Prehabilitation Programs Improve Exercise Capacity Before and After Surgery in Gastrointestinal Cancer Surgery Patients: A Meta-Analysis.

INTRODUCTION: Prehabilitation programs or interventions are employed prior to surgery with the aim to optimize the patient before surgery and to improve their physiologic ability to recover from surgery. Components of these programs often include exercise, nutritional supplementation, and psychological interventions. This meta-analysis examines the impact of prehabilitation programs on both surgical and patient outcomes among gastrointestinal (GI) cancer patients undergoing surgery. METHODS: A comprehensive literature search was conducted to identify all published randomized control trials (RCT) evaluating the use of prehabilitation programs (with one or more interventions) in GI cancer surgery patients. Outcomes assessed were 6-min walk distance (6MWD), postoperative complications, major complications (as defined as Clavien Dindo grade ≥ 3), surgical site infections (SSI), pneumonia, length of stay (LOS), 30-day readmission, and mortality. RESULTS: Eleven RCTs including 929 patients (475 prehabilitation program and 454 controls) were analyzed. Prehabilitation programs were associated with statistically significant improvements in 6MWD between baseline and immediately prior to surgery (MD = 32.542 m; 95% CI, 10.774-54.310; p = 0.003) and 4-8 weeks after surgery (MD = 48.220 m; 95% CI, 1.532-94.908; p = 0.043) compared with patients who did not receive prehabilitation programs. Similar rates of postoperative complications, major complications, SSI, pneumonia, 30-day readmission, and mortality, as well as LOS, were observed (p > 0.05). CONCLUSIONS: Prehabilitation programs improve exercise capacity both before and after surgery, with no significant difference in LOS, or rates of postoperative complications, 30-day readmission, and mortality. Future studies assessing the different components of prehabilitation programs to identify the most beneficial interventions are required.

Determining 30-day readmission risk for heart failure patients: the Readmission After Heart Failure scale.

BACKGROUND: Chronic heart failure (CHF), which affects >5 million Americans, accounts for >1 million hospitalizations annually. As a part of the Hospital Readmission Reduction Program, the Affordable Care Act requires that the Centers for Medicare and Medicaid Services reduce payments to hospitals with excess readmissions. This study sought to develop a scale that reliably predicts readmission rates among patients with CHF. METHODS: The State Inpatient Database (2006-2011) was utilized, and discharge data including demographic and clinical characteristics on 642,448 patients with CHF from California and New York (derivation cohort) and 365,359 patients with CHF from Florida and Washington (validation cohort) were extracted. The Readmission After Heart Failure (RAHF) scale was developed to predict readmission risk. RESULTS: The 30-day readmission rates were 9.42 and 9.17% (derivation and validation cohorts, respectively). Age <65 years, male gender, first income quartile, African American race, race other than African American or Caucasian, Medicare, Medicaid, self-pay/no insurance, drug abuse, renal failure, chronic pulmonary disorder, diabetes, depression, and fluid and electrolyte disorder were associated with higher readmission risk after hospitalization for CHF. The RAHF scale was created and explained the 95% of readmission variability within the validation cohort. The RAHF scale was then used to define the following three levels of risk for readmission: low (RAHF score <12; 7.58% readmission rate), moderate (RAHF score 12-15; 9.78% readmission rate), and high (RAHF score >15; 12.04% readmission rate). The relative risk of readmission was 1.67 for the high-risk group compared with the low-risk group. CONCLUSION: The RAHF scale reliably predicts a patient's 30-day CHF readmission risk based on demographic and clinical factors present upon initial admission. By risk-stratifying patients, using models such as the RAHF scale, strategies tailored to each patient can be implemented to improve patient outcomes and reduce health care costs.

Clinical outcomes after burns in elderly patients over 70 years: A 17-year retrospective analysis.

