Association of Preoperative Blood Transfusion on Postoperative Outcomes in Emergency General Surgery.

INTRODUCTION: Emergency general surgery (EGS) patients often present with anemia, in which preoperative transfusions are performed to mitigate anemia-associated risks. However, transfusions have also been noted to cause worse postoperative outcomes. This study examined how transfusion-associated outcomes vary at different levels of anemia. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2019 was used to identify patients who had undergone any of 12 major EGS procedures using Current Procedural Terminology codes. Patients were divided into two cohorts based on receipt of preoperative transfusion. Cohorts were subdivided into anemia severity levels and propensity score-matched within each using patient demographic and comorbidity variables. We analyzed 30-day postoperative outcomes, including morbidity, mortality, and return to odds ratio (OR), using univariate Chi-squared tests, Wilcoxon signed-rank tests, and multivariate logistic regression analyses. RESULTS: 595,407 EGS cases were identified. Receiving preoperative transfusion were 44.45% (n = 3058) of severely anemic, 10.94% (n = 9076) of moderately anemic, 1.34% (n = 1370) of mildly anemic, and 0.174% (n = 704) of no anemia patients. Transfusion resulted in an increased overall morbidity in the severe (OR 1.54), moderate (OR 1.50), mild (OR 1.71), and no anemia (OR 1.85) groups. Mortality increased in the moderate (OR 1.27), mild (OR 1.61), and no anemia (OR 1.76) subgroups. In severe anemia, transfusion status and mortality were not significantly associated. CONCLUSIONS: Transfusion is associated with higher morbidity and mortality rates in those with higher hematocrit levels, even after controlling for pre-existing comorbidities. A restrictive transfusion strategy should be considered to avoid risks for those with a hematocrit level more than 24%.

Differences in ICSI utilization rates among states with insurance mandates for ART coverage.

BACKGROUND: Assisted reproductive technology (ART) insurance mandates promote more selective utilization of ART clinic resources including intracytoplasmic sperm injection (ICSI). Our objective was to examine whether ICSI utilization differs by state insurance mandates for ART coverage and assess if such a difference is associated with male factor, preimplantation genetic testing (PGT), and/or live birth rates. METHODS: In this retrospective analysis of the Centers for Disease Control (CDC) data from 2018, ART clinics in ART-mandated states (n = 8, AR, CT, HI, IL, MD, MA, NJ, RI) were compared individually to one another and with non-mandated states in aggregate (n = 42) for use of ICSI, male factor, PGT, and live birth rates. ANOVA was used to evaluate differences between ART-mandated states and non-mandated states. Individual ART-mandated states were compared using Welch t-tests. Statistical significance was determined by Bonferroni Correction. RESULTS: There were significant differences in ICSI rates (%, mean ± SD) between MA (53.3 ± 21.3) and HI (90.7 ± 19.6), p = 0.028; IL (86.5 ± 18.7) and MA, p = 0.002; IL and MD (57.2 ± 30.8), p = 0.039; IL and NJ (62.0 ± 26.8), p = 0.007; between non-mandated states in aggregate (79.9 ± 19.9) and MA, p = 0.006, and NJ (62.0 ± 26.8), p = 0.02. Male factor rates of HI (65.8 ± 16.0) were significantly greater compared to CT (18.8 ± 8.7), IL (26.0 ± 11.9), MA (26.9 ± 6.6), MD (29.3 ± 9.9), NJ (30.6 ± 17.9), and non-mandated states in aggregate (29.7 ± 13.7), all p < 0.0001. No significant differences were reported for use of PGT and/or live birth rates across all age groups regardless of mandate status. CONCLUSIONS: ICSI use varied significantly among ART-mandated states while demonstrating no differences in live birth rates. These data suggest that the prevalence of male factor and the presence of a state insurance mandate are not the only factors influencing ICSI use. It is suggested that other non-clinical factors may impact the rate of ICSI utilization in a given state.

Socioeconomic risk factors for mortality and readmission after surgery for bowel obstruction: An analysis of the Nationwide Readmissions Database.

