IBD (rCDI-IBD); 2.) rCDI with IBD (rCDI+IBD); 3.) UC patients without rCDI (UC-rCDI); 4.) CD patients without rCDI (CD-rCDI). Methods: We performed 16S rRNA gene sequence, shotgun DNA sequence and quantitative bile acid metabolomic analyses on stools collected from 55 pairs of subjects and donors enrolled in two prospective single arm FMT clinical trials (Clinical Trials.gov ID NCT03268213, 479696, UC no rCDI ≥ 2x IND 1564 and NCT03267238, IND 16795). Fitted linear mixed models were used to examine the effects of four recipient groups, FMT status (Donor, pre-FMT, 1-week post-FMT, 3-months post-FMT) and first order Group*FMT interactions on microbial diversity and composition, bile acid metabolites and bile acid metabolizing enzyme gene abundance. Results: The pre-FMT stools collected from rCDI ± IBD recipients had reduced α-diversity compared to the healthy donor stools and was restored post-FMT. The α-diversity in the pre-FMT stools collected from UC-rCDI or CD-rCDI recipients did not differ significantly from donor stools. FMT normalized some recipient/donor ratios of genus level taxa abundance in the four groups. Fecal secondary BA levels, including some of the secondary BA epimers that exhibit in vitro immunomodulatory activities, were lower in rCDI±IBD and CD-rCDI but not UC-rCDI recipients compared to donors. FMT restored secondary BA levels. Metagenomic baiE gene and some of the eight bile salt hydrolase (BSH) phylotype abundances were significantly correlated with fecal BA levels. Conclusion: Restoration of multiple secondary BA levels, including BA epimers implicated in immunoregulation, are associated with restoration of fecal baiE gene counts, suggesting that the 7-α-dehydroxylation step is rate-limiting.

Analyzing the Efficacy of Isotretinoin in Treating Dissecting Cellulitis: A Literature Review and Meta-Analysis.

BACKGROUND AND OBJECTIVE: Dissecting cellulitis of the scalp is a primary scarring alopecia. Isotretinoin is commonly referenced in the literature as a treatment for dissecting cellulitis. The objective of this article was to conduct a review and meta-analysis to assess the efficacy of isotretinoin for treating dissecting cellulitis of the scalp. METHODS: The following databases were searched for articles prior to 23 June, 2019: PubMed, Embase, Cochrane Central, CINAHL, and Web of Science. Multi-patient studies (more than three) that reported on the administration of isotretinoin for dissecting cellulitis were included. A pooled meta-analysis for improvement of disease burden after isotretinoin administration in patients with dissecting cellulitis of the scalp was performed. A fixed-effects model was used. RESULTS: Five articles were ultimately used for the quantitative meta-analysis. The overall efficacy rate of isotretinoin in treating dissecting cellulitis of the scalp was estimated to be 0.9 with a 95% confidence interval (0.81-0.97). The sensitivity analysis suggested that the overall efficacy is still very high, with a range of 0.83-0.94. Recurrence was seen in 24% (6/25) of patients. Common associated diseases amongst patients with dissecting cellulitis of the scalp were acne conglobata 20% (30/151) and hidradenitis suppurativa 19% (11/72). CONCLUSIONS: Isotretinoin is an effective treatment for improving symptoms of dissecting cellulitis of the scalp. Disease recurrence is a common finding for those who undergo successful treatment.

Impact of preoperative antibiotics and other variables on integrated microbiome-host transcriptomic data generated from colorectal cancer resections.