INTRODUCTION: In the United Stated population >70years is likely to double by the year 2050. Elderly population (>70years) are most vulnerable to burns and outcomes following such injuries in this special group is poorly studied. This study aimed to look at outcomes following burns in patients >70years over a period of 17 years. MATERIALS AND METHODS: Data on 6512 patients admitted to a Level I Burn Center between 1995 and 2011 was analyzed. Age, gender, ethnicity, TBSA, burn etiology, hospital and burn intensive care unit (ICU) length of stay (LOS) and status at discharge were abstracted. Three broad categories were created based on presence or absence of smoke inhalation, No smoke inhalation (Group A), smoke inhalation only (Group B) and smoke inhalation with burn injury (Group C). Differences were analyzed using the student's t-test for continuous variables and Chi-Square test for categorical variables. RESULTS: The study group was comprised of 564 patients, 72.3% in group A, 4.8% in group B and 22.9% in group C formed the study population. The mean age of the patients studied was 80.4±6.7, with female patients being more common (58%). The number of Caucasians (72.9%) was highest in group C compared to other racial groups (p=0.047). Majority of patients in the group B (59.3%) were admitted directly compared to other two groups (group A=24.0%, group B=34.9%, p<0.001). Overall percent total body surface area (% TBSA) and % TBSA third degree burns were higher in group C, whereas % TBSA second degree burns were common in group B (p<0.05). The number ICU admissions, the mean length of ICU stay, mean duration of ventilator support and mean length of hospitalization were all highest in group C patients (p<0.001). The number of discharges to home without home health aide were higher in group A, whereas the number of discharges to nursing home/rehabilitation/extended care facility were higher in group B (p<0.001). The in-hospital mortality (58.1%, p<0.001) and overall burn related mortality (62.8%, p<0.001) were highest in group C. There was no significant difference between the groups for the number of patients converted to hospice care (p=0.21). On multivariate analysis ICU admission (Odds Ratio [OR]=3.7, 95% Confidence Interval [95% CI]=2.1-6.5), ventilator support (OR=7.1, 95% CI=4.1-12.0), and %TBSA >10% (OR=3.1, 95% CI=1.9-5.0) significantly increased mortality. In terms of complications, group C had a significantly higher incidence of pneumonia (18.6%, p<0.001), respiratory failure (17.1%, p=0.001), and sepsis (7.8%, p=0.003). CONCLUSIONS: Patients >70 years constitute small (8.6%) but significant number among burn patients. The overall ICU admissions, number of days on ventilator, ICU stay, in-hospital mortality and overall mortality is higher in this group of population even for low % TBSA burns. Presence of smoke inhalation increases mortality.

Preoperative intravenous ibuprofen does not influence postoperative narcotic use in patients undergoing elective hernia repair: a randomized, double-blind, placebo controlled prospective trial.

INTRODUCTION: Inguinal and umbilical hernia repairs are among the most common surgical procedures performed in the US. Optimal perioperative pain control regimens remain challenging and opioid analgesics are commonly used. Preoperative nonsteroidal anti-inflammatory drug (NSAID) administration has been shown to reduce postoperative narcotic requirements. This study sought to evaluate the efficacy of perioperative intravenous (IV) ibuprofen on postoperative pain level and narcotic use in patients undergoing open or laparoscopic inguinal and/or umbilical hernia repair. METHODS: A single center, randomized, double-blind placebo-controlled trial involving patients ≥18 years undergoing inguinal and/or umbilical hernia repair was performed. Patients were randomized to receive 800 mg of IV ibuprofen or placebo preoperatively. Outcomes assessed included postoperative pain medication required and visual analog scale (VAS) pain scores. RESULTS: Forty-eight adult male patients underwent inguinal and/or umbilical hernia repair. Patients receiving IV ibuprofen used more oxycodone/acetaminophen (32% vs 13%) and IV hydromorphone (12% vs 8.7%), and fewer combinations of pain medications (44% vs 65.2%) in the first two postoperative hours compared to placebo (p=0.556). The IV ibuprofen group had more patients pain free (28% vs 8.7%, p=0.087) and lower VAS scores (3.08±2.14 vs 3.95±1.54, p=0.134) at 2 hours postoperatively, compared to the placebo group, however, this was not statistically significant. Similar pain levels at 1, 3, and 7 days, postoperative and similar use of rescue medications in both groups were observed. CONCLUSION: Preoperative administration of IV ibuprofen did not significantly reduce postoperative pain among patients undergoing elective hernia repair. Considerable variability in postoperative narcotic analgesic requirement was noted, and larger scale studies are needed to better understand the narcotic analgesic requirements associated with IV ibuprofen in inguinal/umbilical hernia repair patients.

Readmission After COPD Exacerbation Scale: determining 30-day readmission risk for COPD patients.

