Use it or Lose it: Predictors of Compliance and Satisfaction With Postoperative Nasal Stent Therapy After Primary Cleft Lip Repair.

OBJECTIVE: Postoperative nasal stents (NSs) are used to improve esthetic outcomes after primary or secondary cleft lip repair (CLR). Prior studies have utilized anthropometric measurements or physician assessment to determine the efficacy of NS, but data on caregiver-reported outcomes is limited. This study aims to assess caregiver compliance and satisfaction with postoperative NS. METHODS: The authors designed a survey to collect parent-reported postoperative NS usage outcomes. Parents of infants with cleft lip (CL) who used postoperative NS after primary CLR were approached through social media to complete the survey. Data were analyzed to determine factors impacting compliance, satisfaction, and parent-reported outcomes. RESULTS: Eighty-five parents completed the questionnaire, and 60% reported noncompliance with NS. Parents with male children (odds ratio: 5.08, P = 0.019) and patients with incomplete CL (odds ratio: 5.72, P = 0.006) were more likely to be non-compliant with NS for over a week. Complete CL and use of presurgical molding therapy were each associated with better overall experience with postoperative NS ( P = 0.002 and P = 0.037), higher appearance ratings ( P = 0.005 and P = 0.0008), and greater satisfaction with nostril shape after surgery ( P = 0.016 and P = 0.001). CONCLUSIONS: Despite limited literature related to caregiver-reported outcomes after postoperative NS for primary CLR, the authors' results align with what has been published regarding this topic. These results can help guide surgeons in counseling patients preoperatively. Larger, multi-institutional studies are needed to better delineate and address factors associated with compliance and satisfaction after NS therapy.

Perspectives on Development of Optoelectronic Materials in Artificial Intelligence Age.

Optoelectronic devices, such as light-emitting diodes, have been demonstrated as one of the most demanded forthcoming display and lighting technologies because of their low cost, low power consumption, high brightness, and high contrast. The improvement of device performance relies on advances in precisely designing novelty functional materials, including light-emitting materials, hosts, hole/electron transport materials, and yet which is a time-consuming, laborious and resource-intensive task. Recently, machine learning (ML) has shown great prospects to accelerate material discovery and property enhancement. This review will summarize the workflow of ML in optoelectronic materials discovery, including data collection, feature engineering, model selection, model evaluation and model application. We highlight multiple recent applications of machine-learned potentials in various optoelectronic functional materials, ranging from semiconductor quantum dots (QDs) or perovskite QDs, organic molecules to carbon-based nanomaterials. We furthermore discuss the current challenges to fully realize the potential of ML-assisted materials design for optoelectronics applications. It is anticipated that this review will provide critical insights to inspire new exciting discoveries on ML-guided of high-performance optoelectronic devices with a combined effort from different disciplines.

The emergence and prospects of carbon dots with solid-state photoluminescence for light-emitting diodes.

The significant features of carbon dots (CDs), such as bright and tunable photoluminescence, high thermal stability, and low toxicity, endow them with tremendous potential for application in next generation optoelectronics. Despite great progress achieved in the design of high-performance CDs so far, the practical applications in solid-state lighting and displays have been retarded by the aggregation-caused quenching (ACQ) effect ascribed to direct π-π interactions. This review provides a comprehensive overview of the recent progress made in solid-state CD emitters, including their synthesis, optical properties and applications in light-emitting diodes (LEDs). Their triplet-excited-state-involved properties, as well as their recent advances in phosphor-converted LEDs and electroluminescent LEDs, are mainly reviewed here. Finally, the prospects and challenges of solid-state CD-based LEDs are discussed with an eye on future development. We hope that this review will provide critical insights to inspire new exciting discoveries on solid-state CDs from both fundamental and practical standpoints so that the realization of their potential in optoelectronic areas can be facilitated.

Carbon Dots for Electroluminescent Light-Emitting Diodes: Recent Progress and Future Prospects.

