Hernia repair in the presence of ascites

Background

The model for end-stage liver disease (MELD) has been validated as a prediction tool for postoperative mortality, but its role in predicting morbidity has not been well studied. We sought to determine the role of MELD, among other factors, in predicting morbidity and mortality in patients with nonmalignant ascites undergoing hernia repair.

Methods

All patients undergoing hernia repair in the American College of Surgeons National Surgical Quality Improvement database (2009–11) were identified. Those with nonmalignant ascites were compared with patients without ascites. A subset analysis of patients with nonmalignant ascites was performed to evaluate the association between MELD and morbidity and mortality with adjustment for potential confounders. The association of significant factors with the rate of morbidity was displayed using a best-fit polynomial regression.

Results

Of 138,366 hernia repairs, 778 (0.56%) were performed on patients with nonmalignant ascites. Thirty-day morbidity (4% versus 19%) and mortality (0.2% versus 5.3%) were significantly more frequent in patients with ascites (P < 0.001). In univariate analysis of the 636 patients with a calculable MELD, MELD was associated with both morbidity and mortality (P < 0.001 each). In multivariate analysis, MELD remained significantly associated with morbidity (odds ratio [OR] = 1.11). Ventral hernia repair (OR = 2.9), dependent functional status (OR = 2.3), alcohol use (OR = 2.3), emergent operation (OR = 2.0) white blood count (OR = 1.1), and age (OR = 1.02) were also significantly associated with morbidity (P < 0.05).

Conclusions

Before hernia repair, the MELD score can be used to risk-stratify patients with nonmalignant ascites not only for mortality but also morbidity. Morbidity rates increase rapidly with MELD above 15, but other factors should additionally be accounted for when counseling patients on their perioperative risk.     

Systematic review and meta-analysis of rectal washout on risk of local recurrence for cancer

Background

It has been shown that intraluminal washout (WO) can prevent local recurrence (LR) of rectal cancer. This meta-analysis was to evaluate the association of rectal WO and the risk of LR after anterior resection in patients with rectal cancer.

Methods

The relevant studies were identified by a search of the MEDLINE, Embase, Wiley Online Library, and Cochrane Oral Health Group Specialized Register with no restrictions on October 18, 2013, and these studies were included in a systematic review and meta-analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated in fixed effects model.

Results

A total of nine studies were included in our study, yielding a total of 5519 patients, and pooled ORs for overall LR in corresponding subgroups were calculated. Rectal WO was associated with a lower risk for LR (240/4176, 5.75% versus 9.75%, 131/1343, OR = 0.53, 95% CI = 0.42–0.68, and P < 0.00001) in patients with anterior resection, having total mesorectal excisions (234/3942, 5.93% versus 9.34%, 97/1039, OR = 0.59, 95% CI = 0.46–0.75, and P < 0.00001), and after radical resection (RR; 122/2665, 4.99% versus 8.90%, 74/831, OR = 0.56, 95% CI = 0.41–0.78, and P = 0.0005), with an overall LR rate of 6.72% (371/5519). But, the stability of RRs is not high in the total mesorectal excisions or RR subgroup by sensitivity analysis.

Conclusions

The use of rectal WO decreases risks of LR in patients after anterior resection of cancer.     

The impact of pregnancy on surgical Crohn disease: an analysis of the Nationwide Inpatient Sample

Background

The impact of pregnancy on the course of Crohn disease is largely unknown. Retrospective surveys have suggested a variable effect, but there are limited population-based clinical data. We hypothesized pregnant women with Crohn disease will have similar rates of surgical disease as a nonpregnant Crohn disease cohort.

Material and methods

International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify female Crohn patients from all patients admitted using the Nationwide Inpatient Sample (1998–2009). Women were stratified as either pregnant or nonpregnant. We defined Crohn-related surgical disease as peritonitis, gastrointestinal hemorrhage, intra-abdominal abscess, toxic colitis, anorectal suppuration, intestinal–intestinal fistulas, intestinal–genitourinary fistulas, obstruction and/or stricture, or perforation (excluding appendicitis).

