Effects of Preoperative COVID-19 Status on Emergent or Urgent Colectomy Outcomes.

OBJECTIVES: Severe acute respiratory syndrome coronavirus 2 has been described as eliciting a powerful immune response. The association of coronavirus disease 2019 (COVID-19) infection with diseases requiring emergent or urgent colectomies may exacerbate the risk of surgical complications. We investigated the effect of preoperative COVID-19 infection on the clinical outcomes of patients who underwent a nonelective colectomy in 2021. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program Targeted Colectomy database for all of the patients who underwent a colectomy in 2021 and filtered for patients classified as "Urgent" or "Emergent." Two groups were created based on preoperative COVID-19 status: COVID+ (n = 242) and COVID- cohorts (n = 11,049). Several clinical variables were compared. RESULTS: Before filtering for urgent/emergent operations, a large percentage of COVID+ patients were found to have undergone an urgent or emergency colectomy (68.36% vs 25.05%). Preoperatively, these patients were more likely to be taking steroids (21.49% vs 12.41%) or have a bleeding issue requiring a transfusion (19.42% vs 11.00%). A larger percentage of infected patients returned to the operating room (14.05% vs 8.13%) and had a hospital stay >30 days (18.18% vs 5.35%). COVID-19 infection was associated with a higher rate of mortality (14.05% vs 8.08%) but did not independently predict it (odds ratio 1.25, P = 0.233), with all P ≤ 0.001. CONCLUSIONS: Urgent or emergent colectomy patients who were COVID-19+ preoperatively were more likely to present with comorbidities, which, along with the recent viral infection, contributed to markedly worse clinical outcomes, including an increased rate of mortality.

How the COVID-19 pandemic affected the severity and clinical presentation of diverticulitis.

BACKGROUND/AIMS: Single-institution studies showed that patients presented with more severe diverticulitis and underwent more emergency operations during the coronavirus disease 2019 (COVID-19) pandemic. Therefore, we studied this trend using nationwide data from the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: Patients (n = 23,383) who underwent a colectomy for diverticulitis in 2018 (control year) and 2020 (pandemic year) were selected. We compared these groups for differences in disease severity, comorbidities, perioperative factors, and complications. RESULTS: During the pandemic, colonic operations for diverticulitis decreased by 13.14%, but the rates of emergency operations (17.31% vs. 20.04%, P< 0.001) and cases with a known abscess/perforation (50.11% vs. 54.55%, P< 0.001) increased. Likewise, the prevalence of comorbidities, such as congestive heart failure, acute renal failure, systemic inflammatory response syndrome, and septic shock, were higher during the pandemic (P< 0.05). During this same period, significantly more patients were classified under American Society of Anesthesiologists classes 3, 4, and 5, suggesting their preoperative health states were more severe and life-threatening. Correspondingly, the average operation time was longer (P< 0.001) and complications, such as organ space surgical site infection, wound disruption, pneumonia, acute renal failure, septic shock, and myocardial infarction, increased (P< 0.05) during the pandemic. CONCLUSIONS: During the pandemic, surgical volume decreased, but the clinical presentation of diverticulitis became more severe. Due to resource reallocation and possibly patient fear of seeking medical attention, diverticulitis was likely underdiagnosed, and cases that would have been elective became emergent. This underscores the importance of monitoring patients at risk for diverticulitis and intervening when criteria for surgery are met.

Racial Disparities in Clinical Outcomes of Emergency Colectomies for Diverticulitis.

OBJECTIVES: The literature suggests that there are ongoing racial disparities in healthcare outcomes between patients in White and non-White populations. As such, we examined the outcomes of patients who underwent an emergency colectomy for diverticulitis. METHODS: We identified 4841 White and 590 non-White patients, which include Black/African American and Asian patients, using the 2016-2019 American College of Surgeons National Surgical Quality Improvement Program databases. We compared Black/African American and Asian patients with White patients for differences in surgical outcomes. RESULTS: Non-White patients had more comorbidities than White patients (P < 0.05). These patients underwent longer operations, developed more postoperative complications, and were more likely to have lengths of stay >30 days. When controlling for all of the covariates in multivariate logistic regression models, White race was independently associated with a 22.14% lower odds of a hospital stay >30 days compared with non-White patients (P = 0.001). CONCLUSIONS: In this study, non-White patients developed more complications than did White patients and had longer hospitalizations. These disparities represent a more complex societal issue that cannot be managed perioperatively alone.

