Burden of Future Liver Abnormalities in Patients With Intrahepatic Cholestasis of Pregnancy.

INTRODUCTION: There are limited data on the incidence, predictors, and time to future liver abnormalities in patients with intrahepatic cholestasis of pregnancy (ICP). METHODS: Single-center retrospective study of pregnant women with and without ICP who delivered from 2005 to 2009 evaluating incidence and time to future liver abnormalities. Women returning for care with liver function tests at a minimum of 6 months postpartum were included. Liver disease diagnoses and liver functions test abnormalities were compared. Time to development of alanine aminotransferase (ALT) >25 U/L, alkaline phosphatase (ALP) >140 U/L, and diagnosis of liver disease (through imaging or clinical evaluation) were compared between women with and without ICP using Kaplan-Meier methods and Cox regression models. RESULTS: A total of 255 women with ICP and 131 age-matched control subjects with delivery during the same period were identified. Subjects in both groups were similar in follow-up time, age at pregnancy, prepregnancy body mass index, and ethnicity (≥75% were Hispanic in both groups). On univariate analyses, ICP was associated with increased incidence of ALT >25 U/L P < 0.01 ALP >140 U/L (P < 0.01) and liver disease (P = 0.03). Adjusting for metabolic factors, ICP diagnosis was associated with risk of future liver abnormalities: postpartum ALT >25 U/L (hazard ratio [HR] 1.9, P < 0.01), ALP >140 U/L (HR 3.4, P < 0.01), and liver disease (HR 1.5, P = 0.05). DISCUSSION: In our cohort of urban women, ICP diagnosis predicted risk of future liver disease and abnormal liver tests. Women with pregnancies complicated by ICP may benefit from surveillance for postpartum liver abnormalities.

Colonic diverticulitis following open-heart surgery: a case report of an unusual postoperative gastrointestinal complication.

Diverticulitis, though a common gastrointestinal disease, is rare following open-heart surgery. There is insufficient data regarding its incidence and management post-cardiac surgery. Especially in patients with atypical presentation, diagnosis and management can be challenging. This case outlines one such atypical diverticulitis case in which a 57-year-old female patient developed perforated diverticulitis with pelvic abscess accumulation following left ventricular aneurysm (LVA) repair. Diagnosis, appropriate management and treatment approaches are discussed. Cardiac surgeons should consider the possibility of diverticulitis in patients reporting nonspecific abdominal pain following cardiac surgery to ensure early diagnosis and institution of appropriate treatment to prevent associated adverse outcomes.

Characteristics and Trends in Spine Research Over the Last Decade in The Journal of Bone & Joint Surgery from 2008 to 2017.

BACKGROUND: This study reviews and identifies various trends and characteristics of spine research published by The Journal of Bone & Joint Surgery (JBJS) from 2008 through 2017. METHODS: A PubMed search of all studies published in JBJS from 2008 to 2017 was performed using the keyword "spine." A similar search was conducted on the JBJS website. Citations, authorship, academic degrees, country of origin, topic, level of evidence, positive or negative outcome, and patient-reported outcomes were analyzed. RESULTS: A total of 163 articles were selected using exclusion criteria. The most cited article was referenced 513 times per Google Scholar and 318 times per Web of Science. The most popular research topics were related to either the cervical spine (approximately 22% of articles) or scoliosis (approximately 22% of articles). The United States was responsible for 73.0% of the articles in the study, followed by China at 6.1%. Fifty-eight articles used at least one patient-reported outcome measurement (PROM), most commonly the Short Form Questionnaire. CONCLUSIONS: A strong emphasis on international publications and an increase in authorship are evident. Level of evidence (LOE) I or II studies received 2.4 times as many citations on average as LOE III or IV studies. While no evidence of a positive publication bias from JBJS was found, there appears to be a lack of standardization of patient reported outcome measurements in spine research. Finally, spine articles discussing medical protocols or patient management garnered an average of 1.6 times as many citations as spine studies that explored other topics.

Predictors and Outcomes of Cardiac Events following Thoracic Endovascular Aortic Repair in Descending Thoracic Aortic Aneurysm and Dissection.

