Comparative Analysis of Laparoscopic and Open Approaches in Emergency Abdominal Surgery

The objective of this study was to evaluate usage and outcomes of emergency laparoscopic versus open surgery at a single tertiary academic center. Over a three-year period 165 patients were identified retrospectively using National Surgical Quality Improvement Program results. Appendectomies and cholecystectomies were excluded. Open and laparoscopic approaches were compared regarding preoperative and operative characteristics, the development of postoperative complications, 30-day mortality, and length of hospital stay. Indications for operation were similar between groups. Patients who underwent open surgery had more severe comorbidities and higher ASA class. Laparoscopy was associated with reduced complication rates, operative time, length of stay, and discharges to skilled nursing facilities on univariate analysis. In a multivariate model, surgical approach was not associated with the development of complications. Older age, dependent status, and dyspnea were predictors of conversion from attempted laparoscopic to open approaches.

Angiotensin II Type 1 receptor antibodies are associated with inflammatory cytokines and poor clinical outcomes in pediatric kidney transplantation

Angiotensin II type 1 receptor (AT1R) antibody has been linked to poor allograft outcomes in adult kidney transplantation. However, its clinical consequences in children are unknown. To study this, we examined the relationship of AT1R antibody with clinical outcomes, biopsy findings, inflammatory cytokines, and HLA donor-specific antibodies (DSA) in a cohort of pediatric renal transplant recipients. Sixty-five patients were longitudinally monitored for AT1R antibody, HLA DSA, IL-8, TNF-α, IL-1β, IFN-γ, IL-17, and IL-6, renal dysfunction, hypertension, rejection, and allograft loss during the first two years post transplantation. AT1R antibody was positive in 38 of the 65 of children but was not associated with HLA DSA. AT1R antibody was associated with renal allograft loss (odds ratio of 13.1 [95% confidence interval 1.48-1728]), the presence of glomerulitis or arteritis, and significantly higher TNF-α, IL-1β, and IL-8 levels, but not rejection or hypertension. AT1R antibody was associated with significantly greater declines in eGFR in patients both with and without rejection. Furthermore, in patients without rejection, AT1R antibody was a significant risk factor for worsening eGFR over the two-year follow-up period. Thus, AT1R antibody is associated with vascular inflammation in the allograft, progressive decline in eGFR, and allograft loss. AT1R antibody and inflammatory cytokines may identify those at risk for renal vascular inflammation and lead to early biopsy and intervention in pediatric kidney transplantation.

Effectiveness of Ledipasvir/Sofosbuvir with/without Ribavarin in Liver Transplant Recipients with Hepatitis C

Background and Aims: Recurrent infection of hepatitis C virus (HCV) in liver transplant (LT) recipients is universal and associated with significant morbidity and mortality. Methods: We retrospectively evaluated the safety and efficacy of ledipasvir/sofosbuvir with and without ribavirin in LT recipients with recurrent genotype 1 hepatitis C. Results: Eighty-five LT recipients were treated for recurrent HCV with ledipasvir/sofosbuvirwith and without ribavirin for 12 or 24 weeks. The mean (± standard deviation [SD]) time from LT to treatment initiation was 68 (±71) months. The mean (± SD) age of the cohort was 63 (±8.6) years old. Most recipients were male (70%). Baseline alanine transaminase, total bilirubin, and HCV ribonucleic acid (RNA) values (± SD) were 76.8 (±126) mg/dL, 0.8 (±1.3) U/L, and 8,010,421.9 (±12,420,985) IU/mL, respectively. Five of 43 recipients who were treated with ribavirin required drug cessation due to side effects, with 4 of those being anemia complications. No recipient discontinued the ledipasvir/sofosbuvir. Eighty-one percent of recipients had undetectable viral levels at 4 weeks after starting therapy, and all recipients had complete viral suppression at the end of therapy. The sustained viral response at 12 weeks after completion of therapy was 94%. Conclusion : Ledipasvir and sofosbuvir with and without ribavirin therapy is an effective and well-tolerated interferon-free treatment for recurrent HCV infection after LT. Anemia is not uncommon in LT recipients receiving ribavirin.

Outcomes of Recreational Activity-Associated Trauma in Elderly Persons on Blood-Thinning Medications

With increasing life expectancy, the elderly are participating in recreational activities traditionally pursued by younger persons. Elderly patients have many reasons for worse outcomes after trauma, one of which may be the rising use of anticoagulant and/or antiplatelet medications. This study aimed to determine whether preinjury use of these agents yielded worse outcomes in geriatric patients injured during high-impact recreational activities. The National Trauma Data Bank was reviewed from 2007 to 2010 for patients ≥65 years admitted to Level I or II trauma centers with ICD-9 E-codes for specific mechanisms of injury. These included motorcycles, bicycles, snowmobiles, all-terrain vehicles, equestrian, water and alpine skiing, snowboarding, and others. Patients with preinjury bleeding disorder (BD), including warfarin and clopidogrel use, were compared with controls via a coarsened exact matching analysis. BD patients (294) were compared with 3929 controls. Although increased in BD patients, no significant mortality differences were observed in unmatched or matched analyses. BD patients yielded greater hospital length of stay (5 vs 4 days, P = 0.020) with increased odds of receiving five units or more of blood (7.0% vs 2.1%, odds ratio = 4.7, P < 0.001) and of deep vein thrombosis (7.6% vs 3.8%, odds ratio = 2.1, P = 0.018). Elderly patients with BD, including warfarin or clopidogrel use, do not seem to have significantly increased mortality after injury during specified recreational activities. BD patients had greater hospital length of stay, transfusion requirements, and deep vein thrombosis rates. These findings may inform counseling for those taking such medications as to the potential for adverse outcomes.

