Impact of the Nationwide Intravenous Selenium Product Shortage on the Development of Selenium Deficiency in Infants Dependent on Long-Term Parenteral Nutrition.

BACKGROUND: For patients dependent on parenteral nutrition (PN), selenium must be supplemented intravenously. A nationwide intravenous selenium shortage began in April 2011. The impact of this shortage on PN-dependent infants was evaluated by examining the provision of selenium, development of biochemical deficiency, and costs associated with the shortage. MATERIALS AND METHODS: This single-center, retrospective study included PN-dependent infants aged ≤1 year who weighed ≤30 kg, received PN for ≥1 month, and had ≥1 serum selenium measurement. The primary outcome was the incidence of biochemical selenium deficiency. Secondary outcomes included severity of biochemical deficiency, clinical manifestations, costs, and relationship between serum selenium levels and selenium dose. RESULTS: The average selenium dose decreased 2-fold during the shortage (2.1 ± 1.2 µg/kg/d; range, 0.2-4.6 µg/kg/d) versus the nonshortage period (3.8 ± 1 µg/kg/d; range, 2.4-6 µg/kg/d; P < .001). A linear relationship between serum selenium concentration and selenium dose was observed (r(2) = 0.42), with a dose of 6 µg/kg/d expected to result in normal serum levels in most cases. Similar proportions of patients developed biochemical deficiency in both groups: shortage period, 59.1%; nonshortage, 66.7%; P = .13. The severity of biochemical deficiency was similar between groups. A significant increase in incremental cost during the shortage was observed. CONCLUSION: This is the first study examining the impact of the intravenous selenium shortage on PN-dependent infants. Both groups exhibited similarly high incidences of biochemical selenium deficiency, suggesting higher empiric doses may benefit this population. However, ongoing shortages limit the ability to provide supplementation.

A comparison of laparoscopic and robotic colorectal surgery outcomes using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database.

BACKGROUND: Until randomized trials mature, large database analyses assist in determining the role of robotics in colorectal surgery. ACS NSQIP database coding now allows differentiation between laparoscopic (LC) and robotic (RC) colorectal procedures. The purpose of this study was to compare LC and RC outcomes by analyzing the ACS NSQIP database. METHODS: The ACS NSQIP database was queried to identify patients who had undergone RC and LC during 2013. Demographic characteristics, intraoperative data, and postoperative outcomes were identified. Using propensity score matching, abdominal and pelvic colorectal operative and postoperative outcomes were analyzed. RESULTS: A total of 11,477 cases were identified. In the abdomen, 7790 LC and 299 RC cases were identified, and 2057 LC and 331 RC cases were identified in the pelvis. There were significant differences in operative time, conversion to an open procedure in the pelvis, and hospital length of stay. RC operative times were significantly longer in both abdominal and pelvic cases. Conversion rates in the pelvis were less for RC when compared to LC--10.0 and 13.7%, respectively (p = 0.01). Hospital length of stay was significantly shorter for RC abdominal cases than for LC abdominal cases (4.3 vs. 5.3 days, p < 0.001) and for RC pelvic cases when compared to LC pelvic cases (4.5 vs. 5.3 days, p < 0.001). There were no significant differences in surgical site infection (SSI), organ/space SSI, wound complications, anastomotic leak, sepsis/shock, or need for reoperation within 30 days. CONCLUSION: As the robotic platform continues to grow in colorectal surgery and as technical upgrades continue to advance, comparison of outcomes requires continuous reevaluation. This study demonstrated that robotic operations have longer operative times, decreased hospital length of stay, and decreased rates of conversion to open in the pelvis. These findings warrant continued evaluation of the role of minimally invasive technical upgrades in colorectal surgery.

Autologous Fat Grafting After Breast Reconstruction in Postmastectomy Patients: Complications, Biopsy Rates, and Locoregional Cancer Recurrence Rates.