BACKGROUND: COPD affects over 13 million Americans, and accounts for over half a million hospitalizations annually. The Hospital Readmission Reduction Program, established by the Affordable Care Act requires the Centers for Medicare and Medicaid Services to reduce payments to hospitals with excess readmissions for COPD as of 2015. This study sought to develop a predictive readmission scale to identify COPD patients at higher readmission risk. METHODS: Demographic and clinical data on 339,389 patients from New York and California (derivation cohort) and 258,113 patients from Washington and Florida (validation cohort) were abstracted from the State Inpatient Database (2006-2011), and the Readmission After COPD Exacerbation (RACE) Scale was developed to predict 30-day readmission risk. RESULTS: Thirty-day COPD readmission rates were 7.54% for the derivation cohort and 6.70% for the validation cohort. Factors including age 40-65 years (odds ratio [OR] 1.17; 95% CI, 1.12-1.21), male gender (OR 1.16; 95% CI, 1.13-1.19), African American (OR 1.11; 95% CI, 1.06-1.16), 1st income quartile (OR 1.10; 95% CI, 1.06-1.15), 2nd income quartile (OR 1.06; 95% CI, 1.02-1.10), Medicaid insured (OR 1.83; 95% CI, 1.73-1.93), Medicare insured (OR 1.45; 95% CI, 1.38-1.52), anemia (OR 1.05; 95% CI, 1.02-1.09), congestive heart failure (OR 1.06; 95% CI, 1.02-1.09), depression (OR 1.18; 95% CI, 1.14-1.23), drug abuse (OR 1.17; 95% CI, 1.09-1.25), and psychoses (OR 1.19; 95% CI, 1.13-1.25) were independently associated with increased readmission rates, P<0.01. When the devised RACE scale was applied to both cohorts together, it explained 92.3% of readmission variability. CONCLUSION: The RACE Scale reliably predicts an individual patient's 30-day COPD readmission risk based on specific factors present at initial admission. By identifying these patients at high risk of readmission with the RACE Scale, patient-specific readmission-reduction strategies can be implemented to improve patient care as well as reduce readmissions and health care expenditures.

Disease Severity, Presentation, and Clinical Outcomes Among Adolescents With Malignant Breast Neoplasms: A 20-Year Population-Based Outcomes Study From the SEER Database (1973-2009).

INTRODUCTION: Primary breast cancer in adolescents is extremely rare and thus is not widely studied. This study aimed to evaluate trends, characteristics, and outcomes among a cohort of adolescents with breast cancer. PATIENTS AND METHODS: A total of 657,712 female patients with breast cancer from Surveillance Epidemiology and End Results (SEER) database (1973-2009) were analyzed, and 91 adolescents were identified. Three age groups (under 20 years, 20-50 years or premenopausal, and > 50 years or postmenopausal) were compared for tumor size, stage, receptor status, and outcomes. Categorical data were compared by chi-square (Fisher) test and continuous data with Student's t test. RESULTS: Median age was 19 years (range, 10-20 years). A total of 52.7% (n = 48) and 5.5% (n = 5) of patients presented with invasive and in-situ cancers, respectively, and 37.3% (n = 34) with sarcomas. Median tumor size of invasive cancers was 3.2 cm (range, 0.1-12.5 cm). Sixty percent of patients presented with regional disease, and the majority (28%) of those tested were receptor negative. Mortality rates in adolescents were higher than pre- and postmenopausal patients in localized and regional stage. Overall median survival was 106 months. CONCLUSION: Although rare, breast cancer does occur in adolescent girls and must be considered in differential of breast masses in females under 20, especially with strong breast cancer family history. Prognosis maybe worse than in older patients; however, the sample size is small. Delay in diagnosis, aggressive tumor biology, and negative receptor status may affect prognosis. Routine breast examination in high-risk older adolescents may permit early identification and avoid delay in diagnosis and treatment.

Gallbladder Carcinoma in the United States: A Population Based Clinical Outcomes Study Involving 22,343 Patients from the Surveillance, Epidemiology, and End Result Database (1973-2013).

INTRODUCTION: Gallbladder carcinoma (GBC) is the most common malignancy of the biliary tract and the third most common gastrointestinal tract malignancy. This study examines a large cohort of GBC patients in the United States in an effort to define demographics, clinical, and pathologic features impacting clinical outcomes. METHODS: Demographic and clinical data on 22,343 GBC patients was abstracted from the SEER database (1973-2013). RESULTS: GBC was presented most often among Caucasian (63.9%) females (70.7%) as poorly or moderately differentiated (42.5% and 38.2%) tumors, with lymph node involvement (88.2%). Surgery alone was the most common treatment modality for GBC patients (55.0%). Combination surgery and radiation (10.6%) achieved significantly longer survival rates compared to surgery alone (4.0 ± 0.2 versus 3.7 ± 0.1 years, p = 0.004). Overall mortality was 87.0% and cancer-specific mortality was 75.4%. CONCLUSIONS: GBC is an uncommon malignancy that presents most often among females in their 8th decade of life, with over a third of cases presenting with distant metastasis. The incidence of GBC has doubled in the last decade concurrent with increases in cholecystectomy rates attributable in part to improved histopathological detection, as well as laparoscopic advances and enhanced endoscopic techniques. Surgical resection confers significant survival benefit in GBC patients.

Oligodendrogliomas in pediatric and adult patients: an outcome-based study from the Surveillance, Epidemiology, and End Result database.