Analysis of cumulative antibiogram reports in intensive care units at an Egyptian University Hospital.

BACKGROUND: Institutions must have access to antibiograms to monitor changes in antimicrobial resistance and direct empirical antibiotic therapy. The first facility-specific cumulative antibiogram was launched in the ICU in 2019. Consequently, many antibiogram-operation-related actions have been adopted in the institution based on reported data. This study aimed to analyze the cumulative antibiogram reports for multiple intensive care units (ICUs) for 2020, and compare the antimicrobial susceptibility testing (AST) patterns between the 2019 and 2020 years in an academic medical center. METHODS: This cross-sectional study was performed of routine bacterial culture and AST data extracted from a laboratory information system in a 2252-bed capacity hospital. Only the first diagnostic isolate of a given species per patient per year was included in the study. Interpretation and reporting were done in accordance with the applicable Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing guidelines. RESULTS: Of the 46,791 clinical isolates, the Gram-negative bacilli isolation rate witnessed a significant increase: 35,670 isolates in 2020 versus. 33,652 isolates in 2019. Klebsiella pneumoniae showed a statistically significant increase, mainly in pediatric, emergency, and cardiothoracic ICUs (p < 0.001). Neonatal and pediatric ICUs showed statistically significant increases in Pseudomonas aeruginosa and Proteus mirabilis isolates (p < 0.001). A statistically significant decrease was noted in the prevalence of Acinetobacter, Escherichia coli, Burkholderia cepacia, and Enterobacter cloacae. The sensitivities of K. pneumoniae and E. coli to imipenem and tigecycline significantly improved (p < 0.001). The sensitivity to colistin was significantly decreased (p < 0.001). The sensitivity of P. aeruginosa isolates to colistin and carbapenems was improved (p < 0.001). We reported a statistically significant decrease in all Gram-positive cocci (11,121 in 2020 versus. 11,528 in 2019). Staphylococcus aureus showed a statistically significant increase (p < 0.001), particularly in the medical ICU. CONCLUSION: The high susceptibility rates of Enterobacteriaceae toward colistin and tigecycline, should be cautiously considered in empiric therapy while looking for alternatives. The majority of isolates of Gram-positive cocci were coagulase negative staphylococci (CONS), we still need to confirm whether they are true pathogens or commensals before considering anti-staphylococcal agents in the empirical therapy. We underscored some corrective actions that might have improved the susceptibility rates, such as antibiotic cycling.

New legislation in New Jersey reduced opioid use among trauma patients.

PURPOSE: In New Jersey, politicians have emphasized the need to attenuate the ongoing opioid epidemic as opioid use disorder can lead to addiction and, in many cases, mortality. New legislation (New Jersey Senate Bill 3) was enacted in 2017 to reduce opioid prescription from 30 days to 5 days for acute pain in both inpatient and outpatient healthcare settings. Therefore, we sought to evaluate if the enactment of the bill influenced the consumption of opioid pain medication at an American College of Surgeons-verified Level I Trauma Center. METHODS: Patients from 2016 to 2018 were compared for differences in average daily inpatient morphine milligram equivalents (MMEs) consumption and injury severity score (ISS), among other parameters. To ensure that changes in pain medication did not affect the quality of pain management, we compared their average pain ratings. RESULTS: Although the average ISS in 2018 was higher than that in 2016 (10.6 ± 0.2 vs 9.1 ± 0.2, p < 0.001), opioid consumption decreased in 2018 without increasing the average pain rating for patients with an ISS of 9 and 10. More specifically, the average daily inpatient MMEs consumption dropped from 14.1 ± 0.5 in 2016 to 8.8 ± 0.3 in 2018 (p < 0.001). Even among patients with an average ISS >15, the total MMEs consumed per person decreased in 2018 (116.0 ± 14.0 vs 59.4 ± 7.6, p < 0.001). CONCLUSION: Overall, opioid consumption was lower in 2018 without negatively affecting the quality of pain management. This suggests that the implementation of the new legislation has successfully reduced inpatient opioid use.