BACKGROUND: Integrative multi-omic approaches have been increasingly applied to discovery and functional studies of complex human diseases. Short-term preoperative antibiotics have been adopted to reduce site infections in colorectal cancer (CRC) resections. We hypothesize that the antibiotics will impact analysis of multi-omic datasets generated from resection samples to investigate biological CRC risk factors. AIM: To assess the impact of preoperative antibiotics and other variables on integrated microbiome and human transcriptomic data generated from archived CRC resection samples. METHODS: Genomic DNA (gDNA) and RNA were extracted from prospectively collected 51 pairs of frozen sporadic CRC tumor and adjacent non-tumor mucosal samples from 50 CRC patients archived at a single medical center from 2010-2020. The 16S rRNA gene sequencing (V3V4 region, paired end, 300 bp) and confirmatory quantitative polymerase chain reaction (qPCR) assays were conducted on gDNA. RNA sequencing (IPE, 125 bp) was performed on parallel tumor and non-tumor RNA samples with RNA Integrity Numbers scores ≥ 6. RESULTS: PERMANOVA detected significant effects of tumor vs nontumor histology (P = 0.002) and antibiotics (P = 0.001) on microbial ß-diversity, but CRC tumor location (left vs right), diabetes mellitus vs not diabetic and Black/African Ancestry (AA) vs not Black/AA, did not reach significance. Linear mixed models detected significant tumor vs nontumor histology*antibiotics interaction terms for 14 genus level taxa. QPCR confirmed increased Fusobacterium abundance in tumor vs nontumor groups, and detected significantly reduced bacterial load in the (+)antibiotics group. Principal coordinate analysis of the transcriptomic data showed a clear separation between tumor and nontumor samples. Differentially expressed genes obtained from separate analyses of tumor and nontumor samples, are presented for the antibiotics, CRC location, diabetes and Black/AA race groups. CONCLUSION: Recent adoption of additional preoperative antibiotics as standard of care, has a measurable impact on -omics analysis of resected specimens. This study still confirmed increased Fusobacterium nucleatum in tumor.

Incidence of GERD, esophagitis, Barrett's esophagus, and esophageal adenocarcinoma after bariatric surgery.

BACKGROUND: Some bariatric procedures have been associated with increased gastroesophageal reflux disease (GERD) symptoms; however, there are limited data on the long-term changes to the esophagus across bariatric procedures, and how preoperative esophageal disease is impacted by bariatric surgery. OBJECTIVES: To estimate incidence of GERD, esophagitis, Barrett's esophagus, and esophageal adenocarcinoma before and after bariatric surgery and to identify potential risk factors for these conditions. SETTING: Retrospective analysis of New York State Database (SPARCS). METHODS: Adult patients undergoing bariatric surgery (Roux-en-Y gastric bypass, adjustable gastric banding, laparoscopic sleeve gastrectomy, and biliopancreatic diversion) from 1995 to 2010. Multivariable Cox proportional hazard models were used to examine the association between preoperative diagnosis, surgery type, and postoperative diagnosis. RESULTS: A total of 48,967 records were analyzed; 30.3% had a diagnosis of GERD at the time of surgery and .4% had a diagnosis of esophagitis and Barrett's. Preoperative GERD/esophagitis/Barrett's was associated with higher risk of GERD, esophagitis, and Barrett's, but not esophageal adenocarcinoma, postoperatively. Roux-en-Y gastric bypass patients had lowest risk of being diagnosed with GERD postoperatively. Overall, esophageal adenocarcinoma incidence in the sample was .04%; the rate among patients with preoperative GERD and Barrett's was .1% and .9%, respectively. Incidence of esophageal adenocarcinoma did not differ by bariatric surgery type. CONCLUSIONS: Preoperative diagnosis is a risk factor for postoperative esophageal disease after bariatric surgery. Adjustable gastric banding and laparoscopic sleeve gastrectomy are associated with higher risk of postoperative GERD and esophagitis compared with Roux-en-Y gastric bypass. Incidence of esophageal adenocarcinoma did not differ by surgery type.

Hospital utilization 4 years after bariatric surgery: sleeve gastrectomy versus Roux-en-Y gastric bypass.