Carbon dots (CDs), as emerging carbon nanomaterials, have been regarded as promising alternatives for electroluminescent light-emitting diodes (LEDs) owing to their distinct characteristics, such as low toxicity, tuneable photoluminescence, and good photostability. In the last few years, despite remarkable progress achieved in CD-based LEDs, their device performance is still inferior to that of well-developed organic, heavy-metal-based QDs, and perovskite LEDs. To better exploit LED applications and boost device performance, in this review, a comprehensive overview of currently explored CDs is presented, focusing on their key optical characteristics, which are closely related to the structural design of CDs from their carbon core to surface modifications, and to macroscopic structural engineering, including the embedding of CDs in the matrix or spatial arrangement of CDs. The design of CD-based LEDs for display and lighting applications based on the fluorescence, phosphorescence, and delayed fluorescence emission of CDs is also highlighted. Finally, it is concluded with a discussion regarding the key challenges and plausible prospects in this field. It is hoped that this review inspires more extensive research on CDs from a new perspective and promotes practical applications of CD-based LEDs in multiple directions of current and future research.

[Intrinsic "self-consistent" phenomenon based on holistic view of traditional Chinese medicine].

The fundamental principle of traditional Chinese medicine(TCM) is holism, and it is crucial for TCM to address the key issue of the "holistic view" of Chinese herbal medicine. While the overall regulatory effects of Chinese herbal medicine have been widely recognized, the holistic internal logic of individual ingredients of Chinese herbal medicines require further clarification. In order to comprehensively understand the mechanism of action of Chinese herbal medicine, this paper combined the holistic view of Chinese herbal medicine with differentiation thinking to explore the intrinsic logical relationships within Chinese herbal medicine. Starting from the perspective of the coexistence of multiple components in Chinese herbal medicine, this paper systematically examined the "self-consistent" phenomenon within single Chinese herbal medicine. This phenomenon refers to the consistent or opposing actions of various components in terms of their physical and chemical properties, pharmacokinetic effects, biological effects, flavors and properties, and TCM efficacy. The paper summarized various logical relationships of syndrome differentiation exhibited by the same Chinese herbal medicine, analyzed the underlying reasons, and focused on analyzing external factors affecting the "self-consistent" phenomenon in the efficacy of Chinese herbal medicine, aiming to better elucidate the theoretical basis of the pharmacological effects of Chinese herbal medicine, further enrich the scientific connotation of the holistic view of Chinese herbal medicine, and provide theoretical guidance for the preparation process, compatibility patterns, and formulation design of Chinese herbal medicine.

Inflammatory bowel disease and celiac disease: A bidirectional Mendelian randomization study.

Objective: Although previous epidemiological studies have reported substantial links between inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), and celiac disease (CeD), the causal relationship between the two remains unknown. The purpose of the current study was to evaluate the bidirectional causation between IBD and CeD using Mendelian randomization (MR). Method: We obtained genome-wide association study (GWAS) summary data of IBD (CD and UC) and CeD of thoroughly European ancestry from the IEU GWAS database. We screened eligible instrumental variables (IVs) according to the three assumptions of MR. MR was performed using MR-Egger, weighted median (WM), and inverse variance weighted (IVW) methods. The MR-Egger intercept and MR-PRESSO method investigated the horizontal pleiotropy effect. A leave-one-out analysis was performed to prevent bias caused by a single SNP. Results: The study assessed a bidirectional causal effect between CD and CeD; CD increased the risk of CeD (IVW odds ratio (OR) = 1.27, 95% confidence interval (CI) = 1.19-1.35, p = 3.75E-13) and vice-a-versa (IVW OR = 1.09, 95% CI = 1.05-1.13, p = 1.39E-05). Additionally, CeD was influenced by IBD (IVW OR = 1.24, 95% CI = 1.16-1.34, p = 9.42E-10) and UC (IVW OR = 0.90, 95% CI = 0.83-0.98, p = 0.017). However, we observed no evidence of a causal relationship between CeD and IBD (IVW OR = 1.00, 95% CI = 0.97-1.04, p = 0.900) or UC (IVW OR = 0.96, 95% CI = 0.92-1.02, p = 0.172). Conclusion: The present study revealed that IBD and CeD have a bidirectional causal relationship. However, it is slightly different from the results of previous observational studies, recommending that future studies focus on the mechanisms of interaction between CD and CeD.

Incidence of Readmission Following Pediatric Hand Surgery: An Analysis of 6600 Patients.

