Search

BACKGROUND: Sternal wound infections (SWI) can be a devastating long-term complication with significant morbidity and health care cost. The purpose of this analysis was to evaluate the cost-effectiveness of negative pressure incision management systems (NPIMS) in cardiac surgery. MATERIALS AND METHODS: All cardiac surgery cases at an academic hospital with risk scores available (2009–2017) were extracted from an institutional database (n=4,455). Patients were stratified by utilization of NPIMS and high-risk was defined as above the median. Costs included infection related readmissions and were adjusted for inflation. Multivariable regression models assessed the risk-adjusted cost of SWI and efficacy of NPIMS use. Cost-effectiveness was modeled using TreeAge Pro using institutional results. RESULTS: The rate of deep SWI was 0.9% with an estimated cost of $111,175 (p

Objectives The United States has the highest number of Coronavirus Disease 2019 (COVID-19) in the world, with high variability in cases and mortality between communities. We aimed to quantify the associations between socioeconomic status and Coronavirus Disease 2019 (COVID-19) related cases and mortality in the U.S. Study Design: Nationwide COVID-19 data at the county level that was paired with the Distressed Communities Index (DCI) and its component metrics of socioeconomic status. Methods Severely distressed communities were classified by DCI>75 for univariate analyses. Adjusted rate ratios were calculated for cases and fatalities per 100,000 persons using hierarchical linear mixed models. Results This cohort included 1,089,999 cases and 62,298 deaths in 3,127 counties for a case-fatality rate of 5.7%. Severely distressed counties had significantly fewer deaths from COVID-19, but higher number of deaths/100,000. In risk-adjusted analysis, the two socioeconomic determinants of health with the strongest association with both higher cases/100,000 and higher fatalities/100,000 were percent of adults without a high school degree (cases: RR 1.10; fatalities: RR 1.08) and proportion of black residents (cases and fatalities: RR 1.03). The percentage of the population over 65 was also highly predictive for fatalities/100,000 (RR 1.07). Conclusion Lower education levels and greater percentages of black residents are strongly associated with higher rates of both COVID-19 cases and fatalities. Socioeconomic factors should be considered when implementing public health interventions in order to ameliorate the disparities in the impact of COVID-19 on distressed communities., Highlights • Socioeconomic factors play an important role in COVID-19 prevalence and mortality. • Lower education level was the strongest association with both cases and fatalities. • Higher proportion of black residents also associated with cases and fatalities. • The poverty rate and median income were also associated with COVID-19 cases. • Median income and change in employment were also associated with COVID-19 fatalities.

Background Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery. Methods All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care–related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs. Results A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL ( P < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care–related value by 38%. Conclusion Implementation of a protocol consisting of an eGMS paired with a cardiac surgery–specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care–related value increased as a result of eGMS implementation.

The immune regulatory enzyme indoleamine-2,3-dioxygenase (IDO-1) suppresses T cell responses and may reduce efficacy of therapies targeting immune checkpoints such as programmed death receptor-1/programmed death ligand-1 (PD-1/PD-L1). Early phase clinical trials combining IDO-1 and PD-1/PD-L1 inhibitors have shown some promise in non-small cell lung cancers (NSCLCs). However, the coexpression of IDO-1 and PD-L1 has not been thoroughly investigated, and the potential for IDO-1 immunohistochemical expression as a therapeutic biomarker is unknown. One hundred two cases of NSCLC (51 adenocarcinomas, 9 adenosquamous carcinomas, and 42 squamous cell carcinomas) were evaluated for IDO-1 and PD-L1 expression by immunohistochemistry. IDO-1 expression was identified in 43% of NSCLC (42% of adenocarcinomas, 44% of adenosquamous carcinomas, and 43% of squamous cell carcinomas). Coexpression with PD-L1 (≥1%) was common (27% overall; 27% of adenocarcinomas, 33% of adenosquamous carcinomas, and 26% of squamous cell carcinomas). A smaller population of tumors showed isolated PD-L1 (25% overall; 16% of adenocarcinomas, 44% of adenosquamous carcinomas, and 33% of squamous cell carcinomas) or IDO-1 expression (15% overall; 14% of adenocarcinomas, 11% of adenosquamous carcinomas, and 17% of squamous cell carcinomas). In summary, IDO-1 is commonly expressed by NSCLC, and its frequent coexpression with PD-L1 may account for the increased efficacy seen with dual blockade of PD-1/PD-L1 and IDO in clinical studies. IDO-1 immunohistochemistry may be a useful biomarker for selection of patients who could benefit from dual-agent therapy and should be evaluated in prospective clinical trials using PD-1/PD-L1 and IDO inhibitors.

Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m22. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P > 0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis ( P < 0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intra-operative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.

Statins have potent pleiotropic effects that have been correlated with improved perioperative cardiovascular surgery outcomes. We hypothesize that statins may improve morbidity and mortality after ascending aortic surgery. Within a statewide database consisting of 19 centers a total of 1804 patients had ascending aortic repair with or without aortic valve replacement (2004-2016). Patients were stratified by preoperative statin therapy for analysis. To account for baseline differences, patients were propensity matched in a 1:1 fashion by baseline characteristics. Patient characteristics and outcomes were analyzed by paired analysis. Of 1804 patients undergoing ascending aortic repair, 35% took statins preoperatively. After matching, 386 patients in each group were well matched with no statistically significant baseline or operative differences. There was no statistically significant difference in outcomes between patients taking statins preoperatively and those not taking statins, including operative mortality (3.6% vs 3.1%, P = 0.68) and major morbidity (18.4% vs 17.1%, P = 0.62). Postoperative atrial fibrillation (27.2% vs 28.5%, P = 0.71) and acute kidney injury (3.1% vs 4.2%, P = 0.41) also showed no statistically significant difference. Statins have no apparent clinical impact on perioperative outcomes after ascending aortic aneurysm repair. Considering recent evidence suggesting statins may increase perioperative risk of acute kidney injury, there is insufficient evidence to recommend starting preoperative statin before ascending aortic repair.

Degenerative mitral valve disease causing mitral regurgitation is the most common organic valve pathology and is classified based on leaflet motion. The "French correction" mitral valve repair method restores normal valvular anatomy with extensive leaflet resection, chordal manipulation, and rigid annuloplasty. The American correction attempts to restore normal valve function through minimal leaflet resection, flexible annuloplasty, and use of artificial chordae. These differing methods of mitral valve repair reflect an evolution in principles, but both require understanding of the valve pathology and correction of leaflet prolapse and annular dilatation. Adhering to those unifying principles and ensuring that no patient leaves the operating room with significant persistent mitral regurgitation produces durable results and satisfactory patient outcomes.

Following weight-loss surgery, patients who failed to achieve or sustain weight loss have nevertheless reported high satisfaction with their long-term bariatric experience. Understanding this phenomenon better will likely improve patients' experiences.The purpose of this study was to explore patients' long-term experiences following bariatric surgery.A 604-bed academic health system in the USA.Participants rated satisfaction and shared spontaneous comments regarding their gastric bypass experience. A phenomenological mode of inquiry explored participants' experiences. Transcribed phrases were categorized and themes identified.In a 2004 surgical cohort, with 55% (155/281) participation, 99% of participants rated bariatric experience satisfaction (mean score 8.4) and 74% (115/155) shared comments regarding experiences. Responses were categorized as positive (63% 72/115), neutral (25% 29/115), or negative (12% 14/115). Satisfaction, Appreciation, and Gratefulness emerged as themes from positive comments, with 8% (6/72) explicitly acknowledging amount of weight loss achieved. Twenty-five percent (18/72) spontaneously mentioned undergoing surgery again or recommending the procedure to others. Neutral comments contained the themes of Reflection, Acknowledgment, and Wistfulness. Themes of Dissatisfaction, Disappointment, and Regret emerged from negative comments. Forty-three percent (6/14) of negative comments remarked on regaining weight or not reaching goal weight. Twenty-one percent (3/14) of negative comments explicitly stated regret at having undergone surgery.Participants readily shared comments regarding their gastric bypass experience. Exploring themes provided insight into patients' satisfaction with bariatric surgery even when weight-loss goals were not met and conversely substantial dissatisfaction even when weight loss occurred. This study underscores the importance of understanding the patients' long-term experience following bariatric surgery.

