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In non-endemic settings, transfusion-transmitted malaria (TTM) is rare but potentially fatal and becoming more common with globalization. We present two pediatric cases that demonstrate donor screening using questionnaires is subject to error and that TTM should be considered with fever following numerous transfusions in children, particularly sickle cell patients.

BackgroundProviding a positive patient experience for transgender individuals includes making the best care decisions and providing an inclusive care environment in which individuals are welcomed and respected. Over the past decades, introduction of electronic medical record (EMR) systems into healthcare has improved quality of care and patient outcomes through improved communications among care providers and patients and reduced medical errors. Promoting the highest standards of care for the transgender populations requires collecting and documenting detailed information about patient identity, including sex and gender information in both the EMR and laboratory information system (LIS).ContentAs EMR systems are beginning to incorporate sex and gender information to accommodate transgender and gender nonconforming patients, it is important for clinical laboratories to understand the importance and complexity of this endeavor. In this review, we highlight the current progress and gaps in EMR/LIS to capture relevant sex and gender information.SummaryMany EMR and LIS systems have the capability to capture sexual orientation and gender identity (SOGI). Fully integrating SOGI into medical records can be challenging, but is very much needed to provide inclusive care for transgender individuals.

Background Although growing evidence demonstrates the benefits of locally administered nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery. Areas of uncertainty Current data largely support a local site of NSAID action and suggest that effective pain control can be achieved with delivery of NSAIDs intra-articularly (IA) and/or locally at the site of injury, where they can block peripheral production of inflammatory mediators and may desensitize nociceptors. Improvements in postoperative pain control with locally administered NSAIDs have been widely reported in the total joint arthroplasty literature and may offer benefits in patient's undergoing arthroscopic procedures and those with osteoarthritis as well. The purpose of this review is to examine the available evidence in the literature regarding the efficacy and safety profile of the use of local and IA NSAIDs in orthopedic surgery. Data sources Narrative literature review using keywords, expert opinion, either during or from live conference. Therapeutic advances Local and IA administration of NSAIDs for pain management in orthopedic surgery. Conclusion There is convincing evidence that NSAIDs administered locally in and around the joint reduce postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty, yet further research is required regarding the risks of potential chondrotoxicity and the inhibition of bone and soft-tissue healing with locally administered NSAIDs.

Context.—Biomedical terminologies such as Logical Observation Identifiers, Names, and Codes (LOINC) were developed to enable interoperability of health care data between disparate health information systems to improve patient outcomes, public health, and research activities.Objective.—To ascertain the utilization rate and accuracy of LOINC terminology mapping to 10 commonly ordered tests by participants of the College of American Pathologists (CAP) Proficiency Testing program.Design.—Questionnaires were sent to 1916 US and Canadian laboratories participating in the 2018 CAP coagulation (CGL) and/or cardiac markers (CRT) surveys requesting information on practice setting, instrument(s) and test method(s), and LOINC code selection and usage in the laboratory and electronic health records.Results.—Ninety of 1916 CGL and/or CRT participants (4.7%) responded to the questionnaire. Of the 275 LOINC codes reported, 54 (19.6%) were incorrect: 2 codes (5934-2 and 12345-1) (0.7%) did not exist in the LOINC database and the highest error rates were observed in the property (27 of 275, 9.8%), system (27 of 275, 9.8%), and component (22 of 275, 8.0%) LOINC axes. Errors in LOINC code selection included selection of the incorrect component (eg, activated clotting time instead of activated partial thromboplastin time); selection of panels that can never be used to obtain an individual analyte (eg, prothrombin time panel instead of international normalized ratio); and selection of an incorrect specimen type.Conclusions.—These findings of real-world LOINC code implementation across a spectrum of laboratory settings should raise concern about the reliability and utility of using LOINC for clinical research or to aggregate data.

Background The COVID-19 pandemic has resulted in shortages of diagnostic tests, personal protective equipment, hospital beds, and other critical resources. Objective We sought to improve the management of scarce resources by leveraging electronic health record (EHR) functionality, computerized provider order entry, clinical decision support (CDS), and data analytics. Methods Due to the complex eligibility criteria for COVID-19 tests and the EHR implementation–related challenges of ordering these tests, care providers have faced obstacles in selecting the appropriate test modality. As test choice is dependent upon specific patient criteria, we built a decision tree within the EHR to automate the test selection process by using a branching series of questions that linked clinical criteria to the appropriate SARS-CoV-2 test and triggered an EHR flag for patients who met our institutional persons under investigation criteria. Results The percentage of tests that had to be canceled and reordered due to errors in selecting the correct testing modality was 3.8% (23/608) before CDS implementation and 1% (262/26,643) after CDS implementation (P Conclusions The leveraging of EHRs and our CDS algorithm resulted in a decreased incidence of order entry errors and the appropriate flagging of persons under investigation. These interventions optimized reagent and personal protective equipment usage. Data regarding symptoms and COVID-19 exposure status that were collected by using the decision tree correlated with the likelihood of positive test results, suggesting that clinicians appropriately used the questions in the decision tree algorithm.

Supplemental Digital Content is available in the text, Patient satisfaction measures and the opioid epidemic have highlighted the need for effective perioperative pain management. Multimodal analgesia, including non-steroidal anti-inflammatory drugs (NSAIDs), have been shown to maximize pain relief and reduce opioid consumption, but are also associated with potential perioperative bleeding risks. A multidisciplinary panel conducted a clinical appraisal of bleeding risks associated with perioperative NSAID use. The appraisal consisted of review and assessment of the current published evidence related to the statement “In procedures with high bleeding risk, NSAIDs should always be avoided perioperatively.” We report the presented literature and proceedings of the subsequent panel discussion and national pilot survey results. The authors’ assessment of the statement based on current evidence was compared to the attempted national survey data, which revealed a wide range of opinions reflecting the ongoing debate around this issue in a small number of respondents. The appraisal concluded that caution is warranted with respect to perioperative use of NSAIDs. However, summarily excluding NSAIDs from perioperative use based on potential bleeding risks would be imprudent. It is recommended that NSAID use be guided by known patient- and procedure-specific factors to minimize bleeding risks while providing effective pain relief.

