The use of surgical intervention for lower gastrointestinal bleeding and its association with clinical outcomes and resource use.

BACKGROUND: To assess the use of surgical intervention for lower gastrointestinal bleeding and evaluate its associated factors. METHODS: The 2016 to 2019 National Inpatient Sample was queried to identify non-elective adult (≥18 years) hospitalizations for lower gastrointestinal bleeding. The International Classification of Diseases, 10th Revision, codes were used to ascertain patient characteristics, including signs of hemodynamic instability, potential lower gastrointestinal bleed source, and transfusion of blood products, as well as endoscopic, radiologic, and surgical intervention. Multivariable regression analyses were used to elucidate factors associated with operative management of lower gastrointestinal bleeding and evaluate its associated mortality, length of stay, and hospitalization costs. RESULTS: Of an estimated 364,495 patients, 1.7% underwent an operation for lower gastrointestinal bleeding. Compared to those managed conservatively, patients who underwent surgical intervention more commonly had diverticular-related bleeding, signs of hypovolemia, and less frequently underwent endoscopic intervention. After the adjustment of patient and hospital characteristics, ischemic colitis (adjusted odds ratio 7.5, 95% confidence interval 1.8-30.9, ref: hemorrhoids), hemodynamic instability (adjusted odds ratio 1.7, 95% confidence interval 1.5-2.0), and angiographic embolization (adjusted odds ratio 4.9, 95% confidence interval 3.9-6.0, ref: no endoscopic/radiologic intervention) were associated with greater odds of surgical intervention. Additionally, surgical intervention portended greater odds of in-hospital mortality (adjusted odds ratio 6.2, 95% confidence interval 4.5-8.5), a longer length of stay (8.5 days, 95% confidence interval 8.0-9.0), and greater hospitalization cost ($29.1K, 95% confidence interval 26.7K-31.5K). CONCLUSION: Operative management of lower gastrointestinal bleeding is rare and associated with significant morbidity and mortality compared to those managed conservatively. However, when surgical intervention is indicated, preoperative patient characteristics should be used to identify those at greater risk of an operation to facilitate early surgical consultation and inform expectations during the perioperative period.

Perioperative Nephrectomy Outcomes for Patients with Liver Disease: Implications for Liver Transplant Candidates.

OBJECTIVE: To improve the management of cirrhotic patients diagnosed with new renal masses, we used a nationally representative cohort to assess the perioperative outcomes of nephrectomy in the setting of liver disease. The incidences of liver disease and renal masses are both rising in the US. Delaying liver transplantation to address other health concerns may have life changing consequences in these patients, thus these results help to guide treatment decisions at this critical junction in care. METHODS: A retrospective study of the 2016-2019 Nationwide Readmissions Database was performed in adults undergoing nephrectomy for non-emergent indications. Outcomes were compared between 3 cohorts: no chronic liver disease (no CLD), chronic liver disease (CLD), and decompensated cirrhosis (DC). Mixed regression models were used to evaluate the association between CLD and DC with outcomes of interest including morbidity, mortality, readmission rates, non-home discharges, length of stay, and costs. RESULTS: A total of 183,362 patients were evaluated. The mortality rate in the DC cohort (7%) was higher than with CLD (0.4%) and no CLD (0.3%), (P <.001). DC was associated with higher mortality (OR 8.29, 95% CI 4.07 - 16.88), postoperative bleeding requiring transfusion (OR 5.55, 95% CI 3.72 - 8.26), non-home discharge (OR 5.12, 95% CI 3.16 - 8.30) and readmission (OR 1.79, 95% CI 1.09 - 2.94) compared to no CLD. The DC cohort had the greatest length of stay and costs. CONCLUSION: Patients undergoing nephrectomy with DC have increased morbidity, mortality, readmission rates, non-home discharges, LOS and costs. Alternative management strategies may be considered in these patients.

Inorganic sulfur fixation via a new homocysteine synthase allows yeast cells to cooperatively compensate for methionine auxotrophy.

The assimilation, incorporation, and metabolism of sulfur is a fundamental process across all domains of life, yet how cells deal with varying sulfur availability is not well understood. We studied an unresolved conundrum of sulfur fixation in yeast, in which organosulfur auxotrophy caused by deletion of the homocysteine synthase Met17p is overcome when cells are inoculated at high cell density. In combining the use of self-establishing metabolically cooperating (SeMeCo) communities with proteomic, genetic, and biochemical approaches, we discovered an uncharacterized gene product YLL058Wp, herein named Hydrogen Sulfide Utilizing-1 (HSU1). Hsu1p acts as a homocysteine synthase and allows the cells to substitute for Met17p by reassimilating hydrosulfide ions leaked from met17Δ cells into O-acetyl-homoserine and forming homocysteine. Our results show that cells can cooperate to achieve sulfur fixation, indicating that the collective properties of microbial communities facilitate their basic metabolic capacity to overcome sulfur limitation.

