Human Disease due to Mycobacterium bovis Linked to Free-Ranging Deer in Michigan.

BACKGROUND: A unique enzootic focus of Mycobacterium bovis in free-ranging deer was identified in northern lower Michigan in 1994, with subsequent evidence of transmission to local cattle herds. Between 2002 and 2017, 3 Michigan deer hunters with M. bovis disease were previously reported. We present 4 additional human cases linked to the zoonotic focus in deer, utilizing genomic epidemiology to confirm close molecular associations among human, deer and cattle M. bovis isolates. METHODS: Identification of human tuberculosis (TB) cases with cultures of M. bovis was provided from the Michigan Department of Health and Human Services (MDHHS) tuberculosis database. Clinical review and interviews focused on risk factors for contact with wildlife and cattle. Whole genome sequences of human isolates were compared with a veterinary library of M. bovis strains to identify those linked to the enzootic focus. RESULTS: Three confirmed and 1 probable human case with M. bovis disease were identified between 2019 and 2022, including cutaneous disease, 2 severe pulmonary disease cases, and human-to-human transmission. The 3 human isolates had 0-3 single-nucleotide polymorphisms (SNPs) with M. bovis strains circulating in wild deer and domestic cattle in Michigan. CONCLUSIONS: Spillover of enzootic M. bovis from deer to humans and cattle continues to occur in Michigan. Future studies should examine the routes of transmission and degree of risk to humans through expanded epidemiological surveys. A One Health approach linking human, veterinary and environmental health should address screening for TB infection, public education, and mitigation of transmission.

Challenges and opportunities related to penicillin allergy in the Veterans Health Administration: a narrative review.

The presence of a penicillin allergy label in a patient's medical chart is associated with negative clinical and economic outcomes. Given that less than 10% of reported reactions are truly immunoglobulin E-mediated, removal of unverified penicillin allergy labels is a public health priority and an area of ongoing implementation research. The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, with almost 9 million veterans currently enrolled. However, studies analyzing the impact of the penicillin allergy label in this population are limited to single facilities and largely focus on short-term outcomes of allergy documentation correction, usage of ß-lactams, and avoidance of antibiotic-related side effects. Broader, national VHA studies focusing on health outcomes and costs are lacking. As with non-VHA facilities, penicillin allergy evaluations are limited owing to the absence of formal allergy/immunology services at most VHA facilities. Pharmacy-driven screening and referral for clinic-based penicillin skin testing is a promising and frequently discussed modality in the literature, but its scalability within the VHA is not yet proven. Broader, evidence-based strategies that can be adapted to the available resources of individual VHA facilities, including those without on-site access to allergy providers, are needed.

Clinically undetected polyclonal heteroresistance among Pseudomonas aeruginosa isolated from cystic fibrosis respiratory specimens.

BACKGROUND: Pseudomonas aeruginosa infection is the leading cause of death among patients with cystic fibrosis (CF) and a common cause of difficult-to-treat hospital-acquired infections. P. aeruginosa uses several mechanisms to resist different antibiotic classes and an individual CF patient can harbour multiple resistance phenotypes. OBJECTIVES: To determine the rates and distribution of polyclonal heteroresistance (PHR) in P. aeruginosa by random, prospective evaluation of respiratory cultures from CF patients at a large referral centre over a 1 year period. METHODS: We obtained 28 unique sputum samples from 19 CF patients and took multiple isolates from each, even when morphologically similar, yielding 280 unique isolates. We performed antimicrobial susceptibility testing (AST) on all isolates and calculated PHR on the basis of variability in AST in a given sample. We then performed whole-genome sequencing on 134 isolates and used a machine-learning association model to interrogate phenotypic PHR from genomic data. RESULTS: PHR was identified in most sampled patients (n = 15/19; 79%). Importantly, resistant phenotypes were not detected by routine AST in 26% of patients (n = 5/19). The machine-learning model, using the extended sampling, identified at least one genetic variant associated with phenotypic resistance in 94.3% of isolates (n = 1392/1476). CONCLUSION: PHR is common among P. aeruginosa in the CF lung. While traditional microbiological methods often fail to detect resistant subpopulations, extended sampling of isolates and conventional AST identified PHR in most patients. A machine-learning tool successfully identified at least one resistance variant in almost all resistant isolates by leveraging this extended sampling and conventional AST.