INTRODUCTION: Oligodendrogliomas (OGs) account for <20% of all intracranial tumors and 25% of gliomas. Despite improvements in imaging techniques allowing for earlier diagnosis, OG is rare among the pediatric population. This study examines a large cohort of OG patients in an effort to define the demographic, clinical, and pathologic factors associated with clinical and survival outcomes. METHODS: Data on 7,001 OG patients were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1973-2013). Pediatric patients were defined as ≤19 years old, and adult patients were defined as age ≥20 years. RESULTS: Among 7,001 OG patients, 6.5% were pediatric (mean age 12 ± 6 years), and 93.5% were adult (mean age 46 ± 15 years). Overall, OGs were more common among males, with a male-to-female ratio of 1.28:1. Overall, OGs were more common among Caucasians (76.9%) and also among the African American (10.8% pediatric vs. 4.0% adult) and Hispanic (12.8% pediatric vs. 11.8% adult). OGs occurred most commonly in the temporal lobe of pediatric patients and the frontal lobes of adults. Surgical resection was the primary treatment modality for both pediatric and adult populations (70.6% and 40.5%), followed by combined surgery and radiation (19.7% and 41.2%). Surgical resection was associated with significantly improved survival in both groups. Pediatric patients had a lower overall mortality (19.8% vs. 48.5%) and lower cancer-specific mortality (17.6% vs. 36.8%). CONCLUSION: OGs most often present in Caucasian males in their fifth decade of life with tumors >4 cm in size. Children typically present with tumors in the temporal lobe, while adults present with tumors in the frontal lobe. Surgical resection confers a survival advantage among all patients, especially pediatric patients. Overall survival (OS) and cancer-specific survival are higher in the pediatric population. Further studies on novel treatment techniques, including bevacizumab and immunotherapy approaches, are required.

Less Invasive Surfactant Administration Reduces the Need for Mechanical Ventilation in Preterm Infants: A Meta-Analysis.

Neonatal respiratory distress syndrome due to surfactant deficiency is associated with high morbidity and mortality in preterm infants, and the use of less invasive surfactant administration (LISA) has been increasingly studied. This meta-analysis found that LISA via thin catheter significantly reduced the need for mechanical ventilation within the first 72 hours (relative risk [RR] = 0.677; P = .021), duration of mechanical ventilation (difference in means [MD] = -39.302 hours; P < .001), duration of supplemental oxygen (MD = -68.874 hours; P < .001), and duration of nasal continuous positive airway pressure (nCPAP; MD = -28.423 hours; P = .010). A trend toward a reduction in the incidence of bronchopulmonary dysplasia was observed (RR = 0.656; P = .141). No significant difference in overall mortality, incidence of pneumothorax, or successful first attempts was observed. LISA via thin catheter significantly reduces the need for mechanical ventilation within the first 72 hours as well as the duration of mechanical ventilation, supplemental oxygen, and nCPAP. LISA via thin catheter appears promising in improving preterm infant outcomes.

Malignant Melanoma in African-Americans: A Population-Based Clinical Outcomes Study Involving 1106 African-American Patients from the Surveillance, Epidemiology, and End Result (SEER) Database (1988-2011).

Malignant melanoma accounts for 75% of all skin cancer deaths and is potentially curable if identified early. Although melanoma is rare in African-Americans (AA), it is associated with a worse prognosis than in Caucasians. This study examines the demographic, pathologic, and clinical factors impacting AA melanoma outcomes.Data for 1106 AA and 212,721 Caucasian cutaneous melanoma patients were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1988-2011). Data were grouped on the basis of histological subtypes: "Superficial Spreading" (SS), "Nodular" (NM), "Lentigo Maligna" (LM), "Acral Lentiginous" (AL), and "Not otherwise specified" (NOS).Cutaneous malignant melanoma occurs most commonly in the sixth and seventh decade of life. Caucasian patients presented most commonly with trunk melanomas (34.5%), while lower extremity melanomas were more common in AAs (56.1%), P < 0.001. AAs presented with deeper tumors, more advanced stage of disease, and higher rates of ulceration and lymph node positivity than Caucasians. Cancer-specific mortality was significantly higher, while 5-year cancer-specific survival was significantly lower among AAs for NM and AL subtypes. Multivariate analysis identified male gender, regional and distant stage, NM and AL subtypes as independently associated with increased mortality among both ethnic groups.AAs present most often with AL melanoma on the lower extremities, and with deeper and more advanced stage lesions. AAs have higher cancer-specific mortality for NM and LM than Caucasians. Melanoma education for AA patients and health care providers is needed to increase disease awareness, facilitate early detection, and promote access to effective treatment.