Background Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay. Methods The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day. Results Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05). Conclusions Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.

Introduction: Despite advances in resuscitation protocols, including the addition of Extracorporeal Cardiopulmonary Resuscitation (ECPR), survival after cardiac arrest remains less than 40% and novel methods are needed to attenuate global injury and improve outcomes. ATL1223, an adenosine 2A receptor (A2AR) agonist has been shown to attenuate organ specific reperfusion injury by modulating the interaction of inflammatory cells. Hypothesis: A2AR activation during ECPR will improve survival and decrease the burden of injury in a large animal model of cardiac arrest. Methods: Adult swine underwent 20 minutes of circulatory arrest followed by defibrillation and 6 hours of ECPR. Animals were randomized to receive saline control (n=5) or the A2AR agonist Regadenoson (0.144 and 14.4mcg/kg/hr, n=5/group). Animals were subsequently weaned from ECPR and monitored for 24 hours. Clinical and biochemical endpoints were compared between groups. Results: The administration of Regadenoson increased survival after cardiac arrest compared to saline controls (10/10, 100% vs 2/5, 40%, p=0.02, Figure 1). Anesthetic administration (p=0.41), fluid resuscitation (p=0.54), and epinephrine required to maintain target arterial pressure (p=0.08) were similar for all subjects. Biochemical markers of organ damage, including creatinine (p=0.87), aspartate aminotransferase (p=0.89), and troponin I (p=0.38), were similar among groups (Figure 2). Conclusions: In a clinically relevant model of cardiac arrest treated with ECPR, selective A2AR agonism increased survival from 40% to 100% at 24 hours. These results suggest A2AR activation is a promising therapeutic target after cardiac arrest.

BACKGROUND Currently, there are no clinically approved treatments for ischemia-reperfusion injury after lung transplantation. Pre-clinical animal models have demonstrated a promising efficacy of adenosine 2A receptor (A2AR) agonists as a treatment option for reducing ischemia-reperfusion injury. The purpose of this human study, is to conduct a Phase I clinical trial for evaluating the safety of continuous infusion of an A2AR agonist in lung transplant recipients. METHODS An adaptive, two-stage continual reassessment trial was designed to evaluate the safety of regadenoson (A2AR agonist) in the setting of lung transplantation. Continuous infusion of regadenoson was administered to lung transplant recipients that was started at the time of skin incision. Adverse events and dose-limiting toxicities, as pre-determined by a study team and assessed by a clinical team and an independent safety monitor, were the primary end-points for safety in this trial. RESULTS Between January 2018 and March 2019, 14 recipients were enrolled in the trial. Of these, 10 received the maximum infused dose of 1.44 µg/kg/min for 12 hours. No dose-limiting toxicities were observed. The steady-state plasma regadenoson levels sampled before the reperfusion of the first lung were 0.98 ± 0.46 ng/ml. There were no mortalities within 30 days. CONCLUSIONS Regadenoson, an A2AR agonist, can be safely infused in the setting of lung transplantation with no dose-limiting toxicities or drug-related mortality. Although not powered for the evaluation of secondary end-points, the results of this trial and the outcome of pre-clinical studies warrant further investigation with a Phase II randomized controlled trial.