Background: Quality in surgical outcomes is frequently assessed by the 30-day readmission rate. There are limited data available in the published literature regarding readmission rates following pediatric hand surgery. This study aims to identify factors associated with an increased risk of readmission following hand surgery in a pediatric population. Methods: The 2012-2017 National Surgical Quality Improvement Project - Pediatric (NSQIP-P) databases were queried for pediatric patients who underwent procedures with hand-specific current procedural terminology (CPT) codes. The primary outcome was readmission. Results: A total of 6600 pediatric patients were identified and included in the analysis. There were 45 patients who were readmitted in the study cohort, giving an overall readmission rate of 0.68%. The median time to readmission was 12 (IQR 5-20) days. On univariate analysis, factors associated with readmission included younger age, smaller size, prematurity, higher American Society of Anesthesiologists (ASA) class, inpatient admission at index operation, and longer anesthesia and operative times. Complex syndactyly repair was also associated with higher readmission rates. On multivariate analysis, ASA class 3 or 4 and inpatient surgery remained significant predictors of readmission. Conclusions: Overall, pediatric hand surgery is associated with a very low risk of 30-day readmission. Higher ASA class and inpatient surgery increase patients' risk for readmission. In particular, complex syndactyly repair is associated with a higher risk of readmission than other hand procedures. This information is useful in surgical planning and preoperative counseling of parents.

Correlation between neutrophil/lymphocyte ratio and cognitive impairment in cerebral small vessel disease patients: A retrospective study.

Background and objective: The blood neutrophil/lymphocyte ratio (NLR) is an objective and convenient parameter of systemic inflammation. Elevated NLR is associated with an increased risk of mild cognitive impairment (CI) in the elderly. However, few data are available on the impact of the NLR on CI in patients with cerebral small vessel disease (CSVD). Methods: A total of 66 CSVD subjects with CI and 81 CSVD subjects without CI were evaluated in this study. Clinical, laboratory, radiological, and cognitive parameters were collected. The NLR was obtained with the absolute neutrophil count being divided by the absolute lymphocyte count in fasting blood samples. Logistic regression analysis was performed to evaluate the factors associated with CI. Receiver operating characteristic curves were illustrated to predict factors associated with CI in patients with CSVD. Results: The NLR of the CI group was significantly higher than that of subjects without CI (2.59 vs. 2.21, P = 0.003). In multivariate analysis, NLR was positively correlated to the CI (OR: 1.43, 95% CI: 1.05-1.96, P = 0.024). It was suggested that the optimum NLR cutoff point for CI was 1.89 with 69.7% sensitivity and 59.3% specificity. Subjects with NLR ≥ 1.89 showed higher possibilities of CI compared to those with NLR < 1.89 (OR: 3.38, 95% CI: 1.62-7.07). Conclusions: Correlations were found between NLR and CI. Patients with CSVD who have higher NLR might have an increased risk of CI.

Validation of the Adapted Clavien-Dindo in Trauma (ACDiT) Classifications in Medical and Surgical Management of Acute Diverticulitis.

OBJECTIVES: To validate the adapted Clavien-Dindo in trauma (ACDiT) tool as a novel outcome measure for patients with acute diverticulitis managed both operatively and nonoperatively. BACKGROUND: Complications following diverticulitis are difficult to classify because no traditional tools address patients managed both operatively and nonoperatively. The ACDiT grading system-graded from 0 to 5b-is applied in this manner but has not yet been validated for this patient group. METHODS: We performed a 5-year observational study of patients with acute diverticulitis at a safety-net hospital. Baseline demographics and hospitalization data were collected. ACDiT scores were assigned, and validation was undertaken by comparing scores with hospital-free days, and verifying that higher scores were associated with known risk factors for poor outcomes. Inverse probability weighted propensity scores were assigned for surgical management, and inverse probability weighted regression analysis was used to determine factors associated with ACDiT ≥ grade 2. RESULTS: Of 260 patients, 188 (72%) were managed nonoperatively. Eighty (31%) developed a complication; 73 (91%) were grades 1 to 3b. Higher grades correlated inversely with hospital-free days (rs = -0.67, P < 0.0001) for all patients and for nonoperative (rs = -0.63, P < 0.0001) and operative (rs = -0.62, P < 0.0001) patients. Hinchey 2 to 3 and initial operative management had higher odds of having a complication of ACDiT ≥ grade 2. CONCLUSION: The ACDiT tool was successfully applied to acute diverticulitis patients managed operatively and nonoperatively, is associated with known risk factors for adverse outcomes. ACDiT may be considered a meaningful outcome measure for comparing strategies for acute diverticulitis.