Ocular melanoma-when you have seen one, you have not seen them all: a clinical outcome study from the Surveillance, Epidemiology and End Results (SEER) database (1973-2012).

BACKGROUND: Ocular melanoma (OM) comprises <5% of all melanomas. Uveal melanoma (UM) is the most common subtype of OM, while conjunctival melanoma (CM) is rare and differs significantly from UM. The purpose of this study is to evaluate a large cohort of OM patients to differentiate demographic, pathologic, and clinical factors between these two neoplasms, which may affect treatment and outcomes. METHODS: The Surveillance, Epidemiology, and End Results database (1973-2012) was used to extract demographic and clinical data on 8,165 OM patients (92.1% UM and 7.9% CM). RESULTS: Both CM and UM were most prevalent among Caucasian males in the seventh decade of life. UM patients presented more often with localized disease (90.9% vs 81.2, P<0.01). Surgery (42.8%), radiation (43.0%), or combined surgery and radiation (7.0%) were used in the treatment of UM, while CM was treated almost exclusively with surgery (88.7%). Mean overall survival was longer (15.4 vs 14.6 years; P<0.01) and mortality rates were lower in patients (38.8% vs 46.1%; P<0.01) with CM. CONCLUSION: Despite presenting with more advanced disease than UM, CM is associated with an increased overall survival. Surgery is the primary therapy for CM, whereas radiotherapy is the primary therapy for UM and is associated with prolonged survival.

Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis.

INTRODUCTION: Enhanced recovery after surgery (ERAS) programs have been developed to improve patient outcomes, accelerate recovery after surgery, and reduce healthcare costs. ERAS programs are a multimodal approach, with interventions during all stages of care. This meta-analysis examines the impact of ERAS programs on patient outcomes and recovery. METHODS: A comprehensive search of all published randomized control trials (RCTs) assessing the use of ERAS programs in surgical patients was conducted. Outcomes analyzed were length of stay (LOS), overall mortality, 30-day readmission rates, total costs, total complications, time to first flatus, and time to first bowel movement. RESULTS: Forty-two RCTs involving 5241 patients were analyzed. ERAS programs significantly reduced LOS, total complications, and total costs across all types of surgeries (p < 0.001). Return of gastrointestinal (GI) function was also significantly improved, as measured by earlier time to first flatus and time to first bowel movement, p < 0.001. There was no overall difference in mortality or 30-day readmission rates; however, 30-day readmission rates after upper GI surgeries nearly doubled with the use of ERAS programs (RR = 1.922; p = 0.019). CONCLUSIONS: ERAS programs are associated with a significant reduction in LOS, total complications, total costs, as well as earlier return of GI function. Overall mortality and readmission rates remained similar, but there was a significant increase in 30-day readmission rates after upper GI surgeries. ERAS programs are effective and a valuable part in improving patient outcomes and accelerating recovery after surgery.

Immunonutrition Is Associated With a Decreased Incidence of Graft-Versus-Host Disease in Bone Marrow Transplant Recipients: A Meta-Analysis.

INTRODUCTION: Graft-versus-host disease (GVHD) is a serious complication of bone marrow transplantation (BMT), requiring higher doses of glucocorticoids or immunosuppressive therapies and further straining transplant recipients. Immunonutrition, such as vitamins and amino acid supplements, increase immunity and decrease inflammation and oxidative stress. This meta-analysis examines the impact of immunonutrition on the incidence of GVHD and postoperative infections among BMT recipients. METHODS: A comprehensive literature search for all published randomized controlled trials was conducted with PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2016). Keywords in the search included variations of terms related to immunonutrition, such as "vitamin," "glutamine," and "transplant." Outcomes included incidence of GVHD and infection. RESULTS: Ten randomized controlled trials involving 681 BMT recipients were analyzed: 332 receiving immunonutrition and 349 receiving standard nutrition. Immunonutrition is correlated with a decreased incidence of GVHD by 19% (relative risk [RR] = 0.810, 95% CI: 0.695-0.945, P = .007). There was no significant difference in the incidence of infections with immunonutrition (RR = 1.016, 95% CI: 0.819-1.261, P = .885). Subgroup analysis of glutamine compared with N-acetylcysteine, selenium, and eicosapentaenoic acid showed no significant difference in the incidence of GVHD or infections (RR = 0.913, 95% CI: 0.732-1.139, P = .419; RR = 0.951, 95% CI: 0.732-1.235; P = .708, respectively). CONCLUSION: The use of immunonutrition is associated with a reduced risk of GVHD in BMT recipients, potentially as a result of improved immune support and free radical scavenging. Providing immunonutrient supplements is a valuable adjunct in the routine care of BMT recipients, helping to alleviate a common and deadly complication.

