Operative vs Nonoperative Management of Acute Cholecystitis During the Different Trimesters of Pregnancy.

Importance: Acute cholecystitis (AC) management during pregnancy requires balancing the risk of pregnancy loss or preterm delivery (adverse pregnancy outcomes [APOs]) with or without surgery. Guidelines recommend cholecystectomy across trimesters; however, trimester-specific evidence on the risks of AC and its management is lacking. Objective: To assess cholecystectomy frequency in pregnant people with AC, compare the rates of APOs in pregnant people with or without AC, and compare the rates of APOs in people with AC who did or did not undergo cholecystectomy. Design, Setting, and Participants: This retrospective, population-based cohort study used data for pregnant people with AC from the IBM MarketScan Commercial Claims and Encounters Database from January 1, 2007, to December 31, 2019, and a propensity score-matched cohort of pregnant people without AC. Trimester status (first [T1], second [T2], and third [T3]), APOs, and cholecystectomy were defined by administrative claims. Data were analyzed from October 2021 to July 2022. Exposures: Pregnant patients with or without AC. Pregnant patients with AC who did or did not receive cholecystectomy. Main Outcomes and Measures: The main outcomes were cholecystectomy during pregnancy and APOs (ie, preterm delivery and pregnancy loss). Pregnant patients with and without AC were compared to assess the association of AC with risk of APOs. Propensity score inverse-probability weighting was used to calculate treatment-associated APO risk among patients with 1-year follow-up. Results: The study included 5759 pregnant patients with AC (mean [SD] age, 30.1 [6.6] years) and 23 036 controls (mean [SD] age, 29.9 [6.7] years) after propensity score matching. Among 3426 pregnant patients with AC and 1-year follow-up, 1182 (34.5%) underwent cholecystectomy during the pregnancy (684 [41.7%] presenting with AC in T1, 404 [40.4%] in T2, and 94 [12.0%] in T3). Acute cholecystitis during pregnancy, irrespective of treatment, was associated with higher odds of APO compared with no AC during pregnancy across all trimesters (odds ratio [OR], 1.69 [95% CI, 1.54-1.85]). Compared with nonoperative management, receipt of surgery was associated with lower odds of APOs across all trimesters (OR, 0.75 [95% CI, 0.63-0.87]), in T1 (OR, 0.81 [95% CI, 0.66-1.00]), in T2 (OR, 0.71 [95% CI, 0.50-1.00]), and in T3 (OR, 0.45 [95% CI, 0.28-0.70]). Conclusions and Relevance: In this study, cholecystectomy was associated with lower risk of APO in patients with AC across all trimesters, with the greatest benefit in T3. However, only 34.5% overall and 12.0% of patients in T3 had a cholecystectomy. These findings support guidelines recommending cholecystectomy during pregnancy and should inform decision-making discussions. Greater guideline adherence and surgery use, especially in T3, may represent an opportunity to improve outcomes for pregnant people with AC.

Self-selection vs Randomized Assignment of Treatment for Appendicitis.

Importance: For adults with appendicitis, several randomized clinical trials have demonstrated that antibiotics are an effective alternative to appendectomy. However, it remains unknown how the characteristics of patients in such trials compare with those of patients who select their treatment and whether outcomes differ. Objective: To compare participants in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial (RCT) with a parallel cohort study of participants who declined randomization and self-selected treatment. Design, Setting, and Participants: The CODA trial was conducted in 25 US medical centers. Participants were enrolled between May 3, 2016, and February 5, 2020; all participants were eligible for at least 1 year of follow-up, with all follow-up ending in 2021. The randomized cohort included 1094 adults with appendicitis; the self-selection cohort included patients who declined participation in the randomized group, of whom 253 selected appendectomy and 257 selected antibiotics. In this secondary analysis, characteristics and outcomes in both self-selection and randomized cohorts are described with an exploratory analysis of cohort status and receipt of appendectomy. Interventions: Appendectomy vs antibiotics. Main Outcomes and Measures: Characteristics among participants randomized to either appendectomy or antibiotics were compared with those of participants who selected their own treatment. Results: Clinical characteristics were similar across the self-selection cohort (510 patients; mean age, 35.8 years [95% CI, 34.5-37.1]; 218 female [43%; 95% CI, 39%-47%]) and the randomized group (1094 patients; mean age, 38.2 years [95% CI, 37.4-39.0]; 386 female [35%; 95% CI, 33%-38%]). Compared with the randomized group, those in the self-selection cohort were less often Spanish speaking (n = 99 [19%; 95% CI, 16%-23%] vs n = 336 [31%; 95% CI, 28%-34%]), reported more formal education (some college or more, n = 355 [72%; 95% CI, 68%-76%] vs n = 674 [63%; 95% CI, 60%-65%]), and more often had commercial insurance (n = 259 [53%; 95% CI, 48%-57%] vs n = 486 [45%; 95% CI, 42%-48%]). Most outcomes were similar between the self-selection and randomized cohorts. The number of patients undergoing appendectomy by 30 days was 38 (15.3%; 95% CI, 10.7%-19.7%) among those selecting antibiotics and 155 (19.2%; 95% CI, 15.9%-22.5%) in those who were randomized to antibiotics (difference, 3.9%; 95% CI, -1.7% to 9.5%). Differences in the rate of appendectomy were primarily observed in the non-appendicolith subgroup. Conclusions and Relevance: This secondary analysis of the CODA RCT found substantially similar outcomes across the randomized and self-selection cohorts, suggesting that the randomized trial results are generalizable to the community at large. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Patient decision-making in symptomatic gallbladder disease.

