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Objective: To determine how the severity of prior history (Hx) of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection influences postoperative outcomes after major elective inpatient surgery. Background: Surgical guidelines instituted early in the coronavirus disease 2019 (COVID-19) pandemic recommended a delay in surgery of up to 8 weeks after an acute SARS-CoV-2 infection. This was based on the observation of elevated surgical risk after recovery from COVID-19 early in the pandemic. As the pandemic shifts to an endemic phase, it is unclear whether this association remains, especially for those recovering from asymptomatic or mildly symptomatic COVID-19. Methods: Utilizing the National COVID Cohort Collaborative, we assessed postoperative outcomes for adults with and without a Hx of COVID-19 who underwent major elective inpatient surgery between January 2020 and February 2023. COVID-19 severity and time from infection to surgery were each used as independent variables in multivariable logistic regression models. Results: This study included 387,030 patients, of whom 37,354 (9.7%) were diagnosed with preoperative COVID-19. Hx of COVID-19 was found to be an independent risk factor for adverse postoperative outcomes even after a 12-week delay for patients with moderate and severe SARS-CoV-2 infection. Patients with mild COVID-19 did not have an increased risk of adverse postoperative outcomes at any time point. Vaccination decreased the odds of respiratory failure. Conclusions: Impact of COVID-19 on postoperative outcomes is dependent on the severity of illness, with only moderate and severe disease leading to a higher risk of adverse outcomes. Existing perioperative policies should be updated to include consideration of COVID-19 disease severity and vaccination status. [ABSTRACT FROM AUTHOR]

Objective: We sought to characterize differences in pancreatectomy recommendation rates to surgically eligible patients with pancreatic ductal adenocarcinoma of the pancreatic head across age and racial groups. Background: Pancreatectomy is not recommended in almost half of otherwise healthy patients with stage I/II pancreatic ductal adenocarcinoma lacking a surgical contraindication. We characterized differences in pancreatectomy recommendation among surgically eligible patients across age and racial groups. Methods: Non-Hispanic White (NHW) and Non-Hispanic Black (NHB) patients were identified in the National Cancer Database with clinical stage I/II pancreatic head adenocarcinoma, Charlson Comorbidity Index of 0 to 1, and age 40 to 89 years. Rates of surgery recommendation and overall survival (OS) by age and race were compared. A Pancreatectomy Recommendation Equivalence Point (PREP) was defined as the age at which the rate of not recommending surgery matched the rate of recommending and completing surgery. Marginal standardization was used to identify association of age and race with recommendation. OS was compared using Kaplan–Meier and Cox regression models. Results: Among 40,866 patients, 36,133 (88%) were NHW and 4733 (12%) were NHB. For the entire cohort, PREP was 79 years. PREP was 5 years younger in NHB patients than in NHW patients (75 vs 80 years). Adjusted rates of not recommending surgery were significantly higher for NHB than for NHW patients in each age group. After adjusting for surgery recommendation, we found no difference in OS between NHW and NHB patients (hazard ratio 0.98 [95% CI 0.94–1.02]). Conclusions: PREP of NHB patients was 5 years younger than NHW patients, and in every age group, the rate of not recommending pancreatectomy was higher in NHB patients. Age and race disparities in treatment recommendations may contribute to shorter longevity of NHB patients. [ABSTRACT FROM AUTHOR]

Minimally invasive colectomy is associated with improved length of stay and decreased postoperative morbidity. Little is known regarding the impact of prolonged operative time on the benefits afforded by minimally invasive colectomy. The American College of Surgeons National Surgical Quality Improvement Program procedure targeted colectomy dataset was queried to identify elective right and left colectomies performed between 2011 and 2017. Multivariable modeling was used to compare rates of composite 30-day death or serious morbidity, overall morbidity, mortality, anastomotic leak, surgical site infection, and length of stay for prolonged minimally invasive cases to those for average duration open cases. A total of 16,602 right colectomies and 36,557 left colectomies were identified. Median operative times for open and minimally invasive right colectomies were 107 min and 129 min (P <. 01), while that for open left colectomies was 128 min and 156 min for minimally invasive left colectomies (P <. 01). Cohorts were stratified by quartiles of operative time with the highest (fourth) quartile defined as a prolonged operating time. When compared with an average duration open colectomy, prolonged minimally invasive right colectomies and left colectomies were associated with decreased risk-adjusted rates of overall morbidity, surgical site infection, and with lesser lengths of stay (P <. 05). Prolonged minimally invasive left colectomies were also associated with improved rates of composite 30-day death or serious morbidity relative to average open left colectomies (odds ratio 0.66, 95% confidence interval, 0.54–0.79). Prolonged operating times of an minimally invasive approach do not obviate the benefits of an minimally invasive approach to colectomy. [ABSTRACT FROM AUTHOR]