Impact of Early Cholecystectomy on the Cost of Treating Mild Gallstone Pancreatitis: Gallstone PANC Trial.

BACKGROUND: The Gallstone Pancreatitis: Admission vs Normal Cholecystectomy (Gallstone PANC) Trial demonstrated that cholecystectomy within 24 hours of admission (early) compared with after clinical resolution (control) for mild gallstone pancreatitis, significantly reduced 30-day length-of-stay (LOS) without increasing major postoperative complications. We assessed whether early cholecystectomy decreased 90-day healthcare use and costs. STUDY DESIGN: A secondary economic evaluation of the Gallstone PANC Trial was performed from the healthcare system perspective. Costs for index admissions and all gallstone pancreatitis-related care 90 days post-discharge were obtained from the hospital accounting system and inflated to 2020 USD. Negative binomial regression models and generalized linear models with log-link and gamma distribution, adjusting for randomization strata, were used. Bayesian analysis with neutral prior was used to estimate the probability of cost reduction with early cholecystectomy. RESULTS: Of 98 randomized patients, 97 were included in the analyses. Baseline characteristics were similar in early (n = 49) and control (n = 48) groups. Early cholecystectomy resulted in a mean absolute difference in LOS of -0.96 days (95% CI, -1.91 to 0.00, p = 0.05). Ninety-day mean total costs were $14,974 (early) vs $16,190 (control) (cost ratio [CR], 0.92; 95% CI, 0.73-1.15, p = 0.47), with a mean absolute difference of $1,216 less (95% CI, -$4,782 to $2,349, p = 0.50) per patient in the early group. On Bayesian analysis, there was an 81% posterior probability that early cholecystectomy reduced 90-day total costs. CONCLUSION: In this single-center trial, early cholecystectomy for mild gallstone pancreatitis reduced 90-day LOS and had an 81% probability of reducing 90-day healthcare system costs.

Risk Stratification for Superficial Surgical Site Infection after Emergency Trauma Laparotomy.

Background: Superficial surgical site infections (S-SSIs) are common after trauma laparotomy, leading to morbidity, increased costs, and prolonged length of stay (LOS). Opportunities to mitigate S-SSI risks are limited to the intra-operative and post-operative periods. Accurate S-SSI risk stratification is paramount at the time of operation to inform immediate management. We aimed to develop a risk calculator to aid in surgical decision-making at the time of emergency laparotomy. Methods: A retrospective cohort study of patients requiring emergency trauma laparotomy between 2011 and 2017 at a single, level 1 trauma center was performed. Operative factors, skin management strategy, and outcomes were determined by chart review. Bayesian multilevel logistic regression was utilized to create a risk calculator with variables available upon closure of the laparotomy. Models were validated on a 30% test cohort and discrimination reported as an area under the receiver operating characteristics curve (AUROC). Results: Of 1,322 patients, the majority were male (77%) with median age of 33 years, injured by blunt mechanism (54%), and median injury severity score of 19. Eighty-eight (7%) patients developed an S-SSI. Patients who developed S-SSI had higher final lactate, blood loss, transfusion requirements, and wound classification. Patients with S-SSI more frequently had mesenteric or large bowel injury than those without S-SSI. Superficial SSI was associated with increased complications and prolonged length of stay (LOS). The S-SSI predictive model demonstrated moderate discrimination with an AUROC of 0.69 (95% confidence interval [CI], 0.56-0.81). Parameters contributing the most to the model were damage control laparotomy, full-thickness large bowel injury, and large bowel resection. Conclusion: A predictive model for S-SSI was built using factors available to the surgeon upon index emergency trauma laparotomy closure. This calculator may be used to standardize intra- and post-operative care and to identify high-risk patients in whom to test novel preventative strategies and improve overall outcomes for patients requiring emergency trauma laparotomy.