Association of frailty with outcomes of resection for colonic volvulus: A national analysis.

BACKGROUND: With limited national studies available, we characterized the association of frailty with outcomes of surgical resection for colonic volvulus. METHODS: Adults with sigmoid or cecal volvulus undergoing non-elective colectomy were identified in the 2010-2019 Nationwide Readmissions Database. Frailty was identified using the Johns Hopkins indicator which utilizes administrative codes. Multivariable models were developed to examine the association of frailty with in-hospital mortality, perioperative complications, stoma use, length of stay, hospitalization costs, non-home discharge, and 30-day non-elective readmissions. RESULTS: An estimated 66,767 patients underwent resection for colonic volvulus (Sigmoid: 39.6%; Cecal: 60.4%). Using the Johns Hopkins indicator, 30.3% of patients with sigmoid volvulus and 15.9% of those with cecal volvulus were considered frail. After adjustment, frail patients had higher risk of mortality compared to non-frail in both sigmoid (10.6% [95% CI 9.47-11.7] vs 5.7% [95% CI 5.2-6.2]) and cecal (10.4% [95% CI 9.2-11.6] vs 3.5% [95% CI 3.2-3.8]) volvulus cohorts. Frailty was associated with greater odds of acute venous thromboembolism occurrences (Sigmoid: AOR 1.50 [95% CI 1.18-1.94]; Cecal: AOR 2.0 [95% CI 1.50-2.72]), colostomy formation (Sigmoid: AOR 1.73 [95% CI 1.57-1.91]; Cecal: AOR 1.48 [95% CI 1.10-2.00]), non-home discharge (Sigmoid: AOR 1.97 [95% CI 1.77-2.20]; Cecal: AOR 2.56 [95% CI 2.27-2.89]), and 30-day readmission (Sigmoid: AOR 1.15 [95% CI 1.01-1.30]; Cecal: AOR 1.26 [95% CI 1.10-1.45]). Frailty was associated with incremental increase in length of stay (Sigmoid: +3.4 days [95% CI 2.8-3.9]; Cecal: +3.8 days [95% CI 3.3-4.4]) and costs (Sigmoid: +$7.5k [95% CI 5.9-9.1]; Cecal: +$12.1k [95% CI 10.1-14.1]). CONCLUSION: Frailty, measured using a simplified administrative tool, is associated with significantly worse clinical and financial outcomes following non-elective resections for colonic volvulus. Standard assessment of frailty may aid risk-stratification, better inform shared-decision making, and guide healthcare teams in targeted resource allocation in this vulnerable patient population.

Impact of malnutrition on outcomes following groin hernia repair: Insights from the ACS NSQIP.

BACKGROUND: The present study examined the association of nutrition status, as defined by preoperative serum albumin, with postoperative outcomes and resource use after groin hernia repair. METHODS: The 2006 to 2019 American College of Surgeons National Surgical Quality Improvement Program database was queried for adults (≥18 years) undergoing open or laparoscopic repair of inguinal or femoral hernia. Patients were stratified based on the following preoperative serum albumin levels: <2.5 g/dL (severe hypoalbuminemia), 2.5 to <3.0 (moderate hypoalbuminemia), 3.0 to <3.5 (mild), and ≥3.5 (normal albumin). Multivariable regression models were developed to assess the association of hypoalbuminemia with outcomes of interest, including 30-day mortality, postoperative complications, length of stay, and 30-day readmission. RESULTS: Of the 261,052 patients meeting inclusion criteria, 0.3% had severe, 1.1% had moderate, and 7.4% had mild hypoalbuminemia, with 91.2% classified as normal albumin. After risk adjustment, mortality risk was greater for severe (5.8%, 95% confidence interval: 4.1-7.6), moderate (4.4%, 95% confidence interval: 3.4-5.3), and mild hypoalbuminemia (1.5%, 95% confidence interval: 1.2-1.8) relative to normal albumin (0.3%, 95% confidence interval: 0.2-0.3). Decreasing serum albumin levels were associated with a stepwise increase in risk of complications, length of stay, and 30-day readmission. CONCLUSION: Decreased preoperative serum albumin is associated with increased mortality and morbidity after open and laparoscopic groin hernia repair. Serum albumin remains a relevant predictor of postsurgical outcomes and can thus be used in shared decision-making and optimization of malnourished patients in need of groin hernia repair.

