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BACKGROUND Retrograde autologous priming (RAP) before cardiopulmonary bypass (CPB) may minimize allogeneic red cell transfusion. We conducted a systematic review of the literature to examine the impact of RAP on perioperative allogeneic red cell transfusions in cardiac surgical patients. METHODS This study involved a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies evaluating the use of RAP in cardiac surgery involving CPB. The primary outcome was intraoperative allogeneic red cell transfusion. Secondary outcomes included whole hospital allogeneic transfusions and adverse events such as acute kidney injury (AKI) and stroke. RESULTS A total of 11 RCTs (n = 1337 patients) were included, comparing RAP patients (n = 674) to control (n = 663). In addition, 10 observational studies (n = 2327) were included, comparing RAP patients (n = 1257) to control (n = 1070). Overall, RAP was associated with a significantly reduced incidence of intraoperative red cell transfusion (n = 18 studies; odds ratio [OR] = 0.34; 95% confidence interval [CI], 0.22-0.55, P < .001) compared to controls. This effect was seen among RCTs (n = 10 studies; OR = 0.19; 95% CI, 0.08-0.45, P < .001) and observational studies (n = 8 studies; OR = 0.66; 95% CI, 0.50-0.87, P = .004) in isolation. RAP was also associated with a significantly reduced incidence of whole hospital red cell transfusion (n = 5 studies; OR = 0.28; 95% CI, 0.19-0.41, P < .001). Among the studies that reported AKI and stroke outcomes, there was no statistically significant increased odds of AKI or stroke in either RAP or control patients. CONCLUSIONS Based on the pooled results of the available literature, RAP is associated with a significant reduction in intraoperative and whole hospital allogeneic red cell transfusion. Use of RAP may prevent hemodilution of cardiac surgical patients and thus, lessen transfusions. Additional high-quality prospective studies are necessary to determine the ideal priming volume necessary to confer the greatest benefit without incurring organ injury.

Erythropoietic-stimulating agents such as erythropoietin have been used as part of patient blood management programs to reduce or even avoid the use of allogeneic blood transfusions. We review the literature to evaluate the effect of preoperative erythropoietin use on the risk of exposure to perioperative allogeneic blood transfusions.The study involved a systematic review and meta-analysis of randomized controlled trials evaluating the use of preoperative erythropoietin. The primary outcome was the reported incidence of allogeneic red blood cell transfusions during inpatient hospitalizations. Secondary outcomes included phase-specific allogeneic red blood cell transfusions (ie, intraoperative, postoperative), intraoperative estimated blood loss, perioperative hemoglobin levels, length of stay, and thromboembolic events.A total of 32 randomized controlled trials (n = 4750 patients) were included, comparing preoperative erythropoietin (n = 2482 patients) to placebo (n = 2268 patients). Preoperative erythropoietin is associated with a significant decrease in incidence of allogeneic blood transfusions among all patients (n = 28 studies; risk ratio, 0.59; 95% CI, 0.47-0.73; P.001) as well as patients undergoing cardiac (n = 9 studies; risk ratio, 0.55; 95% CI, 0.37-0.81; P = .003) and elective orthopedic (n = 5 studies; risk ratio, 0.36; 95% CI, 0.28-0.46; P.001) surgery compared to placebo, respectively. Preoperative erythropoietin was also associated with fewer phase-specific red blood cell transfusions. There was no difference between groups in incidence of thromboembolic events (n = 28 studies; risk ratio, 1.02; 95% CI, 0.78-1.33; P = .68).Preoperative erythropoietin is associated with a significant reduction in perioperative allogeneic blood transfusions. This finding is also confirmed among the subset of patients undergoing cardiac and orthopedic surgery. Furthermore, our study demonstrates no significant increase in risk of thromboembolic complications with preoperative erythropoietin administration.

INTRODUCTION AND OBJECTIVES: Wound dehiscence is major complication following radical cystectomy. It is a significant cause of readmission, reopearation and potentially delays lifesaving adjuvant therapies. We sought to investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy. METHODS: 2556 patient records with Current Procedural Terminology (CPT) codes for cystectomy between 2005 and 2012 were extracted from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP). Stratification was made on the basis of the occurrence of postoperative wound dehiscence. This was defined as full disintegrity of the skin and fascial layer. Outcomes of interest included overall complication, mortality, prolonged length of stay and prolonged operative time, the latter two defined as measures above the 75th percentile. Descriptive and logistic regression models were performed to identify predictors of postoperative wound dehiscence. RESULTS: Of 2556 patients analyzed, 74 (2.9%) had a documented wound dehiscence. In multivariable analyses, smoking (OR 2.2 p1⁄4.002), prolonged operative time (OR 1.6;p1⁄40.05) and BMI were associated with increased odds of postoperative wound dehiscences. Female gender was associated with decreased odds of dehiscence (OR 0.4; p1⁄40.022). Elevated preoperative creatinine (>1.2 mg/dl), chronic steroid use and diabetes were not independent predictors. CONCLUSIONS: Our study is the first to identify predictors of wound dehiscence following radical cystectomy in a large multi-institutional prospective cohort. Identifying patients at risk for postoperative wound complications may guide the use preventative measures at the time of surgery. Source of Funding: none