Initial Experience with the PONTiS Tendon Repair System in Traumatic Upper Extremity Injuries.

BACKGROUND: Tendon injuries of the upper extremity remain a common surgical condition requiring prompt intervention. The authors review their initial experience with the PONTiS flexor tendon repair system, a knotless, multifilament, stainless steel crimp system. METHODS: Consecutive patients undergoing repair by plastic and orthopedic surgeons with the PONTiS system were reviewed for the period from 2015 to 2017. Multivariate risk and Kaplan-Meier survival analyses were performed to assess risk factors associated with complications. RESULTS: Eighty-one patients, with a mean follow-up of 75 days (range, 0 to 33 months), were identified. The most common demographics showed patients were right-handed (82.9 percent), male (71.4 percent), and laborers (35.7 percent) and sustained laceration injuries (77.1 percent) at zone 2 (27.2 percent). There were, on average, 3.7 tendon injuries per patient. Associated injuries included fractures (21.4 percent), arterial injuries (24.3 percent), and nerve injuries (61.4 percent). Thirteen patients (16.0 percent) developed complications, including adhesions/contracture ( n = 4), rupture ( n = 2), flap ischemia ( n = 2), arterial thrombosis ( n = 1), wound dehiscence ( n = 1), tendon lag ( n = 1), and erosion of the PONTiS system through soft-tissue grafts ( n = 2). Multivariate analysis identified poor soft-tissue coverage (OR, 9.990; p = 0.043) and zone 2 involvement (OR, 7.936; p = 0.016) as risk factors, while epitendinous repairs (OR, 0.096; p = 0.010) were protective against complications. CONCLUSIONS: The PONTiS flexor tendon repair system is rapid, simple to deploy, and advantageous, especially in multiple traumatic tendon injuries. In comparison to traditional suture repair, it has a comparable overall complication profile but superior rupture and tenolysis rates. The authors advise using it with caution in cases with poor soft-tissue coverage to minimize risks of extrusion, and they strongly recommend the use of epitendinous sutures concurrently to limit complications.

COVID-19 Therapeutics for Low- and Middle-Income Countries: A Review of Candidate Agents with Potential for Near-Term Use and Impact.

Low- and middle-income countries (LMICs) face significant challenges in the control of COVID-19, given limited resources, especially for inpatient care. In a parallel effort to that for vaccines, the identification of therapeutics that have near-term potential to be available and easily administered is critical. Using the United States (US), European Union (EU), and World Health Organization (WHO) clinical trial registries, we reviewed COVID-19 therapeutic agents currently under investigation. The search was limited to oral or potentially oral agents, with at least a putative anti-SARS-CoV-2 virus mechanism and with at least five registered trials. The search yielded 1,001, 203, and 1,128 trials, in the US, EU, and WHO trial registers, respectively. These trials covered 13 oral or potentially oral repurposed agents that are currently used as antimicrobials and immunomodulatory therapeutics with established safety profiles. The available evidence regarding proposed mechanisms of action, potential limitations, and trial status is summarized. The results of the search demonstrate few published studies of high quality, a low proportion of trials completed, and the vast majority with negative results. These findings reflect limited investment in COVID-19 therapeutics development compared with vaccines. We also identified the need for better coordination of trials of accessible agents and their combinations in LMICs. To prevent COVID-19 from becoming a neglected tropical disease, there is a critical need for rapid and coordinated efforts in the evaluation and deployment of those agents found to be efficacious.

Dietary intake of sulfur amino acids and risk of kwashiorkor malnutrition in eastern Democratic Republic of the Congo.