Impact of center volume on conversion to thoracotomy during minimally invasive pulmonary lobectomy.

BACKGROUND: Conversion to open is a potentially serious intraoperative event associated with minimally invasive pulmonary lobectomy. However, the impact of institutional expertise on conversion to open has not been studied on a large scale. We used a nationally representative database to evaluate the association between hospital pulmonary lobectomy caseload and rates of conversion to open. METHODS: All adults who underwent minimally invasive pulmonary lobectomy were identified from the 2017 to 2019 Nationwide Readmissions Database. Annual institutional caseloads of open and minimally invasive lobectomy were independently tabulated. Restricted cubic splines were used to parametrize the relationship between conversion to open and hospital volumes. Furthermore, multivariable regression was used to examine the association of conversion to open with in-hospital mortality, length of stay, and hospitalization costs. RESULTS: Of an estimated 52,886 patients who met study criteria, 4.9% required conversion to open. Compared to others, conversion to open patients were slightly younger (66 vs 67 years) and more commonly male (52.2 vs 42.3%, P < .001). After adjustment, male sex (adjusted odds ratio 1.42), history of tobacco use (adjusted odds ratio 1.35), and prior radiation therapy (adjusted odds ratio 1.35, P < .001) were associated with increased odds of conversion to open. Increasing minimally invasive lobectomy volume was linked to lower risk-adjusted rates of conversion to open, whereas greater open lobectomy caseload was associated with higher rates. Despite no impact on mortality (adjusted odds ratio 1.11, P = .73), conversion to open was associated with a 1.2-day increment in length of stay and $5,600 in attributable costs. CONCLUSION: The present study found institutional minimally invasive pulmonary lobectomy caseload to be associated with decreased rates of conversion to thoracotomy, emphasizing the relevance of minimally invasive training among surgeons and perioperative staff.

Clinical and financial impact of chronic kidney disease in emergency general surgery operations.

Introduction: Chronic kidney disease is frequently encountered in clinical practice and often requires more intricate management strategies. However, its impact on outcomes of patients warranting emergency general surgery has not been well characterized. The present study examined the association of chronic kidney disease stage on in-hospital outcomes and readmission following emergency general surgery using a nationally representative cohort. Methods: The 2016-2018 Nationwide Readmissions Database was queried to identify all adult hospitalizations for 1 of 6 common emergency general surgery operations. Patients were stratified by severity of chronic kidney disease into stages 1-3, stages 4-5, end-stage renal disease, and others (non-chronic kidney disease). Regression models were used to examine factors associated with mortality, readmissions, and costs. Results: Of an estimated 985,101 patients undergoing emergency general surgery, 60,949 (6.2%) had a diagnosis of chronic kidney disease (1-3: 67.1%, 4-5: 11.5%, end-stage renal disease: 23.4%). Unadjusted rates of mortality increased with chronic kidney disease in a stepwise manner (2.1% in non-chronic kidney disease to 16.9 in end-stage renal disease, P < .001), as did 90-day readmissions (9.2% to 29.7%, respectively, P < .001). After adjustment, all stages of chronic kidney disease exhibited increases in risk-adjusted rates of mortality (range: 0.2% in chronic kidney disease 1-3 to 12.2% in end-stage renal disease, P < .001). Relative to non-chronic kidney disease, end-stage renal disease had the greatest cost burden for those undergoing small bowel resection (ß +$83,600) and the least in cholecystectomy (+$30,400). Conclusion: Chronic kidney disease severity is associated with a stepwise increase in mortality, hospitalization costs, and 90-day readmissions. Our findings may better inform shared decision-making and have implications in benchmarking. Further studies for optimal management strategies in this high-risk group are needed.

Association of chronic kidney disease with perioperative outcomes following acute lower limb revascularization.