BACKGROUND: One in five people with gallstones develop symptoms (~ 13 million in the US), yet only a fraction undergo cholecystectomy. The frequency of and factors associated with patients choosing medical management for gallbladder disease are not well understood. The goal of this study was to assess patient decision-making regarding cholecystectomy, experiences with medical management, and interest in a clinical trial comparing cholecystectomy with medical management. METHODS: We conducted a cross-sectional survey from January 2020 through May 2020 using Amazon's crowdsourcing platform, MTurk. After a brief screening survey to determine gallbladder disease history and cholecystectomy status, eligible users without prior cholecystectomy were invited to complete the full survey for US $2.50. RESULTS: There were 148 responses included in analysis (93.7% of attempted). Participants were 54% female with a mean age of 36.2 (SD 11.3) years. 36% of participants had used medications or supplements to manage their symptoms with 17% using lecithin and 22% using ursodeoxycholic acid (Ursodiol®). 85% attempted lifestyle modifications to manage symptoms. Surgery was recommended for 60% of which 43% reported planning cholecystectomy. Among those recommended operation, most common reasons for pursuing were symptoms (50%) and symptoms interfering with care of family (42%), while most common reasons for not pursuing were risks of surgery/anesthesia (56%), ongoing medical management (50%), and symptom tolerance (38%). 67% reported willingness to participate in a clinical trial comparing medical management to cholecystectomy. CONCLUSION: A significant portion of patients with symptomatic gallbladder disease choose not to undergo cholecystectomy. One of the most common reasons for avoiding surgery was the use of alternative therapies, despite limited evidence to support their use. The lack of prospective comparison of cholecystectomy to medical therapies for the management of gallbladder disease, along with patient interest, support the need for a clinical trial.

IWATE criteria are associated with perioperative outcomes in robotic hepatectomy: a retrospective review of 225 resections.

BACKGROUND: Robotic hepatectomy (RH) is increasingly utilized for minor and major liver resections. The IWATE criteria were developed to classify minimally invasive liver resections by difficulty. The objective of this study was to apply the IWATE criteria in RH and to describe perioperative and oncologic outcomes of RH over the last decade at our institution. METHODS: Perioperative and oncologic outcomes of patients who underwent RH between 2011 and 2019 were retrospectively collected. The difficulty level of each operation was assessed using the IWATE criteria, and outcomes were compared at each level. Univariate linear regression was performed to characterize the relationship between IWATE criteria and perioperative outcomes (OR time, EBL, and LOS), and a multivariable model was also developed to address potential confounding by patient characteristics (age, sex, BMI, prior abdominal surgery, ASA class, and simultaneous non-hepatectomy operation). RESULTS: Two hundred and twenty-five RH were performed. Median IWATE criteria for RH were 6 (IQR 5-9), with low, intermediate, advanced, and expert resections accounting for 23% (n = 51), 34% (n = 77), 32% (n = 72), and 11% (n = 25) of resections, respectively. The majority of resections were parenchymal-sparing approaches, including anatomic segmentectomies and non-anatomic partial resections. 30-day complication rate was 14%, conversion to open surgery occurred in 9 patients (4%), and there were no deaths within 30 days postoperatively. In the univariate linear regression analysis, IWATE criteria were positively associated with OR time, EBL, and LOS. In the multivariable model, IWATE criteria were independently associated with greater OR time, EBL, and LOS. Two-year overall survival for hepatocellular carcinoma and intrahepatic cholangiocarcinoma was 94% and 50%, respectively. CONCLUSION: In conclusion, the IWATE criteria are associated with surgical outcomes after RH. This series highlights the utility of RH for difficult hepatic resections, particularly parenchymal-sparing resections in the posterosuperior sector, extending the indication of minimally invasive hepatectomy in experienced hands and potentially offering select patients an alternative to open hepatectomy or other less definitive liver-directed treatment options.