BACKGROUND The microparticle content (MP%) of apheresis platelets-a marker of platelet activation-is influenced by donor factors and by external stressors during collection and storage. This study assessed the impact of apheresis technology and other factors on the activation status (MP%) of single-donor apheresis platelets. STUDY DESIGN AND METHODS Data from six US hospitals that screened platelets by measuring MP% through dynamic light scattering (ThromboLUX) were retrospectively analyzed. Relative risks (RRs) were derived from univariate and multivariable regression models, with activation rate (MP% ≥15% for plasma-stored platelets; ≥10% for platelet additive solution [PAS]-stored platelets) and MP% as outcomes. Apheresis platform (Trima Accel vs Amicus), storage medium (plasma vs PAS), pathogen reduction, storage time, and testing location were used as predictors. RESULTS Data were obtained from 7511 platelet units collected using Trima (from 16 suppliers, all stored in plasma, 20.0% were pathogen-reduced) and 2456 collected using Amicus (from four different collection facilities of one supplier, 65.0% plasma-stored, 35.0% PAS-stored, none pathogen-reduced). Overall, 30.0% of Trima platelets were activated compared to 45.6% of Amicus platelets (P

Objectives Automated cell counters have replaced manual enumeration of cells in blood and most body fluids. However, due to the unreliability of automated methods at very low cell counts, most laboratories continue to perform labor-intensive manual counts on many or all cerebrospinal fluid (CSF) samples. This multicenter clinical trial investigated if the GloCyte System (Advanced Instruments, Norwood, MA), a recently FDA-approved automated cell counter, which concentrates and enumerates red blood cells (RBCs) and total nucleated cells (TNCs), is sufficiently accurate and precise at very low cell counts to replace all manual CSF counts. Methods The GloCyte System concentrates CSF and stains RBCs with fluorochrome-labeled antibodies and TNCs with nucleic acid dyes. RBCs and TNCs are then counted by digital image analysis. Residual adult and pediatric CSF samples obtained for clinical analysis at five different medical centers were used for the study. Cell counts were performed by the manual hemocytometer method and with the GloCyte System following the same protocol at all sites. The limits of the blank, detection, and quantitation, as well as precision and accuracy of the GloCyte, were determined. Results The GloCyte detected as few as 1 TNC/μL and 1 RBC/μL, and reliably counted as low as 3 TNCs/μL and 2 RBCs/μL. The total coefficient of variation was less than 20%. Comparison with cell counts obtained with a hemocytometer showed good correlation (>97%) between the GloCyte and the hemocytometer, including at very low cell counts. Conclusions The GloCyte instrument is a precise, accurate, and stable system to obtain red cell and nucleated cell counts in CSF samples. It allows for the automated enumeration of even very low cell numbers, which is crucial for CSF analysis. These results suggest that GloCyte is an acceptable alternative to the manual method for all CSF samples, including those with normal cell counts.

Objective To investigate the utility of a detailed medical history in the interpretation of chromosomal microarray results for pediatric patients with a constitutional disease. Study design A retrospective review and reinterpretation of test results from chromosomal microarrays performed from 2011 to 2013. Previously reported genetic variants were reanalyzed after review of the patient's complete electronic medical record (cEMR). A 3-tier system was used for reclassification of variants: pathogenic or likely pathogenic (P/LP); variant of uncertain significance (VUS); or benign or likely benign (B/LB). Results Over an 18-month period, 998 patients with chromosomal microarray results were identified. The most common reasons for chromosomal microarray testing were developmental delay (n = 336), autism spectrum disorder (n = 241), and seizures (n = 143). Chromosomal microarray testing identified 1 or more variants in 48% (482 of 998) of patients; 516 patients had a negative report. For the 482 patients with variants, the original interpretations were composed of 19.3% P/LP (93 of 482), 44.8% VUS (216 of 482), and 35.9% B/LB (173 of 482) variants. After review of the cEMR, 34% of patient results (164 of 482) were changed in interpretation. One case changed from B/LB to VUS, 7 VUS were upgraded to P/LP, and 156 VUS were downgraded to B/LB. No P/LP variants had a change in interpretation. Conclusions Overall, 16.4% (164 of 998) of patients with chromosomal microarray testing had a change in interpretation. Access to the patient's cEMR improves the interpretation of chromosomal microarrays by decreasing the number of uncertain (VUS) interpretations.

Allergic rhinitis (AR) is a common respiratory disease affecting both adults and children worldwide. Affected patients may experience nasal congestion/stuffiness, rhinorrhea (anterior and/or posterior), nasal/ nasopharyngeal itching and sneezing. Allergen avoidance is the principal step in the management. Nasal saline irrigation to remove allergen (s) in the nose is a useful adjunctive therapy in the management of moderate to severe AR. Symptomatic relief and improved quality of life may be achieved in the majority of patients with appropriate pharmacotherapy. Mild-to-moderate cases are usually managed with either an oral second generation antihistamine or an intranasal corticosteroid. More severe cases may require treatment with an intranasal corticosteroid in combination with various oral medications. Patients who require medications for more than 6 months per year or have intolerable side effects from pharmacotherapy can be considered for immunotherapy. A wide range of complementary and alternative medicines (CAM) have also been proposed. This overview evaluates the evidence of use of CAM for AR. Some methods including acupuncture and herbal medicine have supportive evidence, but the efficacy of other CAM is controversial. Conversely, possible side effects of different modalities are often inadequately documented. The herbal formulae include Butterbur, Nigella sativa, Shi-Bi-Lin, Polyherbal formula, Grapeseed extract, Rosmarinic acid, Spirulina, Biminne, and Bhu-zhong-yi-qi-tong. Further research is needed to assess the efficacy and safety before they are employed in treating AR. This review article also discusses recent CAM patents for use in AR, which are exclusively traditional Chinese medicine (TCM) concoctions primarily for oral consumption but two as topical spray. Only 8 pertinent patents, all TCM compositions for treating AR and registered in 2014, were obtained. Description about their efficacy is impressive but objective outcome evaluation tools are lacking.

Author(s): Jahr, Jonathan S; Bergese, Sergio D; Sheth, Ketan R; Bernthal, Nicholas M; Ho, Hung S; Stoicea, Nicoleta; Apfel, Christian C | Abstract: ObjectiveOpioids represent an important analgesic option for physicians managing acute pain in surgical patients. Opioid management is not without its drawbacks, however, and current trends suggest that opioids might be overused in the United States. An expert panel was convened to conduct a clinical appraisal regarding the use of opioids in the perioperative setting.MethodsThe clinical appraisal consisted of the review, presentation, and assessment of current published evidence as it relates to the statement "Opioids are not overused in the United States, even though opioid adjunct therapy achieves greater pain control with less risk." The authors' evaluation of this statement was also compared with the results of a national survey of surgeons and anesthesiologists in the United States.ResultsWe report the presented literature and proceedings of the panel discussion. The national survey revealed a wide range of opinions regarding opioid overuse in the United States. Current published evidence provides support for the efficacy of opioid therapy in surgical patients; however, it is not sufficient to conclude unequivocally that opioids are-or are not-overused in the management of acute surgical pain in the United States.ConclusionsOpioids remain a key component of multimodal perioperative analgesia, and strategic opioid use based on clinical considerations and patient-specific needs represents an opportunity to support improved postoperative outcomes and satisfaction. Future studies should focus on identifying optimal procedure-specific and patient-centered approaches to multimodal perioperative analgesia.