BACKGROUND: Small bowel obstructions (SBO) are one of the most common surgical emergencies, but they remain a major cause of high morbidity and mortality in patients with previous history of abdominal and pelvic surgery. Socioeconomic factors have not been extensively studied in surgical management of SBO. METHODS: We queried the 2016 NRD database for all surgically managed admissions ≥18 years of age with a primary diagnosis of SBO. The primary outcomes for this analysis were index admission mortality, 30-day mortality, and 30-day readmissions. Multivariate logistic regression models were utilized to examine the association between predictors and primary outcomes. RESULTS: Medicaid patients had a higher likelihood of index admission mortality. Medicare and Medicaid patients both had higher likelihoods of 30-day readmissions.results CONCLUSIONS: Careful consideration should be taken before deciding the optimal surgical approach in patients with SBO. Medicaid beneficiaries and those with existing comorbidities should receive careful post-operative follow-up to ensure optimal outcomes.

The Use of Artificial Neural Network to Predict Surgical Outcomes After Inguinal Hernia Repair.

BACKGROUND: Inguinal hernia repair is one of the most commonly performed surgical procedures. We developed and validated an artificial neural network (ANN) model for the prediction of surgical outcomes and the analysis of risk factors for inguinal hernia repair. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program was used to find patients who underwent inguinal hernia repair. Using logistic regression and ANN models, we evaluated morbidity, readmission, and mortality using the area under the receiver operating characteristic curves, true-positive rate, true-negative rate, false-positive rate, and false-negative rates. RESULTS: There was no significant difference in the power of the ANN and logistic regression for predicting mortality, readmission, and all morbidities after inguinal hernia repair. Risk factors for morbidity, readmission, and mortality outcomes identified using ANN were consistent with logistic regression analysis. CONCLUSIONS: ANNs perform comparably to logistic regression models in the prediction of outcomes after inguinal hernia repair. ANNs may be a useful tool in risk factor analysis of hernia surgery and clinical applications.

Incidence and Cost of Deep Vein Thrombosis in Emergency General Surgery Over 15 Years.

BACKGROUND: Deep vein thromboses (DVTs) are a significant sequela of surgery and are associated with significant of morbidity and mortality in the United States. Operative emergency general surgery (EGS) cases have been demonstrated to have a greater burden of DVT than other types of surgery. MATERIALS AND METHODS: DVT in EGS cases were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2015 Q3 based on ICD-9 code specification. National incidence of DVT in EGS was calculated using the National Inpatient Sample-Healthcare Cost and Utilization Project sampling methodology, and propensity score matching was used to assess costs associated with DVT. RESULTS: Among 15,148,352 sample-weighted hospitalizations, 0.623% (94,392) experienced DVT. Incidence of DVT was greatest in GI ulcer surgery (1.705%) and lowest in appendectomy (0.095%). Patients with a perioperative DVT incurred $22,301 more in hospital-related costs than their counterparts who did not have a DVT. Although rates of DVT remained stable over the period analyzed, DVT-associated costs increased at a 2.09% annual rate in excess of inflation during the period analyzed. This increase in costs was most significant for laparotomy, which increased at a rate of 8.09% annually. CONCLUSIONS: DVT continues to be a significant burden on resources in EGS in spite of efforts with DVT prophylaxis. Considering the increase in costs and little change in incidence, further research on cost-effective management of DVT in EGS is warranted.

Do state insurance mandates alter ICSI utilization?