Probiotics improve the efficacy of standard triple therapy in the eradication of Helicobacter pylori: a meta-analysis.

INTRODUCTION: Helicobacter pylori colonization is present in half of the world's population and can lead to numerous gastrointestinal diseases if left untreated, including peptic ulcer disease and gastric cancer. Although concurrent triple therapy remains the recommended treatment regimen for H. pylori eradication, its success rate and efficacy have been declining. Recent studies have shown that the addition of probiotics can significantly increase eradication rates by up to 50%. This meta-analysis examines the impact of probiotic supplementation on the efficacy of standard triple therapy in eradicating H. pylori. METHODS: A comprehensive literature search was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (time of inception to 2016) to identify all published randomized control trials (RCTs) assessing the use of probiotics in addition to triple therapy for the treatment of H. pylori. Searches were conducted using the keywords "probiotics", "triple therapy", and "Helicobacter pylori". RCTs comparing the use of probiotics and standard triple therapy with standard triple therapy alone for any duration in patients of any age diagnosed with H. pylori infection were included. H. pylori eradication rates (detected using urea breath test or stool antigen) were analyzed as-per-protocol (APP) and intention-to-treat (ITT). RESULTS: A total of 30 RCTs involving 4,302 patients APP and 4,515 patients ITT were analyzed. The addition of probiotics significantly increased eradication rates by 12.2% (relative risk [RR] =1.122; 95% confidence interval [CI], 1.091-1.153; P<0.001) APP and 14.1% (RR =1.141; 95% CI, 1.106-1.175; P<0.001) ITT. Probiotics were beneficial among children and adults, as well as Asians and non-Asians. No significant difference was observed in efficacy between the various types of probiotics. The risk of diarrhea, nausea, vomiting, and epigastric pain was also reduced. CONCLUSION: The addition of probiotics is associated with improved H. pylori eradication rates in both children and adults, as well as Asians and non-Asians. Lactobacillus, Bifidobacterium, Saccharomyces, and mixtures of probiotics appear beneficial in H. pylori eradication. Furthermore, the reduction in antibiotic-associated side effects such as nausea, vomiting, diarrhea, and epigastric pain improves medication tolerance and patient compliance. Given the consequences associated with chronic H. pylori infection, the addition of probiotics to the concurrent triple therapy regimen should be considered in all patients with H. pylori infection. However, further studies are required to identify the optimal probiotic species and dose.

Trends in incidence, survival, and management of uveal melanoma: a population-based study of 7,516 patients from the Surveillance, Epidemiology, and End Results database (1973-2012).

INTRODUCTION: Uveal melanoma (UM) is the most common primary intraocular malignancy, despite comprising <5% of all melanomas. To date, relatively few case series of UM have been published. Moreover, the factors influencing survival remain largely unknown. This study sought to analyze the impact of demographics, histology, clinical presentation, and treatments on the clinical outcomes of UM in a large modern nationwide patient cohort. METHODS: Demographics and clinical data were abstracted on 277,120 histologically confirmed melanoma patients from the Surveillance, Epidemiology, and End Results database between 1973 and 2012. RESULTS: A total of 7,516 cases of UM represented 3.2% of all recorded cases of melanoma. The mean age-adjusted incidence was 5.1 per million (95% CI 4.2-6.1) and was higher in males (5.9, CI =4.4-7.6) compared to females (4.5, CI =3.3-5.8), P<0.001. UM occurred most commonly in the sixth decade of life (61.4±15) and among Caucasians (94.7%). A total of 52.3% of cases were reported in the Western US (35.7% in California). The initial diagnoses in 65.2% of cases were by histopathology, followed by clinical diagnosis (18.8%) and radiographic imaging (16.0%). The percentage of UM cases managed by surgery alone decreased by 69.4% between the 1973-1977 and 2006-2012 time periods, concomitant with a 62% increase in primary radiotherapy, P<0.001. The UM mean overall and cancer-specific 5-year relative survival rates were 79.8%±5.8% and 76%±5.3%, respectively. The mean 5-year cancer-specific survival rate (76%) remained stable during the study period between 1973 and 2012. The mean survival for patients treated with primary radiotherapy was significantly improved compared to those treated with surgery alone (15.4±0.4 vs 13.6±0.3, P<0.001). Multivariate analysis identified male sex (odds ratio [OR] 1.1, CI =1.0-1.3), age >50 years (OR 4.0, CI =3.4-4.6), distant metastases (OR 8.6, CI =4.7-15), and primary surgical treatment (OR 2.6, CI =2.0-3.3) as independently associated with increased mortality, P<0.005. Conversely, patients identified as Hispanic (OR 0.6, CI =0.5-0.8) and patients receiving radiation treatment (OR 0.5, CI =0.4-0.7) were independently associated with reduced mortality, P<0.005. CONCLUSION: UM remains a rare form of melanoma that occurs primarily in Caucasian patients older than 50 years. More than two-thirds of UM patients are curatively treated with primary radiotherapy as opposed to surgery, which has resulted in a significant improvement in both overall survival and cancer-specific survival. Despite this shift in management strategy, the mean 5-year cancer-specific survival rate remained relatively unchanged during the study period. Male sex, older age, distant disease, and primary surgical therapy rather than radiotherapy are associated with an increased risk of mortality.