Background: There is a paucity of data examining the impact of advancing chronic kidney disease stages on outcomes following revascularization for acute limb ischemia. The present study examined the association of chronic kidney disease with in-hospital mortality, amputation, and resource utilization following revascularization for acute limb ischemia using a nationally representative cohort. Methods: The 2016-2018 National Inpatient Sample was queried to identify all adult hospitalizations with lower extremity acute limb ischemia requiring surgical and/or endovascular interventions. Patients were grouped according to the presence of chronic kidney disease and its severity: no chronic kidney disease, chronic kidney disease 1-3 (chronic kidney disease stages 1 through 3), chronic kidney disease 4-5 (chronic kidney disease stages 4 through 5), and end-stage renal disease. Multivariable logistic and linear models were used to evaluate association of chronic kidney disease stage with outcomes of interest. Results: Of an estimated 82,610 patients meeting study criteria, 14.8% had chronic kidney disease (chronic kidney disease 1-3: 63.4%, chronic kidney disease 4-5: 12.1%, end-stage renal disease: 24.5%). Compared to those with chronic kidney disease, chronic kidney disease patients were on average older, were more frequently female, and had a higher median Elixhauser Comorbidity Index. Increasing severity of chronic kidney disease was associated with a stepwise increase in unadjusted mortality rates (4.7% in no chronic kidney disease to 12.6% in end-stage renal disease, P < .001). Following risk adjustment, only end-stage renal disease was associated with increased odds of mortality (adjusted odds ratio 3.10, 95% confidence interval 2.28-4.22) and limb amputation (adjusted odds ratio 1.99, 95% confidence interval 1.59-2.48) compared to patients with no chronic kidney disease. Similarly, advancing chronic kidney disease stage conferred increased odds of prolonged length of stay and greater hospitalization costs. Conclusion: Advanced renal dysfunction demonstrated inferior perioperative outcomes and greater health care expenditures in the study population. These findings imply that quality improvement efforts in acute limb ischemia revascularization should target patients with chronic kidney disease 4-5 and end-stage renal disease.

Association of frailty with clinical and financial outcomes of esophagectomy hospitalizations in the United States.

Background: Frailty, defined as impaired physiologic reserve and function, has been associated with inferior results after surgery. Using a coding-based tool, we examined the clinical and financial impact of frailty on outcomes following esophagectomy. Methods: Adults undergoing elective esophagectomy were identified using the 2010-2018 Nationwide Readmissions Database. Using the binary Johns Hopkins Adjusted Clinical Groups frailty indicator, patients were classified as frail or nonfrail. Multivariable regression models were used to evaluate the association of frailty with in-hospital mortality, complications, hospitalization duration, costs, nonhome discharge, and unplanned 30-day readmission. Results: Of 45,361 patients who underwent esophagectomy, 18.7% were considered frail. Most frail patients were found to have diagnoses of malnutrition (70%) or weight loss (15%) at the time of surgery. After adjustment, frailty was associated with increased risk of in-hospital mortality (adjusted odds ratio 1.67, 95% confidence interval 1.29-2.16) and overall complications (adjusted odds ratio 1.57, 95% confidence interval 1.44-1.71). Frailty conferred a 5.6-day increment in length of stay (95% confidence interval 4.94-6.45) and an additional $19,900 hospitalization cost (95% confidence interval $16,700-$23,100). Frail patients had increased odds of nonhome discharge (adjusted odds ratio 1.53, 95% confidence interval 1.35-1.75) as well as unplanned 30-day readmissions (adjusted odds ratio 1.17, 95% confidence interval 1.02-1.34). Conclusion: Frailty, as detected by an administrative tool, is associated with worse clinical and financial outcomes following esophagectomy. The inclusion of standardized assessment of frailty in risk models may better inform patient selection and shared decision-making prior to operative intervention.

Venous thromboembolism in cancer surgery: A report from the nationwide readmissions database.