Timely Care is Patient-Centered Care for Patients with Acute Cholecystitis at a Safety-Net Hospital.

BACKGROUND: Multiple strategies exist to improve the timeliness and efficiency of surgical care at safety-net hospitals (SNH), such as acute care surgery models and nighttime surgery. However, the patient-centeredness of such approaches is unknown. METHODS: Adults ( ≥18 years) with acute cholecystitis were interviewed upon admission to a SNH. Interviews were semi-structured and designed to obtain both exploratory qualitative data and ratings of patient-centered outcomes, ranked by importance to the patient. Outcomes included for rating were general health, symptom status, quality of life, and return to prior functional status. Latent content analysis applying inductive coding methods were used to code and condense raw qualitative data from interview transcripts. RESULTS: Thematic saturation was reached with a sample size of 15 patients. Most participants were female (87%), Hispanic (87%), and had prior diagnosis of benign biliary disease (60%). Patients identified symptom resolution as the highest-ranked outcome in their treatment. Themes expressed by patients during the exploratory segments of the interview included: desire for pain alleviation, frustration with delays to both symptom resolution and surgical intervention, lack of perceived control over their health care, and reticence in discussing preferences with physicians. All patients preferred to have surgical treatment as soon as possible, even if that meant having nighttime surgery. CONCLUSIONS: Effective and timely resolution of symptoms is of utmost importance to patients with acute cholecystitis at a SNH. Efforts to improve timeliness of surgical care are also perceived as patient-centered.

High tidal volume ventilation is associated with ventilator-associated pneumonia in acute cervical spinal cord injury.

CONTEXT/OBJECTIVE: Pneumonia is the leading cause of death after acute spinal cord injury (SCI). High tidal volume ventilation (HVtV) is used in SCI rehabilitation centers to overcome hypoventilation while weaning patients from the ventilator. Our objective was to determine if HVtV in the acute post-injury period in SCI patients is associated with lower incidence of ventilator-associated pneumonia (VAP) when compared to patients receiving standard tidal volume ventilation. DESIGN: Cohort study. SETTING: Red Duke Trauma Institute, University of Texas Health Science Center at Houston, TX, USA. PARTICIPANTS: Adult Acute Cervical SCI Patients, 2011-2018. INTERVENTIONS: HVtV. OUTCOME MEASURES: VAP, ventilator dependence at discharge, in-hospital mortality. RESULTS: Of 181 patients, 85 (47%) developed VAP. HVtV was utilized in 22 (12%) patients. Demographics, apart from age, were similar between patients who received HVtV and standard ventilation; patients were younger in the HVtV group. VAP developed in 68% of patients receiving HVtV and in 44% receiving standard tidal volumes (P = 0.06). After adjustment, HVtV was associated with a 1.96 relative risk of VAP development (95% credible interval 1.55-2.17) on Bayesian analysis. These results correlate with a >99% posterior probability that HVtV is associated with increased VAP when compared to standard tidal volumes. HVtV was also associated with increased rates of ventilator dependence. CONCLUSIONS: While limited by sample size and selection bias, our data revealed an association between HVtV and increased VAP. Further investigation into optimal early ventilation settings is needed for SCI patients, who are at a high risk of VAP.

Robotic versus laparoscopic ventral hernia repair: multicenter, blinded randomized controlled trial.