Abstract Background Health care spending is driven by a very small percentage of Americans, many of whom are patients with prolonged durations of stay. The objective of this study was to characterize superusers in the trauma population. Methods The National Trauma Data Bank for 2008–2012 was queried. Superusers were defined as those with a duration of stay in the top 0.06% of the population and were compared with the remainder of the population to determine differences in demographic characteristics, comorbidities, prehospital factors, and outcomes. Multivariate analysis was used to determine independent predictors of being classified as a superuser. Results A total of 3,617,261 patients met inclusion criteria, with 34,728 qualifying as superusers. Mean duration of stay for superusers was 58.7 days compared with the average 4.6 days (P <.001). Superusers were more likely to be male, black, Medicaid insured, and have a higher Injury Severity Score and lower Glasgow Coma Scale score. The hospital course of superusers was likely to be complicated by pneumonia, acute respiratory distress syndrome, decubitus ulcer, and acute kidney injury. Conclusion Age, sex, race, and insurance were associated with prolonged use of inpatient care in the trauma patient population. Specific comorbidities and complications are associated with being a superuser. This subset of the trauma population confers a disproportionate burden on the health care system and can serve as a potential target for intervention. [ABSTRACT FROM AUTHOR]

Objective: This study aims to evaluate the trends in cancer (CA) admissions and surgeries after the Affordable Care Act (ACA) Medicaid expansion. Methods: This is a retrospective study using HCUP-SID analyzing inpatient CA (pancreas, esophagus, lung, bladder, breast, colorectal, prostate, and gastric) admissions and surgeries pre- (2010-2013) and post-(2014) Medicaid expansion. Surgery was defined as observed resection rate per 100 cancer admissions. Nonexpansion (FL) and expansion states (IA, MD, and NY) were compared. A generalized linear model with a Poisson distribution and logistic regression was used with incidence rate ratios (IRR) and difference-in-differences (DID). Results: There were 317, 858 patients in our sample which included those with private insurance, Medicaid, or no insurance. Pancreas, breast, colorectal, prostate, and gastric CA admissions significantly increased in expansion states but decreased in nonexpansion states. (IRR 1.12, 1.14, 1.11, 1.34, 1.23; P<.05) Lung and colorectal CA surgeries (IRR 1.30, 1.25; P<.05) increased, while breast CA surgeries (IRR 1.25; P<.05) decreased less in expansion states. Government subsidized, or self-pay patients had greater odds of undergoing lung, bladder, and colorectal CA surgery (OR 0.45 vs 0.33; 0.60 vs 0.48; 0.47 vs 0.39; P<.05) in expansion states after reform. Conclusions: In states that expanded Medicaid coverage under the ACA, the rate of surgeries for colorectal and lung CA increased significantly, while breast CA surgeries decreased less. Parenthetically, these cancers are subject to population screening programs. We conclude that expanding insurance coverage results in enhanced access to cancer surgery. [ABSTRACT FROM AUTHOR]

Background This study aimed to determine whether publicized hospital rankings can be used to predict surgical outcomes. Methods Patients undergoing one of nine surgical procedures were identified, using the Healthcare Cost and Utilization Project State Inpatient Database for Florida and New York 2011–2013 and merged with hospital data from the American Hospital Association Annual Survey. Nine quality designations were analyzed as possible predictors of inpatient mortality and postoperative complications, using logistic regression, decision trees, and support vector machines. Results We identified 229,657 patients within 177 hospitals. Decision trees were the highest performing machine learning algorithm for predicting inpatient mortality and postoperative complications (accuracy 0.83, P <.001). The top 3 variables associated with low surgical mortality (relative impact) were Hospital Compare (42), total procedure volume (16) and, Joint Commission (12). When analyzed separately for each individual procedure, hospital quality awards were not predictors of postoperative complications for 7 of the 9 studied procedures. However, when grouping together procedures with a volume-outcome relationship, hospital ranking becomes a significant predictor of postoperative complications. Conclusion Hospital quality rankings are not a reliable indicator of quality for all surgical procedures. Hospital and provider quality must be evaluated with an emphasis on creating consistent, reliable, and accurate measures of quality that translate to improved patient outcomes. [ABSTRACT FROM AUTHOR]