Objectives: To describe our initial experience with single-site robotic cholecystectomy (SSRC) and its applicability to a broad segment of patients. Background: At the initiation of our study, there were only 3 published reports on SSRC. These initial studies had limited inclusion criteria. We present our experience with the technical aspects and patient outcomes of SSRC in a broadly inclusive patient population. Methods: Prospective cohort study from January 2012 to January 2013, in which 95 patients underwent SSRC. Procedural times, postoperative complications, delayed hospital discharges, and re-admissions were evaluated. Results: Patients were predominantly female (71.6%) had mean age of 45.2 ± 6.1 years and mean body mass index (BMI) of 30.1 ± 7.1 kg/m2. Overall, mean total operative time (TOT) for all patients (n = 95) was 88.63 ± 32.0 (range: 49–220) minutes. SSRC was not completed in 8 (8.42%) patients: 6 conversions to laparoscopy, 1 conversion to open, and 1 aborted case. The group of patients who were able to complete SSRC (n = 87) had a mean TOT of 83.5 ± 24.5 minutes and mean operative robotic time (RT) of 39.6 ± 15.2 minutes. RT was longer in patients with intra-abdominal adhesions (P = 0.0139) and higher BMI (P = 0.03). A minority of patients required hospital admission (11.6%), readmission (6.3%), or reoperation (1.1%). No bile duct injury or death occurred. Conclusions: SSRC is safe and has a manageable learning curve. Patient factors, such as obesity, did not significantly affect conversion rates or TOTs. SSRC is a promising new technique, which can be offered to a wide array of patients.

“Twinning” refers to a constructive partnership between hospitals in developed and developing nations. Such an effort may contribute immensely to capacity building for the developing nation, but one of the reasons given for the lack of sustainability is cost. We share a detailed operating cost analysis of our recent experience with an institution in Vietnam. We were awarded a 1-year $54,000 grant from the Vietnam Education Foundation (VEF) to conduct a live tele-video conferencing course on the “Fundamentals of Clinical Surgery” with Thai Binh Medical University (TBMU). In-country lectures as well as an assessment of the needs at TBMU were performed. Total financial assistance and expenditures were tabulated to assess up-front infrastructure investment and annual cost required to sustain the program. The total amount of direct money ($66,686) and in-kind services ($70,276) was $136,962. The initial infrastructure cost was $41,085, which represented 62% of the direct money received. The annual cost to sustain the program was approximately $11,948. We concluded that the annual cost to maintain a “twinning” program was relatively low, and the efforts to sustain a “twinning” program were financially feasible and worthwhile endeavors. “Twinning” should be a critical part of the surgical humanitarian volunteerism effort.

We describe a case of B-cell lymphoblastic lymphoma with an unusual clinical presentation. A 15-year old male with no significant past medical history presented with persistent foot swelling after an ankle sprain. Imaging revealed a mass in the right foot, which was resected and revealed a diffuse infiltrate of B-lymphoblasts. Peripheral blood and bone marrow examinations revealed no abnormalities. These findings were consistent with B-cell lymphoblastic lymphoma, which is an uncommon disease, accounting for only 2% of lymphomas. This case is a reminder that hematolymphoid malignancies can have presentations that mimic sarcomas with no visible peripheral blood or bone marrow involvement. In addition to describing the clinical and histologic features of this case, we also discuss the challenges that can be encountered when establishing a diagnosis of B lymphoblastic lymphoma

Acute myeloid leukemia is classified based upon recurrent cytogenetic abnormalities. The t(15;17)(q24.1;q21.1) abnormality is found in 5% to 8% of de novo acute myeloid leukemia and is diagnostic of acute promyelocytic leukemia (APL). The translocation results in fusion of the retinoic acid receptor-α (RARA) gene at 17q21.1 and the promyelocytic leukemia (PML) gene at 15q24.1. Standard APL therapy is a combination of all-trans retinoic acid and anthracycline-based chemotherapy. Anthracycline treatment is associated with secondary clonal chromosomal aberrations that can lead to therapy-related secondary myeloid neoplasms. We present a pediatric case of relapsed APL coexistent with treatment-associated secondary myeloid neoplasm with t(11;19)(q23;p13.1).

[Figure][1] A 37-year-old woman initially presented with pancytopenia and found to have leukopenia (2.1 × 103/μL) with 13% atypical promyelocytes, anemia (hemoglobin of 6.8 g/dL), and thrombocytopenia (41 000 per μL). The atypical promyelocytes were medium to large in size with frequent

Chronic myelogenous leukemia (CML) is very rare in the pediatric population. We report the case of a 2-year-old female with CML and concurrent myelodysplastic syndrome (MDS) associated cytogenetic abnormalities. The co-existence of t(9;22) and chromosomal deletions that are associated with MDS poses a unique diagnostic challenge. Given the reported association of t(9;22) and genomic instability, we hypothesize that the chromosomal deletions represent clonal evolution of the CML.

Background: Hypercarbia and elevated intraabdominal pressure resulting from carbon dioxide (CO2) pneumoperitoneum can adversely affect respiratory mechanics. This study examined the changes in mechanical ventilation, CO2 homeostasis, and pulmonary gas exchange in morbidly obese patients undergoing a laparoscopic or open gastric bypass (GBP) procedure. Methods: In this study, 58 patients with a body mass index (BMI) of 40 to 60 kg/m2 were randomly allocated to laparoscopic (n = 31) or open (n = 27) GBP. Minute ventilation was adjusted to maintain a low normal arterial partial pressure of CO2 (PaCO2), low normal end-tidal partial pressure of CO2 (ETCO2), and low airway pressure. Respiratory compliance, ETCO2, peak inspiratory pressure (PIP), total exhaled CO2 per minute (VCO2), and pulse oximetry (SO2) were measured at 30-min intervals. The acid–base balance was determined by arterial blood gas analysis at 1-h intervals. The pulmonary gas exchange was evaluated by calculation of the alveolar dead space–to–tidal volume ratio (VDalv/VT) and alveolar–arterial oxygen gradient (PAO2–PaO2). Results: The two groups were similar in age, gender, and BMI. As compared with open GBP, laparoscopic GBP resulted in higher ETCO2, PIP, and VCO2, and a lower respiratory compliance. Arterial blood gas analysis demonstrated higher PaCO2 and lower pH during laparoscopic GBP than during open GBP (p < 0.05). The VDalv/VT ratio and PAO2–PaO2 gradient did not change significantly during laparoscopic GBP. Intraoperative oxygen desaturation (SO2 < 90%) did not develop in any of the patients in either group. Conclusions: Laparoscopic GBP alters intraoperative pulmonary mechanics and acid–base balance but does not significantly affect pulmonary oxygen exchange. Changes in pulmonary mechanics are well tolerated in morbidly obese patients when proper ventilator adjustments are maintained.