Use of preoperative gabapentin significantly reduces postoperative opioid consumption: a meta-analysis.

OBJECTIVES: Effective postoperative pain management is crucial in the care of surgical patients. Opioids, which are commonly used in managing postoperative pain, have a potential for tolerance and addiction, along with sedating side effects. Gabapentin's use as a multimodal analgesic regimen to treat neuropathic pain has been documented as having favorable side effects. This meta-analysis examined the use of preoperative gabapentin and its impact on postoperative opioid consumption. MATERIALS AND METHODS: A comprehensive literature search was conducted to identify randomized control trials that evaluated preoperative gabapentin on postoperative opioid consumption. The outcomes of interest were cumulative opioid consumption following the surgery and the incidence of vomiting, somnolence, and nausea. RESULTS: A total of 1,793 patients involved in 17 randomized control trials formed the final analysis for this study. Postoperative opioid consumption was reduced when using gabapentin within the initial 24 hours following surgery (standard mean difference -1.35, 95% confidence interval [CI]: -1.96 to -0.73; P<0.001). There was a significant reduction in morphine, fentanyl, and tramadol consumption (P<0.05). While a significant increase in postoperative somnolence incidence was observed (relative risk 1.30, 95% CI: 1.10-1.54, P<0.05), there were no significant effects on postoperative vomiting and nausea. CONCLUSION: The administration of preoperative gabapentin reduced the consumption of opioids during the initial 24 hours following surgery. The reduction in postoperative opioids with preoperative gabapentin increased postoperative somnolence, but no significant differences were observed in nausea and vomiting incidences. The results from this study demonstrate that gabapentin is more beneficial in mastectomy and spinal, abdominal, and thyroid surgeries. Gabapentin is an effective analgesic adjunct, and clinicians should consider its use in multimodal treatment plans among patients undergoing elective surgery.

Leukocyte filtration and postoperative infections.

BACKGROUND: Leukocyte filtration has been hypothesized to reduce the risk of postoperative infections by alleviating the immunosuppressive effect of whole blood. However, the literature regarding the clinical efficacy of leukocyte filtration remains conflicted. This meta-analysis investigates the impact of allogeneic and autologous leukocyte-filtered blood transfusions on the incidence of postoperative infections in adult surgical patients. METHODS: A comprehensive literature search of PubMed, Google Scholar, and Cochrane Central Registry of Controlled trials (1966-2016) was completed for all published randomized controlled trials. Postoperative infections under "as-per-protocol" (APP) and "intention-to-treat" (ITT), length of stay, and mortality were analyzed. RESULTS: Sixteen randomized controlled trials involving 6586 randomized (ITT) patients (4615 APP patients) in various clinical settings were evaluated. The leukocyte-filtered blood group demonstrated an overall 26% risk reduction in postoperative infections when analyzed by APP (relative risk [RR] = 0.74; 95% confidence interval [CI, 0.60-0.92]; P = 0.007) and a 22% risk reduction when analyzed by ITT (RR = 0.78; 95% CI [0.65-0.94]; P = 0.009). Leukocyte-filtered blood was also associated with a significant reduction in length of stay (standardized difference of mean [SDM] = -0.74; 95% CI [-1.32 to -0.15]; P = 0.014) and all-cause mortality (RR = 0.74; 95% CI [0.57-0.95]; P = 0.018). CONCLUSIONS: Leukocyte-filtered blood transfusions are associated with significantly lower postoperative infection rates in both the APP and ITT populations. Leukocyte filtration also shortens length of stay and decreases all-cause mortality in surgical patients and should be considered in all surgical patients.

Acute mental disorders and short and long term morbidity in patients with third degree flame burn: A population-based outcome study of 96,451 patients from the Nationwide Inpatient Sample (NIS) database (2001-2011).