OBJECTIVE: We tested the hypothesis that systemic administration of an adenosine 2A receptor (A2AR) agonist will reduce multiorgan ischemia-reperfusion injury (IRI) in a porcine model of extracorporeal cardiopulmonary resusitation (ECPR). SUMMARY BACKGROUND DATA: Advances in ECPR have decreased mortality after cardiac arrest, however subsequent IRI contributes to late multisystem organ failure. Attenuation of IRI has been reported with use of an A2AR agonist. METHODS: Adult swine underwent 20 minutes of circulatory arrest, induced by ventricular fibrillation, followed by six hours of reperfusion with ECPR. Animals were randomized to vehicle control, low-dose A2AR agonist, or high-dose A2AR agonist. A perfusion specialist using a goal-directed resuscitation protocol managed all animals during the reperfusion period. Hourly blood, urine, and tissue samples were collected. Biochemical and microarray analyses were performed to identify differential inflammatory markers and gene expression between groups. RESULTS: Both treatment groups demonstrated significantly higher percent reduction from peak lactate after reperfusion compared to vehicle controls. Control animals required significantly more fluid, epinephrine, and higher final pump flow while having lower urine output than both treatment groups. The treatment groups had lower urine NGAL, an early marker of kidney injury (p=0.01), lower plasma aspartate aminotransferase, and reduced rate of troponin rise (p=0.01). Pro-inflammatory cytokines were lower while anti-inflammatory cytokines were significantly higher in the treatment groups. CONCLUSIONS: Using a novel and clinically relevant porcine model of circulatory arrest and ECPR, we demonstrated that a selective A2AR agonist significantly attenuated systemic IRI and warrants clinical investigation.

Purpose Employment is an important metric of post-transplant functional status and quality of life, yet remains poorly described after heart transplant. We sought to characterize the prevalence of employment following heart transplantation and identify patients at risk for post-transplant unemployment. Methods Adults undergoing single-organ heart transplantation (2007-2016) were evaluated using the UNOS database. Univariate analysis was stratified by employment status at one year post-transplant. A Kaplan-Meier analysis evaluated time to start of employment while Fine-Gray competing risk regression was used for risk adjustment. Results Of 11,088 heart transplant recipients, 22.0% of survivors were employed and 71.3% unemployed one year post-transplant. Overall employment rate of survivors increased to 32.9% by year two. Employed individuals were more likely white (70.9% vs. 60.4%, p Conclusion Over 20% of heart transplant patients are employed at one year and 30% at two years, while 60% of those working pre-transplant return to work. Postoperative complications, race, education and insurance status are all drivers of employment. Quality improvement focused on addressing socioeconomic disparities may maximize functional status post-transplant.

Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m-2. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis (P0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intraoperative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.

Background Thrombosis within a left ventricular assist device (LVAD) is a devastating complication that often necessitates device exchange. Few studies have evaluated the relationship between patient anatomy and pump thrombosis. We hypothesize that lateral displacement of the left ventricular (LV) apex increases risk for pump thrombosis. Methods All patients who underwent primary implantation of a HeartMate II (HM2) device (Thoratec, Pleasanton, CA) at a single center (2009-2015) were evaluated. Operative mortalities and patients without imaging were excluded. The angle of the LV apex relative to the midline was measured on preoperative computed tomography scans by two independent surgeons. Pump thrombosis was defined as lactic dehydrogenase >700 with clinical symptoms of hemolysis or LVAD malfunction. Univariate and Cox Proportional Hazards analysis was performed to evaluate the impact of LV apex angle on long-term freedom from pump exchange for thrombosis. Results Of 122 patients who met inclusion criteria for this study, 16 (13.1%) underwent exchange for presumed pump thrombosis. Of these patients, six (37.5%) required more than one exchange. Patients undergoing exchange for thrombosis had greater LV angle (43.8 ± 9.7 vs 49.5 ± 11.2, p = 0.037) with LV apex angle being a significant predictor of LVAD exchange for thrombosis (hazard ratio = 1.047, P = 0.046). Additionally, when surgeon measurements were compared there was good inter-observer reliability (Pearson Correlation = 0.89). Conclusion A laterally displaced left ventricular apex correlates with a higher risk of pump thrombosis in patients undergoing HM2 implantation. LV apex angle is an easily obtained, reproducible measurement that should be considered when selecting a ventricular assist device.