BACKGROUND: Autologous fat grafting is widely used for refinements in postmastectomy breast reconstruction. However, there are few studies evaluating outcomes in this patient population. The purpose of this study was to assess outcomes of autologous fat grafting after breast reconstruction in postmastectomy patients. METHODS: We retrospectively reviewed the records of consecutive postmastectomy patients who underwent autologous fat grafting after breast reconstruction at a university center over a 5-year period. Patients with at least 6 months of follow-up were included. Medical records were reviewed for demographics, operative details, complications, incidence of palpable masses, and/or suspicious breast imaging findings requiring biopsy, and locoregional cancer recurrence. Descriptive statistics were generated. RESULTS: Between January 2008 and July 2013, 108 women and a total of 167 breast reconstructions underwent autologous fat grafting for revision of postmastectomy breast reconstruction. Their ages ranged from 22 to 71 years (mean, 48 years). Fat grafts were harvested, processed, and injected using the Coleman technique. The mean number of fat grafting procedures was 1.3 (range, 1-4) per breast. Follow-up ranged from 6 to 57 months (mean, 20.2 months). Fifty-three (31.7%) breasts underwent imaging after autologous fat grafting. Suspicious imaging findings requiring biopsy were discovered in 4 (2.4%) breasts, and clinically palpable lesions combined with suspicious imaging findings requiring biopsy were present in another 4 (2.4%) breasts. All 8 biopsies showed fat necrosis, scar, or oil cysts without evidence of malignancy. One (0.6%) local complication (a wound infection at the recipient site requiring oral antibiotics) after autologous fat grafting was reported. During the limited follow-up period, there were no locoregional cancer recurrences. CONCLUSIONS: Autologous fat grafting in conjunction with breast reconstruction resulted in a biopsy rate of 4.8%, and no cases of locoregional cancer recurrence were observed. Based on these preliminary findings, autologous fat grafting appears to be a relatively safe procedure for refinement of the reconstructed breast in postmastectomy patients.

Patients Prefer Propofol to Midazolam Plus Fentanyl for Sedation for Colonoscopy: Results of a Single-Center Randomized Equivalence Trial.

BACKGROUND: Common sedation options for colonoscopy include propofol alone or a combination of midazolam and fentanyl. The former usually requires the presence of an anesthesia caregiver. The strategy that optimizes patient satisfaction has not yet been determined. OBJECTIVE: This study was designed to assess whether patient satisfaction at the time of colonoscopy is equivalent for propofol compared with midazolam and fentanyl. DESIGN: In this prospective, single-center, parallel group, single-blind, randomized, equivalence trial (NCT-01488045), 262 patients blinded to treatment received propofol (n = 126) or midazolam plus fentanyl (n = 136) at the time of colonoscopy. A patient satisfaction survey was administered in the recovery room and 1 to 5 days postprocedure. The endoscopist completed a survey immediately postprocedure. SETTINGS: This study was conducted at a tertiary academic hospital with a dedicated colon and rectal surgery division. PATIENTS: Patients over the age of 18 years who were undergoing elective colonoscopy were included in this study. MAIN OUTCOME MEASURES: The primary outcome was patient satisfaction with the colonoscopy. Secondary outcomes included physician and patient perception of patient pain, physician perception of patient tolerance of and difficulty of procedure, procedure duration, percentage of patients with cecal intubation, recovery time, and adverse events. RESULTS: Patient overall satisfaction scores in the recovery room after using the combination of midazolam and fentanyl (n = 136) during colonoscopy were not equivalent to patient satisfaction scores after using propofol (n = 126) alone (mean = 83.9 and 98.0 visual analog scale points) because the 90% CI (-18.5 to -9.6) for the mean treatment difference (-14.1) was completely outside the prespecified range of equivalence (±5 visual analog scale points). Patient pain as reported by the patient and as perceived by the physician and difficulty of the procedure were significantly worse for the midazolam/fentanyl group (n = 136) compared with the propofol group (n = 126). Time in the colonoscopy suite was significantly shorter for the propofol group, but the difference was small (4 minutes). There were no significant differences in percentage with cecal intubation, recovery time, or adverse events. LIMITATIONS: This is a single-institution, single-endoscopist study and is limited by the inability to perform blinding of the endoscopist. CONCLUSIONS: The use of propofol for conscious sedation during colonoscopy is associated with greater patient satisfaction and less pain when compared with midazolam/fentanyl, as perceived by the patient and endoscopist.

Nonsteroidal Anti-inflammatory Drugs: Do They Increase the Risk of Anastomotic Leaks Following Colorectal Operations?