The adjuncts of profound hypothermic circulatory arrest and aortic tailoring are combined with standard graft replacement of the noncritical portions of the aorta. This combination permits single-stage replacement of the arch, thoracic, and abdominal aorta in patients with postdissection aneurysm. Reconstruction is begun with repair of the mid to distal aortic arch and Dacron graft replacement of the proximal descending thoracic aorta, usually under profound hypothermic circulatory arrest. The proximal graft is then cannulated and the patient partially warmed while the middle segment is "tailored." Aortic tailoring consists of longitudinal aortotomy and removal of the dissection membrane(s) from the distal third of the descending thoracic aorta to below the renal arteries. The aorta is then closed creating a single channel 2 to 3 cm in diameter and containing the origins of the important intercostal, lumbar, and visceral arteries. A Dacron graft is used to replace the infrarenal segment. Five patients have successfully undergone single-stage, total repair of the aorta including the arch, thoracic, and abdominal segments. All survival without paraplegia or significant visceral ischemia. Follow-up has not shown dilatation of the tailored segment. We believe that reduction in diameter of the tailored aortic segment and thus wall tension, growth of neointima on all luminal aortic surfaces, and active collagen deposition contribute to the success of this procedure.

BACKGROUND: The Southern Nursery Integrated Pest Management (SNIPM) working group surveyed ornamental nursery crop growers in the southeastern United States to determine their pest management practices. Respondents answered questions about monitoring practices for insects, diseases and weeds, prevention techniques, intervention decisions, concerns about IPM and educational opportunities. Survey respondents were categorized into three groups based on IPM knowledge and pest management practices adopted. RESULTS:Thethreegroupsdifferedintheuseofstandardizedsamplingplansforscoutingpests,inmonitoringtechniques,e.g. sticky cards, phenology and growing degree days, in record-keeping, in the use of spot-spraying and in the number of samples sent to a diagnostic clinic for identification and management recommendation. CONCLUSIONS: Stronger emphasis is needed on deliberate scouting techniques and tools to monitor pest populations to provideearlierpestdetectionandgreaterflexibilityofmanagementoptions.MostrespondentsthoughtthatIPMwaseffective and beneficial for both the environment and employees, but had concerns about the ability of natural enemies to control insectpests,andabouttheavailabilityandeffectivenessofalternativestochemicalcontrols.Researchandfielddemonstration is needed for selecting appropriate natural enemies for augmentative biological control. Two groups utilized cooperative extension almost exclusively, which would be an avenue for educating those respondents. c � 2012 Society of Chemical Industry