Assessment of Risk Factors for Iatrogenic Genitourinary Injuries During a Proctectomy.

BACKGROUND: It is critical to avoid iatrogenic injuries affecting genitourinary organs in order to prevent postoperative urinary or sexual dysfunction, which lead to lengthier recovery and possibly reoperation. METHODS: Using the 2016-2019 American College of Surgeons National Quality Improvement Program (ACS NSQIP) Targeted Proctectomy Database, we collated 2577 patients with non-metastatic rectal cancer who underwent a laparoscopic or open proctectomy. Univariate analysis was used to identify differences in perioperative factors and genitourinary injuries (GUIs) between operative approaches, and multivariate logistic regression was used to identify independent risk factors for sustaining an intraoperative GUI. RESULTS: The rates of preoperative comorbidities were significantly higher among patients who received an open operation. The proportion of GUIs was also significantly higher in this patient population. Multivariate logistic regression demonstrated that patients who underwent a laparoscopic proctectomy were associated with a 51.4% lower risk of sustaining a GUI. Furthermore, >10% body weight loss in the past 6 months and ASA class 3 status were independently associated with a higher risk of GUI regardless of operation type. CONCLUSION: Patients who undergo a laparoscopic proctectomy are associated with a lower risk of GUI. On the other hand, patients with >10% body weight loss and ASA class 3: Severe Systemic Disease were associated with a higher risk of GUI.

The Effects of the COVID-19 Pandemic on Mastectomy Outcomes for Breast Cancer.

BACKGROUND: Single center studies have shown that during the Coronavirus Disease 2019 (COVID-19) pandemic, many patients had surgical procedures postponed or modified. We studied how the pandemic affected the clinical outcomes of breast cancer patients who underwent mastectomies in 2020. METHODS: Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we compared clinical variables of 31,123 and 28,680 breast cancer patients who underwent a mastectomy in 2019 and 2020, respectively. Data from 2019 served as the control, and data from 2020 represented the COVID-19 cohort. RESULTS: Fewer surgeries of all kinds were performed in the COVID-19 year than in the control (902,968 vs. 1,076,411). The proportion of mastectomies performed in the COVID-19 cohort was greater than in the control year (3.18% vs. 2.89%, <0.001). More patients presented with ASA level 3 in the COVID-19 year vs. the control (P < .002). Additionally, the proportion of patients with disseminated cancer was lower during the COVID-19 year (P < .001). Average hospital length of stay (P < .001) and time from operation to discharge were shorter in the COVID vs. control cohort (P < .001). Fewer unplanned readmissions were seen in the COVID year (P < .004). CONCLUSION: The ongoing surgical services and mastectomies for breast cancer during the pandemic produced similar clinical outcomes to those seen in 2019. Prioritization of resources for sicker patients and the use of alternative interventions produced similar results for breast cancer patients who underwent a mastectomy in 2020.

Comparing carotid endarterectomies with or without shunting in symptomatic and asymptomatic patients.

BACKGROUND: Recent research shows that placement of an intraluminal shunt during a carotid endarterectomy (CEA) can be associated with postoperative complications. Therefore, we compared CEA operations with or without shunting to further analyze their clinical outcomes. METHODS: From the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, 13,736 cases between 2016 and 2019 were analyzed to compare adult symptomatic and asymptomatic carotid stenosis patients who underwent a CEA operation, with or without shunt placement. RESULTS: Rates of stroke with a neurological deficit (p = 0.012), myocardial infarction (p = 0.021), and urinary tract infection (p = 0.030) were higher among symptomatic patients with shunting. Multivariate logistic regression revealed that risk of CNI was higher among both symptomatic (93.63%, p < 0.001) and asymptomatic (69.58%, p = 0.001) patients with shunting, irrespective of confounding variables. CONCLUSION: Shunting was found to be associated with higher rates of postoperative complications in both symptomatic and asymptomatic patient populations.