BACKGROUND: Nonsteroidal anti-inflammatory drugs have become an important component of narcotic-sparing postoperative pain management protocols. However, conflicting evidence exists regarding the adverse association of nonsteroidal anti-inflammatory drug use with intestinal anastomotic healing in colorectal surgery. OBJECTIVE: This study compares patients receiving nonsteroidal anti-inflammatory drugs on postoperative day 1 with patients who did not receive nonsteroidal anti-inflammatory drugs with regard to the occurrence of anastomotic leaks. DESIGN: This is a retrospective study from a protocol-driven prospectively collected statewide database. A propensity score model was used to adjust for differences between the groups in patient demographics, characteristics, comorbidities, and laboratory values. SETTINGS: The multicenter data set used in this analysis represents a variety of academic and community hospitals within the state of Michigan from July 2012 through February 2014. PATIENTS: Nonpregnant patients over the age of 18 who underwent colon and rectal surgery with bowel anastomosis were selected. MAIN OUTCOME MEASURES: Occurrence of anastomotic leak, composite surgical site infection, sepsis, and death within 30 days of surgery were the primary outcomes measured. RESULTS: A total of 4360 patients met inclusion criteria, of which 1297 (29.7%) received nonsteroidal anti-inflammatory drugs and 3063 (70.3%) did not receive nonsteroidal anti-inflammatory drugs. There was no statistically significant difference between the 2 groups in the proportion of cases with anastomotic leak (OR, 1.33; CI, 0.86-2.05; p = 0.20), composite surgical site infection (OR, 1.26; CI, 0.96-1.66; p = 0.09), or death within 30 days (OR, 0.58; CI, 0.28-1.19; p = 0.14). There was a significantly greater risk of sepsis for patients given nonsteroidal anti-inflammatory drugs than for those patients not given nonsteroidal anti-inflammatory drugs (OR, 1.47; CI, 1.05-2.06; p = 0.03). LIMITATIONS: This is a nonrandomized study performed retrospectively, and it is based on data collected only within a subset of hospitals in the state of Michigan. CONCLUSIONS: No statistically significant increase in the proportion of patients with anastomotic leak was observed when prescribing nonsteroidal anti-inflammatory drugs for analgesia in the early postoperative period for patients undergoing elective colorectal surgery. Unexpectedly, there was an increased risk of sepsis that warrants further investigation (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A192, for a synopsis of this study).

Postoperative hyperglycemia and adverse outcomes in patients undergoing colorectal surgery: results from the Michigan surgical quality collaborative database.

PURPOSE: Our objective was to assess the relationship between high blood glucose levels (BG) in the early postoperative period and the incidence of surgical site infections (SSIs), sepsis, and death following colorectal operations. METHODS: The Michigan Surgical Quality Collaborative database was queried for colorectal operations from July 2012 to December 2013. Normoglycemic (BG < 180 mg/dL) and hyperglycemic (BG ≥ 180 mg/dL) groups were defined by using the highest BG within the first 72 h postoperatively. Outcomes of interest included the incidence of superficial, deep, and organ/space SSIs, sepsis, and death within 30 days. Initial unadjusted analysis was followed by propensity score matching and multiple logistic regression modeling after adjusting for significant predictors. Separate analyses were performed for previously diagnosed diabetic and non-diabetic patients. RESULTS: A total of 5145 cases met inclusion criteria, of which 1072 were diabetic. For diabetic patients, there was a marginally significant association between high BG and superficial SSI in the unadjusted analysis (OR = 1.75, p = 0.056), but not in the adjusted analysis (OR = 1.35, p = 0.39). There was no significant relationship between elevated BG and deep SSI, organ/space SSI, sepsis, or death among diabetic patients. For non-diabetic patients, there was a significant association between high BG and superficial SSI (OR = 1.53, p = 0.03), sepsis (OR = 1.61, p < 0.01), and death (OR = 2.26, p < 0.01), but not deep or organ/space SSI. CONCLUSIONS: Following colorectal operations, superficial SSI, sepsis, and death are associated with postoperative serum hyperglycemia in patients without diabetes, but not those with diabetes. Vigilant postoperative BG monitoring is critical for all patients undergoing colorectal surgery.

Is hepato-imino diacetic acid scan a better imaging modality than abdominal ultrasound for diagnosing acute cholecystitis?