Background The fastest growing segment of the American population is the elderly (>65 years). This change in demographics also is being seen in trauma centers. Emergency department thoracotomy is utilized in an attempt to restore circulation for patients arriving in extremis. The purpose of this study was to investigate the relationship between clinical variables, particularly age, and outcomes for injured patients receiving an emergency department thoracotomy. Methods Using the National Trauma Data Bank for years 2008–2012, observations with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for exploratory thoracotomy were identified. Emergency department thoracotomy was defined as any observation that occurred at a time to thoracotomy less than the total time spent in the emergency department thoracotomy, and within 15 minutes of arrival. Mechanisms of injury, demographic data, and injuries were analyzed for predictors of survival and mortality rates. Mortality rates were determined for each decade and year of life. Results There were 11,380 observations for thoracotomy identified. Of these, 2,519 were emergency department thoracotomy, with the majority ( n   =  2,026, 80% observations) performed for penetrating wounds. Mortality rates ranged from 80% to 100% for each decade of life. Mortality was 100% for patients >57 years old with either penetrating or blunt mechanisms of injury. Conclusion Emergency department thoracotomy offered no survival benefit for patients older than 57 years of age. These data suggest that emergency department thoracotomy performed in elderly patients may be futile. [ABSTRACT FROM AUTHOR]

Background Cancer cells metastasize to the bone marrow to create the premetastatic niche. Cancer stemness (expression of stem cell characteristics) is regulated by the tumor microenvironment and associated with self-renewal and poor clinical outcomes. Osteopontin induces mesenchymal stem cells in the tumor microenvironment to adopt a cancer-associated fibroblast phenotype to potentiate cancer growth and metastasis. The mechanisms by which cancer cells and tumor microenvironment regulate stemness in the bone marrow premetastatic niche is unknown. Methods Human breast cancer cell lines, MDA-MB-231 and MCF-7 were used in an orthotopic murine xenograft model. NOD-scid mice were implanted with 2 × 10 6 tumor cells in the presence and absence of human mesenchymal stem cells-green fluorescent protein cells and/or osteopontin aptamer, which blocks and inactivates extracellular osteopontin, or mutant aptamer (osteopontin mutant aptamer). In select instances, MCF-7 cells transfected to express osteopontin were coimplanted instead of MCF-7. Stemness markers (Nanog, Oct4, Sox2) in the tumor cells and cancer-associated fibroblast ( α -smooth muscle actin, Vimentin) markers in the mesenchymal stem cells were measured in femoral bone marrow via real-time polymerase chain reaction. Cell number was determined by titrating cell number to Ct value in vitro. Results Tumor cells and mesenchymal stem cells migrate from the primary tumor site to the bone marrow. Migration of mesenchymal stem cells is osteopontin dependent. In both MDA-MB-231 and MCF-7 cell lines, levels of both cancer-associated fibroblast and stemness markers were 3 to 4 times greater under conditions wherein mesenchymal stem cells were present with osteopontin. Inactivation of extracellular osteopontin with an aptamer decreased migration of mesenchymal stem cells and expression of both cancer-associated fibroblast and stemness markers. Cancer cells exhibited a significantly increased stem cell profile in the presence of cancer-associated fibroblast in the bone marrow. In the presence and absence of osteopontin, Sox2 knockdown abolished expression of both Nanog and Oct4. Conclusion We conclude that osteopontin-dependent migration of cancer-associated fibroblast is required for increased cancer cell stemness in the bone marrow premetastatic niche. [ABSTRACT FROM AUTHOR]