Patients with typical signs and symptoms of acute appendicitis should have a prompt surgical consultation for timely appendectomy. The use of diagnostic imaging tests such as CT scan or ultrasonography should be selective in those with atypical presentation or findings. The high accuracy of imaging tests can be achieved when they are utilized according to well thought out clinical pathways. The use of imaging modalities in suspected acute appendicitis should be complement to, but not replacing, clinical assessment and judgement. The skillful use of clinical assessment and imaging modalities will reduce the negative appendectomy rate yet assure low perforation and mortality rates.

Background. We recently demonstrated that pancreatitis-associated ascitic fluid (PAAF) contains cytotoxic factor(s), inducing apoptosis in hepatocytes, and that PAAF induces hepatic adenosine triphosphate depletion, hepatocellular acidosis, and accumulation of hepatic intracellular sodium. Because ascitic fluid and serum from patients with hemorrhagic pancreatitis contain a lot of hematin, we aimed to test the hypothesis that hematin can induce hepatocellular injury, and then we compared its cytotoxicity with that of PAAF. Methods. In vivo effects of intraperitoneal injection of hematin into the liver of healthy rats were evaluated with in situ nick-end labeling, blood biochemical analysis, and nuclear magnetic resonance spectroscopy. In vitro cytotoxic and apoptosis-inducing activities of hematin on rat primary culture hepatocytes were investigated with a cellular proliferation assay kit and DNA fragmentation enzyme-linked immunosorbent assay, respectively. Furthermore, PAAF was fractionated with Sephacryl S-300 gel column chromatography, and cytotoxic activities of its fractions on a human hepatoma cell line (HuH-7) were compared with those of hematin. Results. Intraperitoneal injection of hematin into healthy rats caused apoptosis in the hepatocytes and elevated serum glutamate oxaloacetic transaminase and lactate dehydrogenase levels. Intraperitoneal injection of hematin also caused a significant decrease in the hepatic β-adenosine triphosphate/inorganic phosphate ratio, severe hepatic intracellular acidosis, and a significant increase of hepatic intracellular sodium (Na + ) concentration, similar to the effects of PAAF. In vitro, hematin decreased hepatocyte viability and increased the DNA fragmentation of hepatocytes, similar to the effects of 10% PAAF. Albumin reversed the cytotoxic effects of hematin and PAAF on HuH-7 cells nearly completely and partially, respectively. Fractionation of PAAF and hematin by gel column chromatography revealed that the first peak of cytotoxic activity of PAAF corresponded to that of hematin and that the cytotoxic activity was reversed by albumin nearly completely. Conclusions. These results suggest that hematin is one of the cytotoxic factors in PAAF that causes hepatocellular injury and that cellular injuries caused by hematin may be involved in the development of multiple organ failure associated with severe acute pancreatitis. (Surgery 2002;131:66-74.)

We describe a case of acute leukemia of ambiguous lineage with a novel cytogenetic abnormality. A 1-year-old boy presented with abnormal complete blood count findings, and was found to have blasts and mild dysgranulopoiesis. The blasts showed immunophenotypic evidence of myeloid and T-lineage differentiation. Subsequent cytogenetic analysis showed r(2)(p25q31) as the sole stem line cytogenetic defect with clonal evolution. While cytogenetic abnormalities can have a critical role in the classification and prognostication of acute lymphoblastic and acute myeloid leukemia, the significance of cytogenetic abnormalities in acute leukemia of ambiguous lineage remains unclear. This finding has not been reported previously to the best of our knowledge.

The stirred tank reactor is one of the most commonly used devices in industry for achieving mixing and reaction. We consider a combined experimental=computational approach for the simulation of oerent r–z planes phase locked at 0

BACKGROUND: Hypercarbia and increased intraabdominal pressure during prolonged pneumoperitoneum can adversely affect cardiac function. This study compared the intraoperative hemodynamics of morbidly obese patients during laparoscopic and open gastric bypass (GBP). METHODS: Fifty-one patients with a body mass index (BMI) of 40-60 kg/m2 were randomly allocated to undergo laparoscopic (n = 25) or open (n = 26) GBP. Cardiac output (CO), mean pulmonary artery pressure (MPAP), pulmonary artery wedge pressure (PAWP), central venous pressure (CVP), heart rate (HR), and mean arterial pressure (MAP) were recorded at baseline, intraoperatively at 30-min intervals, and in the recovery room. Systemic vascular resistance (SVR) and stroke volume (SV) were also calculated. RESULTS: The two groups were similar in terms of age, weight, and BMI. Operative time was longer in the laparoscopic than in the open group (p < 0.05). The HR and MAP increased significantly from baseline intraoperatively, but there was no significant difference between the two groups. In the laparoscopic group, CO was unchanged after insufflation, but it increased by 5.3% at 2.5 h compared to baseline and by 43% compared to baseline in the recovery room. In contrast, during open GBP, CO increased significantly by 25% after surgical incision and remained elevated throughout the operation. CO was higher during open GBP than during laparoscopic GBP at 0.5 h and at 1 h after surgical incision (p < 0.05). During laparoscopic GBP, CVP, MPAP, and SVR increased transiently and PAWP remained unchanged. During open GBP, CVP, MPAP, and PAWP decreased transiently and SVR remained unchanged. There was no significant difference in the amount of intraoperative fluid administered during laparoscopic (5.5 +/- 1.6 L) and open (5.6 +/- 1.7 L) GBP. CONCLUSION: Prolonged pneumoperitoneum during laparoscopic gastric bypass does not impair cardiac function and is well tolerated by morbidly obese patients.

A significant problem facing American surgery today is the lack of participation from women and minorities. In 1995 and 1996, 15.1 and 15.8% of United States general surgical residency graduates were women. Of our 71 graduates in the last 12 years, 38% were women. The aim of this study was to identify the factors influencing our residents' choice of training program and the reasons why our program has a high percentage of female graduates.Between 1989 and 2000, 27 women and 44 men completed general surgical training at our university and 44/71 (59%) responded to our survey. The age at residency completion was 34 +/- 2.2 years for men and 33.9 +/- 2.8 years for women. Fifty-five percent of men and 30% of women went on to fellowship training; and 36% of men and 20% of women are in academia.Factors influencing our graduates' selection of training program are: Only 23% of men had a female faculty as their mentor, whereas 90% of women had a male faculty as their mentor during training. Only 59% of men but 80% of women (P0.05) agreed that female medical students need role models of successful female faculty members. Fifty-five percent of men and 45% of women would encourage a female medical student to choose surgery as a career, but 82% of men and 50% of women would encourage a male medical student to do so. Ninety-one percent of men and 85% of women would choose surgery as a career again.A surgical residency training program with strong leadership, good clinical experience, and high resident morale will equally attract both genders. Women may pay more attention to the program's gender mix and geographic location.