Skin targeting by chitosan/hyaluronate hybrid nanoparticles for the management of irritant contact dermatitis: In vivo therapeutic efficiency in mouse-ear dermatitis model.

Irritant contact dermatitis (ICD) is an inflammatory skin condition characterized by severe eczematous lesions. Nanoparticulate drug delivery is the most predominant way to improve dermal penetration and have gained remarkable recognition for targeted delivery of therapeutic payload and reduced off-target effects. Therefore, the current work aimed to fabricate polyelectrolyte complex nanoparticles (PENPs) containing two natural biodegradable polymers namely; chitosan (CS) and hyaluronic acid (HA) to deliver the non steroidal anti-inflammatory drug etoricoxib (ETX) to the deeper skin layers to alleviate any systemic toxicity and improve its therapeutic efficacy against ICD. ETX loaded-PENPs were prepared and optimized utilizing three independent variables; CS: HA mass ratio, chitosan solution pH and molecular weight of chitosan. Following the various physicochemical optimizations, the optimum ETX-loaded PENPs formulation (N1 0.15 %) exhibited spherical nature with an average diameter of 267.9 ± 9.4 nm, Polydispersity index of 0.366 ± 0.02, and positive zeta potential (+32.9 ± 0.47 mV). The drug was successfully entrapped and the entrapment efficiency reached 95 ± 0.2 %. N1 0.15 % formula showed efficient dermal targeting by significantly enhanced percentage of ETX permeated and retained in the various skin layers in comparison to ETX conventional gel during the ex-vivo skin permeation experiments. Furthermore, N1 0.15 % exhibited superior anti-inflammatory properties in vivo compared to ETX conventional gel in dithranol induced mice ear dermatitis. Conclusively, ETX-loaded PENPs could be a promising therapeutic approach for effecient management of ICD.

Computer Guided Generated Dual-Purpose Splint for Bilateral Sagittal Split Osteotomy.

Purpose: to evaluate the efficacy of dual-purpose computer-generated splint in guiding the proximal and the distal segment in bilateral sagittal split osteotomy. Patients and Method: It was a prospective case series study directed on 8 class III patients indicating the need of maxillary advancement and mandibular set back by bilateral sagittal split osteotomy. A CAD/CAM splint is generated to guide the distal segment to the stable maxilla and at the same time a grooved extension to engage the proximal segment ensuring the condyle in its planned position during fixation. The primary outcome was measured by calculating the difference between the pre- and post-operative condylar segment position. Results: The present study included five female patient and three male patient with mean age of 28.4 ± 5.1 years. The accuracy of the splint in positioning the mandibular proximal segment showed promising results ranging from 2.59 to 0.49. Conclusion: The dual-purpose splint introduced in this study showed satisfied results in maintaining the pre-operative condylar position while securing the distal segment in the desired plan.

The impact of gender on clinical outcomes after sustaining a pelvic fracture.

INTRODUCTION: In trauma care, pelvic fractures contribute to morbidity and mortality. Since men and women have different pelvic structures and hormonal milieu, we studied if these gender differences affect clinical outcomes after pelvic fractures. METHODS: Using the 2016 American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) database, we stratified 24,425 patients with pelvic fractures by gender. Male and female patients were analyzed for differences in comorbidities,  mechanism of injury, complications, and other clinical parameters. RESULTS: Female patients were older (p < 0.001) and had more comorbidities (p < 0.001), such as bleeding disorder, congestive heart failure, chronic obstructive pulmonary disorder, dementia, chronic renal failure, diabetes mellitus, and hypertension. Although female patients were sicker before sustaining pelvic fractures, male patients had higher rates of post-trauma complications (p < 0.001), such as acute kidney injury, deep vein thrombosis, unplanned admission to the intensive care unit (ICU), and unplanned return to the operating room (OR). Multivariate logistic regression further supports this as male gender was independently associated with a 26.1% higher risk of developing at least one complication (p < 0.001), despite having a higher average Injury Severity Score (ISS) (21.91 ± 0.09 versus 20.71 ± 0.11, p < 0.001). Interestingly, male patients also had a longer hospital length of stay than female patients (13.36 ± 0.12 days versus 11.8 2± 0.14 days, p < 0.001). CONCLUSION: Even though female patients were older and had more pre-existing comorbidities, male patients developed more complications and had longer hospital stays. Trial registration number Not a clinical trial.