BACKGROUND: The number of patients with end-stage pulmonary disease awaiting lung transplantation is at an all-time high, while the supply of available organs remains stagnant. Utilizing donation after circulatory death (DCD) donors may help to address the supply-demand mismatch. The objective of this study is to determine the potential donor pool expansion with increased procurement of DCD organs from patients who die at hospitals. MATERIAL AND METHODS: The charts of all patients who died at a single, rural, quaternary-care institution between August 2014 and June 2015 were reviewed for lung transplant candidacy. Inclusion Criteria were age 65 years (n=497, 58%). Those without cancer totaled 778 (90.8%) and 512 (59%) did not have lung pathology. This leaves 85 patients qualifying for DCD lung donation (Pediatric n=10, Young n=75, and Old n=0). Potential donors were significantly more likely to have clear chest X-rays (24.3% vs 10.0%, p

Purpose As the population becomes increasingly obese, so does the pool of potential organ donors. However, many centers are hesitant to accept hearts from morbidly obese donors, limiting the donor pool. We hypothesized that utilization of hearts from obese donors would not impact recipient outcomes. . Methods Single-organ first-time adult heart transplants from 2003 to 2017 were evaluated from the UNOS database and stratified by donor BMI ≥ 40 (morbid obesity). Univariate analysis compared characteristics and short-term outcomes between groups. Kaplan-Meier analysis evaluated long-term survival. Cox regression assessed the risk-adjusted impact of donor obesity on mortality. Sensitivity analyses evaluated donor BMI cutoffs of 30, 35, and 45. Results A total of 26,532 transplants were evaluated, of which 939 (3.5%) had donors with BMI ≥ 40. Transplants from morbidly obese donors increased over time (2.2% in 2003, 5.3% in 2017). Obese donors were more likely to have diabetes (10.4% vs. 3.1%) and hypertension (33.3% vs. 14.8%, p 130% of recipient). Short-term outcomes were similar, including primary graft dysfunction (1.7% vs. 2.7%, p=0.06), pacemaker need (3.8% vs. 3.3%, p=0.34), dialysis requirement (9.4% vs. 10.0%, p=0.34) and one year survival (10.6% vs. 10.7%, p=0.93). Unadjusted survival was equivalent for those with morbidly obese donors (Log-rank p=0.67), and obesity did not impact survival in risk adjusted analysis (Table). Sensitivity analyses for donor BMI ≥ 30, 35, or 45 and analysis of BMI as a continuous variable demonstrated similar results. Conclusion We demonstrate donor obesity did not impact post-transplant outcomes. Evaluation of hearts from morbidly obese donors has the potential to expand the critically low donor pool.

Background Cigarette smoking is strongly associated with atherosclerotic disease. It is incumbent on vascular surgeons to provide smoking cessation counseling (SCC) to their patients. The objective of this study was to determine the association of SCC and improvement in quality of care. Methods As a quality project using retrospective data, the study received institutional review board exemption status. A retrospective review of prospectively maintained database from April 2014 through March 2015 of outpatient encounters in a vascular surgery clinic was performed of current smokers. Through the quality support team, providers were encouraged to counsel smokers to quit, document the discussion, and bill specific Evaluate and Management codes (99406 and 99407). The number of outpatients by smoking status, documentation and billing of SCC, demographics of current smokers, and monetary collections were collected. Data were compared using a correlation coefficient calculated and tested for statistical significant using two-tailed t -test. Results A sample of 1,077 visits by 612 currently smoking patients accounted for 24% of all outpatient vascular surgery visits. The average age was 61 years, and 64% were male. Comorbidities included 77% with hypertension, 32% with diabetes mellitus, and 14% with chronic kidney disease. Medically, 72% were on aspirin, 71% on statin, and 48% on beta blocker. A total of 208 (34%) never underwent a vascular intervention, and 183 (30%) had an intervention during the study period (44% for peripheral artery disease, 10% for carotid stenosis, 14% amputations, and 10% abdominal aortic aneurysm). Documentation improved from 65% of encounters during the first month to 89% in the peak month and 79% of total encounters. All-cause mortality rate was 2%, and this cohort demonstrated 75% SCC for 28 encounters. Fifty-five patients (9%) quit smoking for more than 30 days at the end of the study period, and this cohort had 69% of their 97 encounters with documented SCC. Increased SCC was correlated with decreased 30-day readmissions during the concurrent month ( r = −0.711, P = 0.009) and the following month ( r = −0.719, P = 0.008). There was a weak correlation with decreased amputations the following month ( r = −0.5, P = 0.08). From a financial perspective, $1,373 was collected for 33 patients with a potential for collection of $7,460 predicted for minimum Medicare payment of 1 visit per patient. Conclusions Advising vascular patients in the arduous process of smoking cessation benefits both the patient and the health system. Proper documentation and billing decreases costs of early readmissions and increases departmental revenue.