Background: We evaluated the safety and feasibility of performing a laparoscopic intracorporeal end-toside small bowel anastomosis using a stapling technique as part of a Roux-en-Y gastric bypass operation (RYGBP). Methods: 80 consecutive patients who underwent RYGBP with laparoscopic jejunojejunostomy were evaluated. Operative time and intraoperative and postoperative complications directly related to the jejunojejunostomy anastomosis were recorded. Results: All 80 laparoscopic jejunojejunostomy procedures were successfully performed without conversion to laparotomy. Mean operative time was longer for the first 40 laparoscopic RYGBP than for the last 40 RYGBP (32±18 min vs 21±14 min, respectively, p

Isolated Fallopian tube torsion is a rare gynecological cause of acute lower abdominal pain. Currently, there are no pathognomonic symptoms, clinical findings, imaging or laboratory characteristics for this condition, and the diagnosis can rarely be made before operation. We have identified six cases of isolated Fallopian tube torsion treated over a period of 3 years. It was observed that acute onset of abdominal pain with gastrointestinal symptoms can be the initial presenting features. Clinical and laboratory findings included positive peritoneal signs, fever, tachycardia and leucocytosis. Most of the women had preoperative ultrasound showing tubular adnexal masses of heterogeneous echogenicity with cystic component and the presence of free fluid. In contrast to the belief that isolated Fallopian tube torsion is more common in the right side, in five of our cases it occurred in the left side.

Background: Laparoscopic Roux-en-Y gastric bypass (GBP) has been previously described, but a comparative study between laparoscopic and open GBP has not been reported. The purpose of this study was to compare surgical outcomes of laparoscopic GBP with those of open GBP for treatment of morbid obesity. Study Design: From August 1998 to September 1999, we prospectively collected outcome data on 35 patients with body-mass indices between 40 kg/m 2 and 60 kg/m 2 who underwent laparoscopic GBP. Demographics, operative data, perioperative complications, and weight losses were collected and compared with those obtained from a retrospective chart review of 35 patients with body-mass indices between 40 kg/m 2 and 60 kg/m 2 who underwent open GBP before August 1998. Results: Age, gender, preoperative body-mass index, preoperative comorbidity, and earlier abdominal surgery were similar in both groups. All laparoscopic operations were completed without conversion to laparotomy. Mean operative time, operative blood loss, length of intensive care stay, and length of hospital stay were significantly less after laparoscopic GBP than after open GBP (p Conclusions: Laparoscopic Roux-en-Y gastric bypass is technically feasible and safe. Laparoscopic GBP confers the clinical benefits of laparoscopy and an initial weight loss similar to that of open GBP.

Living donor renal transplantation has achieved a high level of acceptance from the general public and is the ideal renal replacement therapy for those with end-stage renal disease. Living donor nephrectomy has been proven safe and is associated with minimal complications and a negligible death rate. 1 The recipient benefits of living donor renal transplantation are multiple: superior patient and graft survival, no prolonged waiting time, decreased incidence of delayed allograft function, and a shorter hospital stay. 2 These superior results and the current shortage of cadaver kidneys provide an incentive to increase the frequency of living donor transplantation. However, a significant disincentive is the invasive nature of the donor nephrectomy and its relatively long postoperative recovery period. Recent reports of laparoscopically assisted living donor nephrectomy have shown that this less invasive approach results in reduced postoperative pain, a shorter hospital stay, and a more rapid return to the work for the donor. 3–6 In addition, decreased donor discomfort and a shorter convalescence have resulted in a substantially increased rate of consent to living donation and may help to alleviate the ongoing transplant organ shortage. A critical analysis with regard to the rate of donor complications and death and the status of the procured kidney is needed before laparoscopic living donor nephrectomy can be fully accepted by the transplant community. In particular, the excellent immediate renal allograft function usually obtained with standard open donor nephrectomy must be reproduced with the laparoscopic technique. A major concern regarding laparoscopic living donor nephrectomy is compelling evidence demonstrating that the prolonged CO2 pneumoperitoneum during laparoscopy decreases renal blood flow and contributes to postoperative renal dysfunction in the recipient. 7,8 The combination of prolonged CO2 pneumoperitoneum and an ischemic period during organ procurement may expose these grafts to an increased risk of early posttransplant renal dysfunction. The purported adverse effects of pneumoperitoneum on renal function have been supported by the initial reports of laparoscopic donor nephrectomy, which suggest either a decrease in urine output during the donor operation or early renal allograft dysfunction. 3,5,6 Gaseous pneumoperitoneum has been found to induce significant systemic hemodynamic alterations that appear to depend on the type of gas, the magnitude of intraabdominal pressure, the baseline hemodynamic function, and intravascular volume status. The cardiovascular effects most frequently associated with CO2 pneumoperitoneum are tachycardia, increased total peripheral resistance, and decreased stroke volume. 8–10 Some investigators have also reported a decrease in cardiac output, but previous studies from our laboratory showed that cardiac output decreased only in hypovolemic animals. 11,12 The effects of intravascular volume expansion on renal blood flow and function during prolonged CO2 pneumoperitoneum remain unknown. Hypertonic saline volume expansion has been shown to improve renal blood flow in other animal models of hypovolemia. 13,14 The use of hypertonic saline solution for volume expansion may provide protection to the kidneys without significant fluid overload to the donor. The objectives of this study were to test the hypothesis that intravascular volume expansion would improve renal blood flow and function during prolonged CO2 pneumoperitoneum, and to compare the beneficial effects of volume expansion on renal hemodynamics using isotonic (normal saline) and hypertonic (2400 mOsm NaCl) solutions.