The deleterious effect of xylene-induced ear edema in rats: Protective role of dexketoprofen trometamol transdermal invasomes via inhibiting the oxidative stress/NF-κB/COX-2 pathway.

Pain and inflammation could have a negative impact on a patient's quality of life and performance, causing them to sleep less. Dexketoprofen trometamol (DKT) is a water-soluble, nonselective NSAIDs. Because DKT is quickly eliminated in the urine after oral delivery, its efficacy is limited and must be taken repeatedly throughout the day. The main ambition of this work is to develop and characterize the potential of invasomes to enhance the transdermal transport of DKT to achieve efficient anti-inflammatory and pain management. The optimum formulation (C1) showed the least %RE (53.29 ± 2.68 %), the highest %EE (86.51 ± 1.05 %), and spherical nanosized vesicles (211.9 ± 0.57 nm) with (PDI) of 0.353 ± 0.01 and (ZP) of -19.15 ± 2.45 mV. DKT flux and deposition in stratum corneum, epidermal, and dermal skin layers were significantly augmented by 2.6 and 3.51 folds, respectively, from the optimum invasomal gel formulation (C1-G) compared to DKT conventional gel (DKT-G). The anti-inflammatory activity of C1-G was evaluated using a model of xylene-induced ear edema in rats. Xylene exposure upregulated the ear expression of COX-2 level and MPO activity. Xylene also significantly increased the ear NF-κB p65, TNF-α, IL-Iß, and MDA levels. Furthermore, xylene induced oxidative stress, as evidenced by a significant decrease in ear GSH and serum TAC levels. These impacts were drastically improved by applying C1-G compared to rats that received DKT-G and plain invasomal gel formulation (plain C1-G). The histopathological findings imparted substantiation to the biochemical and molecular investigations. Thereby, C1-G could be a promising transdermal drug delivery system to improve the anti-inflammatory and pain management of DKT.

A Single-Institution Comparison of Robot-Assisted and Conventional Laparoscopic Colorectal Surgeries.

There has been ongoing discussion regarding the superiority of robotic laparoscopic surgery (RLS) over conventional laparoscopic surgery (CLS) in many surgical subspecialties. We therefore sought to elucidate if RLS is associated with more favorable clinical outcomes than CLS among patients who underwent colorectal surgery. Using data from a high-volume single institution in New Jersey, we identified 145 patients who underwent an elective RLS or CLS sigmoid resection for colon cancer or diverticulitis in 2019 and 2020. We analyzed operation time, hospitalization cost, complications, readmissions, reoperations, and lymph node retrieval. Operation time and operation to discharge time were not significantly different among patients undergoing surgery for colon cancer (P > .05), but operation time was found to be longer in diverticulitis patients (P = .03). Additionally, RLS was significantly more costly ($86,003 ± $3520 vs. $68,277 ±$1,168, P < .001) for patients with diverticulitis. Our data demonstrate that the benefit of RLS over CLS in colon resections for diverticulitis and colon cancer is not evident due to the increased costs associated with RLS procedures.

Comparison of Robotic and Laparoscopic Colectomies Using the 2019 ACS NSQIP Database.