The incidence of new onset or worsening diabetes is surprisingly low in patients after partial pancreatectomy for cancer, leading us to question what factors predict diminished glycemic control in those undergoing resection. All patients undergoing pancreatectomy for cancer at a large, rural university teaching hospital between 1996 and 2010 were identified. The incidence of new onset, or worsening, existing diabetes was determined based on pre and postoperative medication requirement. Univariate analysis was undertaken to identify factors that predict worsened glycemic control. One hundred and one (1 total, 79 Whipple, 21 distal) patients were identified, 41 per cent of which had preexisting diabetes. Nearly half of existing diabetics manifested an increased medication requirement prior to their cancer diagnosis. New onset diabetes occurred in 20 per cent of postoperative patients. Of established diabetics, 34 per cent had either improved glycemic control (9/41) or were cured (5/41) despite the reduction of islet cell mass that occurred with surgery. On univariate analysis, only prolonged hospitalization was associated with worsened glycemic control. Diminished glycemic control is a frequent presenting symptom of pancreatic cancer. Worsened or new onset diabetes is associated with length of stay, which can be influenced by a number of factors including complications and comorbidities.

Background Roux-en-Y gastric bypass (RYGB) effectively treats obesity and gastroesophageal reflux disease (GERD). As more surgeons recommend RYGB to treat GERD in patients with obesity, there are concerns about this approach in patients with previous non-bariatric foregut surgery. This study aims to evaluate the effect of previous non-bariatric foregut surgery on subsequent RYGB.

The incidence of new onset or worsening diabetes is surprisingly low in patients after partial pancreatectomy for cancer, leading us to question what factors predict diminished glycemic control in those undergoing resection. All patients undergoing pancreatectomy for cancer at a large, rural university teaching hospital between 1996 and 2010 were identified. The incidence of new onset, or worsening, existing diabetes was determined based on pre and postoperative medication requirement. Univariate analysis was undertaken to identify factors that predict worsened glycemic control. One hundred and one (1 total, 79 Whipple, 21 distal) patients were identified, 41 per cent of which had preexisting diabetes. Nearly half of existing diabetics manifested an increased medication requirement prior to their cancer diagnosis. New onset diabetes occurred in 20 per cent of postoperative patients. Of established diabetics, 34 per cent had either improved glycemic control (9/41) or were cured (5/41) despite the reduction of islet cell mass that occurred with surgery. On univariate analysis, only prolonged hospitalization was associated with worsened glycemic control. Diminished glycemic control is a frequent presenting symptom of pancreatic cancer. Worsened or new onset diabetes is associated with length of stay, which can be influenced by a number of factors including complications and comorbidities.

Since the discovery that gastric bypass surgery leads to the rapid reversal of type 2 diabetes mellitus in morbidly obese patients, researchers have been searching for possible mechanisms to explain the result. The significance of bariatric surgery is twofold. It offers hope and successful therapy to the severely obese; those with T2DM, sleep apnea, or polycystic ovary disease; and others plagued by the comorbidities of the metabolic syndrome. This article examines four surgical procedures and their outcomes.