Results

Of the 92,335 women admitted with a primary Crohn-related diagnosis, 265 (0.3%) were pregnant. Pregnant patients were younger (29 versus 44 y; P < 0.001) and had lower rates of tobacco use (6% versus 13%; P < 0.001). Pregnant women with Crohn disease had higher rates of intestinal–genitourinary fistulas (23.4% versus 3.0%; P < 0.001), anorectal suppuration (21.1% versus 4.1%; P < 0.001), and overall surgical disease (59.6% versus 39.2%; P < 0.001). On multivariate logistic regression analysis controlling for malnutrition, smoking, age, and prednisone use, pregnancy was independently associated with higher rates of anorectal suppuration (odds ratio [OR], 5.2; 95% confidence interval [CI], 3.8–7.0; P < 0.001), intestinal–genitourinary fistulas (OR, 10.4; 95% CI, 7.8–13.8; P < 0.001), and overall surgical disease (OR, 2.9; 95% CI, 2.3–3.7; P < 0.001).

Conclusions

Pregnancy in women with Crohn disease is a significant risk factor for Crohn-related surgical disease, in particular, anorectal suppuration and intestinal–genitourinary fistulas.     

Racial disparity in early graft failure after infrainguinal bypass

Background

Racial disparities have been shown to be associated with increasing health-care costs. We sought to identify racial disparities in 30-d graft failure rates after infrainguinal bypass in an effort to define targets for improved health care among minorities.

Methods

The 2005–2011 National Surgical Quality Improvement Program database was queried for patients with peripheral arterial disease who underwent infrainguinal bypass as their primary procedure. A bivariate analysis was done to assess pre and intraoperative risk factors across race (whites, blacks, and Hispanics). Multivariate logistic regression was performed to assess the independent association of race with 30-d graft failure.

Results

Of a total of 16,276 patients, 12,536 (77.0%) were whites, 2940 (18.1%) blacks, and 800 (4.9%) Hispanics. Black patients were more likely to be younger, female, current smokers, and on dialysis (P < 0.001, all). In addition, whites were less likely to present with critical limb ischemia compared with blacks and Hispanics (44.2 versus 55.4 versus 52.8%, respectively; P < 0.001). Similarly, fewer whites underwent femoral-tibial (31.4 vs. 34.7 vs. 38.6% respectively) or popliteal-tibial level bypasses (8.9 versus 13.4 versus 16.1%, respectively) than blacks and Hispanics (P < 0.001, all). There was no difference in the use of autogenous conduit across the groups (P = 0.266). Proportionally more blacks than whites developed early graft failure (6.7 versus 4.5%; P < 0.001) but there was no difference comparing Hispanics to whites (6.0 versus 4.5%; P = 0.057). On multivariable analysis, black race remained independently associated with early graft failure (adjusted odds ratio = 1.26, 95% confidence interval 1.05–1.51; P = 0.011).

Conclusions

More blacks and Hispanics present with critical limb ischemia, requiring distal revascularization. Even when controlling for anatomic differences and degree of peripheral arterial disease, black race remained independently associated with early graft failure after infrainguinal bypass. These results identify a target for improved outcomes.     

Diabetes remission and glycemic response to pre-bariatric surgery diet

Background

Before bariatric surgery, some patients with type 2 diabetes mellitus (T2DM) experience improvement in blood glucose control and reduced insulin requirements while on a preoperative low-calorie diet (LCD). We hypothesized that patients who exhibit a significant glycemic response to this diet are more likely to experience remission of their diabetes in the postoperative period.

Materials and methods

Insulin-dependent T2DM patients undergoing bariatric surgery between August 2006 and February 2011 were eligible for inclusion. Insulin requirements at day 0 and 10 of the LCD were compared. Patients with a ≥50% reduction in total insulin dosage to maintain appropriate blood glucose control were considered rapid responders to the preoperative LCD. All others were non–rapid responders. We analyzed T2DM remission rates up to 1 y postoperatively.