BACKGROUND: Kwashiorkor is an often-fatal type of severe acute malnutrition affecting hundreds of thousands of children annually, but whose etiology is still unknown. Evidence suggests inadequate sulfur amino acid (SAA) status may explain many signs of the condition but studies evaluating dietary protein intake in relation to the genesis of kwashiorkor have been conflicting. We know of no studies of kwashiorkor that have measured dietary SAAs. OBJECTIVES: We aimed to determine whether children in a population previously determined to have high prevalence of kwashiorkor [high-prevalence population (HPP)] have lower dietary intakes of SAAs than children in a low-prevalence population (LPP). METHODS: A cross-sectional census survey design of 358 children compared 2 previously identified adjacent populations of children 36-59 mo old in North Kivu Province of the Democratic Republic of the Congo. Data collected included urinary thiocyanate (SCN), cyanogens in cassava-based food products, recent history of illness, and a 24-h quantitative diet recall for the child. RESULTS: The HPP and LPP had kwashiorkor prevalence of 4.5% and 1.7%, respectively. A total of 170 children from 141 households in the LPP and 169 children from 138 households in the HPP completed the study. A higher proportion of HPP children had measurable urinary SCN (44.8% compared with 29.4%, P < 0.01). LPP children were less likely to have been ill recently (26.8% compared with 13.6%, P < 0.01). Median [IQR] intake of SAAs was 32.4 [22.9-49.3] mg/kg for the LPP and 29.6 [18.1-44.3] mg/kg for the HPP (P < 0.05). Methionine was the first limiting amino acid in both populations, with the highest risk of inadequate intake found among HPP children (35.1% compared with 23.6%, P < 0.05). CONCLUSIONS: Children in a population with a higher prevalence of kwashiorkor have lower dietary intake of SAAs than children in a population with a lower prevalence. Trial interventions to reduce incidence of kwashiorkor should consider increasing SAA intake, paying particular attention to methionine.

Unravelling the Complexity Myth for Minimally Invasive Right Hepatectomy: Liver Parenchymal Features and their Correlation to Objective Outcomes in Major Anatomical Resections.

BACKGROUND: Minimally invasive approaches to major liver resection have been limited by presumed difficulty of the operation. While some concerns arise from mastering the techniques, factors such as tumor size and liver parenchymal features have anecdotally been described as surrogates for operative difficulty. These factors have not been systematically studied for minimally invasive right hepatectomy (MIRH). METHODS: Seventy-five patients who underwent MIRH during 2007-2016 by the senior author were evaluated; these were compared to control group of open right hepatectomy. Demographics, operative, and post-operative variables were collected. Operative times and estimated blood loss, two objective parameters of operative difficulty were correlated to volume of hepatic resection, parenchymal transection diameter and liver parenchymal features using regression analysis. RESULTS: Thirty-eight (50.6%) resections were performed for malignant indications. Average tumor size was 5.7 cm (±3.6), mean operative time was 196 min (±74), and mean EBL was 220 mL (±170). Average transection diameter was 10.1 cm (±1.7). There was no correlation between operative difficulty with parenchymal transection diameter or presence of steatosis. Blood loss was higher with increased right hepatic lobe volume and body mass index. CONCLUSIONS: This analysis of a very defined anatomical resection suggests that the often quoted radiographic and pathologic features indicative of a challenging procedure were not significant in determining operative difficulty.

Safety of CPX4 Breast Tissue Expanders in Primary Reconstruction Patients.

In the United States, 2-stage expander-to-implant-based breast reconstruction accounts for more than half of all breast reconstruction procedures. Tissue expansion technology has undergone significant advancements in the past few decades. Previous reports suggest that the most common perioperative complications associated with breast tissue expanders are infection and skin flap necrosis. However, little clinical data are available for CPX4 Breast Tissue Expanders. The aim of the study was to measure real-world outcomes related to safety and effectiveness of the tissue expansion process, in patients who underwent primary breast reconstruction following the use of CPX4 Breast Tissue Expanders. METHODS: This was a single-arm retrospective cohort design looking at patients who underwent 2-stage, expander-to-implant-based primary breast reconstruction at a single site between April 2013 and December 2016 and who had a minimum of 2 years follow-up. Descriptive statistics were used to summarize baseline characteristics and safety outcomes. RESULTS: A total of 123 patients were followed for an average of 3.73 ± 0.94 years. At least 1 complication during the time of tissue expansion, before the permanent implant, was reported in 39/123 (31.7%) patients [51/220 implants (23.2%)]. The most frequently reported complications were delayed wound healing (13.8%) and cellulitis/infection (9.7%). CONCLUSION: Analyses of real-world data from a single site provide further support for the safety and effectiveness of the CPX4 Breast Tissue Expander for women undergoing 2-stage expander-to-implant primary breast reconstruction.

Safety and Effectiveness of Silicone Gel-Filled Breast Implants in Primary Augmentation Patients.