BACKGROUND: Assisted reproductive technology (ART) insurance mandates resulted in improved access to infertility treatments like intracytoplasmic sperm injection (ICSI). Our objective was to examine whether ART insurance mandates demonstrate an increased association with ICSI use. METHODS: In this retrospective cohort study, clinic-specific data for 2000-2016 from the Centers for Disease Control (CDC) were grouped by state and subgrouped by the presence and extent of ART state insurance mandates. Mandated (n = 8) and non-mandated (n = 22) states were compared for ICSI use and male factor (MF) infertility in fresh non-donor ART cycles with a transfer in women < 35 years. Clinical pregnancy (CPR), live birth (LBR) rates, preimplantation genetic testing (PGT), elective single-embryo transfer (eSET) and twin birth rates per clinic were evaluated utilizing Welch's t-test. Pearson correlation was used to measure the strength of association between MF and ICSI; ICSI and CPR, and ICSI and LBR over time. Results were considered statistically significant at a p-value of < 0.05, with Bonferroni correction used for multiple comparisons. RESULTS: From 2000 to 2016, ICSI use per clinic increased in both mandated and non-mandated states. ICSI use per clinic in non-mandated states was significantly greater from 2011 to 2016 (p < 0.05, all years) than in mandated states. Clinics in mandated states had less MF (30.5 ± 15% vs 36.7 ± 15%; p < 0.001), lower CPR (39.8 ± 4% vs 43.4 ± 4%; p = 0.02) and lower LBR (33.9 ± 3.5% vs 37.9 ± 3.5%; p < 0.05). PGT rates were not significantly different. ICSI use in non-mandated states correlated with MF rates (r = 0.524, p = 0.03). A significant correlation between ICSI and CPR (r = 0.8, p < 0.001) and LBR (r = 0.7, p < 0.001) was noted in mandated states only. eSET rates were greater and twin rates were lower in mandated compared with non-mandated states. CONCLUSIONS: There was greater use of ICSI per clinic in non-mandated states, which correlated with an increased frequency of MF. In mandated states, lower ICSI rates per clinic were accompanied by a positive correlation with CPR and LBR, as well as a trend for greater eSET rates and lower twin rates, suggesting that state mandates for ART coverage may encourage more selective utilization of laboratory resources.

Laparoscopic colectomy for diverticulitis in patients with pre-operative respiratory comorbidity: analysis of post-operative outcomes in the United States from 2005 to 2017.

BACKGROUND: Current studies suggest that laparoscopic colorectal surgery is an advantageous alternative to open surgery due to improved post-operative outcomes in high-risk patient groups. Limited data is currently available on the benefits of minimally invasive colectomy for diverticulitis in patients with significant pre-operative respiratory comorbidities. STUDY DESIGN: The NSQIP 2005-2017 datasets were used to identify patients that underwent partial colectomies due to diverticulitis. Partial colectomy cases were identified using CPT codes and then filtered to include only ICD 9 and 10 codes for diverticulitis. Pre-operative respiratory comorbidities included dyspnea, chronic obstructive pulmonary disease (COPD), and smoking status. Propensity matching was performed based on patient demographic and pre-operative risk factor data to create comparable groups for each respiratory comorbidity subset. Outcomes of interest were 30-day post-operative mortality and morbidity, incidence of return to operating room (ROR), and hospital length of stay (LoS). Laparoscopy and open surgery groups were compared using Chi square tests for categorical variables and t tests for continuous variables. A p value less than 0.05 was considered statistically significant. RESULTS: Among 70,420 cases with diverticulitis, 15,237 cases were identified as smokers, 3934 had dyspnea, and 3219 had COPD. Patients that had open procedures had significantly greater odds of mortality (OR 2.624 for smokers; OR 2.698 for dyspnea; OR 2.663 for COPD), morbidity (OR 2.590 for smokers; OR 2.344 for dyspnea; OR 2.883 for COPD), wound complication (OR 1.989 for smokers; OR 1.461 for dyspnea; OR 1.956 for COPD), and ROR (OR 1.184 for smokers; OR 1.634 for dyspnea; OR 1.975 for COPD). Laparoscopic procedures resulted in significantly lower average LoS (5.34 vs. 9.46 days for smokers; 6.84 vs. 11.06 days for dyspnea; 7.41 vs. 12.62 days for COPD; all p < .0001). CONCLUSION: Laparoscopic colectomy for diverticulitis diagnosis for a matched cohort of patients with pre-operative respiratory comorbidities such as smoking status, dyspnea, and COPD resulted in significantly improved post-operative outcomes, lower odds of mortality and morbidity, and shorter LoS.

The Cost of Surgical Site Infections after Colorectal Surgery in the United States from 2001 to 2012: A Longitudinal Analysis.