BACKGROUND: Cardiac events following thoracic endovascular aortic repair (TEVAR) have been associated with significant morbidity and mortality. However, predictors of post-TEVAR cardiac events in descending thoracic aortic aneurysm or dissection are poorly understood. METHODS: A retrospective analysis of completed TEVAR procedures performed from 2010 to 2016 was conducted using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) participant user file database. Adult patients (≥18 years) who underwent TEVAR for descending thoracic aortic aneurysm or dissection were identified and 30-day outcomes were examined. An initial univariate analysis was performed to determine associations between all patient variables and cardiac events, defined as myocardial infarction or cardiac arrest that occurred ≤30 days of surgery. Multivariate logistic regression was subsequently performed to identify independent risk factors for cardiac events following TEVAR. RESULTS: The study identified 150 out of 2,905 (5.2%) patients who underwent TEVAR for descending thoracic aortic aneurysm or dissection who developed cardiac events. No significant difference in incidence of cardiac events was noted among patients presenting with aortic aneurysm or dissection (p = 0.339). The overall 30-day mortality rate for all patients was 9.1%. Independent preoperative predictors of post-TEVAR cardiac events included emergency procedure (odds ratio [OR] 2.80, 95% confidence interval [CI] 1.9-4.1, p < 0.01); American Society of Anesthesiologists score >3 (OR 1.71, 95% CI 1.1-2.6, p = 0.01), ventilator dependence (OR 2.33, 95% CI 1.3-4.2, p < 0.01), renal failure (OR 2.53, 95% CI 1.50-4.3, p < 0.01), blood transfusion (OR 1.84, 95% CI 1.1-3.2, p = 0.03), and preoperative leukocytosis (OR 2.45, 1.6-3.8, p < 0.01). After TEVAR, unplanned reintubation (OR 5.52, 95% CI 3.5-8.8, p < 0.01), prolonged mechanical ventilation (OR 1.94, 95% CI 1.2-3.2, p = 0.011), and postoperative blood transfusion (OR 4.02, 95% CI 2.70-6.0, p < 0.01) were independent predictors of cardiac events. Cardiac events greatly increased mortality (60.7 vs. 5.5%), total length of hospital stay (13.2 ± 14.7 days vs. 8.3 ± 9.3 days), and readmission rates (19.3 vs. 8.2%, p < 0.01). CONCLUSIONS: Cardiac events following TEVAR are associated with significant mortality. Patients with these risk factors should be appropriately monitored to improve outcomes.

Evaluating strategies and outcomes following rotator cuff tears.

INTRODUCTION: Rotator cuff tear surgical repair techniques have significantly progressed. However, tendon retear following primary repair persistently occurs at high rates. Rehabilitation protocols, surgical fixation techniques, biologic therapy with scaffolds, platelet-rich plasma, and even stem cell applications are under study to promote adequate tendon healing. METHODS: A nonsystematic query of the PubMed database was conducted in July 2016 utilizing the search terms "rotator cuff repair," "tear," "rehabilitation," "scaffold," "platelet-rich plasma," and "stem cell" to identify, analyze, and summarize relevant studies. CONCLUSION: Individualized rehabilitation protocols may be the best approach for small to medium sized tears. Surgical fixation will continue to be debated as modifications to single-row technique and increases in suture number have improved tensile strength. Double-row repairs have been associated with higher costs. Transosseous equivalent technique exhibits comparable subjective and objective outcomes to single- and double-row repair at two-year follow-up. Biocompatible scaffold augmentation has showed inconsistent short-term results. Platelet-rich plasma has lacked uniformity in treatment preparation, administration, and outcome measurement with mixed results. Few human studies have suggested decreased retear rates and improved repair maintenance following bone marrow-derived mesenchymal stem cell augmentation. This review reiterated the necessity of additional high-quality, large-sample studies to develop any final verdict regarding efficacy.

Unplanned postoperative reintubation following general and vascular surgical procedures: Outcomes and risk factors.