Results

A total of 51 patients met inclusion criteria and 29 were categorized as rapid responders (57%). The remaining 22 were considered non–rapid responders (43%). The two groups did not differ demographically. Rapid responders had greater T2DM remission rates at 6 (44% versus 13.6%; P = 0.02) and 12 mo (72.7% versus 5.9%; P < 0.01). In patients undergoing laparoscopic gastric bypass, rapid responders showed greater excess weight loss at 3 mo (40.1% versus 28.2%; P < 0.01), 6 mo (55.2% versus 40.2%; P < 0.01), and 12 mo (67.7% versus 47.3%; P < 0.01).

Conclusions

Insulin-dependent T2DM bariatric surgery patients who display a rapid glycemic response to the preoperative LCD are more likely to experience early remission of T2DM postoperatively and greater weight loss.     

Analytic morphomics corresponds to functional status in older patients

Background

Older patients account for nearly half of the United States surgical volume, and age alone is insufficient to predict surgical fitness. Various metrics exist for risk stratification, but little work has been done to describe the association between measures. We aimed to determine whether analytic morphomics, a novel objective risk assessment tool, correlates with functional measures currently recommended in the preoperative evaluation of older patients.

Materials and methods

We retrospectively identified 184 elective general surgery patients aged >70 y with both a preoperative computed tomography scan and Vulnerable Elderly Surgical Pathways and outcomes Assessment within 90 d of surgery. We used analytic morphomics to calculate trunk muscle size (or total psoas area [TPA]) and univariate logistic regression to assess the relationship between TPA and domains of geriatric function mobility, basic and instrumental activities of daily living (ADLs), and cognitive ability.

Results

Greater TPA was inversely correlated with impaired mobility (odds ratio [OR] = 0.46, 95% confidence interval [CI] 0.25–0.85, P = 0.013). Greater TPA was associated with decreased odds of deficit in any basic ADLs (OR = 0.36 per standard deviation unit increase in TPA, 95% CI 0.15–0.87, P <0.03) and any instrumental ADLs (OR = 0.53, 95% CI 0.34–0.81; P <0.005). Finally, patients with larger TPA were less likely to have cognitive difficulty assessed by Mini-Cog scale (OR = 0.55, 95% CI 0.35–0.86, P <0.01). Controlling for age did not change results.

Conclusions

Older surgical candidates with greater trunk muscle size, or greater TPA, are less likely to have physical impairment, cognitive difficulty, or decreased ability to perform daily self-care. Further research linking these assessments to clinical outcomes is needed.     

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

Background

The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC).

Methods

Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score–matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness.

Results

We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P < 0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P < 0.001), and have a reencounter (17.5% versus 11.4%, P < 0.001) within 30 d of discharge. However, in the PSM cohort (n = 4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio = 3.95, 95% confidence interval: 1.45, 10.71).

Conclusions

After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.     

The role of clinical care pathways: an experience with distal pancreatectomy

Background

Previous studies have indicated that clinical pathways may shorten hospital length of stay (HLOS) among patients undergoing distal pancreatectomy (DP). Here, we evaluate an institutional standardized care pathway (SCP) for patients undergoing DP.

Materials and methods

A retrospective review of patients undergoing DP from November 2006 to November 2012 was completed. Patients treated before and after implementation of the SCP were compared. Multivariable linear regression was then performed to identify independent predictors of HLOS.

Results

There were no differences in patient characteristics between SCP (n = 50) and pre-SCP patients (n = 100). Laparoscopic technique (62% versus 13%, P < 0.001), splenectomy (52% versus 38%, P = 0.117), and concomitant major organ resection (24% versus 13%, P = 0.106) were more common among SCP patients. Overall, important complication rates were similar (24% versus 26%, P = 0.842). SCP patients resumed a normal diet earlier (4 versus 5 d, P = 0.025) and had shorter HLOS (6 versus 7 d, P = 0.026). There was no increase in 30-d resurgery or readmission. In univariate comparison, SCP, cancer diagnoses, intraductal papillary mucinous neoplasm diagnoses, neoadjuvant therapy, operative technique, major organ resection, and feeding tube placement were associated with HLOS; however, after multivariable adjustment, only laparoscopic technique (−33%, P = 0.001), concomitant major organ resection (+38%, P < 0.001), and feeding tube placement (+68%, P < 0.001) were independent predictors of HLOS.