BACKGROUND: The role of hepato-imino diacetic acid scan (HIDA) in the diagnosis of acute cholecystitis remains controversial when compared with the more commonly used abdominal ultrasound (AUS). METHODS: The diagnostic imaging workup of 1,217 patients who presented to the emergency department at a single hospital with acute abdominal pain and suspicion of acute cholecystitis was reviewed to calculate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of AUS and HIDA. RESULTS: In patients undergoing both imaging modalities, HIDA had significantly higher sensitivity (90.7% vs 64.0%, P < .001) and specificity (71.4% vs 58.4%, P = .005) than AUS for the diagnosis of acute cholecystitis. Additionally, PPV and NPV of HIDA (56.2% and 95.0%, respectively) were higher than PPV and NPV of AUS (38.4% and 80.0%, respectively) when both imaging modalities were used for the same patient. CONCLUSION: In adults with acute abdominal pain, HIDA significantly increases the accuracy of the correct diagnosis.

Chlorhexidine with isopropyl alcohol versus iodine povacrylex with isopropyl alcohol and alcohol- versus nonalcohol-based skin preparations: the incidence of and readmissions for surgical site infections after colorectal operations.

BACKGROUND: Surgical site infections are a major cause of morbidity and mortality after colorectal operations. Preparation of the surgical site with antiseptic solutions is an essential part of wound infection prevention. To date, there is no universal consensus regarding which preparation is most efficacious. OBJECTIVE: This study compared 2.0% chlorhexidine with 70.0% isopropyl alcohol versus 0.7% iodine povacrylex with 74.0% isopropyl alcohol and alcohol-based versus nonalcohol-based skin preparations with regard to efficacy in preventing postoperative wound infections. DESIGN: This is a retrospective study from 2 prospectively collected statewide databases combined. A propensity score model was used to adjust for differences between the groups in patient demographics, characteristics, comorbidities, and laboratory values. SETTINGS: The multicenter data set used in this analysis represents a variety of academic and community hospitals within the state of Michigan from January 2010 through June 2012. PATIENTS: Patients over the age of 18 years who underwent clean-contaminated colorectal operations were included. MAIN OUTCOME MEASURES: The incidence of superficial surgical site infections, any surgical site infection, any wound complication, and readmission within 30 days for surgical site infection were measured. RESULTS: When 2.0% chlorhexidine with 70.0% isopropyl alcohol (n = 425) and 0.7% iodine povacrylex with 74.0% isopropyl alcohol (n = 115) were compared, a total of 540 colorectal cases met inclusion criteria. When alcohol-based (n = 610) and nonalcohol-based (n = 177) skin preparations were compared, a total of 787 colorectal cases met inclusion criteria. There was no significant difference in the propensity-adjusted odds for having any of the 4 outcomes of interest when comparing 2.0% chlorhexidine with 70.0% isopropyl alcohol to 0.7% iodine povacrylex with 74.0% isopropyl alcohol and when comparing alcohol-based with nonalcohol-based skin preparations. LIMITATIONS: This was a nonrandomized study performed retrospectively based on data collected within the state of Michigan. CONCLUSIONS: The use of 2.0% chlorhexidine with 70.0% isopropyl alcohol versus 0.7% iodine povacrylex with 74.0% isopropyl alcohol or alcohol-based versus nonalcohol-based skin preparations does not significantly influence the incidence of surgical site infections or readmission within 30 days for surgical site infection after clean-contaminated colorectal operations.

Preliminary findings of long-term neurodevelopmental outcomes of infants treated with intravenous fat emulsion reduction for the management of parenteral nutrition-associated cholestasis.

INTRODUCTION: Parenteral nutrition-associated cholestasis (PNAC) is linked with the administration of soybean-based intravenous fat emulsion (IVFE). IVFE reduction (IFER) may be an effective management strategy for PNAC; however, long-term associated neurodevelopmental outcomes (NDOs) for infants undergoing IFER have not been measured previously. This single-institution, prospective study examined the risk for negative NDOs and key predictors of NDOs associated with IFER. METHODS: Patients (2-5 years) treated with soybean-based IFER as neonates underwent NDO measurements, including Ages and Stages Questionnaires-3 (ASQ-3), Parents' Evaluations of Developmental Status (PEDS), and Behavior Assessment System for Children, Second Edition Preschool, Parent (BASC-2 PRS-P). The relationship between NDOs and predictive variables was evaluated. RESULTS: A total of 25 children had a complete PEDS survey, and 17 were found to be "not at risk." The BASC-2 PRS-P evaluation (n = 18 patients) showed that all 4 composite domains fell within the normative developmental range, and 67%-89% of patients were observed to be "typically developing." For the primary outcome measure, ASQ-3, 82.4%-94.4% of patients were "not at risk." Logistical regression analyses were performed to examine risk factors contributing to negative NDOs. Of children completing all NDO studies, IFER-related variables (eg, development of essential fatty acid deficiency, duration of IFER, and mean IVFE dose) were not found to be predictors of adverse NDOs. CONCLUSIONS: This study represents the first report of NDOs in pediatric patients treated with IFER. IFER-treated patients score within the normative range most of the time. IFER-related variables were not found to be associated with negative NDOs. The results set the stage for a larger, multicenter, prospective study.