Purpose Postoperative urinary retention is a common complication across surgical specialties. To our knowledge no literature to date has examined postoperative urinary retention as a predictor of long-term receipt of surgery for bladder outlet obstruction. Materials and Methods We retrospectively reviewed the records of inpatients who underwent nonurological surgery in California between 2008 and 2010. Postoperative urinary retention during the index admission was identified, as was receipt of a bladder outlet procedure (transurethral prostate resection, prostate photoselective vaporization or suprapubic prostatectomy) at a subsequent encounter. Patients were matched using propensity scoring of demographics, comorbidities and surgery type. Adjusted Kaplan-Meier analysis was performed to determine the cumulative incidence of subsequent bladder outlet procedures by patient group, including group 1—age 60 years or greater and postoperative urinary retention, group 2—age 60 years or greater and no postoperative urinary retention, group 3—age less than 60 years and postoperative urinary retention, and group 4—age less than 60 years and no postoperative urinary retention. Results Of 769,141 eligible male patients postoperative urinary retention developed in 8,051 (1.1%). Following hospital discharge 1,855 patients (0.24%) underwent a bladder outlet procedure. Those treated with a bladder outlet procedure were significantly more likely to have experienced postoperative urinary retention during the index admission (6.3% vs 1.0%, p <0.001). On matched analysis the bladder outlet procedure rate at 3 years was 7.1%, 2.2%, 0.8% and 0.0% in groups 1, 2, 3 and 4, respectively. Conclusions In men 60 years old or older postoperative urinary retention identified those with an increased incidence of bladder outlet procedures within 3 years. Men younger than 60 years had a low rate of subsequent bladder outlet procedures regardless of a postoperative urinary retention diagnosis. [ABSTRACT FROM AUTHOR]

Objective: To examine the development of acute kidney injury (AKI) after burn injury as an independent risk factor for increased morbidity and mortality over initial hospitalization and 1-year follow-up. Background: Variability in fluid resuscitation and difficulty recognizing early sepsis are major barriers to preventing AKI after burn injury. Expanding our understanding of the burden AKI has on the clinical course of burn patients would highlight the need for standardized protocols. Methods: We queried the Healthcare Cost and Utilization Project State Inpatient Databases in the states of Florida and New York during the years 2009 to 2013 for patients over age 18 hospitalized with a primary diagnosis of burn injury using ICD-9 codes. We identified and grouped 18,155 patients, including 1476 with burns >20%total body surface area, by presence of AKI. Outcomes were compared in these cohorts via univariate analysis and multi-variate logistic regression models. Results: During initial hospitalization, AKI was associated with increased pulmonary failure, mechanical ventilation, pneumonia, myocardial infarction, length of stay, cost, and mortality, and also a lower likelihood of being discharged home. One year after injury, AKI was associated with development of chronic kidney disease, conversion to chronic dialysis, hospital readmission, and long-term mortality. Conclusions: AKI is associated with a profound and severe increase in morbidity and mortality in burn patients during initial hospitalization and up to 1 year after injury. Consensus protocols for initial burn resuscitation and early sepsis recognition and treatment are crucial to avoid the consequences of AKI after burn injury. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to investigate whether post-hospital syndrome (PHS) places patients undergoing elective hernia repair at increased risk for adverse postoperative events. Summary of Background Data: PHS is a transient period of health vulnerability following inpatient hospitalization for acute illness. PHS has been well studied in nonsurgical populations, but its effect on surgical outcomes is unclear. Methods: State-specific datasets for California in 2011 available through the Healthcare Cost and Utilization Project (HCUP) were linked. Patients older than 18 years who underwent elective hernia repair were included. The primary exposure variable was PHS, defined as any inpatient admission within 90 days of an elective hernia repair performed in an ambulatory surgery center. The primary outcome was an adverse event, defined as any unplanned emergency department visit or inpatient admission within 30 days postoperatively. Mixed-effects logistic models were used for multivariable analyses. Results: A total of 57,988 patients met inclusion criteria. The 30-day risk-adjusted adverse event rate was significantly higher for PHS patients versus non-PHS patients (11.8%vs 5.8%, P < 0.001). PHS patients were more likely than non-PHS patients to experience postoperative complications (odds ratio 2.2, 95% confidence interval 1.6-3.0). Adverse events attributable to PHS cost an additional $63,533.46 per 100 cases in California. The risk of adverse events due to PHS remained elevated throughout the 90-day window between hospitalization and surgery. Conclusions: Patients hospitalized within 90 days of an elective surgery are at increased risk of adverse events postoperatively. The impact of PHS on outcomes is independent of baseline patient characteristics, medical comorbidities, quality of center performing the surgery, and reason for hospitalization before elective surgery. Adverse events owing to PHS are costly and represent a quality improvement target. [ABSTRACT FROM AUTHOR]