BACKGROUND: Results from the MemoryGel Breast Implants Core Clinical Study suggest these devices are safe and effective at 10 years after implantation. Although clinical trials are essential for measuring the safety and effectiveness of a device, real-world evidence can supplement clinical trials by providing information on outcomes observed in diverse clinical settings for a more heterogeneous population, without fixed treatment patterns, and without continuous patient monitoring, such that follow-up is more representative of normal clinical practice. OBJECTIVES: The aim of this study was to measure real-world outcomes, including safety and effectiveness, in patients who underwent primary breast augmentation with smooth MemoryGel implants. METHODS: This was a case series looking at patients, age 22 years and older, who underwent primary breast augmentation at a single site between December 2006 and December 2016 and who had a minimum of 2 years of follow-up. Descriptive statistics were used to summarize baseline characteristics and outcomes. Kaplan-Meier models were used to estimate safety outcomes for capsular contracture (Baker grade III/IV), infection, and rupture. RESULTS: A total of 50/777 (6.4%) patients reported a complication, with an average time to complication of 3.9 years (range, 19 days-11.8 years) postprocedure. Kaplan-Meier estimates of the 10-year cumulative incidence of capsular contracture (Baker grade III/IV), infection, and rupture were 4.7%, 0.1%, and 1.6%, respectively. CONCLUSIONS: Analyses of a large population from a single site provide further support for the long-term safety and effectiveness of MemoryGel breast implants in a primary augmentation cohort.

Aortic Aneurysm Natural Progression is Not Influenced by Concomitant Malignancy and Chemotherapy.

BACKGROUND: Aortic aneurysms occur concomitantly with malignancy in approximately 1.0-17.0% of patients. There is little published information regarding the effects of subsequent oncological therapies on aortic aneurysm growth. The aim of this study was to determine the effects of chemoradiation therapies on the natural progression of small abdominal aortic aneurysm (AAA), thoracic aortic aneurysm, and thoracoabdominal aortic aneurysm. METHODS: Patients with aortic aneurysms with and without malignancy between 2005 and 2017 were identified within institutional databases using Current Procedural Terminology and International Classification of Disease codes. Inclusion criteria included complete chemotherapy documentation, a minimum of 3 multiplanar axial/coronal imaging or ultrasonography before, during, and after receiving therapy or 2 studies for patients without malignancy. Propensity matching, Cox and linear regression, and Kaplan-Meier survival analyses were performed. RESULTS: A total of 159 (172 aneurysms) patients with malignancy and 127 (149 aneurysms) patients without malignancy were included. Average patient demographics were 74.4 ± 9.8-years-old, Caucasian (66.8%), male (70.3%), with hypertension (71.1%), current smoking (24.5%), coronary atherosclerotic disease (26.2%), and AAA (71.0%). The most common malignancy was lung cancer (48.4%) with most chemotherapy regimens including a platinum-based alkylating agent and concurrent antimetabolite (56.0%). The overall median follow-up time was 28.2 (range 3.1-174.4) months. Aortic aneurysms in patients without malignancy grew to larger sizes (4.43 ± 0.96 vs. 4.14 ± 1.00, P = 0.008) with similar median growth rates (0.12 vs. 0.12 cm/year, P = 0.090), had more atypical morphologic features (14.1% vs. 0.6%, P < 0.001), more frequently underwent repair (22.1% vs. 8.7%, P = 0.001), and more frequently required emergency repair for rupture (5.4% vs. 0.0%, P = 0.087). Cox regression identified initial aortic size ≥4.0 cm (hazard ratio [HR] 3.028), AAA (HR 2.146), chronic aortic findings (3.589), and the use of topoisomerase inhibitors (HR 2.694). Linear regression demonstrated increased growth rates predicted by antimetabolite chemotherapy (ß 0.170), initial aortic size (ß 0.086), and abdominal aortic location (ß 0.139, all P < 0.002). CONCLUSIONS: Small aortic aneurysms with concomitant malignancies are discovered at smaller initial sizes, grow at similar rates, require fewer interventions, and have fewer ruptures and acute dissections than patients without malignancy. Antimetabolite therapies modestly accelerate aneurysmal growth, and patients receiving topoisomerase inhibitors may require earlier repair. Patients with concomitant disease can be confidently treated according to standard institutional aneurysm surveillance protocols. Overall, we recommend treatment of the malignancy before small aortic aneurysm repair as these aneurysms behave similarly to those in patients without malignancy.