OBJECTIVE: To determine whether robotic ventral hernia repair is associated with fewer days in the hospital 90 days after surgery compared with laparoscopic repair. DESIGN: Pragmatic, blinded randomized controlled trial. SETTING: Multidisciplinary hernia clinics in Houston, USA. PARTICIPANTS: 124 patients, deemed appropriate candidates for elective minimally invasive ventral hernia repair, consecutively presenting from April 2018 to February 2019. INTERVENTIONS: Robotic ventral hernia repair (n=65) versus laparoscopic ventral hernia repair (n=59). MAIN OUTCOME MEASURES: The primary outcome was number of days in hospital within 90 days after surgery. Secondary outcomes included emergency department visits, operating room time, wound complications, hernia recurrence, reoperation, abdominal wall quality of life, and costs from the healthcare system perspective. Outcomes were pre-specified before data collection began and analyzed as intention to treat. RESULTS: Patients from both groups were similar at baseline. Ninety day follow-up was completed in 123 (99%) patients. No evidence was seen of a difference in days in hospital between the two groups (median 0 v 0 days; relative rate 0.90, 95% confidence interval 0.37 to 2.19; P=0.82). For secondary outcomes, no differences were noted in emergency department visits, wound complications, hernia recurrence, or reoperation. However, robotic repair had longer operative duration (141 v 77 min; mean difference 62.89, 45.75 to 80.01; P≤0.001) and increased healthcare costs ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P=0.004). Among patients with robotic ventral hernia repair, two had an enterotomy compared none with laparoscopic repair. The median one month postoperative improvement in abdominal wall quality of life was 3 with robotic ventral hernia repair compared with 15 following laparoscopic repair. CONCLUSION: This study found no evidence of a difference in 90 day postoperative hospital days between robotic and laparoscopic ventral hernia repair. However, robotic repair increased operative duration and healthcare costs. TRIAL REGISTRATION: Clinicaltrials.gov NCT03490266.

Do early non-steroidal anti-inflammatory drugs for analgesia worsen acute kidney injury in critically ill trauma patients? An inverse probability of treatment weighted analysis.

BACKGROUND: Administration of nonsteroidal anti-inflammatory drugs (NSAIDs) for acute posttraumatic analgesia is increasing in popularity as an alternative to opioids despite reservations regarding its potential impact on the development of acute kidney injury (AKI). We hypothesized that early NSAID administration for analgesia would be associated with worsened renal function in severely injured trauma patients. METHODS: A retrospective cohort study of severely injured adult (≥16 years) patients admitted to the intensive care unit with ≥1 rib fracture between 2010 and 2017 was performed. The early NSAID group was defined by receipt of one or more doses of NSAID within the first 48 hours of hospitalization. Acute kidney injury diagnosis and staging were defined by the Kidney Disease Improving Global Outcomes Guidelines. The primary outcome was a composite measure of two outcomes within the first week of hospitalization: (1) AKI progression (increase in AKI stage from arrival) or (2) death. Secondary outcomes included AKI progression, AKI improvement, AKI duration, and mortality. Inverse propensity of treatment weights were generated using clinically sound covariates suspected to be associated with the decision to give early NSAIDs and the primary or secondary outcomes. Multivariable analyses were performed adjusting for inverse propensity of treatment weights, covariates, and length of stay. RESULTS: Of 2,340 patients, 268 (11%) were administered early NSAIDs. When compared with the control group, patients who received early NSAIDs were less severely injured. Renal outcomes were worse in the control group. Standardized mean differences were minimal after weighting. On multivariable analysis, administration of early NSAIDs was not associated with worsened renal outcomes or increased mortality. CONCLUSION: Although only 11% of patients received early NSAIDs after trauma for analgesia, early NSAID exposure was not associated with increased AKI progression, decreased AKI improvement, prolonged duration, or increased mortality. Given the lack of evidence showing harm, early NSAIDs for analgesia may be underused for severely injured patients. LEVEL OF EVIDENCE: Prognostic, level III, Therapeutic, level IV.

The Influence of Obesity on Outcomes After Pediatric Reduction Mammaplasty: A Retrospective Analysis of the Pediatric National Surgical Quality Improvement Program-Pediatric Database.