BACKGROUND: Unplanned postoperative reintubation (UPR) is a marker for severe adverse outcomes following general and vascular surgery. STUDY DESIGN: A retrospective analysis of 8809 adult patients, aged 18 years and older, who underwent major general and vascular surgery at a large single-center urban hospital was conducted from January 2013 to September 2016. Patients were grouped into those who experienced UPR and those who did not. Univariate and multivariate regression analyses were used to identify predictors of UPR, and association of UPR with adverse postoperative outcomes. All regression models had Hosmer-Lemeshow P > 0.05, and C-statistic >0.75, indicating excellent goodness-of-fit and discrimination. RESULTS: Of the 8809 patients included, 138 (1.6%) experienced UPR. There was no statistical difference in incidence of UPR between general and vascular surgery patients (p = 0.53). Independent predictors of UPR advanced age (OR 5.1, 95%CI 3.5-7.5, p < 0.01), higher ASA status (OR 7.9, 95%CI 5.6-11.1, p < 0.01), CHF (OR 7.0, 95%CI 3.6-13.9, p = 0.02), acute renal failure or dialysis (OR 3.1, 95%CI 1.8-5.7, p = 0.01), weight loss (OR 5.2, 95%CI 2.8-9.6, p = 0.01), systemic sepsis (OR 4.8, 95%CI 3.4-6.9, p < 0.01), elevated preoperative creatinine (OR 4.2, 95%CI 3.0-5.9, p = 0.01), hypoalbuminemia (OR 5.3, 95% CI 3.8-7.5, p = 0.01), and anemia (OR 4.0, 95%CI 2.8-5.9, p < 0.01). Following surgery, UPR was associated with increased mortality (OR 3.8, 95%CI 2.7-5.2, p < 0.01), pulmonary complications (OR 1.8, 95%CI 1.7-2.0, p < 0.01), renal complications (OR 2.6, 95%CI 1.7-3.5, p < 0.01), cardiac complications (OR 4.6, 95%CI 2.0-6.7, p < 0.01), postoperative RBC transfusion (OR 5.7, 95%CI 3.8-8.6,p < 0.01), and prolonged hospitalization (OR 1.8, 95%CI 1.5-2.4, p < 0.01). CONCLUSION: UPR is significantly associated with postoperative morbidity and mortality. Perioperative management aimed at decreasing incidences of UPR after noncardiac surgery should target preoperative anemia in addition to previously identified predictors.

Risk factors contributing to cardiac events following general and vascular surgery.

BACKGROUND: Cardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes. STUDY DESIGN: This was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE. RESULTS: Out of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4-6.9,p < 0.01), ASA >3(OR 12.0, 95%CI 8.5-16.9,p < 0.01), emergency surgery(OR 3.7, 95%CI 2.7-5.1,p = 0.01), CHF(OR 11.2, 95%CI 6.4-16.7,p = 0.02), COPD(OR 3.9, 95%CI 2.4-6.4,p = 0.04), acute renal failure or dialysis(OR 8.0, 95%CI 5.2-12.1,p = 0.04), weight loss(OR 3.3, 95%CI 1.7-6.7,p < 0.01), preoperative creatinine >1.2 mg/dL(OR 5.1, 95%CI 3.7-7.1,p = 0.01), hematocrit <34%(OR 4.0, 95%CI 2.8-5.7,p < 0.01), and operative time >240 min(OR 2.0, 95%CI 1.3-3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2-6.5,p < 0.01), pulmonary complications(OR 5.0, 95%CI 3.1-8.9,p < 0.01), renal complications(OR 2.3, 95%CI 1.9-4.5,p < 0.01), neurologic complications(OR 2.5, 95%CI 1.4-5.2,p < 0.01), systemic sepsis(OR 2.2, 95%CI 1.7-4.0,p < 0.01), postoperative RBC transfusion(OR 4.4, 95%CI 2.7-6.5,p < 0.01), unplanned return to operating room(OR 4.0, 95%CI 2.3-6.9,p < 0.01), and prolonged hospitalization (OR 5.5, 95%CI 3.1-8.8,p = 0.03). There was no statistical difference in incidence of CE between general and vascular surgery patients (p = 0.44); however, predictors of CE differed between the two surgical groups. CONCLUSION: Postoperative CE are associated with significant morbidity and mortality. Identified predictors of CE should allow for adequate risk stratification and optimization of perioperative surgical management.