Emotion Regulation through Movement: Unique Sets of Movement Characteristics are Associated with and Enhance Basic Emotions.

We have recently demonstrated that motor execution, observation, and imagery of movements expressing certain emotions can enhance corresponding affective states and therefore could be used for emotion regulation. But which specific movement(s) should one use in order to enhance each emotion? This study aimed to identify, using Laban Movement Analysis (LMA), the Laban motor elements (motor characteristics) that characterize movements whose execution enhances each of the basic emotions: anger, fear, happiness, and sadness. LMA provides a system of symbols describing its motor elements, which gives a written instruction (motif) for the execution of a movement or movement-sequence over time. Six senior LMA experts analyzed a validated set of video clips showing whole body dynamic expressions of anger, fear, happiness and sadness, and identified the motor elements that were common to (appeared in) all clips expressing the same emotion. For each emotion, we created motifs of different combinations of the motor elements common to all clips of the same emotion. Eighty subjects from around the world read and moved those motifs, to identify the emotion evoked when moving each motif and to rate the intensity of the evoked emotion. All subjects together moved and rated 1241 motifs, which were produced from 29 different motor elements. Using logistic regression, we found a set of motor elements associated with each emotion which, when moved, predicted the feeling of that emotion. Each emotion was predicted by a unique set of motor elements and each motor element predicted only one emotion. Knowledge of which specific motor elements enhance specific emotions can enable emotional self-regulation through adding some desired motor qualities to one's personal everyday movements (rather than mimicking others' specific movements) and through decreasing motor behaviors which include elements that enhance negative emotions.

Abdominal ultrasound versus hepato-imino diacetic acid scan in diagnosing acute cholecystitis--what is the real benefit?

BACKGROUND: Acute cholecystitis is one of the most common surgical problems, yet substantial debate remains over the utility of simple examination, abdominal ultrasound (AUS), or advanced imaging such as hepato-imino diacetic acid (HIDA) scan to support the diagnosis. MATERIALS AND METHODS: The preoperative diagnostic workup of patients who underwent cholecystectomy with histologically confirmed acute cholecystitis was reviewed to calculate the sensitivity of AUS, HIDA scan, or both. In addition, the sensitivity of the commonly described ultrasonographic findings was assessed. RESULTS: From 2010 through 2012, 406 patients among 9087 reviewed charts presented to the emergency department with acute upper abdominal pain and met inclusion criteria. 32.5% (N = 132) of patients underwent AUS only, 11.3% (N = 46) underwent HIDA scan only, and 56.2% (N = 228) had both studies performed for workup. 52.7% (N = 214) of patients had histopathologically confirmed acute cholecystitis. The sensitivities of AUS, HIDA, and AUS combined with HIDA for acute cholecystitis were 73.3% (95% confidence interval [CI] = 66.3%-79.5%), 91.7% (95% CI = 86.2%-95.5%), and 97.7% (95% CI = 93.4%-99.5%), respectively. Although of limited sensitivity, AUS findings of sonographic Murphy sign, gallbladder distension, and gallbladder wall thickening were associated with a diagnosis of acute cholecystitis. CONCLUSIONS: The sensitivity of AUS for diagnosing acute cholecystitis in patients with acute upper abdominal pain is limited. The addition of a HIDA scan in the diagnostic workup significantly improves sensitivity and can add valuable information in the appropriate clinical setting.

Improved perioperative and short-term outcomes of robotic versus conventional laparoscopic colorectal operations.