Conclusions

Implementation of a clinical pathway did not improve HLOS at our institution. The increasing use of laparoscopy likely accounts for shorter HLOS in the SCP cohort. In the future, it will be important to identify clinical scenarios most likely to benefit from implementation of a clinical pathway.     

Impact of a blood conservation program on 30-day morbidity and mortality: a cohort study

Background

There are little published data on outcomes of blood conservation (BC) patients after noncardiac surgery. The objective of this study was to compare the surgical outcomes of patients enrolled in our BC program with that of the general population of surgical patients.

Methods

BC patients at our institution undergoing various surgical procedures were identified from the 2007–2009 National Surgical Quality Improvement Program database and compared with a cohort of conventional care (CC) patients matched by age, gender, and surgical procedure. Univariate and multiple logistic regression analyses were performed to evaluate 30-d postoperative outcomes.

Results

One hundred twenty BC patients were compared with 238 CC patients. The two groups were similar for all preoperative variables except smoking, which was lower in the BC group. On univariate analysis, BC patients had similar mean operating time (148 versus 155 min; P = 0.5), length of stay (5.9 versus 5.5 d; P = 0.7), and rate of return to the operating room (7.5% versus 5.5%; P = 0.4) compared with CC patients. BC and CC patients had similar 30-d morbidity (18% versus 14%; P = 0.3) and mortality rates (1.6% versus 1.3%; P = 1.0), respectively. On multivariable analysis, enrollment in the BC program had no impact on postoperative 30-d morbidity (odds ratio, 1.78; 95% confidence interval, 0.71–4.47) or 30-d mortality (unadjusted odds ratio, 1.33; 95% confidence interval, 0.22–8.05).

Conclusions

Short-term postoperative outcomes in BC patients are similar to the general population, and these patients should not be denied surgical treatment based on their unwillingness to receive blood products.     

Primary hyperparathyroidism across the ages: presentation and outcomes

Background

Primary hyperparathyroidism (PHPT) is a disease process traditionally thought to present during middle age, but can occur at any age. The purpose of this study was to compare PHPT patient characteristics based on patient age at the time of surgical referral.

Methods

A retrospective review of a prospectively managed database of adult patients undergoing parathyroid surgery for PHPT was conducted. Patients with a negative family history, no previous parathyroid surgery, and ≥6-mo follow-up were included. Patients were grouped by age for comparison.

Results

From 2001–2012, 1372 patients met inclusion criteria. Age groups were as follows: ≤50 y, 51–60 y, 61–70 y, and >70 y. Female predominance increased with age (P > 0.01). Baseline serum parathyroid hormone levels were higher at the extremes of age (P < 0.001). Young patients had the highest serum calcium (P < 0.01), urinary calcium (P < 0.001), and T-score (P < 0.001) measures, and greater incidence of vitamin D deficiency (P = 0.03). The use of local anesthesia increased with age, whereas use of outpatient parathyroidectomy decreased with age (both P < 0.01). Rates of disease persistence (2.3%–2.9%, P = 0.95) and recurrence (2.1%–3.3%, P = 0.75) were low, and did not differ.

Conclusions

Patients at the extremes of age are referred with more elevated laboratory indices whereas those in the traditional age range have milder biochemical indices. This may result from differential surgical referral. Individuals with laboratory evidence of abnormal calcium and parathyroid hormone regulation should be evaluated for parathyroidectomy regardless of age because all ages can be successfully treated.     

American Society of Anesthesiologists class and Charlson's Comorbidity index as predictors of postoperative colorectal anastomotic leak: a single-institution experience

Background

The American Society of Anesthesiologists (ASA) physical status classification and Charlson comorbidity index (CCI) was adopted to assess patients' physical condition before surgery. Studies suggest that ASA score and CCI might be a prognostic criterion (indicator) for patient outcome. The aim of this study is to determine if ASA classification and CCI can determine the risk of anastomotic leaks (AL) in patients who underwent colorectal surgery.