Background It is well established that transient postoperative atrial fibrillation (TPAF) is associated with adverse postoperative outcomes after major cardiac and noncardiac operations. The purpose of this study was to elucidate the incidence, impact, and risk factors associated with the development of TPAF in patients undergoing revascularization surgery for occlusive diseases of the abdominal aorta and its branches (AAB). Methods By use of the Healthcare Cost and Utilization Project State Inpatient Database from Florida and California, patients who underwent open revascularization of AAB between 2006 and 2011 were identified. Patients diagnosed with aortic dissection or abdominal aortic aneurysm were excluded to limit the study cohort to include only patients with occlusive etiology. Also excluded were those with a pre-existing diagnosis of atrial fibrillation and those who underwent thoracic aortic repair and peripheral artery revascularization procedures. Multivariable logistic and linear regression analyses with treatment effects were conducted to analyze the association between TPAF and length of stay (LOS); the mortality rates at index admission, 1 month, and 1 year; and the readmission rates at 1 month and 1 year (adjusted for comorbidities and surgical and demographic factors). A backwards stepwise logistic regression model was built to identify predictors of TPAF. Results A total of 4462 patients were identified; 3253 underwent aortoiliac/femoral bypasses (72.9%), 1514 endarterectomies of AAB (33.9%), and 288 bypasses of AAB (6.5%). The incidence of TPAF was 2.4% (109 patients). Multivariate regression analysis with treatment effects showed that TPAF was associated with significantly increased LOS, mortality, and readmission rates. Factors identified as predictors of TPAF by backwards stepwise logistic regression modeling include electrolyte disorders, increasing age, and Charlson Comorbidity Index (C statistic = .69; accuracy = 58%). Conclusions TPAF after revascularization of AAB is associated with increased LOS, inpatient mortality, 1-year mortality, and hospital readmissions. Strategies to identify patients at risk for development of TPAF and implementation of appropriate prophylactic measures may improve surgical outcomes and reduce cost of care. [ABSTRACT FROM AUTHOR]

Background “Take the Volume Pledge” proposes restricting pancreatectomies to hospitals that perform ≥20 per year. Our purpose was to identify those factors that characterize patients at risk for loss of access to pancreatic cancer care with enforcement of volume standards. Methods Using the Healthcare Cost and Utilization Project State Inpatient Database from Florida, we identified patients who underwent pancreatectomy for pancreatic malignancy from 2007–2011. American Hospital Association and United States Census Bureau data were linked to patient-level data. High-volume hospitals were defined as performing ≥20 pancreatic resections per year. Univariable and multivariable statistics compared patient characteristics and utilization of high-volume hospitals. Classification and Regression Tree modeling was used to predict patients at risk for losing access to care. Results Our study included 1,663 patients. Five high-volume hospitals were identified, and they treated 1,056 (63.5%) patients. Patients residing far from high-volume hospitals, in areas with the highest population density, non-Caucasian ethnicity, and greater income had decreased odds of obtaining care at high-volume hospitals. Using these factors, we developed a Classification and Regression Tree–based predictive tool to identify these patients. Conclusion Implementation of “Take the Volume Pledge” is an important step toward improving pancreatectomy outcomes; however, policymakers must consider the potential impact on limiting access and possible health disparities that may arise. [ABSTRACT FROM AUTHOR]

Background With more hospital consolidations as an inevitable part of our future health care ecosystem, we investigated the relationship between hospital consolidations and operative outcomes. Methods Using the Health Care Cost and Utilization Project State Inpatient Database (Florida and California), the American Hospital Association Annual Survey Database, and Medicare's Case Mix Index data, we identified 19 hospitals that consolidated between 2007 and 2013 and propensity matched them with 19 independent hospitals, using patient and hospital characteristics. One year before consolidation and again 1 year after, we used difference-in-differences analysis to compare changes in the risk-adjusted complication rate of 7 elective operations performed in the consolidated hospitals and in the matched control group. Results Of the 7 procedures studied, 2 procedures saw a decrease in complication rate (lumbar and lumbosacral fusion of the posterior column posterior technique, difference-in-differences = −0.6%, P < .01; total hip replacement, difference-in-differences = −0.6%, P < .01); 3 procedures saw an increase in complication rate (transurethral prostatectomy, difference-in-differences = 4.1%, P < .01; cervical fusion of the anterior column anterior technique, difference-in-differences = 1.5%, P < .01; total knee replacement, difference-in-differences = 0.3%, P < .01); and 2 procedures saw no change in complication rate (laparoscopic cholecystectomy, lumbar and lumbosacral fusion of the anterior column posterior technique, both P > .05) after hospital consolidation. Conclusion Arguments have been made that consolidated health care systems can share high-performing clinical services and infrastructure resources, such as electronic medical records, to improve quality. Our results indicate that hospital consolidation does not uniformly improve postoperative complication rates. [ABSTRACT FROM AUTHOR]