Effect of Resident Involvement on Morbidity and Mortality Following Thoracic Endovascular Aortic Repair.

OBJECTIVE: To evaluate the effect of resident involvement in thoracic endovascular aortic repair (TEVAR). SUMMARY OF BACKGROUND DATA: Although the influence of resident intraoperative involvement in several types of surgical procedures has been reported, the effect of resident participation in TEVAR is unknown. We evaluated patient outcomes in resident-involved TEVAR procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analyzed for TEVAR performed from 2010 to 2012. Current procedural terminology codes were used to identify adult patients (≥18 y) who underwent TEVAR. Patients were grouped into those with and without resident involvement. Descriptive and binomial logistic statistics were used to determine the effect of resident involvement on post-TEVAR outcomes. p values < 0.05 were considered statistically significant. RESULTS: A total of 676 patients met inclusion criteria for this study. Of these, 517 (76.5%) had residents involved. Overall mortality was 9.8%, with no significant difference between the 2 groups (p = 0.88). Resident involvement was not a significant predictor of any post-TEVAR complication. Postoperative pneumonia (3.5% vs 6.9%, p = 0.06), prolonged mechanical ventilation (11.8% vs 11.9%, p = 0.96), stroke (2.7% vs 5.7%, p = 0.07), urinary tract infection (3.3% vs 4.4%, p = 0.50), progressive renal insufficiency (1.2% vs 2.5%, p = 0.22), acute renal failure (4.1% vs 5.0%, p = 0.60), cardiac arrest (2.9% vs 5.0%, p = 0.20), myocardial infarction (1.7% vs 1.9%, p = 0.91), deep venous thrombosis (1.7% vs 1.3%, p = 0.67), red blood cells transfusions (29.2% vs 36.5%, p = 0.08), sepsis (2.9% vs 4.4%, p = 0.35), septic shock (1.9% vs 3.8%, p = 0.18), and unplanned reintubation (8.7% vs 9.4%, p = 0.78) were not significantly affected. Additionally, resident involvement did not significantly affect operative time (176.1 ± 122.8 min vs 180.3 ± 119.1 min, p = 0.71) and anesthesia time (282.1 ± 146.6 min vs 278.3 ± 140.5 min, p = 0.78). CONCLUSIONS: The participation of residents in TEVAR did not significantly affect all 30-day patient outcomes. Resident involvement in TEVAR is safe and should be encouraged. MINI ABSTRACT: This study evaluated the effect of resident participation on postoperative outcomes of thoracic endovascular aortic repair (TEVAR) using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Results showed that resident involvement in TEVAR does not negatively affect patient outcomes.

Cancer screening information at community health fairs: What the participants do with information they receive.

BACKGROUND: To assess participants' reasons for seeking cancer screening information at community health fairs and what they do with the information they receive. DESIGN AND METHODS: Mixed quantitative and qualitative approach was used. Community health fairs are organized in underserved New York City neighbourhoods. From June 14, 2016 to August 26, 2016, cancer prevention tables providing information about various cancer screenings were established at 12 local community health fairs in New York City. In-person and follow up telephone surveys assessing interest in the cancer prevention table, personal cancer screening adherence rates, information-sharing behaviours and demographic variables have been taken into account. Statistical analyses were performed using IBM SPSS 22.0: frequencies, descriptive, cross tabulations. All qualitative data was coded by theme so that it could be analysed through SPSS. For example, Were you interested in a specific cancer? may be coded as 2 for yes, breast cancer. RESULTS: One hundred and sixteen patrons participated in the initial survey. Of those, 88 (78%) agreed to give their contact information for the follow-up survey and 60 follow-up surveys were completed (68%). Of those who reported reading the material, 45% shared the information; 15% subsequently spoke to a provider about cancer screenings and 40% intended to speak to a provider. CONCLUSIONS: Participants disseminated information without prompting; suggesting the reach of these fairs extends beyond the people who visit our table. Future studies should look at whether patrons would share information at higher rates when they are explicitly encouraged to share the information.