OBJECTIVES: Robot-assisted laparoscopic surgeries (RLSs) have become increasingly common in the past decade alongside conventional laparoscopic surgeries (CLSs). In general, RLSs have been reported to be superior to CLSs; therefore, we compared both methods among patients undergoing an elective colectomy for differences in perioperative factors and postoperative complications. METHODS: A retrospective analysis was conducted using the 2019 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. We stratified 5879 patients into two cohorts according to their preoperative diagnosis of either colon cancer or chronic diverticulitis. Patients within each group were further stratified by operative approach. RESULTS: Of the 5879 patients, 3210 colon cancer and 2669 chronic diverticulitis patients underwent an elective colectomy. There were no differences in length of stay and time from operation to discharge between RLSs and CLSs. RLSs, however, had significantly longer operation times (minutes; colon cancer: RLS 242.9 ± 91.0 vs CLS 177.4 ± 78.2, P < 0.001; chronic diverticulitis: RLS 226.2 ± 87.4 vs CLS 181.7 ± 74.4, P < 0.001). Among all of the colon cancer patients, RLS had higher rates of unplanned return to the operating room (P = 0.028) and organ space surgical site infection (P = 0.035). Among chronic diverticulitis patients, RLS was associated with higher rates of postoperative sepsis, anastomotic leak, organ space surgical site infection, and unplanned readmission (all P < 0.05). CONCLUSIONS: CLS may be the more efficient operative technique because it was associated with a shorter average operation time and fewer postoperative complications. This paradigm, however, may change as the robotic technology develops and surgeons become more experienced with RLS.

Mucin1 expression and gustatory function in postmenopausal females: A case-control observational study.

Background: Investigating possible relationship between Mucin1 expression levels in saliva, gustatory function, and taste perception in postmenopausal females. Material and Methods: Using whole mouth taste test, twenty-five post-menopausal females (51.35 ± 5.22 years) and twenty-five premenopausal females (39.65 ± 6.46 years) were prospectively evaluated for gustatory function. The expression of mucin1 was investigated; RNA was isolated from stimulated whole saliva samples and real-time PCR was used to determine mucin1 mRNA levels relative to bactin and GAPDH mRNA levels. Results: Significant difference was observed between postmenopausal and premenopausal women regarding intensity judgments of all tastants. The difference was more evident for sucrose taste perception (p<0.00001). Mucin1 expression levels were significantly decreased in postmenopausal females compared with premenopausal ones (p<0.00001). Mucin1 expression level had significant negative correlation with the salt taste sensitivity but did not correlate significantly with intensity judgments of the other tastants. Conclusions: Postmenopausal women have a reduced gustatory function, especially sucrose. Mucin1 expression was significantly decreased in postmenopausal females and had a significant negative correlation with the salt taste sensitivity. However, no correlation was found between mucin1 expression level and taste sensitivity of other tastants. Key words:Gustatory function, MUC1, taste, postmenopausal.

Association of iron infusion reactions with ABO blood type.

OBJECTIVES: We sought to determine risk factors for iv iron infusion-related reactions (IRR), and identify strategies for iron repletion after IRR. METHODS: We conducted a retrospective chart review of patients treated in the classical hematology clinic at Yale Cancer Center (n = 330 consecutive patients) from 2016 to 2021, who received iv ferumoxytol (60.3%), iron sucrose (14.8%), or iron dextran (10.9%). RESULTS: The iv iron IRR was noted in 58 (17.6%) patients, 62.1% of whom had previously tolerated iv iron. The severity of IRR was mild in 22, moderate in 23, and severe in 11 patients. Most (72.4%) patients who experienced IRR tolerated a subsequent iv iron infusion. On multivariable analysis, a history of non-medication allergies was associated with greater odds of IRR (odds ratio [OR] 2.12, 95% confidence interval (CI): 1.16-3.87, p = .01). No patients with type AB blood, and few with type A blood (n = 6), had IRR; compared to type A or AB together, patients with type B (OR 5.00, 95% CI: 1.56-16.06, p = .007) or type O (OR 3.71, 95% CI: 1.44-9.55, p = .007) blood had greater odds of IRR. CONCLUSIONS: This study highlights a possible association of blood type with iv iron IRR; prospective studies with larger patient numbers are warranted to explore this association.

Metastatic insidious super giant basal cell carcinoma.