Immune suppression associated with trauma has been demonstrated to be proportional to the magnitude of injury. Laparoscopic surgery has been shown to produce a diminished stress response compared to open surgery. Postoperative immune function, specifically cellular immunity, may be better preserved after laparoscopic surgery compared to open surgery. The aim of this study was to examine the effect of open versus laparoscopic surgery on cellular immunity in a swine model. Twenty domestic female pigs were randomly selected for laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). Cellular immune functions were evaluated with delayed-type hypersensitivity (DTH) skin test and serial phytohemoagglutinin (PHA)-induced T-cell proliferation of the peripheral blood. There was a significant reduction in PHA-induced T-cell proliferation in both LC and OC groups on days 1 and 3 compared to preoperative values (p < 0.05). The reduction of mitogen-induced T-cell proliferation after LC was significantly less than after OC on day 1 (p = 0.03). The mean DTH reaction was 29.7 +/- 3.7 mm2 in the LC group compared to 13.9 +/- 1.2 mm2 in the OC group (p < 0.001). There was no difference in postoperative white blood count values between the two groups. Suppression of cellular immunity occurred after both LC and OC. The magnitude and duration of impaired cellular immunity after laparoscopic surgery was less than after open surgery as measured by T-cell proliferation and DTH response.

Background. Multiple organ failure (MOF) is the most serious complication in severe acute pancreatitis, contributing to its high mortality. It has been suggested that changes of high-energy phosphates, intracellular pH, and intracellular cation homeostasis are closely related to hepatocellular injury associated with MOF. Methods. Phosphorus metabolites, intracellular pH (pH i ), and intracellular Na + concentration ([Na + ] i ) were measured in rat livers in vivo using 31 P and 23 Na NMR spectroscopy after deoxycholic acid (DCA)-induced pancreatitis or intraperitoneal injection (ip) of pancreatitis-induced ascitic fluid (PAF). Results. Two hours after induction of DCA-pancreatitis, the liver experienced significant intracellular acidosis (pH i = 6.99 ± 0.16) and sodium loading (75 ± 9 mM) and a reduction in its energy state (β-ATP/P i = 0.2 ± 0.03 and P i = 164 ± 12). Although ip injection of PAF into healthy rats did not induce systemic hypotension, the livers under these conditions also developed severe disturbances in hepatocellular ion homeostasis and depletion of its bioenergetics. The longer the abdomen was exposed to the PAF, the worse the changes were. At 3 h after ip injection of PAF, hepatic [Na + ] i significantly increased (42 ± 3 mM) along with a significant decrease in pH i (7.30 ± 0.03). At 6 h after ip injection of PAF, the hepatic β-ATP/P i ratio decreased to 0.34 ± 0.05 and P i increased to 97 ± 27. Conclusions. PAF induced severe hepatocellular acidosis, rapid accumulation of hepatic intracellular sodium, impaired hepatic cytosolic phosphorylation potential, and increased hepatic utilization of ATP. These effects may account for the eventual development of liver dysfunction associated with necrotizing pancreatitis.

Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy is an effective surgical procedure for patients with chronic pancreatitis. It is simple to perform, and ca

BACKGROUND Latrepirdine is an orally administered experimental small molecule that was initially developed as an antihistamine and subsequently was shown to stabilize mitochondrial membranes and function, which might be impaired in Huntington disease. OBJECTIVE To determine the effect of latrepirdine on cognition and global function in patients with mild to moderate Huntington disease. DESIGN Randomized, double-blind, placebo-controlled study. SETTING Sixty-four research centers in Australia, Europe, and North America. PATIENTS Four hundred three patients with mild to moderate Huntington disease and baseline cognitive impairment (Mini-Mental State Examination score, 10-26). INTERVENTION Latrepirdine (20 mg) vs matching placebo administered orally 3 times daily for 26 weeks. MAIN OUTCOME MEASURES The co-primary outcome measures were cognition as measured by the change in Mini-Mental State Examination score from baseline to week 26 and global function at week 26 as measured by the Clinician Interview-Based Impression of Change, plus carer interview, which ranges from 1 (marked improvement) to 7 (marked worsening). Secondary efficacy outcome measures included behavior, daily function, motor function, and safety. RESULTS The mean change in Mini-Mental State Examination score among participants randomized to latrepirdine (1.5-point improvement) did not differ significantly from that among participants randomized to placebo (1.3-point improvement) (P = .39). Similarly, the distribution of the Clinician Interview-Based Impression of Change, plus carer interview did not differ significantly among those randomized to latrepirdine compared with placebo (P = .84). No significant treatment effects were detected on the secondary efficacy outcome measures. The incidence of adverse events was similar between those randomized to latrepirdine (68.5%) and placebo (68.0%). CONCLUSION In patients with mild to moderate Huntington disease and cognitive impairment, treatment with latrepirdine for 6 months was safe and well tolerated but did not improve cognition or global function relative to placebo. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00920946.

A marked diuresis has been observed following resuscitation of hypotensive hemorrhaged animals with small volume hypertonic saline/dextran (HSD), 7.5% NaCl/6% dextran-70. We tested the hypothesis that high arginine vasopressin (AVP) levels associated with severe hemorrhage may exacerbate the diuretic effect of HSD infusion in euvolemic sheep. Following AVP infusion, a significant bradycardia (55% of baseline) and decreased cardiac output (62% of baseline) was observed (p < or = .05). Urine output increased during AVP infusion (25.4 +/- 2.3 ml/20 min) compared to control group (10.5 +/- 1.0 ml/20 min) (p < or = .0001). With HSD volume expansion, urine flow in the AVP group was initially 1.7 times greater than the control group (104.8 +/- 10 ml/20 min vs. 60.2 +/- 15 ml/20 min) (p < or = .05). High serum levels of AVP (600 +/- 33 pg/ml) may contribute to the diuresis seen with HSD resuscitation and possibly contribute to the bradycardia observed with severe hemorrhage.

The hemodynamic effects of argon pneumoperitoneum were studied to define its possible role as an alternative gas for intraperitoneal insufflation during minimally invasive surgery. Adult pigs were anesthetized and placed on mechanical ventilation. Parameters measured or determined included mean arterial (MAP), pulmonary arterial (PAP), pulmonary arterial wedge (PAWP), right atrial (CVP), and inferior vena cava venous (IVC) pressures, total excretion of CO2 (VCO2), oxygen consumption (VO2), minute ventilation, and arterial blood gases. Also determined were cardiac output, stroke volume, and systemic vascular resistance all indexed to weight (CI, SVI, SVRI). Data were recorded during a 1-h baseline, 2 h of insufflation with argon gas at a constant pressure of 15 mmHg, and 1 h recovery after desufflation. There was no significant change from baseline in VCO2, VO2, MAP, PAP, PAWP, CVP, PaCO2, or arterial pH. Argon pneumoperitoneum significantly increased systemic vascular resistance index and exerted a depressant effect on stroke volume index and cardiac index by 25% and 30% from baseline values, respectively (P < 0.05). Inferior vena cava pressure increased as a reflection of the intraabdominal pressure. Argon insufflation had no effect on respiratory function. Argon gas may not be physiologically inert, and in patients with cardiovascular disease its effects may be clinically important.