BACKGROUND: Robotic assistance may offer unique advantages over conventional laparoscopy in colorectal operations. METHODS: This prospective observational study compared operative measures and postoperative outcomes between laparoscopic and robotic abdominal and pelvic resections for benign and malignant disease. RESULTS: From 2005 through 2012, 200 (58%) laparoscopic and 144 (42%) robotic operations were performed by a single surgeon. After adjustment for differences in demographics and disease processes using propensity score matching, all laparoscopic operations had a significantly shorter operative time (P < .01), laparoscopic left colectomies had a longer length of hospital stay (2009 and 2010: 6.5 vs 3.6 days, P = .01); and laparoscopic right colectomies had a higher risk for overall complications (P = .03) and postoperative ileus (P = .04). There were no significant differences in the outcomes of pelvic operations (P = .15). CONCLUSIONS: Compared with conventional laparoscopy, some types of robotic-assisted colorectal operations may offer advantages regarding postoperative length of stay and perioperative complications.

Dietary outcomes in a Spanish-language randomized controlled diabetes prevention trial with pregnant Latinas.

OBJECTIVES: We evaluated the effectiveness of a community-based healthy lifestyle intervention in improving dietary behaviors of pregnant Latinas from 2004 to 2006 in Detroit, Michigan. METHODS: The 11-week, culturally tailored, Spanish-language Healthy Mothers on the Move (MOMs) intervention offered home visits, group classes, related activities, and social support from trained community health workers (CHWs) and peers. Dietary behaviors were measured by food frequency questionnaire. Linear mixed models estimated pre- and post-intervention changes, within and between MOMs intervention and minimal intervention (MI) groups. RESULTS: MOMs (n = 139) and MI (n = 139) participants had similar baseline characteristics and dietary intake. Post-intervention, MOMs participants showed significant improvement in all dietary behaviors, except fruit and fiber consumption. Compared with MI participants, MOMs participants had significantly decreased consumption of added sugar (P = .05), total fat (P < .05), saturated fat (P < .01), percentage of daily calories from saturated fat (P < .001), solid fats and added sugars (P < .001), and had increased vegetable consumption (P < .001). Their increase in fiber consumption (P < .05) was significant relative to MI participants' decrease in fiber intake. CONCLUSIONS: We confirmed the hypothesis that a community-planned, CHW-led healthy lifestyle intervention could improve dietary behaviors of low-income Latina women during pregnancy.

Tissue oxygen saturation for the risk stratification of septic patients.

PURPOSE: Peripheral tissue oxygen saturation (Sto2) has shown promise as an early indicator of tissue hypoperfusion and as a risk stratification tool in various forms of shock. The purpose of this study was to determine if Sto2 would predict admission to an intensive (ICU) or progressive care unit in patients with early signs of sepsis. METHODS: In this prospective observational study, a rapid response team measured Sto2 levels in patients screening positive for sepsis. Using a logistic regression model, the value of Sto2 as a predictor for ICU admission within 72 hours of the initial assessment was determined. RESULTS: The 31 (47%) of 66 patients who required ICU admission within 72 hours of evaluation had a significantly lower Sto2 value (median, 78% vs 81%; P = .05). All patients with Sto2 less than 70% required ICU admission. A 1-point increase in Sto2 was associated with a 7% decrease in the odds of requiring ICU admission, and the area under the curve for Sto2 was 0.64 (0.51-0.77, P = .01). CONCLUSIONS: Low Sto2 levels in patients screening positive for sepsis are associated with an increased risk of ICU admission, but their reliability as a predictor is rather low. An Sto2 below 70% might be an interesting cutoff value for further study.

Periconception diet does not vary by duration of US residence for Mexican immigrant women.

This cross-sectional study assessed the influence of duration of residence in the United States on periconception dietary intake of pregnant Mexican immigrant women, using baseline data from Healthy Mothers on the Move, a randomized control trial conducted with 234 women from 2004 to 2006 in Detroit, MI. Average maternal age was 27.3±5.2 years (range=18 to 41 years) with 5.99±4.76 years of US residence (range=0 to 36 years). Women's usual dietary intake during the past 12 months was recorded on a validated food frequency questionnaire (17.3 weeks average gestation). Intakes of selected micronutrients, macronutrients, and food groups were compared by US residence categories (≤5, 6 to 10, or ≥11 years) using analysis of covariance. The percent of women with intakes below the Estimated Average Requirement and the percent not meeting US dietary guidelines were calculated. There was no association between dietary intake and duration of US residence in this population. Percentages of women with dietary intake below the Estimated Average Requirement were: 12.0% for folate, 7.7% for vitamin C, 23.9% for calcium, 11.2% for protein, and 5.1% for carbohydrates. US dietary guidelines were not met for fruit by 17.5% and for vegetables by 74.8% of women. Typical diets were high in saturated fat and cholesterol. Of the 2,195 kcal average daily energy intake, >25% came from saturated fats, trans fats, and added sugars that may replace nutrients important for healthy fetal growth and development and women's health. Interventions to improve intake before, during, and after pregnancy are important in this population, regardless of duration of US residence.