Background Our objective was to determine the hospital resources required for low-volume, high-quality care at high-volume cancer resection centers. Methods Patients who underwent esophageal, pancreatic, and rectal resection for malignancy were identified using Healthcare Cost and Utilization Project State Inpatient Database (Florida and California) between 2007 and 2011. Annual case volume by procedure was used to identify high- and low-volume centers. Hospital data were obtained from the American Hospital Association Annual Survey Database. Procedure risk-adjusted mortality was calculated for each hospital using multilevel, mixed-effects models. Results A total of 24,784 patients from 302 hospitals met the inclusion criteria. Of these, 13 hospitals were classified as having a high-volume, oncologic resection ecosystem by being a high-volume hospital for ≥2 studied procedures. A total of 11 of 31 studied hospital factors were strongly associated with hospitals that performed a high volume of cancer resections and were used to develop the High Volume Ecosystem for Oncologic Resections (HIVE-OR) score. At low-volume centers, increasing HIVE-OR score resulted in decreased mortality for rectal cancer resection ( P = .038). HIVE-OR was not related to risk-adjusted mortality for esophagectomy ( P = .421) or pancreatectomy ( P = .413) at low-volume centers. Conclusion Our study found that in some settings, low-volume, high-quality cancer surgical care can be explained by having a high-volume ecosystem. [ABSTRACT FROM AUTHOR]

Purpose Obstructing nephrolithiasis is a common condition that can require urgent intervention. In this study we analyze patient factors that contribute to delayed intervention during acute stone admission. Materials and Methods We retrospectively reviewed the HCUP SID (Healthcare Cost and Utilization Project State Inpatient Database) for Florida and California from 2007 to 2011. Patients who were admitted urgently with nephrolithiasis and an indication for decompression (urinary tract infection, acute renal insufficiency and/or sepsis) were included in the study. Intervention was timely or delayed, defined as a procedure that occurred within or after 48 hours, respectively. Adjusted multivariate models were fit to assess factors that predicted a delayed procedure as well as mortality. Results Overall 10,301 patients were admitted urgently for nephrolithiasis with indications for decompression. Early intervention occurred in 6,689 patients (65%) and was associated with a decrease in mortality (11, 0.16%), compared to delayed intervention (17 of 3,612, 0.47%, p=0.002). On multivariate analysis timely intervention significantly decreased the odds of inpatient mortality (OR 0.43, p=0.044). Weekend day admission significantly influenced time to intervention, decreasing patient odds of timely intervention by 26% (p <0.001). Other factors decreasing patient odds of timely intervention included nonCaucasian race and nonprivate insurance. Presenting medical diagnoses of urinary tract infection, sepsis and acute renal failure did not appear to influence time to intervention. Conclusions Delayed operative intervention for acute nephrolithiasis admissions with indications for decompression results in increased patient mortality. Nonmedical factors such as the “weekend effect,” race and insurance provider exerted the greatest influence on the timing of intervention. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to determine whether new-onset transient postoperative atrial fibrillation (TPAF) affects mortality rates after abdominal aortic aneurysm (AAA) repair and to identify predictors for the development of TPAF. Methods Patients who underwent open aortic repair or endovascular aortic repair for a principal diagnosis AAA were retrospectively identified using the Healthcare Cost and Utilization Project-State Inpatient Database (Florida) for 2007 to 2011 and monitored longitudinally for 1 year. Inpatient and 1-year mortality rates were compared between those with and without TPAF. TPAF was defined as new-onset atrial fibrillation that developed in the postoperative period and subsequently resolved in patients without a history of atrial fibrillation. Cox proportional hazards models, adjusted for age, gender, comorbidities, rupture status, and repair method, were used to assess 1-year survival. Predictive models were built with preoperative patient factors using Chi-squared Automatic Interaction Detector decision trees and externally validated on patients from California. Results A 3.7% incidence of TPAF was identified among 15,148 patients who underwent AAA repair. The overall mortality rate was 4.3%. The inpatient mortality rate was 12.3% in patients with TPAF vs 4.0% in those without TPAF. In the ruptured setting, the difference in mortality was similar between groups (33.7% vs 39.9%, P = .3). After controlling for age, gender, comorbid disease severity, urgency (ruptured vs nonruptured), and repair method, TPAF was associated with increased 1-year postoperative mortality (hazard ratio, 1.48; P < .001) and postdischarge mortality (hazard ratio, 1.56; P = .028). Chi-squared Automatic Interaction Detector-based models (C statistic = 0.70) were integrated into a Web-based application to predict an individual's probability of developing TPAF at the point of care. Conclusions The development of TPAF is associated with an increased risk of mortality in patients undergoing repair of nonruptured AAA. Predictive modeling can be used to identify those patients at highest risk for developing TPAF and guide interventions to improve outcomes. [ABSTRACT FROM AUTHOR]