Optimizing recruitment of the next surgical generation is paramount. Unfortunately, many nonsurgeons perceive surgeons' lifestyle as undesirable. It is unknown, however, whether the surgeons-important opinion makers about their profession-are indeed dissatisfied.We analyzed responses to a survey mailed to all surgeons who were certified by the American Board of Surgery in 1988, 1992, 1996, 2000, and 2004. We performed multivariate analyses to study career dissatisfaction and inability to achieve work-life balance, while adjusting for practice characteristics, demographics, and satisfaction with reimbursement.A total of 895 (25.5%) surgeons responded: mean age was 46 years; 80% were men; 88% were married; 86% had children; 45% were general surgeons; 72% were in urban practice; and 83% were in nonuniversity practice. Surgeons worked 64 hours per week; ideally, they would prefer to work 50 hours per week (median). Fifteen percent were dissatisfied with their careers. On multivariate analysis, significant (p0.05) risk factors were nonuniversity practice (odds ratio [OR] 3.3) and dissatisfaction with reimbursement (OR 5.9). Forty percent would not recommend a surgical career to their own children. On multivariate analysis, significant risk factors were nonuniversity practice (OR 2.5) and dissatisfaction with reimbursement (OR 3.4). In all, 33.5% did not achieve work-life balance. On multivariate analysis, dissatisfaction with reimbursement (OR 3.0) was a significant risk factor. Respondents' lives could be improved by "limiting emergency call" (77%), "diminishing litigation" (92%), and "improving reimbursement" (94%).Most surgeons are satisfied with their careers. Areas in need of improvement, particularly for nonuniversity surgeons, include reimbursement, work hours, and litigation. Strong local and national advocacy may not only improve career satisfaction, but could also render the profession more attractive for those contemplating a surgical career.

Copper deficiency is likely an underrecognized cause of anemia and neutropenia and may masquerade as a myelodysplastic syndrome (MDS). We report 2 cases of copper deficiency in which the diagnosis was suggested based on the characteristic morphologic findings, such as cytoplasmic vacuolization of erythroid and myeloid precursors and iron-containing plasma cells. It is interesting that both patients had hematogone hyperplasia. This phenomenon, largely absent in MDS, may aid in distinguishing nonclonal causes of cytopenias, such as copper deficiency, from MDS. It is of crucial importance to identify treatable causes of cytopenias when MDS is suspected. We recommend copper level assessment in patients suspected of having low-grade MDS, especially patients with neuropathy and normal results of cytogenetic studies.

Historically, the lack of classic symptoms and delay in presentation make diagnosing acute appendicitis more difficult in children, resulting in a higher perforation rate. Despite this, the morbidity of acute appendicitis is usually lower in children. We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the two age groups. A retrospective review of 210 consecutive cases of pediatric appendectomy and 744 adult cases for suspected acute appendicitis from January 1995 to December 2000. Pediatric patients were defined as being 13 years and younger. Pediatric patients were similar to adult patients with respect to duration of pain before presentation (2.4 ± 4.3 days vs 2.5 ± 7.3 days), number of patients previously evaluated (22.0 vs 17.7%), number of imaging tests (computed tomography or ultrasound; 32.9 vs 40.2%), and number of patients observed (16.7 vs 17.2%). However, pediatric patients required less time for emergency room evaluation (4.0 ± 2.7 hours vs 5.7 ± 4.9 hours, P = 0.0001). In children and adults, a history of classic, migrating pain had the highest positive predictive value (94.2 vs 89.6%), followed by a white blood cell count ≥12 x 109/L (91.5 vs 84.3%). The overall negative appendectomy rate was 10.0 per cent for children and 19.0 per cent for adults (P = 0.003); the perforation rate was 19.0 per cent and 13.8 per cent, respectively (P > 0.05). The perforation rate in children was not associated with a delay in presentation (perforated cases, 2.9 ± 3.3 days compared with nonperforated cases, 2.3 ± 4.6 days). Mortality and morbidity, including wound infection rate and intra-abdominal abscess rate, were similar. Contrary to traditional teaching, diagnosing acute appendicitis in children is similar to that in adults. A history of migratory pain together with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. Perforation rate and morbidity in children is similar to those in adults. The outcomes of acute appendicitis in children are not associated with a delay in presentation or delay in diagnosis.

Background The optimal palliative method for patients with unresectable pancreatic cancer remains controversial. Methods A retrospective chart review evaluated patients who underwent exploration for presumed resectable pancreatic cancer. Cost-based analysis was performed using relative value units (RVUs) that included the initial surgical procedure and any additional procedure required to achieve satisfactory palliation. Results Of 96 patients (1993–2002), 6% had biliary bypass, 42% had duodenal bypass, 40% had double bypass, and 13% had no procedure with equivalent clinical outcomes. If biliary bypass was not initially performed, there was a significant incidence of biliary complications before definitive endoscopic stenting ( P = .01). If duodenal bypass was not initially performed, 11% developed duodenal obstruction ( P = .04). Total RVUs was highest for a double bypass and lowest for no initial surgical palliative procedure. Conclusions Although surgical bypass procedures at initial exploration provide durable palliation, these procedures are associated with greater costs.

PURPOSE To determine the safety and utility of percutaneous transhepatic portography (PTP) with intravascular ultrasonography (IVUS) for preoperative evaluation of major spleno-mesenteric-portal venous invasion by tumors of the pancreas, porta hepatis, or liver. MATERIALS AND METHODS This is a 2-year prospective observational study including 15 consecutive patients (five men, 10 women; mean age, 63.3 y=10.2) with tumors of the pancreas ( n = 8), liver ( n = 3), or porta hepatis ( n = 4) who underwent PTP/IVUS after computed tomography indicated possible tumor invasion into a major portal radical. Transhepatic portal access was created under fluoroscopic guidance with an 8-F vascular sheath and IVUS was performed with an 8-F, 10-MHz system. When appropriate, operative exploration was performed (nine of 15) and findings were correlated with imaging data from PTP/IVUS. RESULTS PTP/IVUS was performed successfully in all patients and good visualization of the major portal radicals was achieved. There were no complications from PTP/IVUS, which was performed as an outpatient procedure in most ( n = 14) patients. PTP/IVUS provided precise anatomic data regarding the longitudinal and circumferential extent of major portal venous invasion by these tumors. There was excellent correlation between PTP/IVUS and operative findings. CONCLUSIONS PTP/IVUS can be performed safely in a preoperative outpatient setting and accurately defines the extent of major portal venous invasion by tumors of the pancreas, porta hepatis, and liver.