Neoadjuvant chemotherapy for pancreatic cancer and changes in the biliary microbiome.

BACKGROUND: The use of neoadjuvant chemotherapy (NAC) for pancreatic ductal adenocarcinoma (PDAC) has increased in recent years. Limited data exists on the impact of NAC on biliary microbiome. METHODS: Patients who underwent pancreaticoduodenectomy (PD) for PDAC between 2014 and 2017 were reviewed. Patients were stratified into two groups based on their NAC status for comparison. RESULTS: Of 168 patients included, 63 (37.5%) received NAC. Patients who received NAC exhibited significantly increased growth of Gram-negative anaerobic bacteria (p = 0.043). Patients in the non-NAC group were more likely to grow pathogens resistant to ampicillin-sulbactam (47% vs 21%, p = 0.007), cefazolin (49% vs 28%, p = 0.040), cefoxitin (42% vs 11%, p = 0.009) and cefuroxime (26% vs 4%, p = 0.019). NAC status did not impact infectious postoperative outcomes, including SSIs. CONCLUSION: Patients who did not receive NAC were more likely to grow pathogens resistant to cephalosporins. Perioperative antibiotic prophylaxis should be tailored to cover Gram-negative organisms and enterococci.

Ultrarestrictive intraoperative intravenous fluids during pancreatoduodenectomy is not associated with an increase in post-operative acute kidney injury.

BACKGROUND: The amount of IV fluids sufficient to prevent post-operative acute kidney injury (AKI) during pancreaticoduodenectomy (PD) is unknown. We assessed the restrictive IOIVF use in PD on the rate of post-operative AKI, delayed gastric emptying and ileus, and pancreatic fistulas (POPF). METHODS: Patients who underwent PD between 2012 and 2017 were reviewed. Univariate and multivariate analyses looked for association between pre- and intra-operative factors on AKI, ileus and POPF. RESULTS: Of 395 included patients, 97, 172, and 126 patients received less than 1000 mL (ultra-restrictive), 1000 mL to less than 2000 mL (restrictive), and 2000 mL and greater (nonrestrictive) normalized total IOIVF respectively. Of these 23 (24.2%), 34(20.4%), and 21(17.4%) developed AKI respectively, most of them mild. There was no difference in odds of developing AKI, ileus, or pancreatic fistula among fluid groups. While there was no difference in Clavien-Dindo III-IV complications, the incidence of Clavien-Dindo type I-II complications was lower in the restricted fluid groups. DISCUSSION: Restricted fluids did not lead to higher AKI rates but were associated with fewer low-grade complications.

Association of ABO blood group with survival following pancreatoduodenectomy for pancreatic ductal adenocarcinoma.

BACKGROUND: Existing research suggests patients with blood group O are less likely to develop pancreatic ductal adenocarcinoma (PDAC) compared to those with non-O blood groups, and that survival from PDAC may be affected by ABO blood type. This study assessed survival outcomes in PDAC patients who underwent pancreatoduodenectomy (PD) in one health system. METHODS: From 2010 to 2017, demographic, operative, chemotherapy and survival data for patients undergoing PD at Emory Healthcare were reviewed. Patients with blood type AB were excluded due to small sample size. The relationship between ABO blood group and survival was analyzed using Kaplan-Meier survival curves and multivariate cox proportional regression analysis. RESULTS: Of 449 PDAC patients assessed, 204 (45.4%), 60 (13.4%) and 185 (41.2%) were blood groups A, B and O, respectively. Patients were well matched in clinicopathologic characteristics. Median survival did not differ by blood group (p = 0.82), and this relationship remained insignificant on cox regression analysis (p = 0.15). On multivariate analysis, lymph node positivity (p < 0.001) and increasing age (p = 0.001) were associated with reduced survival. CONCLUSION: In contrast to recent reports, this larger study found that blood group did not impact overall survival among patients undergoing PD for PDAC.

Post-Pancreatectomy Diabetes Index: A Validated Score Predicting Diabetes Development after Major Pancreatectomy.

