Gender Inequity in the Clinical Setting.

Women in surgery continue to face inequitable treatment from surgical leadership, their peers, hospital staff, and even from their patients. Despite this, women surgeons continue to produce equal, or improved, clinical outcomes for their patients, with their work being given less remuneration than that of their male peers. The cultural stereotypes and biases that drive these inequities are implicit and subtle; however, they have dramatic effects on the lives and careers of women surgeons.

Patterns of care after cholecystostomy tube placement.

BACKGROUND: The use of cholecystostomy (c-tube) in acute cholecystitis (AC) has increased yet there is limited evidence to guide surgical decision-making after placement. As a result, there is variability in the use and timing of cholecystectomy after c-tube. We aimed to describe patient characteristics, outcomes, and biliary-related utilization in those who did and did not have cholecystectomy after c-tube. METHODS: This is a retrospective cohort study (2007-2017) using the MarketScan® claims database of patients (18-63 years) with at least 3 months of follow-up (or death). ICD-9/10 and CPT codes were used to identify AC, c-tube placement, cholecystectomy and determine Elixhauser comorbidity index. RESULTS: A total of 2386 patients (47.5% female, mean age 52.5 [SD 9.9] years) with AC underwent c-tube with an 11.2% 90-day mortality. Among survivors, by three months 57% underwent cholecystectomy (mean 34.8 days [95% CI: 33.3-36.3]). Cholecystectomy after c-tube was more common in those with fewer comorbid conditions (mean 2.41 [95% CI: 2.26-2.56] vs 4.56 [95%CI: 4.36-4.76]). Biliary episodes prior to cholecystectomy occurred in 12.5% and were associated with eventual cholecystectomy (HR 1.49 [1.32-1.68]). Biliary-specific hospital and ICU days were similar between groups. Biliary-specific ED visits were more common among patients with cholecystectomy (mean 1.39 [95% CI: 1.29-1.48] vs 0.94 [95% CI: 0.85-1.03]). CONCLUSION: More than half of patients treated with c-tube underwent cholecystectomy by three months-most within five weeks of AC diagnosis. The high frequency of use and short time to cholecystectomy after c-tube raises questions about potential overuse of c-tube in the initial period. Future work should aim to understand how patient experience and indication for c-tube influence the likelihood and timing of subsequent cholecystectomy.

Use of post-discharge heparin prophylaxis and the risk of venous thromboembolism and bleeding following bariatric surgery.

INTRODUCTION: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality after bariatric surgery. Roughly 80% of VTEs occur post-discharge. The frequency of post-discharge heparin (PDH) prophylaxis use is unknown, and evidence about benefits and risks is limited. We aimed to determine the rate of use of PDH prophylaxis and evaluate its relationship with VTE and bleeding events. METHODS: Using the Truven Health MarketScan® database, we performed a retrospective cohort study (2007-2015) of adult patients who underwent sleeve gastrectomy or gastric bypass. We determined PDH prophylaxis from outpatient pharmacy claims, and post-discharge 90-day VTE and bleeding events from outpatient and inpatient claims. We used propensity score-adjusted regression models to mitigate confounding bias. RESULTS: Among 43,493 patients (median age 45 years; 78% women; 77% laparoscopic gastric bypass, 17% laparoscopic sleeve gastrectomy, 6% open gastric bypass), 6% received PDH prophylaxis. Overall, 224 patients (0.52%) experienced VTEs, and 806 patients (1.85%) experienced bleeding. The unadjusted VTE rate did not differ between patients who did and did not receive PDH prophylaxis (0.39% vs. 0.52%, respectively; p = 0.347). The unadjusted bleeding rate was higher for the PDH prophylaxis group (2.74% vs. 1.80%, p < 0.001). In our adjusted analysis, a 23% lower risk of VTE in the PDH prophylaxis group was not statistically significant (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.41 to 1.46), whereas the 47% higher risk of bleeding was statistically significant (OR 1.47, 95% CI 1.14 to 1.88). CONCLUSIONS: PDH prophylaxis after bariatric surgery is uncommon. In our analysis, use was not associated with a lower VTE risk but was associated with a higher bleeding risk.

Bariatric Surgery Among Medicare Subgroups: Short- and Long-Term Outcomes.