Background The purpose of this study was to measure how the duration of nonoperative intervention for intestinal obstruction impacted patient outcomes and whether hospital characteristics influenced the timing of operative intervention. Methods The State Inpatient Database (Florida) of the Health Care Utilization Project and the Annual Survey database of the American Hospital Association were linked from 2006 to 2011. Included were patients ≥18 years of age with a primary diagnosis of intestinal obstruction. Patient factors included age, sex, socioeconomic factors, and comorbid conditions. Results A total of 116,195 patients met our inclusion criteria, and 43,079 underwent operative intervention (37.1%). Patients who required operative correction of the intestinal obstruction after the fifth day of hospitalization, compared with patients who underwent an operation on the day of admission, had increases in mortality (6.1% vs 1.8%, P < .001), complication rates (15.4% vs 4.0%, P < .001), and postoperative hospital stay (9 vs 5 days, P < .001). Patients cared for at a large teaching facility (with surgery residents) had increased odds of early operative intervention by 23% (odds ratio 1.23, [1.20–1.28]), whereas patients at low-volume hospitals had decreased odds of early intervention (odds ratio 0.88, [0.73–0.91]). Conclusion Initial nonoperative treatment in patients with uncomplicated intestinal obstruction is an important strategy, but the odds of having an adverse event increase as intestinal obstruction is delayed. Importantly, the presence of surgery residents and increasing bed size are hospital characteristics associated with earlier operative intervention, suggesting a quality benefit for care at large teaching hospitals. [ABSTRACT FROM AUTHOR]

Introduction Osteopontin (OPN) mediates metastasis and invasion of hepatocellular carcinoma (HCC). Epigallocatechin-3-gallate (EGCG), found in green tea, suppresses HCC tumor growth in vitro. We sought to investigate the role of EGCG in modulating OPN in cell lines of metastatic HCC. Methods Experimental HCC cell lines included HepG2 and MHCC-97H HCC cells, which express high levels of OPN, and the Hep3B cells, which express lesser levels of OPN. Cells were treated with EGCG (0.02–20 μg/mL) before measurement of OPN with enzyme-linked immunosorbent assay and reverse transcriptase-polymerase chain reaction. Scratch assay measured cell migration. Binding of the OPN promoter to RNA pol II was evaluated by the use of Chromatin-IP assay after EGCG treatment. Transcriptional regulation of OPN was investigated with luciferase reporter plasmids containing various deletion fragments of the human OPN promoter. Measurement of the half-life of OPN mRNA was conducted using actinomycin D. Results Treatment of MHCC-97H and HepG2 cells with 2 μg/mL and 20 μg/mL EGCG caused a ∼6-fold and ∼90-fold decrease in secreted protein levels of OPN (All P < .001). OPN mRNA was decreased with EGCG concentrations of 0.2–20 μg/ml (All P < .001). The 3-(4, 5-dimethylthiazolyl-2)-2,5-diphenyltetrazolium bromide (ie, MTT) assay revealed that differences in OPN expression were not due to viability of the HCC cell lines. Promoter assay and chromatin immunoprecipitation analysis revealed no effect of EGCG on the transcriptional regulation of OPN. Posttranscriptionally, EGCG decreased the half-life of OPN mRNA from 16.8 hours (95% confidence interval 9.0–125.1) to 2.5 hours (95% confidence interval 2.1–3.2) ( P < .001). Migration was decreased in EGCG treated cells at 24 hours (8.0 ± 2.4% vs 21.2 ± 10.8%, P < .01) and at 48 hours (13.2 ± 3.6% vs 53.5 ± 19.8%, P < .001). Conclusion We provide evidence that EGCG decreases OPN mRNA and secreted OPN protein levels by decreasing the half-life of OPN mRNA in MHCC-97H cells. The translatability of EGCG for patients with HCC is promising, because EGCG is an inexpensive, easily accessible chemical with an extensive history of safety. [ABSTRACT FROM AUTHOR]