BACKGROUND: The magnitude of the systemic stress response is proportional to the degree of operative trauma. We hypothesized that laparoscopic gastric bypass (GBP) is associated with reduced operative trauma compared with open GBP, resulting in a lower systemic stress response. STUDY DESIGN: Forty-eight patients with a body mass index of 40 to 60 were randomly assigned to laparoscopic (n = 26) or open (n = 22) GBP. Blood samples were measured at baseline and at 1, 24, 48, and 72 hours postoperatively. Metabolic (insulin, glucose, epinephrine, norepinephrine, dopamine, ACTH, cortisol), acute phase (C-reactive protein), and cytokine (interleukin [IL]-6, IL-8, tumor necrosis factor [TNF]-α) responses were measured. Catabolic response was also measured by calculating the nitrogen balance at 24 and 48 hours postoperatively. RESULTS: The two groups of patients were similar in terms of age, gender, and preoperative body mass index. The mean operative time was longer for laparoscopic GBP than for open GBP (229 ± 50 versus 207 ± 43 minutes). After laparoscopic and open GBP, plasma concentrations of insulin, glucose, epinephrine, dopamine, and cortisol increased; IL-8 and TNF-α remained unchanged; and negative nitrogen balances occurred at 24 and 48 hours. There was no significant difference in these parameters between groups. Concentrations of norepinephrine, ACTH, C-reactive protein, and IL-6 levels also increased, but these levels were significantly lower after laparoscopic GBP than after open GBP (p CONCLUSIONS: Systemic stress response after laparoscopic GBP is similar to that after open GBP, except that concentrations of norepinephrine, ACTH, C-reactive protein, and IL-6 are lower after laparoscopic than after open GBP. These findings may suggest a lower degree of operative injury after laparoscopic GBP.

Background: Pancreatic leak is a major source of morbidity associated with pancreatic surgery. We sought to identify disease and technique-dependent factors associated with morbidity and mortality after distal pancreatectomy. Methods: Retrospective review of patients who underwent distal pancreatectomy during a 5-year period. Clinical, technical, and pathologic data were correlated with operative morbidity or mortality. Results: Fifty-one patients underwent distal pancreatectomy for primary pancreatic disease, extrapancreatic malignancy, or trauma. Overall perioperative mortality and morbidity rates were 4% and 47%, respectively. Pancreatic leak was the most common complication, occurring in 26% of patients. Overall complications and pancreatic leaks occurred more often after distal pancreatectomy for trauma and in patients with a sutured pancreatic stump closure. Conclusions: Distal pancreatectomy can be performed with a low rate of mortality, though pancreatic leak is a common cause of morbidity. The urgency of the procedure and the method of pancreatic stump closure may influence postoperative morbidity.

Background: Many surgeons have complained of fatigue and musculoskeletal pain after laparoscopic surgery. We evaluated differences in surgeons’ axial skeletal and upper extremity movements during laparoscopic and open operations. Methods: Five surgeons were videotaped performing 16 operations (8 laparoscopic and 8 open) to record their neck, trunk, shoulder, elbow, and wrist movements during the first hour of surgery. We also compared postprocedural complaints of pain, stiffness, or numbness between the two groups. Results: Compared with surgeons performing open surgery, surgeons performing laparoscopic surgery exhibited less lateral neck flexion; less trunk flexion; more internal rotation of the shoulders; more elbow flexion; more wrist supination and wrist ulnar and radial deviation. There was a trend of more shoulder stiffness after laparoscopic operations than after open operations. Conclusions: Laparoscopic surgery involves a more static posture of the neck and trunk, but more frequent awkward movements of the upper extremities than open surgery. Ergonomic changes in the operating room environment and instrument design could ease the physical stress imposed on surgeons during laparoscopic operations.

Purpose: The c.*233G>C nucleotide substitution in the HBB gene was recently proposed as a novel β thalassemia allele based on genetic analysis of 11 thalassemic individuals. Based on this single report, the c.*233G>C allele has been provisionally included as a β (+) thal allele in a commonly used β globin database (HbVar). The c.*233G>C is frequently seen in HBB gene sequencing for hemoglobinopathies. A clinical review was performed to determine the phenotype and hematologic characteristics of the c.*233G>C nucleotide substitution. Methods: At a tertiary-care pediatric institution, a retrospective review was performed of all HBB gene sequencing tests over a 30-month period. A chart review was performed for all cases with the c.*233G>C variant. Results: Of a total of 104 HBB cases, the c.*233G>C variant was identified in 18 individuals; 17 were heterozygotes and 1 was a homozygote (Patient 17) (Table 1). HBB gene sequencing was performed as part of the work-up for suspected variant hemoglobin (Hb) but can detect non-coding alterations including β thalassemia alleles as well. Red cell indices in our series (Table 1) do not demonstrate the characteristics of heterozygous β thalassemia (microcytosis, mildly elevated RBC count, and mild anemia). MCV and RBC count data available for 9 individuals showed MCV values in the normocytic or macrocytic range and RBC counts within the normal range for all 9 patients. Of 13 patients with recorded Hb values, only one patient (Patient 14) was anemic but was found to have iron deficiency. The patients in our series did not have elevated Hb A2, which in patients with β thalassemia is typically above the normal range (>4%); the 9 patients who could be evaluated for Hb A2 had values ranging from 2.4% to 3.7%. The remaining individuals were either too young to be evaluated for Hb A2 or possessed a variant Hb that co-eluted with HbA2. The 13 patients in our series who were heterozygous for a Hb variant showed no excess in the variant Hb relative to Hb A. In patients with compound heterozygosity with a β thalassemia allele, the amount of the variant hemoglobin typically exceeds the amount of Hb A. Conclusions: Red cell indices and Hb proportions in this series of 18 individuals with c.*233G>C substitution are not consistent with a thalassemic phenotype. Our analysis supports a hypothesis that c.*233G>C substitution is not a β (+) thalassemia allele but is rather a fairly common benign polymorphism. This information has important implications in the diagnosis and genetic counseling of individuals with the c.*233G>C substitution. References: 1. Sirdah et al. The spectrum of β-thalassemia mutations in Gaza Strip, Palestine. Blood Cells, Molecules and Diseases. 2013; 50: 247-251. 2. HbVar: A Database of Human Hemoglobin Variants and Thalassemias. http://globin.cse.psu.edu/hbvar/menu.html. Disclosures No relevant conflicts of interest to declare.

Management of chronic pancreatitis is mainly palliative. Most patients with chronic pancreatitis require surgical evaluation and intervention when there is suspicion of pancreatic malignancy, evidence of intractable pain, or development of pancreatitis-related local complications. The ideal operation for chronic pancreatitis, therefore, should be designed to exclude the existence of malignancy, provide long-lasting pain relief, and correct the local complications. It should be as simple and safe as possible and should preserve the remaining endocrine and exocrine functions of the pancreas.