OBJECTIVE: This study sought to examine weight change, postoperative adverse events, and related outcomes of interest among age-qualified (AQ) and disability-qualified (DQ) Medicare recipients compared with non-Medicare (NM) patients undergoing an initial bariatric procedure. METHODS: The Longitudinal Assessment of Bariatric Surgery (LABS-2) is an observational cohort study of 2,458 adults who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) bariatric surgery. Weight, percentage body fat, functional status, and comorbidities, as well as postoperative adverse events, were assessed at baseline and annually for 5 years. The 1,943 participants who reported insurance type were categorized into the following groups: AQ, DQ, or NM. RESULTS: The median preoperative BMI ranged from 45 to 48 kg/m2 across groups. For RYGB, 5-year BMI loss was approximately 30% for all groups, and for LAGB, BMI loss was 12% to 15%. Diabetes remission after 5 years was also similar across groups within procedure types (RYGB: 33%-40%; LAGB: 13%-19%). The frequency of adverse events after RYGB ranged from 4.1% for NM participants to 6.7% for DQ participants. After LAGB, there were no adverse events for the AQ group, whereas 3% of DQ participants and 1.8% of NM participants had at least one adverse event. CONCLUSIONS: Medicare participants experienced substantial BMI loss and diabetes remission, with a frequency of adverse events similar to that of NM participants.

Surgical Techniques and Differences in Postoperative Outcomes for Patients With Crohn's Disease With Ileosigmoid Fistulas: A Single-Institution Experience, 2010-2016.

BACKGROUND: Surgical treatment of ileosigmoid fistulas in Crohn's disease is poorly characterized. OBJECTIVE: The purpose of this study was to identify differences in patient postoperative outcomes for isolated ileosigmoid fistulas by surgical approach (laparoscopic versus open) and sigmoid colon repair type (sigmoid resection versus primary repair). DESIGN: Using a prospectively collected database, we gathered perioperative data from chart reviews to calculate differences and associations between treatment groups. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients with Crohn's disease who underwent surgery for isolated ileosigmoid fistulas between July 1, 2010, and June 30, 2016 were included. RESULTS: We identified 84 patients, with an average age of 37 years. A total of 51 were men and 33 were women; 34 underwent a sigmoid resection, whereas 50 had a primary repair of the sigmoid. All of the patients underwent an ileocolic resection. A total of 67 surgeries were initially attempted laparoscopically, of which 17 (25.4%) were converted to open, with 50 (59.5%) completed laparoscopically. There were no significant differences in length of stay or incidence of postoperative complications by surgical approach (laparoscopic versus open). For patients who underwent a primary sigmoid repair versus a sigmoid resection, there were no significant differences in postoperative complications, but there was a significant difference in the length of stay (6.36 vs 9.56 d for primary repair versus resection; multivariate p value of 0.022). MAIN OUTCOME MEASURES: Postoperative complications and length of stay were measured. LIMITATIONS: The study was limited by its small sample size, cross-sectional nature of the data, and limited information about preoperative outpatient medical treatment. CONCLUSIONS: Laparoscopic surgery for isolated ileosigmoid fistulas in Crohn's disease is safe and does not result in a different length of stay or incidence of postoperative complications. Primary repair (rather than resection) of the sigmoid colon in these cases, when feasible, appears to be safe and is likely to be cost-effective given the reduced length of stay. See Video Abstract at http://links.lww.com/DCR/A993. TÉCNICAS QUIRÚRGICAS Y DIFERENCIAS EN LOS RESULTADOS POSTOPERATORIOS PARA LOS PACIENTES CON ENFERMEDAD DE CROHN CON FÍSTULAS ILEO-SIGMOIDEAS: UNA EXPERIENCIA EN UNA SOLA INSTITUCIÓN, 2010-2016: El tratamiento quirúrgico de las fístulas ileo-sigmoideas en la enfermedad de Crohn está mal caracterizado. OBJETIVO: Identificar las diferencias en los resultados postoperatorios de los pacientes para las fístulas ileo-sigmoideas aisladas por abordaje quirúrgico (laparoscópica versus abierta) y tipo de reparación de colon sigmoide (resección sigmoidea versus reparación primaria). DISEÑO:: Utilizando una base de datos recopilada de forma prospectiva, se recopilaron datos perioperatorios de las revisiones de los gráficos para calcular las diferencias y las asociaciones entre los grupos de tratamiento. AJUSTE: Un solo centro de atención terciaria. PACIENTES: Pacientes con enfermedad de Crohn que se sometieron a una cirugía para fístulas ileo-sigmoideas aisladas entre el 1 de julio de 2010 y el 30 de junio de 2016. RESULTADOS: Se identificaron 84 pacientes, con una edad promedio de 37 años. Un total de 51 eran hombres y 33 mujeres; 34 se sometieron a una resección sigmoidea, mientras que 50 tuvieron una reparación primaria del sigmoide. Todos los pacientes fueron sometidos a resección ileocólica. Inicialmente, un total de 67 círugias se intentaron por vía laparoscópica, de las cuales 17 (25,4%) se convirtieron en cirugías abiertas, y 50 (59,5%) se completaron por vía laparoscópica. No hubo diferencias significativas en la duración de la estancia o la incidencia de complicaciones postoperatorias por abordaje quirúrgico (laparoscópica versus abierta). Para los pacientes que se sometieron a una reparación sigmoidea primaria versus una resección sigmoidea, no hubo diferencias significativas en las complicaciones postoperatorias, pero sí hubo una diferencia significativa en la duración de la estancia hospitalaria (6,36 versus a 9,56 días para la reparación primaria frente a la resección; p multivariable -valor de 0.022). PRINCIPALES MEDIDAS DE RESULTADOS: Complicaciones postoperatorias y duración de la estancia. LIMITACIONES: Tamaño de muestra pequeño, naturaleza transversal de los datos e información limitada sobre el tratamiento médico ambulatorio preoperatorio del paciente. CONCLUSIONES: La cirugía laparoscópica para fístulas ileo-sigmoideas aisladas en la enfermedad de Crohn es segura y no ocasiona una duración diferente de la estancia hospitalaria ni una incidencia diferente de complicaciones postoperatorias. La reparación primaria (en lugar de la resección) del colon sigmoide en estos casos, cuando es posible, parece ser segura y es probable que sea rentable, dada la duración reducida de la estancia. Vea el Resumen del Video en http://links.lww.com/DCR/A993.