Background: The present study characterized the incidence of venous thromboembolism in a contemporary cohort of surgical oncology patients and its association with index hospitalization and postdischarge outcomes. Methods: Adults undergoing 7 major thoracic and abdominal cancer resections were identified in the 2016-2019 Nationwide Readmissions Database. Multivariable models stratified by operative subtype were developed to evaluate the association of venous thromboembolism with outcomes of interest. Results: Of an estimated 436,368 patients, venous thromboembolism was identified in 9,811 (2.2%) patients during index hospitalization. Esophageal (4.1%) and gastric (4.1%) resections exhibited the highest rates of venous thromboembolism, whereas pulmonary resection (1.0%) the lowest. Following adjustment, cancer resection type demonstrated the strongest association with venous thromboembolism development among all factors analyzed (adjusted odds ratio: 3.13, 95% confidence interval: 2.60-3.78). Diagnosis of venous thromboembolism was associated with increased mortality (10.2%, 95% confidence interval: 9.4-11.1 vs 1.7, 95% confidence interval: 1.6-1.7) and prolonged index hospital stay (19.5 days, 95% confidence interval: 19.1-20.0 vs 7.5, 95% confidence interval: 7.4-7.5). Of patients who survived index hospitalization, venous thromboembolism occurrence was associated with increased risk of nonhome discharge (56.4%, 95% confidence interval: 54.7-58.0 vs 14.4, 95% confidence interval: 14.2-14.7) and readmission (30.0%, 95% confidence interval: 28.5-31.1 vs 16.9, 95% confidence interval: 16.7-17.1). Additionally, venous thromboembolism substantially increased index hospitalization ($40,000, 95% confidence interval: $38,000-$42,000) and readmission costs ($3,200, 95% confidence interval: $1,700-$4,700). Conclusion: Rates of venous thromboembolism remain high in surgical oncology patients, with cancer resection type as a major predictor of venous thromboembolism incidence. Venous thromboembolism was associated with inferior clinical and financial outcomes that extended beyond discharge. These findings underscore the importance of continued vigilance and procedure-specific prophylaxis measures.

Insurance-based disparities and risk of financial toxicity among patients undergoing gynecologic cancer operations.

OBJECTIVE: To evaluate the risk of financial toxicity (FT) among inpatients undergoing gynecologic cancer resections and the association of insurance status with clinical and financial outcomes. METHODS: Using the 2008-2019 National Inpatient Sample, we identified adult hospitalizations for hysterectomy or oophorectomy with a diagnosis of cancer. Hospitalization costs, length of stay (LOS), mortality, and complications were assessed by insurance status. Risk of FT was defined as health expenditure exceeding 40% of post-subsistence income. Multivariable regressions were used to analyze costs and factors associated with FT risk. RESULTS: Of 462,529 patients, 49.4% had government-funded insurance, 44.3% private, and 3.2% were uninsured. Compared to insured, uninsured patients were more commonly Black and Hispanic, admitted emergently, and underwent open operations. Uninsured patients experienced similar mortality but greater rates of complications, LOS, and costs. Overall, ovarian cancer resections had the highest median costs of $17,258 (interquartile range: 12,187-25,491) compared to cervical and uterine. Approximately 52.8% of uninsured and 15.4% of insured patients were at risk of FT. As costs increased across both cohorts over the 12-year study period, the disparity in FT risk by payer status broadened. After risk adjustment, perioperative complications were associated with nearly 2-fold increased risk of FT among uninsured (adjusted odds ratio 1.75, 95% confidence interval 1.46-2.09, p < 0.001). Among the insured, Black and Hispanic race, public insurance, and open operative approach exhibited greater odds of FT. CONCLUSION: Patients undergoing gynecologic cancer operations are at substantial risk of FT, particularly those uninsured. Targeted cost-mitigation strategies are warranted to minimize financial burden.

Cost-volume analysis of deep inferior epigastric artery perforator flaps for breast reconstruction in the United States.

BACKGROUND: Deep inferior epigastric artery perforator flaps are increasingly utilized over other autologous methods of breast reconstruction. We evaluated the relationship between annual hospital volume and costs after breast reconstruction with the deep inferior epigastric artery perforator flap. METHODS: All female patients undergoing elective implant or autologous tissue breast reconstruction were identified using the 2016-2019 Nationwide Readmission Database. Annual hospital volume of deep inferior epigastric artery perforator reconstructions was tabulated and modeled using restricted cubic splines. Institutions were categorized into high- and low-volume based on the inflection point of the spline between annual caseload and costs. The association between high volume status and costs, complications, length of stay, and 30-day nonelective readmission was assessed using multivariable regression. RESULTS: Of an estimated 94,524 patients meeting inclusion criteria, 33,046 (34.6%) underwent deep inferior epigastric artery perforator flap reconstruction. Deep inferior epigastric artery perforator flap utilization increased from 31% in 2016 to 40% in 2019 (P < .001) among inpatient breast reconstructions. High-volume hospitals more frequently performed bilateral reconstructions (43.3 vs 37.7%, P = .021) but had similar rates of concurrent mastectomy (28.7 vs 30.6%, P = .46), relative to low-volume hospitals. The median cost of deep inferior epigastric artery perforator reconstruction was lower ($29,900 [interquartile range: 22,400-37,400] vs $31,600 [interquartile range: 22,500-44,900], P = .036) at high-volume hospitals compared to low-volume. On adjusted analysis, high-volume status was associated a $3,800 (95% confidence interval: -6,200 to -1,400) decrement in hospitalization costs, and reduced odds of perioperative complications (adjusted odd ratio: 0.68 95% confidence interval: 0.54-0.86). High-volume status was not associated with length of stay or likelihood of unplanned readmission. CONCLUSION: The present study demonstrated an inverse cost-volume relationship in deep inferior epigastric artery perforator flap breast reconstruction. In line with goals of value-based health care delivery, our findings may inform referral patterns to suitable centers for deep inferior epigastric artery perforator breast reconstruction.