Surgical site infections (SSIs) are among the most common types of postoperative complications in the United States and are associated with significant prevalence of morbidity and mortality in patients undergoing surgical interventions, especially in colorectal surgery (CRS) where SSI rates are significantly higher than those of similar operative sites. SSIs were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2012 based on the specification of an ICD-9 code. Propensity score matching was used to compare costs associated with SSI cases with those of non-SSI controls among elective and nonelective admissions. Results were projected nationally using Healthcare Cost and Utilization Project sampling methodology to evaluate the incidence of SSIs and ascertain the national cost burden retrospectively. Among 4,851,359 sample-weighted hospitalizations, 4.2 per cent (203,597) experienced SSI. Elective admissions associated with SSI-stayed hospitalized for an average of 7.8 days longer and cost $18,410 more than their counterparts who did not experience an SSI. Nonelective admissions that experienced an SSI had an 8.5-day longer hospital stay and cost $20,890 more than counterparts without perioperative infections. This represents a 3 per cent annual growth in costs for SSIs and seems to be largely driven by cost increases in treatment of SSIs for elective surgeries. Current efforts of SSI management after CRS focused on compliance with guidelines and tracking of infection rates would benefit from some improvements. Considering the growing costs and increase in resource utilization associated with SSIs from 2001 to 2012, further research on costs associated with management of SSIs specific to CRS is necessary.

The role of socioeconomic disparity in colorectal cancer stage at presentation.

Colorectal cancer, despite multiple screening measures being available, is the second leading cause of death due to cancer. Cancer stage at diagnosis is an important determinant of survival, where earlier stages have significantly increased rates of survival. By looking at various social health disparities (at a patient and geographic level) and their effect on stage at presentation, we will gain a better understanding of the effect they have on cancer outcomes. Data were collected from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database for the years 2007-2014. Covariates extracted were patient-level variables such as age, race, primary site, state/county, insurance status as well as county-level data which included percent urban population, median family income, rural-urban continuum code classification, percent of population that has not completed high school, percent of population below the poverty line, percent of population foreign-born, percent of language-isolated persons, and unemployment rate. The primary outcome analyzed was cancer staging at diagnosis. A χ2 analysis and multivariate binary logistic regression was modeled to elucidate the associations between study covariates and late stage of cancer presentation. Chi-squared analysis demonstrated significant associations (at p < 0.05) between stage of diagnosis with race, age, insurance status, location of primary site, percent of population below poverty line, percent of language-isolated persons, and percent of unemployed. To help reduce these disparities, community resources and increased screening and prevention techniques must be implemented to target the unique populations at greatest risk for developing the disease.

Egg freezing for fertility preservation and family planning: a nationwide survey of US Obstetrics and Gynecology residents.

BACKGROUND: Little is known about resident attitudes toward elective egg freezing (EF) or how educational exposure to EF affects residents' views and ability to counsel patients. This study aimed to evaluate US OB/GYN residents' views on elective EF, decisions regarding family planning, and whether education on EF affects these views and self-reported comfort discussing EF with patients. METHODS: A 32 question survey was emailed to program directors at all US residency programs for distribution to residents. Chi-square tests were used to evaluate the relationship between educational factors and views on EF and comfort counselling patients. RESULTS: Of those surveyed, 106 residents and 7 fellows completed the survey (103 female). Almost three quarters of female respondents reported postponing pregnancy due to residency (71.8%). Non-exclusive reasons for this choice included career plans (54.4%) and concern for childcare (51.5%) and for fellow residents and their program (50.5%). Of the male and female residents who reported educational exposure to EF (57.5%), almost all of them (95.4%) received this in an REI rotation. Only half of female residents reported being comfortable counseling a patient on EF (49.5%). For female residents, education on EF (p = 0.03) and more advanced level of residency (p = 0.02) were significantly associated with comfort counseling a patient on EF. CONCLUSIONS: Female OB/GYN residents are choosing to delay pregnancy during residency for career and social support reasons. Few residents feel comfortable counseling patients on EF, but appropriate curricular content on EF during residency could improve residents' comfort in assisting patients with reproductive planning.

Temporal Differences in Utilization of Intracytoplasmic Sperm Injection Among U.S. Regions.