A middle-aged woman presented with a mechanical fall. Physical examination revealed a massive purulent ulcerated lesion spanning her entire back and axilla, which had reportedly been brewing for over a decade. Punch biopsy revealed infiltrative basal cell carcinoma. She was treated with Vismodegib, with a remarkable decrease in the size of the cancer. However, surveillance imaging after 6 months of treatment revealed new bone metastases. In the setting of progressive disease, medical therapy was switched to cemiplimab instead. Basal cell carcinoma is commonly known as a benign tumour of the skin, rarely larger than 5 cm. Here, we discuss the entity of metastatic super giant basal cell carcinoma; this case is one of the largest reported lesions. As locoregional therapy, such as surgery is sometimes not appropriate for such advanced lesions, we discuss the current forefront of therapy including oral hedgehog pathway and check point inhibitors.

Vessel Sealant Devices in Thyroidectomies: An ACS-NSQIP Study.

OBJECTIVES: Thyroidectomies involve meticulous dissection of a highly vascularized organ and complications may develop, such as hematoma, hypocalcemia, and even hypoparathyroidism. Because some of these complications may be fatal, we sought to identify the differences in postthyroidectomy outcomes when the use of a vessel sealant device (VSD) such, as LigaSure or Harmonic scalpel, is compared with more traditional techniques, such as ligatures and clips. METHODS: Using the 2016 American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy database, we compared patients who underwent a thyroidectomy using a VSD with patients without a VSD for differences in postoperative complications. RESULTS: A total of 5146 cases were identified and 3452 of those cases used a VSD, whose use was associated with significantly lower rates of hematoma, deep vein thrombosis, and hypocalcemia before discharge, as well as a shorter length of stay and longer operation time. Multivariate logistic regression showed that VSD was associated with 32.27% and 39.15% lower odds of hypocalcemia and hematoma, respectively. VSDs also were used more frequently in cases that had multinodular, severe, or substernal goiter or Graves disease as the primary indication for surgery and in patients with a higher body mass index. There was no significant difference in the incidence of recurrent laryngeal nerve injury between the two groups. CONCLUSIONS: Analysis of the American College of Surgeons National Surgical Quality Improvement Program data indicates that VSDs are associated with a lower risk of complications, such as hypocalcemia, hematoma, and deep vein thrombosis, suggesting that VSDs may be a more effective method of hemostasis than traditional techniques.

Hemophagocytic Lymphohistiocytosis After Inactivated Influenza Vaccination in a Young Man Complicated by Severe Rhabdomyolysis.

Hemophagocytic lymphohistiocytosis (HLH) is an immune response disorder that is usually fatal despite treatment. It is characterized by a dysregulation in natural killer (NK) T-cell function, causing activation of lymphocytes and histiocytes, resulting in a cytokine storm, end-organ damage, and eventually death. In this report, we describe the case of a previously healthy 38-year-old Caucasian man who presented with fever, nausea, vomiting, abdominal pain, myalgias, and weight loss for one week after inactivated influenza vaccination. The initial evaluation showed leukocytosis, lactic acidosis, and a severely elevated creatine kinase level (19,639 IU/L). The presentation was consistent with a diagnosis of sepsis, likely secondary to viral etiology and rhabdomyolysis. Subsequently, he rapidly deteriorated, requiring mechanical ventilation and developed refractory shock requiring pressor support and continuous veno-venous hemofiltration for acute kidney injury due to rhabdomyolysis. Later, he developed bicytopenia, hyperferritinemia, hypertriglyceridemia, and elevated inflammatory markers, raising the possibility of underlying HLH. Further tests showed low NK cell cytotoxicity and elevated sCD25. The H-score, which is a clinical tool to estimate the probability of HLH, showed an 88-93% probability of that potentially fatal disorder. The patient was treated with pulse-dose corticosteroids, intravenous immunoglobulins (IVIGs), and anakinra. He had a prolonged and complicated hospital stay for about two months. However, he was able to slowly recover. We believe that he developed secondary HLH in the setting of vaccination. Although rare, an early suspicion of HLH leads to the early initiation of directed therapy with immunosuppressant that would limit morbidity and mortality.