Association of frailty with outcomes after elective colon resection for diverticular disease.

BACKGROUND: Frailty has been associated with greater postoperative morbidity and mortality but its impact has not been investigated in patients with diverticulitis undergoing elective colon resection. Therefore, the present study examined the association of frailty with perioperative outcomes following elective colectomy for diverticular disease. METHODS: The 2017-2019 American College of Surgeons-National Surgical Quality Improvement Program data registry was queried to identify patients (aged ≥18 years) undergoing elective colon resection for diverticular disease. The 5-factor modified frailty index (mFI-5) was used to stratify patients into non-frail (mFI 0), prefrail (mFI 1), and frail (mFI ≥2) cohorts. Major adverse events, surgical site infection, and postoperative ileus as well as prolonged length of stay, nonhome discharge, and unplanned readmission were evaluated using multivariable logistic models. RESULTS: Of the 20,966 patients, 10.0% were frail. Compared to others, frail patients were generally older (non-frail: 55 years, [46-63], prefrail: 62, [54-70], frail: 64, [57-71]) and more commonly female (non-frail: 53.1%, prefrail: 58.6, frail: 64.4, P < .001). Frail patients more frequently underwent open colectomy and stoma creation compared with others. Frailty was associated with greater adjusted odds of major adverse event (adjusted odds ratio 1.25, 95% confidence interval 1.06-1.48), surgical site infection (adjusted odds ratio 1.28, 95% confidence interval 1.06-1.54), and postoperative ileus (adjusted odds ratio 1.59, 95% confidence interval 1.27-1.98). Similarly, frailty portended greater odds of prolonged length of stay, nonhome discharge, and unplanned readmission. CONCLUSION: Frailty as defined by the mFI-5 was associated with greater morbidity and hospital resource use. Deployment of frailty instruments may augment traditional risk calculators and improve patient selection for elective colectomy.

Factors and Outcomes Associated With Venous Thromboembolism Following Bariatric Surgery.

BACKGROUND: The present national study characterized the incidence and factors associated with VTE following bariatric operations and its association with postoperative outcomes and resource use. METHODS: Adults (≥18 years) undergoing elective sleeve gastrectomy or gastric bypass (laparoscopic and open) were identified in the 2016-2018 Nationwide Readmissions Database. International Classification of Diseases 10th Revision codes for deep venous thrombosis and/or pulmonary embolism were used to ascertain the presence of VTE. Multivariable linear and logistic models were developed to evaluate the independent association of VTE with outcomes of interest. RESULTS: Of an estimated 537,522 patients meeting inclusion criteria, .55% developed VTE during index hospitalization (.14%) or within 90 days of index discharge (.41%). Compared to others, VTE patients were older (51.8 vs 44.9 years, P<.001), more commonly male (20.0% vs 31.5%, P<.001), and had gastric bypass (56.3% vs 31.9%, P<.001) or an open procedure (21.9% vs 2.6%, P<.001). After risk adjustment, several factors including increasing age, male gender, gastric bypass and open approach remained associated with increased odds of VTE. Patients with VTE during index hospitalization had greater odds of mortality (AOR 11.6, 95% CI: 6.12-22.19) and increased index LOS (ß:+14.1 days, 95% CI: 11.7-16.5) and hospitalization costs (ß: +$53,100, 95% CI: 43,100-63,500). Additionally, VTE patients had greater odds of readmission within 90 days (AOR 1.86, 95% CI: 1.40-2.47). CONCLUSIONS: Although VTE is uncommon following bariatric operations, it is significantly associated with increased mortality, readmission, and resource use. Further research is necessary to ascertain optimal management of VTE for bariatric surgery patients.

Bariatric surgery outcomes in geriatric patients: a contemporary, nationwide analysis.