BACKGROUND: Symptomatic macromastia causes negative physical and psychosocial effects, which support the need for early intervention, even in the adolescent population (Plast Reconstr Surg 2012;130:785-789). Reduction mammaplasty is a proven treatment that reliably addresses symptoms from macromastia. The National Surgical Quality Improvement Program-Pediatric is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care (Pediatrics 2012;130:e339-e346). In adults, obesity is associated with increased early postoperative complications after mammaplasty (Pediatrics 2017;140(5)). We hypothesized that obesity would increase the incidence of postoperative complications in pediatric patients undergoing reduction mammaplasty. METHODS: The National Surgical Quality Improvement Program-Pediatric database was queried for female patients 18 years or younger who underwent reduction mammaplasty from January 2012 to December 2017 using Current Procedural Terminology code 19318. Demographic, clinical, and outcomes data were abstracted from the database. A composite postoperative adverse events variable was created from a list of 21 individual adverse events. Patients were stratified by presence of obesity (body mass index ≥30 kg/m) on univariate analyses. Multivariable logistic regression was used to determine factors associated with any postoperative adverse events. RESULTS: A total of 542 female patients underwent reduction mammaplasty, with 48% of the cohort being obese. Patients were similar in age (median, 17 years) and comorbidities between obese and nonobese groups. Obese patients were more likely to be African American, have higher American Society of Anesthesiologists class, and endure longer operations. Composite adverse event rates were significantly higher in the obese group (7% vs 2%, P = 0.013). Individual adverse events were similar between groups, with the exception of 30-day readmissions, which was higher in the obese group (3% vs 1%, P = 0.04). On multivariable logistic regression, obesity increased the odds of having a postoperative adverse event by 3-fold after adjusting for operative duration. CONCLUSIONS: Obesity was significantly associated with greater postoperative adverse events in obese adolescent females after reduction mammaplasty compared with their nonobese counterparts. Although recorded rates of adverse events after reduction mammaplasty were low, preoperative weight loss programs may further improve outcomes for obese pediatric populations undergoing reduction mammaplasty.

Positive Fluid Balance and Association with Post-Traumatic Acute Kidney Injury.

BACKGROUND: Acute kidney injury (AKI) is common in severely injured trauma patients and is associated with poor outcomes. A positive fluid balance is associated with AKI and poor long-term renal outcomes among general ICU and cardiac surgery patients. Currently, the optimal endpoint of resuscitation of severely injured trauma patients is unknown, which may result in excess fluid administration. We hypothesized that positive fluid balance is common after severe trauma and is associated with increased AKI development. STUDY DESIGN: A cohort study of adult (≥16 years old) trauma patients requiring ICU admission from January 2017 to June of 2017 was conducted. Patients were excluded for early death, rhabdomyolysis, or previous history of end-stage renal disease or congestive heart failure. Acute kidney injury within 7 days of admission was defined according to Kidney Disease Improving Global Outcomes creatinine-based criteria. Univariate and multivariable analyses were performed. RESULTS: Of 364 patients, 74% were male. The median age was 41 years (interquartile range [IQR] 27 to 59 years), and the median Injury Severity Score (ISS) was 18 (IQR 10 to 29). Positive fluid balance (>2 L) was observed in 49% of patients. Acute kidney injury was diagnosed in 105 (29%) patients. After adjustment, there was an increased risk of AKI with a positive fluid balance >2 L (relative risk [RR] 1.98 [95% CI 1.24 to 3.17]). Additionally, the risk of AKI incrementally increased by 1.22 with each liter fluid positive above a zero balance (95% CI 1.11 to 1.34). CONCLUSIONS: Positive fluid balance in excess of 2 L at 48 hours occurs in half of severely injured trauma patients, and fluid positivity is independently and incrementally associated with AKI development. Fluid responsiveness should be investigated as an end point of post-traumatic resuscitation to prevent unnecessary fluid administration and subsequent AKI.

Implementation of a multi-modal pain regimen to decrease inpatient opioid exposure after injury.

INTRODUCTION: In 2013, we implemented a pill-based, multi-modal pain regimen (MMPR) in order to decrease in-hospital opioid exposure after injury at our trauma center. We hypothesized that the MMPR would decrease inpatient oral morphine milligram equivalents (MME), decrease opioid prescriptions at discharge, and result in similar Numerical Rating Scale (NRS) pain scores. METHODS: Adult patients admitted to a level-1 trauma center with ≥1 rib fracture from 2010 to 2017 were included - spanning 3 years before and 4 years after MMPR implementation. MME were summarized as medians and interquartile range (IQR) by year of admission. The effect of the MMPR on daily total MME was estimated using Bayesian generalized linear model. RESULTS: Over the 8 year study period, 6,933 patients who met study inclusion criteria were included. No significant differences between years were observed in Abbreviated Injury Scale (AIS) Chest or Injury Severity Scores (ISS). After introduction of the MMPR, there was a significant reduction in median total MME administered per patient day from 60 MME/patient day (IQR 36-91 MME/patient day) pre-MMPR implementation to 37 MME/patient day (IQR 18-61 MME/patient day) in 2017, p < 0.01. Total MME administered per patient day decreased by 31% in 2017 as compared to 2010 (rate ratio 0.69, 95% CI 0.64-0.75). Average NRS pain scores decreased by 0.8 points (95% CI -0.87, -0.81) from 2010 to 2017. CONCLUSION: The introduction of a multi-modal pain regimen resulted in significant reduction in in-patient opioid exposure after injury. The reduction in inpatient opioid use from 2010 to 2017 was equivalent to 11 mg less oxycodone or 17 mg less hydrocodone per patient per day. Additionally, use of the MMPR was associated with a reduction in NRS pain scores.