OBJECTIVE: To analyze changes in intracytoplasmic sperm injection (ICSI) utilization, indications, and outcomes across U.S. regions. METHODS: We conducted a retrospective cohort study. Data sets for 2000-2014 were obtained from the Centers for Disease Control and Prevention. Clinics with 100 or greater fresh, nondonor cycles were grouped by 10 nationally recognized Department of Health and Human Services (DHHS) regions and were compared for use of ICSI, frequency of male factor infertility, preimplantation genetic therapies, pregnancy, and live birth rates per cycle among fresh in vitro fertilization cycles in women younger than 35 years of age. RESULTS: Nationwide ICSI utilization increased 52% (46.3±6.1% to 70.0±7.1%) from 2000 to 2014, whereas pregnancy and live birth rates per cycle modestly increased by 8.5% (39.2±3.8% to 42.5±2.5%) and 7.6% (34.4±3.6% to 37±2.6%), respectively, showing a positive correlation (r=0.78, P<.001; r=0.76, P=.001) with ICSI rates per clinic. All DHHS Services regions demonstrated increases in ICSI utilization over time, although the magnitude of increase varied in different regions. Regions also had similarities in trends for pregnancy and live birth rates per cycle in women younger than 35 years. There was no correlation between male factor and ICSI rates per clinic from 2000 to 2010 (r=0.32, P=.33) or 2011 to 2014 (r=0.85, P=.068). From 2007 to 2014, ICSI and preimplantation genetic testing did not demonstrate a strong correlation (r=0.68, P=.062). CONCLUSION: From 2000 to 2014, ICSI rates per clinic significantly varied among geographic regions. Increased use of ICSI did not correlate with an increase in male factor diagnoses. These findings suggest that ICSI may be overused, because its use is not accompanied by proportionate increases in medical indications or effectiveness.

Differences in utilization of Intracytoplasmic sperm injection (ICSI) within human services (HHS) regions and metropolitan megaregions in the U.S.

BACKGROUND: Anecdotal evidence suggests that US practice patterns for ART differ by geographical region. The purpose of this study was to determine whether use of ICSI differs by region and to evaluate whether these rates are correlated with differences in live birth rates. METHODS: Public data for 2012 were obtained from the Centers for Disease Control and Prevention. Clinics with ≥100 fresh, non-donor cycles were grouped by 10 nationally recognized Department of Health & Human Services regions and 11 metropolitan Megaregions and were compared for use of ICSI, frequency of male factor infertility, and live birth rate in women <35 years. RESULTS: There were 274 clinics in the Health & Human Services regions and 247 in the Megaregions. ICSI utilization rates in Health & Human Services groups ranged between 52.5-78.2% (P < 0.0001). Live birth rates per cycle in women <35 years differed (34.1-47.6%; P < 0.0001) but did not correlate with rates of ICSI (R2 = 0.2096; P = 0.18) per cycle. For Megaregions, rates of ICSI per cycle differed (63.4%-93.5%, P < 0.0001) as did live birth rates per cycle for women <35 (36.0%-59.0%, P = 0.001) but there was only minimal correlation between them (R2 = 0.5347; P = 0.01). Highest rates of ICSI occurred in Front Range (93.5%) and Gulf Coast (83.1%) Megaregions. Lowest rates occurred in the Northeast (63.4%) and Florida (64.8%) Megaregions. Male factor infertility rates did not differ across regions. CONCLUSIONS: ICSI utilization and live birth rates per cycle for each clinic group were significantly different across geographical regions of the U.S. However, higher ICSI utilization rate was not associated with higher rates of male factor infertility nor were they strongly correlated with higher live birth rates per cycle. Studies are needed to understand factors that may influence ICSI overutilization in the U.S.

YKL-40 expression in traumatic brain injury: an initial analysis.

YKL-40 (chitinase 3-like protein 1) is expressed in a broad spectrum of inflammatory conditions and cancers. We have previously reported that YKL-40 levels are elevated in the cerebrospinal fluid (CSF) of macaques and humans with lentiviral encephalitis, as well as multiple sclerosis (MS). The current study assessed temporal CSF YKL-40 levels in subjects with severe traumatic brain injury (TBI; Glasgow Coma Scale [GCS] score