OBJECTIVE: This retrospective study sought to characterize the incidence of mortality in elderly patients following bariatric surgery and assessed the association of geriatric status with postoperative outcomes and resource use. BACKGROUND: Bariatric surgery is a safe and efficacious intervention for obesity and related diseases. The clinical and economic impact of geriatric status on bariatric surgery is largely unexplored. SETTING: Academic, university-affiliated hospital; US. METHODS: Adults (≥45 yr) undergoing elective laparoscopic gastric bypass or sleeve gastrectomy were identified in the 2016-2019 Nationwide Readmissions Database. Patients ≥65 years were categorized into the geriatric cohort. Multivariable linear and logistic models were developed to evaluate the independent association of geriatric status with outcomes of interest. RESULTS: Of an estimated number of 351,292 patients meeting inclusion criteria, 44,183 (12.6%) comprised the geriatric cohort. Of these patients, .3% died during the index hospitalization. Geriatric status was associated with significantly increased odds of in-hospital mortality (adjusted odds ratio [AOR] = 2.39, 95% confidence interval [CI]: 1.33-4.30), respiratory (AOR = 1.34, 95% CI: 1.13-1.59), infectious (AOR = 1.65, 95% CI: 1.25-2.17), and renal complications (AOR = 1.27, 95% CI: 1.12-1.46), and prolonged hospitalization (AOR = 1.35, 95% CI: 1.24-1.48). Elderly patients experienced a .19-day increment in the length of stay (95% CI: .11-.27) and $620 in attributable hospitalization costs (95% CI: 310-930). CONCLUSIONS: While overall rates of postoperative death and complications are low, geriatric patients experience significantly increased mortality, morbidity, and resource use following bariatric operations relative to younger adults. These findings may aid in shared decision-making for obesity management in geriatric patients.

Hospital variation in the development of respiratory failure after pulmonary lobectomy: A national analysis.

BACKGROUND: Respiratory failure after pulmonary lobectomy is a serious complication associated with increased mortality in limited institutional series. The present study evaluated factors associated with respiratory failure and sought to ascertain the presence of interhospital variation. METHODS: The 2016-2018 Nationwide Readmissions Database was queried to identify elective adult (≥18 years) hospitalizations for pulmonary lobectomy with the diagnosis of lung cancer. Multi-level, mixed-effects models were developed to identify factors associated with respiratory failure and evaluate its associated in-hospital mortality, length of stay, and hospitalization costs. Random effects were predicted with Bayesian methodology and used to rank hospitals by increasing respiratory failure risk attributable to each institution. RESULTS: Of an estimated 70,992 patients, 8.0% developed respiratory failure. Compared to those without, patients with respiratory failure were on average older and less commonly female. After multivariable adjustment, coagulopathy, pulmonary circulation disorders, and open operative approach were associated with increased odds of respiratory failure. However, relative to right upper, right middle resections were associated with a reduction in likelihood of respiratory failure. Approximately 27% of the variance in respiratory failure was attributable to the hospital-level effects, with baseline risk ranging from 0.1% to 20.7%. Notably, respiratory failure was associated with increased mortality, longer length of stay, and greater hospitalization costs. CONCLUSION: The present work identified several factors associated with respiratory failure after lobectomy and found it to be associated with inferior clinical outcomes and greater resource use. We noted significant interhospital variation in the development of respiratory failure, suggesting the need for systemic quality improvement efforts.

Pericardiocentesis or surgical drainage: A national comparison of clinical outcomes and resource use.

BACKGROUND: While institutional series have sought to define the optimal strategy for drainage of pericardial effusions, large-scale comparisons remain lacking. Using a nationally representative sample, the present study examined clinical and financial outcomes following pericardiocentesis (PC) and surgical drainage (SD) in patients admitted for pericardial effusion and tamponade. METHODS: Adults undergoing PC or SD within 2 days of admission for non-surgically related pericardial effusion or tamponade were identified in the 2016-2019 Nationwide Readmissions Database. Multivariable logistic and linear models were developed to evaluate the association between intervention type and outcomes. The primary outcome of interest was mortality while secondary endpoints included reintervention, periprocedural complications, hospital length of stay (LOS), hospitalization costs and 30-day non-elective readmission. RESULTS: Of an estimated 44,637 records meeting inclusion criteria, 28,862 (64.7%) underwent PC while the remainder underwent SD for initial management of pericardial effusion or tamponade. PC was associated with significantly increased odds of in-hospital mortality, reintervention and 30-day readmission relative to SD. PC was also associated with greater odds of cardiac complications but lower odds of infection, respiratory failure and blood transfusions compared to SD. Although PC was associated with shorter index hospital length of stay and costs, the two strategies yielded similar 30-day cumulative costs. CONCLUSION: Management of pericardial effusion with PC is associated with greater odds of mortality, reintervention and 30-day readmission but similar 30-day cumulative costs compared to SD. In the setting of adequate hospital capability and operator expertise, SD is a reasonable initial treatment strategy for pericardial effusion.