BACKGROUND: Literature is varied regarding risk factors associated with diabetes development after major pancreatic resection. The aim was to develop and validate a scoring index that preoperatively predicts the development of diabetes after pancreaticoduodenectomy and distal pancreatectomy. STUDY DESIGN: In this prospective study, perioperative fasting and postprandial (OGTT, oral glucose tolerance test) plasma glucose, glycated hemoglobin A1c (HbA1c), insulin, and c-peptide were measured in select consecutive patients undergoing pancreaticoduodenectomy and distal pancreatectomy by the senior author, from 2007 to 2018. American Diabetes Association definitions were used for glycemic classifications. Statistical analyses included multivariate generalized estimated equation for factor identification and variable weighting; area under the receiver operating curve (ROC) c-statistic for predictive ability, and survival analysis risk score grouping. RESULTS: Of 1,083 included patients with preoperative normoglycemia (253; 23.4%), prediabetes (362; 33.4%), and diabetes (468; 43.2%), the overall postoperative incidence of each diabetic class at 120 months was 152 (14.0%), 466 (43.0%), and 465 (42.9%), respectively. The development and validation groups included 1,023 and 60 patients, respectively. Five factors were identified predicting diabetes development, with a total possible score of 8. The C-statistics for development and validation groups were 0.727 (CI 0.696 to 0.759, p < 0.001) and 0.823 (CI 0.718 to 0.928, p < 0.001), respectively. At a cut point of 3 (sensitivity 0.691, specificity 0.644) the Post-pancreatectomy Diabetes Index (PDI) independently predicted diabetes in development (odds ratio [OR] 4.298, relative risk [RR] 2.486, CI 1.238 to 5.704, p < 0.001) and validation (OR 6.970, RR 2.768, CI 2.182 to 22.261, p < 0.001) groups. The PDI similarly predicted pre-diabetes in development (OR 1.961, RR 1.325, CI 1.202 to 2.564, p < 0.001) and validation (OR 4.255, RR 1.798, CI 1.247 to 14.492, p = 0.021) groups. CONCLUSIONS: The Post-pancreatectomy Diabetes Index predicts the development of diabetes and pre-diabetes in patients undergoing major pancreatectomy using routine endocrine laboratories and pre-surgical clinical data.

The Biosynthetic Option as an Alternative in Complex Abdominal Wall Reconstruction.

Synthetic mesh and acellular dermal matrix reinforcement during complex abdominal wall reconstruction (CAWR) have significantly improved outcomes. In an attempt to further improve outcomes, we combined both into a single biosynthetic by suturing a synthetic mesh on top of porcine acellular dermal matrix. Our aim was to review our experience with this new technique. Patients undergoing CAWR with the biosynthetic mesh were reviewed from a prospective database from 2015 to 2018. A total of 39 patients were 56.3 ± 10.9 years old, white (59.0%), and female (74.4%), with 31.9 ± 7.4 kg/m of body mass index. Eight repairs were performed on patients classified as greater than or equal to modified Ventral Hernia Working Group (mVHWG) class 3a, and 41.0% followed a concurrent resection of previously placed mesh. The biosynthetic mesh was placed as an underlay (51.3%) or inlay (46.2%) with primary closure in 51.3% and component separation in 12.8%. Recurrence at 3 years of follow-up occurred in 3 patients (7.7%). Complications within 60 days occurred in 6 patients (15.4%), including 4 soft tissue infections-one requiring explantation, with a total of 2 patients (5.1%) requiring explantation overall. Type 2 diabetes, previous mesh removal, component separation, and mVHWG class 3b independently predicted noninfectious complications. Male sex and mVHWG class 3b independently predicted surgical site infection. No predictors were found for recurrence. Biosynthetic mesh does not seem to increase the risk of early complications and may reduce recurrences and improve long-term outcomes after CAWR.

The hidden costs of open hepatectomy: A 10-year, single institution series of right-sided hepatectomies.