The Association Between Kidney Disease and Diabetes Remission in Bariatric Surgery Patients With Type 2 Diabetes.

RATIONALE & OBJECTIVE: The association between bariatric surgery, type 2 diabetes, and chronic kidney disease (CKD) is poorly understood. We studied whether remission of type 2 diabetes induced by bariatric surgery influences markers of kidney disease, if CKD is associated with remission of diabetes after bariatric surgery, and if baseline levels of gut hormones and peptides modify these associations. STUDY DESIGN: Prospective observational study. STUDY PARTICIPANTS: 737 bariatric surgery patients with type 2 diabetes who participated in a multicenter cohort study for up to 5 years. PREDICTORS: Demographics, blood pressure, medications, type of bariatric surgery, anthropometrics, markers of kidney disease, and circulating levels of gut hormones and peptides. OUTCOMES: Estimated glomerular filtration rate (eGFR), urinary albumin excretion, prognostic risk for CKD, and remission of diabetes. ANALYTICAL APPROACH: Linear mixed models for eGFR; generalized linear mixed models with logit link for albuminuria, prognostic risk for CKD, and diabetes remission. RESULTS: Remission of diabetes at 5 years post-bariatric surgery was not independently associated with eGFR but was associated with lower risk for moderate/severe increase in albuminuria (risk ratio, 0.66; 95% CI, 0.48-0.90) and stabilization in prognostic risk for CKD. These findings were modified by baseline ghrelin level. Lower preoperative eGFR and greater prognostic risk for CKD were independently associated with reduced likelihood of diabetes remission. The association with preoperative GFR was modified by C-peptide level. Higher baseline circulating ghrelin level was independently associated with a lower prognostic risk for CKD. LIMITATIONS: A minority of participants had baseline CKD; lack of comparison group; no information on duration of diabetes, other clinical end points, or kidney biopsy results. CONCLUSIONS: Remission of type 2 diabetes 5 years after bariatric surgery was associated with improvements in albuminuria and stabilized prognostic risk for CKD, but not with eGFR. Lower kidney function and greater prognostic risk at the time of bariatric surgery was linked to a lower likelihood of diabetes remission. These results highlight the need to identify the mechanisms through which bariatric surgery may delay the long-term progression of CKD in type 2 diabetes.

Biliary Disease in Immunocompromised Patients: a Single-Center Retrospective Analysis.