Association of Frailty with Perioperative Outcomes Following Hepatic Resection: A National Study.

OBJECTIVES: Risk of mortality and major comorbidity remains high following hepatic resection. Given recent advancements in nonsurgical techniques to control hepatic malignancy, accurate assessment of surgical candidates, especially those considered frail, has become imperative. The present study aimed to characterize the impact of frailty on clinical and financial outcomes following hepatic resection in older individuals. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: All older adults (≥65 years) undergoing elective hepatic resection were identified from the 2012 to 2019 National Inpatient Sample. METHODS: Frailty was defined by using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Multivariable regression models were developed to assess the independent association of frailty with mortality, perioperative complications, and resource utilization. Marginal effects were tabulated to assess the impact of hospital volume on frailty-associated mortality. RESULTS: Of an estimated 40,735 patients undergoing major hepatic resection, 9.0% were considered frail. After multivariable adjustment, frailty was associated with increased odds of mortality (adjusted odds ratio [AOR] 2.9; 95% confidence interval [CI] 2.0-4.3; P < .001) and perioperative complication (AOR 2.9; 95% CI 2.4-3.4; P < .001). Furthermore, frail patients incurred longer risk-adjusted length of stay (14.2 vs 6.7 days, P < .001) and greater hospitalization costs ($55,100 vs $29,300, P < .001). In assessing the impact of institutional expertise on perioperative outcomes, the marginal effect of frailty on mortality became less pronounced with increasing operative volume. CONCLUSIONS AND IMPLICATIONS: As the population of the United States continues to age, surgeons are increasingly likely to encounter candidates for major hepatic resection who are frail. The present study associated frailty with inferior clinical and financial outcomes; however, frailty-associated mortality became less pronounced at centers with high hepatic resection operative volume. Coding-based instruments, such as the Johns Hopkins Adjusted Clinical Groups, may identify patients from electronic medical records who may benefit from further geriatric assessment and targeted treatments.

BMPs as new insulin sensitizers: enhanced glucose uptake in mature 3T3-L1 adipocytes via PPARγ and GLUT4 upregulation.

Insulin-resistance is the main cause of type 2 diabetes. Here we describe the identification and characterization of BMP2 and BMP6 as new insulin-sensitizing growth factors in mature adipocytes. We show that BMP2 and BMP6 lead to enhanced insulin-mediated glucose uptake in both insulin-sensitive and -insensitive adipocytes. We exclude a direct effect of BMP2 or BMP6 on translocation of GLUT4 to the plasma membrane and demonstrate that these BMPs increase GLUT4 protein levels equipotent to Rosiglitazone. BMPs induce expression of PPARγ as the crucial mediator for the insulin-sensitizing effect. A comprehensive RNA-Seq analysis in mature adipocytes revealed regulation of both BMP/Smad and PPARγ target genes. The effects of BMP2 and BMP6 are not completely redundant and include regulation of genes involved in glucose and fatty acid metabolism and adipokine expression. Collectively, these findings suggest the BMP2 and BMP6 pathway(s) as promising new drug targets to treat insulin resistance.

Measurement of sternal curvature angle on patients with pectus excavatum.

BACKGROUND: Pectus excavatum (PE) is a chest deformity characterized by marked sternal depression. The objective of this study was to quantify the sternal curvature observed in patients diagnosed with PE using the sternal curvature angle (SCA). METHODS: A retrospective review of lateral chest X-rays of patients with PE from 2006 to 2013 was performed. The SCA was measured in a manner similar to the method of Cobb's angle is used to measure spinal curvature. SCA and Haller index were calculated from the chest X-rays for all patients. RESULTS: Lateral chest X-rays of 202 PE and 196 normal control patients were analyzed. The mean SCA ± SD of PE patients was 40.56° ± 12.88° compared to 22.02° ± 7.65° for normal patients. The difference was statistically significant with a p value of <0.0001. No significant concordance between SCA and Haller index measurements in the PE group was found (Kendall τ = -0.00015, p value = 0.9975). CONCLUSION: The difference in sternal curvature as measured by the sternal curvature angle between the pectus excavatum and normal patients was statistically significant. Our data suggest that sternal depression evident in PE patients is not a simple linear depression of the sternum but due to curvature in the sternal body.