Postoperative surgical site infections after ventral/incisional hernia repair: a comparison of open and laparoscopic outcomes.

BACKGROUND: The purpose of this study was to compare the incidence of postoperative surgical site infections (SSIs), operative times (OTs), and length of hospital stay (LOS) after open and laparoscopic ventral/incisional hernia repair (VIHR) using multicenter, prospectively collected data. METHODS: The incidence of postoperative SSIs, OTs, and LOS was determined for cases of VIHR in the American College of Surgeons' National Surgical Quality Improvement Program database in 2009 and 2010. Open and laparoscopic techniques were compared using a propensity score model to adjust for differences in patient demographics, characteristics, comorbidities, and laboratory values. RESULTS: A total of 26,766 cases met the inclusion criteria; 21,463 cases were open procedures (reducible, n = 15,520 [72 %]; incarcerated/strangulated, n = 5,943 [28 %]), and 5,303 cases were laparoscopic procedures (reducible, n = 3,883 [73 %]; incarcerated/strangulated, n = 1,420 [27 %]). Propensity score adjusted odds ratios (ORs) were significantly different between open and laparoscopic VIHR for reducible and incarcerated/strangulated hernias with regard to superficial SSI (OR 5.5, p < 0.01 and OR 3.1, p < 0.01, respectively), deep SSI (OR 6.9, p < 0.01, and OR 8.0, p < 0.01, respectively) and wound disruption (OR 4.6, p < 0.01 and OR 9.3, p = 0.03, respectively). The risk for organ/space SSI was significantly greater for open operations among reducible hernias (OR 1.9, p = 0.02), but there was no significant difference between the open and laparoscopic repair groups for incarcerated/strangulated hernias (OR 0.8, p = 0.41). The OT was significantly longer for laparoscopic procedures, both for reducible (98.5 vs. 84.9 min, p < 0.01) and incarcerated/strangulated hernias (96.4 vs. 81.2 min, p < 0.01). LOS (mean, 95 % confidence interval) was significantly longer for open repairs for both reducible (open = 2.79, 2.59-3.00; laparoscopic = 2.39, 2.20-2.60; p < 0.01) and incarcerated/strangulated (open = 2.64, 2.55-2.73; laparoscopic = 2.17, 2.02-2.33; p < 0.01) hernias. CONCLUSIONS: Laparoscopic VIHR for reducible and incarcerated/strangulated hernias is associated with shorter LOS and decreased risk for superficial SSI, deep SSI, and wound disruption, but longer OTs when compared to open repair.

Classic Whipple versus pylorus-preserving pancreaticoduodenectomy in the ACS NSQIP.

BACKGROUND: The classic Whipple operation carries substantial risk of complications. A pylorus-preserving pancreaticoduodenectomy might confer the benefit of decreased perioperative morbidity, but existing data comparing both techniques are inconclusive. METHODS: Using a propensity score model to adjust for potentially confounding differences in patient characteristics, 30-d mortality, operative time, red blood cell transfusion requirements, major complications, and length of hospital stay were compared between both techniques in the American College of Surgeons' National Surgical Quality Improvement Program database. Separate analyses were carried out for underlying malignancy or benign disease, as defined by International Classification of Diseases, Ninth Revision codes. RESULTS: A total of 6988 pancreaticoduodenectomies from 2005 through 2010 were included. In 5424 patients (77.6%) with underlying malignancy, there were no significant differences for 30-d mortality (2.4% versus 2.8%, P = 0.33) and major organ system complications (all P > 0.10). Patients undergoing the classic Whipple operation had a significantly longer operative time (389 versus 366 min, P < 0.01), longer length of hospital stay (13.1 versus 12.0 days, P < 0.01), and higher red blood cell transfusion requirements (1.0 versus 0.8 units, P < 0.01). Results were similar for 1564 patients (22.4%) with underlying benign disease, except for a higher occurrence of postoperative pulmonary (P = 0.02) and renal (P = 0.05) complications in patients undergoing the classic Whipple operation. CONCLUSIONS: Short-term outcomes after classic and pylorus-preserving pancreaticoduodenectomy in this large, multicenter database are excellent, without significant differences in postoperative mortality and most major organ system complications. However, small advantages in resource and blood utilization may be accomplished with the pylorus-preserving technique.