BACKGROUND: Although burn patients with preexisting mood disorders have been shown to have diminished clinical recovery, acute mental disorders (AMD) are often unrecognized despite a link with post-traumatic stress disorder and social maladjustment later on. This study assessed the clinical profile of a large cohort of burn patients who developed AMD compared to those with chronic mental illness (CMI) and those without mental health problems to assess the impact of AMI on burn outcomes. METHODS: Admission data on 96,451 patients with third degree flame burns was abstracted from the Nationwide Inpatient Sample (NIS) Database from 2001 to 2011. AMD was defined as adjustment disorder (ICD-10 codes F43.2-F43.29) and acute stress disorder (F43.0), while CMI was defined as major depressive disorder (F33.0-F33.9) and bipolar disorder (F31.0-F31.9). Data was compared across three subgroups: AMD, CMI, and patients without any mood disorders. Categorical variables were compared using the Chi-square test, and continuous variables were compared using Student t-test and analysis of variance (ANOVA). Multivariate analysis using the "backward Wald" method was performed to calculate odds ratios (OR) and determine independent factors which increased the risk of developing AMD after burn. RESULTS: 979 (1%) burn patients were diagnosed with AMD, compared to 5971 (6.2%) with CMI and 89,501 (92.8%) without mood disorders at the time of the burn. Patients with AMD were significantly younger, predominantly male and Caucasian. Patients with AMD had a higher frequency of multiple third-degree burn sites. AMD patients had a significantly longer length of hospitalization and shorter actuarial survival. More AMD patients lacked social or family support, suffered from alcoholism or illicit drug abuse, and had a history of psychological trauma or self-inflicted injuries compared to other groups. After burn, 4.9% of AMD patients developed burn wound infections, 5.0% had nutritional deficiencies, 1.7% had skin graft failure, 0.7% had acute psychosis, and 3.7% had suicidal ideation, p<0.05. Multivariate analysis identified age 10-39 (OR 4.6), alcoholism (OR 1.4), drug abuse (OR 1.9), psychoses (OR 1.4), and total body surface are (TBSA) 10-39% third degree burns (OR 1.8) as independently associated with developing AMD, p<0.005. CONCLUSION: The development of AMD in burn patients is associated with poor clinical outcomes including longer hospitalization, decreased survival, and increased complication rates. Premorbid psychopathology, substance abuse and age were associated with a higher incidence AMD after burn than was the severity of the burn wound itself. Routine screening for psychological symptoms of AMD should be performed in all burn patients to avoid increased rates of short and long-term morbidity and mortality.

Pediatric Burns: A Single Institution Retrospective Review of Incidence, Etiology, and Outcomes in 2273 Burn Patients (1995-2013).

Unintentional burn injury is the third most common cause of death in the U.S. for children age 5 to 9, and accounts for major morbidity in the pediatric population. Pediatric burn admission data from U.S. institutions has not been reported recently. This study assesses all pediatric burn admissions to a State wide Certified Burn Treatment Center to evaluate trends in demographics, burn incidence, and cause across different age groups. Demographic and clinical data were collected on 2273 pediatric burn patients during an 18-year period (1995-2013). Pediatric patients were stratified by age into "age 0 to 6," "age 7 to 12," and "age 13 to 18." Data were obtained from National Trauma Registry of the American College of Surgeons and analyzed using standard statistical methodology. A total of 2273 burn patients under age 18 were treated between 1995 and 2013. A total of 1663 (73.2%) patients were ages 0 to 6, 294 (12.9%) were 7 to 12, and 316 (13.9%) were age 13 to 18. A total of 1400 (61.6%) were male and 873 (38.4%) were female (male:female ratio of 1.6:1). Caucasians had the highest burn incidence across all age groups (40.9%), followed by African-Americans (33.6%), P < .001. Caucasian teenagers formed 62.1% of patients age 13-18, P < .001. A total of 66.3% of all pediatric burns occurred at home, P < .001. Mean TBSA burned was 8.9%, with lower extremity being the most common site (38.5%). Scald burns constituted the majority of cases (71.1%, n = 1617), with 53% attributable to hot liquids related to cooking, including coffee or tea, P < .001. In the teenage group, flame burns were the dominant cause (53.8%). Overall mean length of stay was 10.5 ± 10.8 days for all patients, and15.5 ± 12 for those admitted to the intensive care unit, P < .005. One hundred (4.4%) patients required ventilator support (P = .02), and average duration of mechanical ventilation was 11.9 ± 14.5 days. Skin grafting was performed for 520 (22.9%) patients, P < .001. Overall mortality was 0.9% (n = 20), with mean TBSA involved of 61.5%. The majority of pediatric burn injuries are scald burns that occur at home and primarily affect the lower extremities in Caucasian and African-American males. Among Caucasian teenagers flame burns predominate. Mean length of stay was 10 days, 23% of patients required skin grafting surgery, and mortality was 0.9%. The results of this study highlight the need for primary prevention programs focusing on avoiding home scald injuries in the very young, as well as fire safety training for teenagers.