BACKGROUND: Incisional ventral hernias(IVH) are a common complication following open abdominal surgery. The aim of this study was to uncover the hidden costs of IVH following right-sided hepatectomy. METHODS: Outcomes and hospital billing data for patients undergoing open(ORH) and laparoscopic right-sided hepatectomies(LRH) were reviewed from 2008 to 2018. RESULTS: Of 327 patients undergoing right-sided hepatectomies, 231 patients were included into two groups: ORH(n = 118) and LRH(n = 113). Median follow-up-times and time-to-hernia were 24.9-months(0.3-128.4 months) and 40.5-months(0.4-81.4 months), respectively. The incidence of hernias at 1, 3, 5, and 10 years was 6/231(2.6%), 13/231(5.6%), 15(6.5%), and 17/231(7.4%); ORH = 14, LRH = 3, p = 0.003), respectively. In terms of IVH repair(IVHR), total operative costs ($10,719.27vs.$4,441.30,p < 0.001) and overall care costs ($20,541.09vs.$7,149.21,p = 0.044) were significantly greater for patients undergoing ORH. Patients whom underwent ORHs had longer hospital stays and more complications following IVHR. Risk analysis identified ORH(RR-10.860), male gender(RR-3.558), BMI ≥30 kg/m2(RR-5.157), and previous abdominal surgery(RR-6.870) as predictors for hernia development (p < 0.030). CONCLUSION: Evaluation of pre-operative hernia risk factors and utilization of a laparoscopic approach to right-sided hepatectomy reduces incisional ventral hernia incidence and cost when repair is needed.

Bile cultures are poor predictors of antibiotic resistance in postoperative infections following pancreaticoduodenectomy.

BACKGROUND: Bile cultures (BC) have routinely been used to guide empiric antibiotic therapy for developing postoperative infections. The ability of BCs to predict sensitivity and resistance patterns (SRP) of site of infection cultures (SOIC) remains controversial. The aim was to assess the concordance of pathogens and SRPs between paired BC/SOICs. METHODS: Medical records of consecutive patients undergoing pancreaticoduodenectomy were reviewed between 2014 and 2018. BC/SOIC pathogens and SRPs were compared on a patient-by-patient basis and concordance (K) was assessed. RESULTS: Common patient characteristics of 522 included patients were 65-years-old, Caucasian (75.5%), male (54.2%), malignant indication (79.3%), and preoperative biliary stent (59.0%). Overall, 275 (89.6%) BCs matured identifiable isolates with 152 (55.2%) demonstrating polymicrobial growth. Ninety-two (17.6%) SOICs were obtained: 48 and 44 occurred in patients with and without intraoperative BCs. Stents were associated with bacteriobilia (85.7%, K = 0.947, p < 0.001; OR 22.727, p < 0.001), but not postoperative infections (15.2%; K = 0.302, p < 0.001; OR 1.428, p = 0.122). Forty-eight patients demonstrated paired BC/SOICs to evaluate. Pathogenic concordance of this group was 31.1% (K = 0.605, p < 0.001) while SRP concordance of matched pathogens was 46.7% (K = 0.167, p = 0.008). CONCLUSION: Bile cultures demonstrate poor concordance with the susceptibility/resistance patterns of postoperative infections following pancreaticoduodenectomy and may lead to inappropriate antibiotic therapies.

Diabetes development after distal pancreatectomy: results of a 10 year series.

BACKGROUND: Limited literature is available on the postoperative development of impaired glucose tolerance (IGT) and new-onset diabetes mellitus (NODM) following Distal Pancreatectomy (DP). We aimed to study the post-surgical clinical evolution of IGT/DM and its association with preoperative glycemic profiles of patients undergoing DP. METHODS: Pre- and postoperative glycemic laboratories were measured in patients undergoing DP by the senior author from 2007-2017. Multivariate risk factor analysis was performed to determine risk factors for new-onset IGT/DM after DP. Kaplan-Meier curves were constructed for development of NODM postoperatively. RESULTS: Of 216 included patients, n = 63, n = 68 and n = 85 were preoperatively diagnosed with no-diabetes (No-DM), pre-diabetes (Pre-DM), and diabetes (DM), respectively. At 2-year follow-up, n = 37, n = 80 and n = 99 were classified as No-DM, Pre-DM or DM, respectively. Pre-diabetics had a higher risk of developing postoperative dysglycemia (RR 2.230, 95% CI 1.732-2.870, p = 0.001). Preoperative OGTT>130, HbA1c >6.0, and chronic pancreatitis were risk factors for postoperative DM. CONCLUSION: 40% of patients undergoing DP were unaware of their dysglycemic status (pre-DM or DM) pre-operatively. At 2-year follow-up, 36% non-diabetic and 57% pre-diabetic patients had developed NODM. Appropriate pre-operative diabetic assessment is warranted for all patients undergoing pancreatic resections.