Methods

A retrospective analysis of 505 consecutive colorectal resections with primary anastomoses between 2008 and 2012 was performed at a university hospital. ASA score, CCI, surgical procedure, length of stay, age, body mass index (BMI), comorbidities, and postoperative outcomes were analyzed.

Results

Two hundred sixty-five patients had an ASA score of I and II, 227 patients had an ASA score of III, and 13 patients had an ASA score of IV. A total of 19 patients had an anastomotic leak (ASA I–II: 5 patients, 1.9%; ASA III: 12 patients, 5.58%; ASA IV: 2 patients, 18.18%). A higher ASA score was significantly associated with AL on further analysis (OR: 2.99, 95% CI: 1.345–6.670, P = 0.007). When matched for age, BMI, and CCI on logistic regression analysis, increased ASA level was independently related to an increased likelihood of leak (OR_steroids = 14.35, P < 0.01; OR_{ASA_III v I–II} = 2.02, P = 0.18; OR_{ASA_IVvI–II} = 8.45, P = 0.03). There were no statistically significant differences in means between the leak and no-leak patients with respect to age (60.69 versus 65.43, P = 0.17), BMI (28.03 versus 28.96, P = 0.46), and CCI (6.19 versus 7.58, P = 0.09).

Conclusions

ASA score, but not CCI, is independently associated with anastomotic leak. Patients with a high ASA class should be closely followed postoperatively for AL after colorectal operations.     

Inhibition of AAA in a rat model by treatment with ACEI perindopril

Background

The purpose of the present study was to evaluate the effect of a new angiotensin converting enzyme inhibitor perindopril on the formation of experimental abdominal aortic aneurysms (AAAs) in a rat model induced by intraluminal elastase infusion and extraluminal calcium chloride (CaCl₂) application.

Materials and methods

Thirty-six male Sprague–Dawley rats were randomly distributed into three groups (n = 12 per group): model (A), sham (B), and perindopril (C). Rats in model and perindopril groups underwent intra-aortic elastase perfusion and extraluminal CaCl₂ application to induce AAAs. Rats in the sham group received aortic perfusion and extraluminal application of saline. A dose of 3 mg/kg/d of perindopril was fed orally in the perindopril group. The maximum abdominal aortic diameter was measured in vivo on days 0 and 28 and by ultrasound on days 7, 14, and 21. The arterial blood pressure was measured directly using a pressure transducer after cannulation in surgery and before death. AAA tissue samples were harvested at day 28 and evaluated using normal hematoxylin and eosin stain, Verhoeff-van Gieson stain for elastin, and image analysis technique.

Results

Aortic diameters of rats in the model group consistently increased within 28 d, coinciding with the development of a transmural inflammatory response, thickening of intima, and destruction of the elastic media. Without alteration in blood pressure, the AAA formation rate and mean maximal diameter of aorta at day 28 were significantly lower in the perindopril group compared with the control group (1.71 ± 0.20 versus 2.70 ± 0.69 mm, P < 0.001; 0% versus 90.91%, P < 0.001) and were similar to those in the sham group (1.79 ± 0.29 mm, P = 0.175; 0%, P = 1). The thickness of intima in the perindopril group was lower than that in the model group (20.68 ± 9.96 versus 58.49 ± 32.01 μm, P = 0.001), but higher than that in the sham group (7.23 ± 2.68 μm, P = 0.005). The intensity of elastin fiber showed the opposite trend (0.8541 ± 0.0495 in sham group versus 0.7376 ± 0.1024 in perindopril group versus 0.5413 ± 0.0912 in model group, P < 0.001).

Conclusions

Perindopril inhibited the aortic degeneration and AAA formation in the experimental AAA model induced by elastase and CaCl₂. This effect, which was independent of its influence on hemodynamics, appeared to be induced by the suppression of the inflammatory cell influx and intimal thickening and the preservation of aortic medial elastin.     

Identifying predictors of a difficult thyroidectomy

Background

A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS.

Methods

A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P < 0.05) variables from a univariate analysis.

Results

A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P = 0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P = 0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P = 0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23–15.36, P = 0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28–9.66, P = 0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06–6.42, P = 0.037) were independently associated with DT.