Objective: We hypothesized that perioperative hospital resources could overcome the ''weekend effect'' (WE) in patients undergoing emergent/ urgent surgeries. Summary Background Data: The WE is the observation that surgeonindependent patient outcomes are worse on the weekend compared with weekdays. The WE is often explained by differences in staffing and resources resulting in variation in care between the week and weekend. Methods: Emergent/urgent surgeries were identified using the Healthcare Cost and Utilization Project State Inpatient Database (Florida) from 2007 to 2011 and linked to the American Hospital Association (AHA) Annual Survey Database to determine hospital level characteristics. Extended median length of stay (LOS) on the weekend compared with the weekdays (after controlling for hospital, year, and procedure type) was selected as a surrogate for WE. Results: Included were 126,666 patients at 166 hospitals. A total of 17 hospitals overcame the WE during the study period. Logistic regression, controlling for patient characteristics, identified full adoption of electronic medical records (OR 4.74), home health program (OR 2.37), pain management program [odds ratio (OR) 1.48)], increased registered nurse-to-bed ratio (OR 1.44), and inpatient physical rehabilitation (OR 1.03) as resources that were predictors for overcoming the WE. The prevalence of these factors in hospitals exhibiting the WE for all 5 years of the study period were compared with those hospitals that overcame the WE (P<0.001). Conclusions: Specific hospital resources can overcome the WE seen in urgent general surgery procedures. Improved hospital perioperative infrastructure represents an important target for overcoming disparities in surgical care. Keywords: AHA annual survey, emergency general surgery, HCUP, health disparities, hospital perioperative resources, weekend effect [ABSTRACT FROM AUTHOR]

Background There is growing concern that the quality of inpatient care may differ on weekends versus weekdays. We assessed the “weekend effect” in common urgent general operative procedures. Methods The Healthcare Cost and Utilization Project Florida State Inpatient Database (2007−2010) was queried to identify inpatient stays with urgent or emergent admissions and surgery on the same day. Included were patients undergoing appendectomy, cholecystectomy for acute cholecystitis, and hernia repair for obstructed/gangrenous hernia. Outcomes included duration of stay, inpatient mortality, hospital-adjusted charges, and postoperative complications. Controlling for hospital and patient characteristics and type of surgery, we used multilevel mixed-effects regression modeling to examine associations between patient outcomes and admissions day (weekend vs weekday). Results A total of 80,861 same-day surgeries were identified, of which 19,078 (23.6%) occurred during the weekend. Patients operated on during the weekend had greater charges by $185 ( P < .05), rates of wound complications (odds ratio [OR] 1.29, 95% confidence interval [95% CI] 1.05–1.58; P < .05), and urinary tract infection (OR 1.39, 95% CI 1.05–1.85; P < .05). Patients undergoing appendectomy had greater rates of transfusion (OR 1.43, 95% CI 1.09–1.87; P = .01), wound complications (OR 1.32, 95% CI 1.04–1.68; P < .05), urinary tract infection (OR 1.76, 95% CI 1.17–2.67; P < .01), and pneumonia (OR 1.41, 95% CI 1.05–1.88; P < .05). Patients undergoing cholecystectomy had a greater duration of stay ( P = .001) and greater charges ( P = .003). Conclusion Patients undergoing weekend surgery for common, urgent general operations are at risk for increased postoperative complications, duration of stay, and hospital charges. Because the cause of the “weekend effect” is still unknown, future studies should focus on elucidating the characteristics that may overcome this disparity. [ABSTRACT FROM AUTHOR]