"I Would Go if My Arm Were Hanging off": A Qualitative Study of Healthcare-Seeking Behaviors of Small Farm Owners in Central New York State.

Compared to their rural non-farming peers, farmers are less likely to access preventive healthcare services; however, the reasons for this disparity are poorly understood. We conducted semi-structured interviews with a total of 30 farm household members in central New York. Interview topics included farming identity, perceptions of one's health, past experiences with acute and preventive healthcare, and attitudes toward seeking healthcare services. Grounded Theory analysis of the interview transcripts revealed that (1) utilizing healthcare services is felt to be in conflict with the farming identity, (2) the need to conserve time and money for farm applications poses a barrier to healthcare utilization, (3) farmers decide to seek healthcare when they believe it is necessary to ensure survival of the farm, and (4) the decision to seek healthcare is most strongly driven by the presence of intolerable symptoms, prompting from others, and the perception that treatment will yield clear benefits. Efforts to increase farmers' utilization of healthcare services must address these considerations.

Symbolic Interactionism: A Framework for Understanding Risk-Taking Behaviors in Farm Communities.

Risk behaviors are key drivers of occupationally related injuries and illnesses, considerably impacting the uptake and success of injury interventions, technologies, and practices. This is certainly true in the agricultural sector, where farmers often ignore recommended safety practices or have even been known to disable safety technologies. Although research studies have characterized specific individual safety or risk behaviors, few studies have thoroughly examined farmers' risk and safety orientations or how these develop in response to environmental and societal exposures. This study utilizes data collected over the past decade with a variety of small to midsize farm personnel to explore the meanings that farmers ascribe to risk and safety and how these influence risk and safety behaviors. In all, over 90 interviews with farmers, farm-wives, and family members were reviewed. Researchers used a grounded theory approach to identify patterns of environmental and societal exposures, as well as their impact on farmers' risk and safety orientations. Analysis revealed exposures and orientations to risk and safety, which could be largely explained through the lens of symbolic interactionism. This framework posits that people create a sense-of-self as a way of adjusting and adapting to their environment. For farmers in this study, belief in their ability to persevere allows them to succeed, despite the considerable stressors and challenges they face each day. However, this identity can, at times, be maladaptive when it is applied to safety decisions and hazard exposures. The authors discuss the implications of this research and how it may be used to productively inform future farm safety efforts.

Protein carbonylation and adipocyte mitochondrial function.

Carbonylation is the covalent, non-reversible modification of the side chains of cysteine, histidine, and lysine residues by lipid peroxidation end products such as 4-hydroxy- and 4-oxononenal. In adipose tissue the effects of such modifications are associated with increased oxidative stress and metabolic dysregulation centered on mitochondrial energy metabolism. To address the role of protein carbonylation in the pathogenesis of mitochondrial dysfunction, quantitative proteomics was employed to identify specific targets of carbonylation in GSTA4-silenced or overexpressing 3T3-L1 adipocytes. GSTA4-silenced adipocytes displayed elevated carbonylation of several key mitochondrial proteins including the phosphate carrier protein, NADH dehydrogenase 1α subcomplexes 2 and 3, translocase of inner mitochondrial membrane 50, and valyl-tRNA synthetase. Elevated protein carbonylation is accompanied by diminished complex I activity, impaired respiration, increased superoxide production, and a reduction in membrane potential without changes in mitochondrial number, area, or density. Silencing of the phosphate carrier or NADH dehydrogenase 1α subcomplexes 2 or 3 in 3T3-L1 cells results in decreased basal and maximal respiration. These results suggest that protein carbonylation plays a major instigating role in cytokine-dependent mitochondrial dysfunction and may be linked to the development of insulin resistance in the adipocyte.