BACKGROUND: Acute cholecystitis is a life-threatening disease process in immunocompromised patients. The purpose of this study is to determine the incidence, clinical course, and management of calculous and acalculous acute cholecystitis in immunocompromised patients. METHODS: A single center's database was queried for all patients with a diagnosis of acute cholecystitis from January 1, 2003 to September 30, 2016 with concomitant diagnosis of neutropenia, leukopenia, leukemia, or lymphoma. These cases subsequently underwent chart review. Data on demographics, diagnostic studies, and management were collected and analyzed. RESULTS: There were 4525 patients diagnosed with acute cholecystitis during the study window. One hundred twenty patients were identified to be immunocompromised at time of diagnosis. Seventy-nine patients (65.8%) had acute calculous cholecystitis while 41 patients (34.2%) had acalculous cholecystitis. There were no significant demographic differences between calculous and acalculous groups. There was similar use of percutaneous cholecystostomy tube (7.6%, 9.8%, p = 0.69), laparoscopic cholecystectomy (70.9%, 61.0%, p = 0.27), and open cholecystectomy (10.3%, 2.4%, p = 0.13) in both calculous and acalculous groups. DISCUSSION: While immunosuppression is commonly thought to be associated with acalculous cholecystitis, our data suggest the majority of acute cholecystitis in immunocompromised patients are calculous. Most patients in our studies were managed successfully with laparoscopic cholecystectomy with acceptably low complication rates. CONCLUSION: Calculous cholecystitis is more common than acalculous cholecystitis in immunocompromised patients. Both are often managed successfully with laparoscopic cholecystectomy with very low rates of conversion to open cholecystectomy.

Gustatory perception and fat body energy metabolism are jointly affected by vitellogenin and juvenile hormone in honey bees.

Honey bees (Apis mellifera) provide a system for studying social and food-related behavior. A caste of workers performs age-related tasks: young bees (nurses) usually feed the brood and other adult bees inside the nest, while older bees (foragers) forage outside for pollen, a protein/lipid source, or nectar, a carbohydrate source. The workers' transition from nursing to foraging and their foraging preferences correlate with differences in gustatory perception, metabolic gene expression, and endocrine physiology including the endocrine factors vitellogenin (Vg) and juvenile hormone (JH). However, the understanding of connections among social behavior, energy metabolism, and endocrine factors is incomplete. We used RNA interference (RNAi) to perturb the gene network of Vg and JH to learn more about these connections through effects on gustation, gene transcripts, and physiology. The RNAi perturbation was achieved by single and double knockdown of the genes ultraspiracle (usp) and vg, which encode a putative JH receptor and Vg, respectively. The double knockdown enhanced gustatory perception and elevated hemolymph glucose, trehalose, and JH. We also observed transcriptional responses in insulin like peptide 1 (ilp1), the adipokinetic hormone receptor (AKHR), and cGMP-dependent protein kinase (PKG, or "foraging gene" Amfor). Our study demonstrates that the Vg-JH regulatory module controls changes in carbohydrate metabolism, but not lipid metabolism, when worker bees shift from nursing to foraging. The module is also placed upstream of ilp1, AKHR, and PKG for the first time. As insulin, adipokinetic hormone (AKH), and PKG pathways influence metabolism and gustation in many animals, we propose that honey bees have conserved pathways in carbohydrate metabolism and conserved connections between energy metabolism and gustatory perception. Thus, perhaps the bee can make general contributions to the understanding of food-related behavior and metabolic disorders.

Honeybee associative learning performance and metabolic stress resilience are positively associated.

BACKGROUND: Social-environmental influences can affect animal cognition and health. Also, human socio-economic status is a covariate factor connecting psychometric test-performance (a measure of cognitive ability), educational achievement, lifetime health, and survival. The complimentary hypothesis, that mechanisms in physiology can explain some covariance between the same traits, is disputed. Possible mechanisms involve metabolic biology affecting integrity and stability of physiological systems during development and ageing. Knowledge of these relationships is incomplete, and underlying processes are challenging to reveal in people. Model animals, however, can provide insights into connections between metabolic biology and physiological stability that may aid efforts to reduce human health and longevity disparities. RESULTS: We document a positive correlation between a measure of associative learning performance and the metabolic stress resilience of honeybees. This relationship is independent of social factors, and may provide basic insights into how central nervous system (CNS) function and metabolic biology can be associated. Controlling for social environment, age, and learning motivation in each bee, we establish that learning in Pavlovian conditioning to an odour is positively correlated with individual survival time in hyperoxia. Hyperoxia induces oxidative metabolic damage, and provides a measure of metabolic stress resistance that is often related to overall lifespan in laboratory animals. The positive relationship between Pavlovian learning ability and stress resilience in the bee is not equally established in other model organisms so far, and contrasts with a genetic cost of improved associative learning found in Drosophila melanogaster. CONCLUSIONS: Similarities in the performances of different animals need not reflect common functional principles. A correlation of honeybee Pavlovian learning and metabolic stress resilience, thereby, is not evidence of a shared biology that will give insight about systems integrity in people. Yet, the means to resolve difficult research questions often come from findings in distant areas of science while the model systems that turn out to be valuable are sometimes the least predictable. Our results add to recent findings indicating that honeybees can become instrumental to understanding how metabolic biology influences life outcomes.