Choice of Reference Creatinine for Post-Traumatic Acute Kidney Injury Diagnosis.

BACKGROUND: Acute kidney injury (AKI) after trauma is associated with poor outcomes. According to current guidelines, a diagnosis of AKI should be made based on an increase in serum creatinine from a reference value. However, a true reference is often unknown in patients presenting with traumatic injury. The aim of this study was to determine the optimal reference creatinine estimate for post-traumatic AKI diagnosis and staging. The optimal reference estimate was defined by a high incidence, strong prognostic ability, and incrementality at each stage. STUDY DESIGN: This was a cohort study of adult trauma patients (older than 16 years) requiring ICU admission between 2009 and 2018 (n = 8,026) at a single Level I trauma center. AKI was determined using the following 4 reference creatinine estimates: Modified Diet of Renal Diseases (MDRD), Trauma MDRD, admission creatinine, and the first-day creatinine nadir. Inclusivity was assessed by incidence of AKI diagnosed with different reference creatinine estimates; prognostic ability was assessed by multivariable modified Poisson regression; and incrementality was assessed by correlation of mortality risk by AKI stage. RESULTS: There was a wide range of AKI incidence, from 21% when using admission creatinine to 76% using the Trauma MDRD. The MDRD reference creatinine estimate resulted in an AKI incidence of 41% and a diagnosis that was both prognostic of mortality and incremental with each AKI stage. All other reference estimates resulted in AKI diagnoses that were either not prognostic or not incremental. CONCLUSIONS: Reference creatinine estimate determines the clinical importance of AKI diagnoses. In this study, the MDRD reference resulted in optimal AKI diagnoses.

Gallstone Pancreatitis: Admission Versus Normal Cholecystectomy-a Randomized Trial (Gallstone PANC Trial).

INTRODUCTION: Early cholecystectomy shortly after admission for mild gallstone pancreatitis has been proposed based on observational data. We hypothesized that cholecystectomy within 24 hours of admission versus after clinical resolution of gallstone pancreatitis that is predicted to be mild results in decreased length-of-stay (LOS) without an increase in complications. METHODS: Adults with predicted mild gallstone pancreatitis were randomized to cholecystectomy with cholangiogram within 24 hours of presentation (early group) versus after clinical resolution (control) based on abdominal exam and normalized laboratory values. Primary outcome was 30-day LOS including readmissions. Secondary outcomes were time to surgery, endoscopic retrograde cholangiopancreatography (ERCP) rates, and postoperative complications. Frequentist and Bayesian intention-to-treat analyses were performed. RESULTS: Baseline characteristics were similar in the early (n = 49) and control (n = 48) groups. Early group had fewer ERCPs (15% vs 29%, P = 0.038), faster time to surgery (16 h vs 43 h, P < 0.005), and shorter 30-day LOS (50 h vs 77 h, RR 0.68 95% CI 0.65 - 0.71, P < 0.005). Complication rates were 6% in early group versus 2% in controls (P = 0.613), which included recurrence/progression of pancreatitis (2 early, 1 control) and a cystic duct stump leak (early). On Bayesian analysis, early cholecystectomy has a 99% probability of reducing 30-day LOS, 93% probability of decreasing ERCP use, and 72% probability of increasing complications. CONCLUSION: In patients with predicted mild gallstone pancreatitis, cholecystectomy within 24 hours of admission reduced rate of ERCPs, time to surgery, and 30-day length-of-stay. Minor complications may be increased with early cholecystectomy. Identification of patients with predicted mild gallstone pancreatitis in whom early cholecystectomy is safe warrants further investigation.