Conclusions

Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.     

Impact of liver-directed therapy in colorectal cancer liver metastases

Background

There is a paucity of data on the current management and outcomes of liver-directed therapy (LDT) in older patients presenting with stage IV colorectal cancer (CRC). The aim of the study was to evaluate treatment patterns and outcomes in use of LDT in the setting of improved chemotherapy.

Methods

We used Cancer Registry and linked Medicare claims to identify patients aged ≥66 y undergoing surgical resection of the primary tumor and chemotherapy after presenting with stage IV CRC (2001–2007). LDT was defined as liver resection and/or ablation-embolization.

Results

We identified 5500 patients. LDT was used in 34.9% of patients; liver resection was performed in 1686 patients (30.7%), and ablation-embolization in 554 patients (10.1%), with 322 patients having both resection and ablation-embolization. Use of LDT was negatively associated with increasing year of diagnosis (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.93–0.99), age >85 y (OR = 0.61, 95% CI 0.45–0.82), and poor tumor differentiation (OR = 0.73, 95% CI 0.64–0.83). LDT was associated with improved survival (median 28.4 versus 21.1 mo, P < 0.0001); however, survival improved for all patients over time. We found a significant interaction between LDT and period of diagnosis and noted a greater survival improvement with LDT for those diagnosed in the late (2005–2007) period.

Conclusions

Older patients with stage IV CRC are experiencing improved survival over time, independent of age, comorbidity, and use of LDT. However, many older patients deemed to be appropriate candidates for resection of the primary tumor and receipt of systemic chemotherapy did not receive LDT. Our data suggest that improved patient selection may be positively impacting outcomes. Early referral and optimal selection of patients for LDT has the potential to further improve survival in older patients presenting with advanced colorectal cancer.     

Predictors of appendiceal perforation in an equal access system

Background

Discrepancies in socioeconomic factors have been associated with higher rates of perforated appendicitis. As an equal-access health care system theoretically removes these barriers, we aimed to determine if remaining differences in demographics, education, and pay result in disparate outcomes in the rate of perforated appendicitis.

Materials and methods

All patients undergoing appendectomy for acute appendicitis (November 2004–October 2009) at a tertiary care equal access institution were categorized by demographics and perioperative data. Rank of the sponsor was used as a surrogate for economic status. A multivariate logistic regression model was performed to determine patient and clinical characteristics associated with perforated appendicitis.

Results

A total of 680 patients (mean age 30 ± 16 y; 37% female) were included. The majority were Caucasian (56.4% [n = 384]; African Americans 5.6% [n = 38]; Asians 1.9% [n = 13]; and other 48.9% [n = 245]) and enlisted (87.2%). Overall, 6.4% presented with perforation, with rates of 6.6%, 5.8%, and 6.7% (P = 0.96) for officers, enlisted soldiers, and contractors, respectively. There was no difference in perforation when stratified by junior or senior status for either officers or enlisted (9.3% junior versus 4.40% senior officers, P = 0.273; 6.60% junior versus 5.50% senior enlisted, P = 0.369). On multivariate analysis, parameters such as leukocytosis and temperature, as well as race and rank were not associated with perforation (P = 0.7). Only age had a correlation, with individuals aged 66–75 y having higher perforation rates (odds ratio, 1.04; 95% confidence interval, 1.02–1.05; P < 0.001).

Conclusions

In an equal-access health care system, older age, not socioeconomic factors, correlated with increased appendiceal perforation rates.     

Fenofibrate does not affect burn-induced hepatic endoplasmic reticulum stress

Background

Burn injury causes major metabolic derangements such as hypermetabolism, hyperlipidemia, and insulin resistance and is associated with liver damage, hepatomegaly, and hepatic endoplasmic reticulum (ER) stress. Although the physiological consequences of such derangements have been delineated, the underlying molecular mechanisms remain unknown. Previously, it was shown that fenofibrate improves patient outcome by attenuating postburn stress responses.