Transfusion of red blood cells (RBCs) is vitally important for the care of patients (pts) undergoing myelosuppressive therapy for acute leukemia (AL). At diagnosis and before bone marrow recovery, RBCs are given liberally with hemoglobin (Hb) transfusion triggers of 8-9 g/dL or higher, often with two RBC units given at a time. Research in a variety of non-oncologic settings suggests that lower Hb triggers (7-8 g/dL) do not increase mortality whereas higher Hb triggers (9 g/dL) may increase mortality. For pts with hematologic malignancies, the ideal Hb threshold is unknown. Also, there is literature to suggest that higher Hb values force platelets to the periphery of capillaries and reduce bleeding events. A study of red cell triggers in pts with thrombocytopenia (as in AL) is important as we may not be able to rely on trigger data from others in this setting. This feasibility study was designed to determine whether a randomized trial of Hb triggers could be performed and what challenges may be encountered with this select population. In this prospective randomized study, we enrolled adult pts with AL (myeloid and lymphoid) undergoing intensive induction therapy to evaluate both patient and physician tolerance for a transfusion threshold of 7g/dL (LOW) compared to the standard threshold of 8g/dL (HIGH), as well as operationalize transfusion to a single unit per episode. Pts were randomized with a 2:1 ratio of LOW threshold to HIGH threshold. Pts were ineligible if there was clinical concern for acute coronary syndrome or active blood loss. Pts were monitored from the study enrollment date through the next marrow evaluation after completion of induction therapy. Vital status at Day 60, accrual rate, and safety endpoints (mortality, length of stay, infection, fatigue scores, renal, respiratory, thrombotic, bleeding events) were monitored. Total transfusions, length of inpatient stay, and percentage of pts who crossed over to HIGH threshold for symptomatic reasons were also monitored. Between April 15, 2014 and July 23, 2015, 162 acute leukemia pts would have been eligible for this trial. Of the eligible pts, 112 (69%) were approached and 90 (of planned 90) have enrolled to date. Twenty-two pts (19.6%) of those offered the trial declined. Seventy-four pts are currently evaluable for response (13 pts have not been on-study long enough to evaluate and 3 pts are not eligible for data analysis): 51 pts in LOW arm and 23 in HIGH arm. Interim data is shown in Table 1. In the LOW arm, three pts withdrew consent due to self-reported fatigue and one patient was removed by physician due to clinical scenario. Seventeen pts (33%) in the LOW arm and six pts (26%) in the HIGH arm were transfused outside their hemoglobin trigger without meeting criteria to discontinue the study. No deaths were attributable to Hb thresholds in this study. Significant bleeding events (Grade 3 or 4 by CTCAE 4.0) were comparable with 4 in LOW arm and 3 in HIGH arm. More minor bleeding events (Grade 1 or 2 by CTCAE 4.0) were higher in LOW (24 events) than in HIGH arm (15 events). Acute leukemia and its therapies carry a significant mortality risk and it is not clear how transfusion thresholds and number of PRBC units transfused impact this mortality. Furthermore, blood is an expensive and scarce resource. Without a clear benefit of higher Hb thresholds, the added risks and costs of transfusion may not be justified. This pilot study shows that both pts and leukemia physicians will tolerate randomization between Hb thresholds and there is not a signal for harm in either Hb threshold at present. Pts in the LOW arm receive fewer transfusions and do not experience higher fatigue scores nor increased significant bleeding events. Length of hospitalization was similar in both arms. This safety data will serve as a platform for a larger mortality study in leukemia and possibly additional studies in other oncologic diseases. Table 1. LOW HIGH P value Patients (n) 51 (69%) 23 (31%) Gender Male 23 (45%) 11 (48%) Median Age (Years) 58 63 0.35 AML 44 (86%) 18 (78%) ALL 5 (10%) 5 (22%) APL 2 (4%) 0 Patients Alive at Day 60 46 (90%) 21 (91%) Red Cell Transfusions in Units (Median) 8 (IQR: 5) 10 (IQR: 4) 0.008* Platelet Transfusions in Episodes (Median) 9 (IQR: 6.5) 9 (IQR: 5) 0.86 Length of Stay (Median) 35 (IQR: 10) 36 (IQR: 15) 0.72 Fatigue Scale Score (Median) 4.33 (IQR: 1) 4.54 (IQR: 1.25) 0.40 AML: acute myeloid leukemia; ALL: acute lymphoid leukemia; APL: acute promyelocytic leukemia Disclosures No relevant conflicts of interest to declare.

In a porcine model, we demonstrated that laparoscopic Nissen fundoplication causes a significant drop in cardiac output (30%) because it exposes both the peritoneal cavity and the mediastinum to CO(2) under pressure. To determine if this occurs in humans, we examined cardiovascular physiology during laparoscopic Nissen fundoplication. Because of invasiveness required in this pilot trial, only six patients were studied.The arterial blood pressure (via radial arterial catheter) and the pulmonary artery diastolic pressure and cardiac index (via pulmonary artery thermodilution catheter) were measured at seven points in time during each laparoscopic Nissen fundoplication.The systolic blood pressure decreased in all patients, and the cardiac index decreased in all but one patient. The exception was a patient with Huntington disease, in whom the cardiac output did not decrease. In four of the five patients, the cardiac output was lowest during hiatal dissection, and in the fifth, it was lowest after reverse Trendelenburg positioning. No significant change in the pulmonary artery diastolic pressure was noted. All patients received adequate intravenous fluid replacement (average, 58 +/- 16 mL/kg) to support blood pressure. In one patient, with a particularly large paraesophageal hernia, profound hypotension (40/25 mm Hg) developed during the mediastinal phase of the procedure, and this patient required alpha-adrenergic support followed by laparotomy to eliminate a surgical cause (none found).Although it is a tremendous advance for patients, laparoscopic Nissen fundoplication can be associated with a significant reduction in cardiac output and blood pressure. Surgeons and anesthesiologists must be alert to changes reflecting these decreases during procedures, which violate both the peritoneal cavity and the mediastinum. We propose careful hemodynamic monitoring during these procedures, especially in patients with coronary artery disease or significant left ventricular dysfunction.