BACKGROUND: While sleeve gastrectomy (SG) has lower perioperative risk compared with Roux-en-Y gastric bypass (RYGB), long-term data about their differential impact on overall health are unclear. Hospital use after bariatric surgery is an important parameter for improving peri- and postoperative care. OBJECTIVE: This present study was aimed to compare SG and RYGB in terms of their effect on long-term hospital-based healthcare utilization. SETTING: Multicenter, statewide database. METHODS: A retrospective cohort study of adult patients who underwent SG and RYGB between 2009 and 2011, with follow-up until 2015 and 2-year presurgery information. Propensity score-matched SG and RYGB groups were created using preoperative demographic characteristics, co-morbidities, and presurgery hospital use, measured by cumulative length of stay (LOS) and frequency of emergency department visits. Postsurgery yearly LOS, incidence of hospital visits, and the reason for the visit were compared. Primary outcomes included postoperative hospital visits during years 1 to 4 after bariatric surgery and cumulative LOS. Secondary outcomes included specific reasons for hospital use. RESULTS: There were 3540 SG and 13,587 RYGB patients, whose mean (95% confidence interval [CI]) LOS was 1.3 (1.3-1.4), .9 (.8-1), 1 (.9-1.1), and 1.2 (1-1.3) days at years 1 through 4, respectively. Postoperative yearly LOS was similar between the 2 propensity-matched groups. The risk of hospitalizations (odd ratio .73, 95% CI .64-.84, P < .0001) and emergency department visits (odds ratio .84, 95% CI .75-.95, P = .005) was significantly lower for SG, during the first postoperative year. The reverse was seen at the fourth postoperative year, with higher risk of emergency department use after SG (odds ratio 1.16, 95% CI 1.01-1.33, P = .035). CONCLUSION: Postoperative 4-year hospital utilization remains low for both SG and RYGB. The previously established lower early perioperative risk of SG was not appreciated for longer-term hospital use compared with RYGB.

Increases in Postmastectomy Reconstruction in New York State Are Not Related to Changes in State Law.

BACKGROUND: Postmastectomy reconstruction remains underused. In 2011, new legislation in New York State mandated discussion of reconstructive options before mastectomy. This study assesses the impact of this policy on immediate breast reconstruction rates. METHODS: The Statewide Planning and Research Cooperative System database was queried to identify women undergoing mastectomy from January of 2005 to October of 2015 and follow them for at least 1 year postoperatively to determine the incidence and timing of reconstruction. Demographic and socioeconomic characteristics were collected. Chi-square test and multivariable logistic regression were used to compare periods before (2005 to 2010) and after (2011 to 2015) the legislative change. RESULTS: Of 52,837 records, there were 24,340 patients (46 percent) who underwent immediate breast reconstruction. The incidence of immediate breast reconstruction increased over the study period, most significantly in 2008 to 2009. Rates of immediate breast reconstruction continued to increase, although at a slower rate, after 2011 compared with before 2011 across all subgroups. Both implant and autologous reconstructive techniques increased over time. Implant-based reconstruction increased steadily, whereas autologous reconstruction increased most significantly between 2008 and 2009. CONCLUSIONS: Despite an overall increase in immediate breast reconstruction, there was an overall lack of effect on post-2011 reconstructive rates attributable to the legislative changes. Reconstructive rates have increased significantly in New York State over the past decade, and these changes appear to be largely independent of the 2011 New York State Breast Reconstruction Act. There are likely nonlegislative drivers of breast reconstruction use.

Disparities in death rates in women with peripartum cardiomyopathy between advanced and developing countries: A systematic review and meta-analysis.

There is limited information about differences in maternal deaths from peripartum cardiomyopathy (PPCM) between advanced and developing countries. To review the literature to define the global prevalence of death from PPCM, and to determine the differences in PPCM mortality rates and risk factors between advanced and developing countries. Studies in the English language reporting mortality data on patients with PPCM were included from searches of MEDLINE, Embase, CINAHL, the Cochrane Library, the Web of Science Core Collection and Scopus from 01 January 2000 to 11 May 2016. Of the 4294 articles identified, 1.07% were included. The primary outcome was death; rates of heart transplant, acute myocardial infarction, heart failure, arrhythmia, cerebrovascular events, embolism and cardiac arrest were recorded. Studies were categorized as having been conducted in advanced or developing countries. Data from 46 studies, 4925 patients and 13 countries were included. There were 22 studies from advanced countries (n=3417) and 24 from developing countries (n=1508); mean follow-up was 2.6 (range 0-8.6) years. Overall mortality prevalence was 9% (95% confidence interval [CI] 6-11%). The mortality rate in developing countries (14%, 95% CI 10-18%) was significantly higher than that in advanced countries (4%, 95% CI 2-7%). There was no difference in the prevalence of risk factors (chronic hypertension, African descent, multiple gestation and multiparity) between advanced and developing countries. Studies with a higher prevalence of women of African descent had higher death rates (correlation coefficient 0.29, 95% CI 0.13-0.52). The risk of death in women with PPCM was higher in developing countries than in advanced countries. Women of African descent had an increased risk of death.