Thermal hyperalgesia after sciatic nerve block in rat is transient and clinically insignificant.

Ropivacaine has been associated with transient heat hyperalgesia in sciatic nerve blocks in rat. The goal of the present study was to evaluate the hypothesized presence of transient heat hyperalgesia after perineural injection of ropivacaine with a secondary subanalysis of 2 published studies. Paw withdrawal latency was used to assess the duration of sensory blockade and presence of heat hyperalgesia at 210, 240, 270, and 300 minutes and 24 hours after injection. The analysis revealed hyperalgesia at a single time point (240 minutes after injection; mean difference, -0.60 seconds; P = 0.012) that resolved within 30 minutes, and there was no other significant hyperalgesia at other time points. Although statistically significant, the single time point measurement represented only an 11% change from baseline and was no longer present 30 minutes later. These data support the need for a reevaluation of the interpretation that pain can be worsened by perineural ropivacaine injection.

Association between bilirubin and mode of death in severe systolic heart failure.

The bilirubin level has been associated with worse outcomes, but it has not been studied as a predictor for the mode of death in patients with systolic heart failure. The Prospective Randomized Amlodipine Evaluation Study (PRAISE) cohort (including New York Heart Association class IIIB-IV patients with left ventricular ejection fraction <30%, n = 1,135) was analyzed, divided by bilirubin level: ≤0.6 mg/dl, group 1; >0.6 to 1.2 mg/dl, group 2; and >1.2 mg/dl, group 3. Multivariate Cox proportional hazards models were used to determine the association of bilirubin with the risk of sudden or pump failure death. Total bilirubin was entered as a base 2 log-transformed variable (log2 bilirubin), indicating doubling of the bilirubin level corresponding to each increase in variable value. The higher bilirubin groups had a lower ejection fraction (range 19% to 21%), sodium (range 138 to 139 mmol/L), and systolic blood pressure (range 111 to 120 mm Hg), a greater heart rate (range 79 to 81 beats/min), and greater diuretic dosages (range 86 to 110 furosemide-equivalent total daily dose in mg). The overall survival rates declined with increasing bilirubin (24.3, 31.3, and 44.3 deaths per 100 person-years, respectively, for groups 1, 2, and 3). Although a positive relation was seen between log2 bilirubin and both pump failure risk and sudden death risk, the relation in multivariate modeling was significant only for pump failure mortality (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82, p = 0.0004), not for sudden death mortality (hazard ratio 1.21, 95% confidence interval 0.98 to 1.49, p = 0.08). In conclusion, an increasing bilirubin level was significantly associated with the risk of pump failure death but not for sudden death in patients with severe systolic heart failure.

Effect of the healthy MOMs lifestyle intervention on reducing depressive symptoms among pregnant Latinas.

Depression during the prenatal and postpartum periods is associated with poor maternal, perinatal and child outcomes. This study examines the effectiveness of a culturally and linguistically tailored, social support-based, healthy lifestyle intervention led by trained community health workers in reducing depressive symptoms among pregnant and early postpartum Latinas. A sample of 275 pregnant Latinas was randomized to the Healthy MOMs Healthy Lifestyle Intervention (MOMs) or the Healthy Pregnancy Education (control) group. More than one-third of participants were at risk for depression at baseline. MOMs participants were less likely than control group participants to be at risk for depression at follow-up. Between baseline and 6 weeks postpartum, MOMs participants experienced a significant decline in depressive symptoms; control participants experienced a marginally significant decline. For MOMs participants, most of this decline occurred during the pregnancy intervention period, a time when no change occurred for control participants. The change in depressive symptoms during this period was greater among MOMs than control participants ("intervention effect"). From baseline to postpartum, there was a significant intervention effect among non-English-speaking women only. These findings provide evidence that a community-planned, culturally tailored healthy lifestyle intervention led by community health workers can reduce depressive symptoms among pregnant, Spanish-speaking Latinas.