Methods

Fenofibrate, a peroxisome proliferator–activated receptor alpha agonist, regulates liver lipid metabolism and has been used to treat hypertriglyceridemia and hypercholesterolemia for many years. The aim of the present study is to determine the effects of fenofibrate on burn-induced hepatic morphologic and metabolic changes. We randomized rats to sham, burn injury, and burn injury plus fenofibrate. Animals were sacrificed and livers were assessed at 24 or 48 h post burn.

Results

Burn injury decreased albumin and increased alanine transaminase (P = 0.1 versus sham), indicating liver injury. Fenofibrate administration did not restore albumin or decrease alanine transaminase. In addition, ER stress was significantly increased after burn injury both with and without fenofibrate (P < 0.05 versus sham). Burn injury increased fatty acid metabolism gene expression (P < 0.05 versus sham), downstream of peroxisome proliferator–activated receptor alpha. Fenofibrate treatment increased fatty acid metabolism further, which reduced postburn hepatic steatosis (burn versus sham P < 0.05, burn + fenofibrate versus sham not significant).

Conclusions

Fenofibrate did not alleviate thermal injury–induced hepatic ER stress and dysfunction, but it reduced hepatic steatosis by modulating hepatic genes related to fat metabolism.     

Insurance status predicts survival for trauma patients undergoing urgent intervention

Background

The purpose of this study was to investigate the relationship between insurance status and outcomes for trauma patients presenting without vital signs undergoing urgent intervention.

Materials and methods

The National Trauma Data Bank was queried for patients presenting with a systolic blood pressure equal to zero and a Glasgow Coma Scale score of three (“clinically dead”), who underwent urgent thoracotomy and–or laparotomy (UTL). Insured patients were compared with uninsured (INS [−]) patients.

Results

There were 18,171 patients presenting clinically dead having a payment source documented. INS (−) patients were more likely to undergo UTL (5.4% [416–7704] versus 2.7% [285–10,467], 1.481 [1.390–1.577], <0.001). Out of 689 patients who underwent UTL and meeting inclusion criteria, 416 (60.4%) were INS (−). Patients with insurance demonstrated a significantly greater survival (9.9% [27–273] versus 1.7% [7–416], 5.878 [2.596–13.307] P < 0.001). Adjusting for mechanism, race, age, injury severity, and comorbidities, insured status was independently associated with survival.

Conclusions

The presence of health insurance is independently associated with survival in trauma patients presenting with cardiovascular collapse who undergo urgent surgical intervention.     

Age and gender differences in substance screening may underestimate injury severity: a study of 9793 patients at level 1 trauma center from 2006 to 2010

Background

Although the relationship between psychoactive substance use and injury is known, evidence remains conflicting on the impact of substance use on clinical outcomes after injury. We hypothesized that preinjury substance use would negatively impact clinical outcomes.

Methods

National Trauma Registry American College of Surgeons identified patients (n = 9793) presenting to Duke Hospital from 2006 to 2010. Logistic regression models assessed potential predictors of receiving substance screening, mortality, length of stay, ventilator requirement, intensive care admission, or emergency department disposition.

Results

Forty-seven percent (4607/9793) of patients received blood alcohol screen (BAS) and 31% (3017/9793) received urine drug screen (UDS). Men were more likely to receive both BASs (P < 0.001) and UDSs (P = 0.001) than women after controlling for potential confounders. There was no significant difference between men and women over the legal limit for alcohol (OLLA; 27.2%, 95% confidence interval [CI]: 25.7%–28.8% versus 24.8%, 95% CI: 22.3%–27.5%). Similarly, younger patients more likely received both BASs (P < 0.001) and UDSs (P < 0.001) compared with older patients. The proportion of patients aged ≤45 y OLLA (26.5 %, 95% CI: 24.9%–28.2%) was similar to those aged >45 y OLLA (26.8%, 95% CI: 24.5%–29.3%). After controlling for potential confounders neither alcohol, nor tetrahydrocannabinol, nor cocaine was predictive of mortality, ventilator requirement, length of stay, or emergency department disposition, but a higher alcohol level (P = 0.0174) predicted intensive care admission.

Conclusions

Females and those aged >45 y are less likely to receive BASs and UDSs. Differential screening that is biased may place patients at risk for receiving inadequate care.