Outcomes of Recreational Activity-Associated Trauma in Elderly Persons on Blood-Thinning Medications

With increasing life expectancy, the elderly are participating in recreational activities traditionally pursued by younger persons. Elderly patients have many reasons for worse outcomes after trauma, one of which may be the rising use of anticoagulant and/or antiplatelet medications. This study aimed to determine whether preinjury use of these agents yielded worse outcomes in geriatric patients injured during high-impact recreational activities. The National Trauma Data Bank was reviewed from 2007 to 2010 for patients ≥65 years admitted to Level I or II trauma centers with ICD-9 E-codes for specific mechanisms of injury. These included motorcycles, bicycles, snowmobiles, all-terrain vehicles, equestrian, water and alpine skiing, snowboarding, and others. Patients with preinjury bleeding disorder (BD), including warfarin and clopidogrel use, were compared with controls via a coarsened exact matching analysis. BD patients (294) were compared with 3929 controls. Although increased in BD patients, no significant mortality differences were observed in unmatched or matched analyses. BD patients yielded greater hospital length of stay (5 vs 4 days, P = 0.020) with increased odds of receiving five units or more of blood (7.0% vs 2.1%, odds ratio = 4.7, P < 0.001) and of deep vein thrombosis (7.6% vs 3.8%, odds ratio = 2.1, P = 0.018). Elderly patients with BD, including warfarin or clopidogrel use, do not seem to have significantly increased mortality after injury during specified recreational activities. BD patients had greater hospital length of stay, transfusion requirements, and deep vein thrombosis rates. These findings may inform counseling for those taking such medications as to the potential for adverse outcomes.

Decrease of Alpha-fetoprotein in Patients with Cirrhosis Treated with Direct-acting Antivirals

Background and Aims: The lack of specificity has limited the role of serum alpha-fetoprotein (AFP) for hepatocellular carcinoma (HCC) screening among patients with cirrhosis related to hepatitis C virus (HCV) infection. We sought to examine whether AFP may decrease after achieving a sustained virological response (SVR) in patients with HCV-related cirrhosis. Methods: We performed a retrospective study of patients with HCV-related cirrhosis who were cured with direct-acting antiviral (DAA) therapy at the University of California, Los Angeles. Laboratory values, including serum AFP, were measured before and after completing the DAA treatment. Results: Fifty-six patients met the inclusion criteria, with median (interquartile range [IQR]) age of 67 (58-69) years and with 51.8% being male. All patients received DAA therapy without interferon. AFP decreased from median (IQR) 7.2 (4.2-13.4) ng/mL before DAAs to 4.2 (2.7-6.3) ng/mL at the end of treatment and 4.2 (2.9-6.8) ng/mL at 12 weeks after treatment (p < 0.001). Model for end-stage liver disease (MELD), fibrosis-4 (FIB4), and aspartate transaminase (AST) to platelet ratio index (APRI) scores at baseline were not significantly associated with AFP reduction. On multivariate analysis, platelet count, AST and total bilirubin at baseline were significantly correlated to AFP reduction (p = 0.04, 0.009 and 0.04, respectively). The higher the baseline AFP, the greater the reduction in AFP. There was no statistically significant correlation between baseline AFP and MELD, FIB4 or APRI scores. Conclusion: There was a significant decrease in AFP in patients with cirrhosis who achieved a SVR with DAAs. Given a reduction in AFP after DAA treatment, AFP should be further studied as a screening modality for HCC in patients with cirrhosis.

National Outcomes after Pressure Ulcer Closure: Inspiring Surgery

Over two million Americans receive treatment for pressure ulcers (PUs) annually, but national surgical outcomes are not well described. This study investigated rates and risk factors of postoperative complications in patients with PU. The 2011 and 2012 American College of Surgeons-National Surgical Quality Improvement Project database was queried and PU patients undergoing flap closure were identified. Descriptive statistics and multivariate regression analysis was used and reported as odds ratios (ORs) if (P < 0.05). Of 1196 patients identified with a primary diagnosis of PU, 327 (27%) underwent flap closure. Emergency interventions were performed in seven patients who were excluded from analysis. Characteristics were average age 53.3 (±17); 65 per cent male; 41 per cent with grossly contaminated or infected wounds; 29 per cent frail; and 16 per cent with an American Society of Anesthesiologists score of four or five. Myocutaneous or fasciocutaneous flaps were performed in 82 per cent of patients, local skin rearrangements in 17 per cent, and free flap in one patient. Complications were low with 1.9 per cent recurrence and 4.7 per cent reoperation rates. Higher American Society of Anesthesiologists was independently associated with mortality (odds ratio = 6.6) and steroid use correlated with flap failure (odds ratio = 15). No differences in complication profiles were identified based on technique, frailty, or contamination. Surgical closure can be considered reasonable in all patients fit for anesthesia.

National Outcomes after Pressure Ulcer Closure: Inspiring Surgery

Over two million Americans receive treatment for pressure ulcers (PUs) annually, but national surgical outcomes are not well described. This study investigated rates and risk factors of postoperative complications in patients with PU. The 2011 and 2012 American College of Surgeons-National Surgical Quality Improvement Project database was queried and PU patients undergoing flap closure were identified. Descriptive statistics and multivariate regression analysis was used and reported as odds ratios (ORs) if ( P < 0.05). Of 1196 patients identified with a primary diagnosis of PU, 327 (27%) underwent flap closure. Emergency interventions were performed in seven patients who were excluded from analysis. Characteristics were average age 53.3 (±17); 65 per cent male; 41 per cent with grossly contaminated or infected wounds; 29 per cent frail; and 16 per cent with an American Society of Anesthesiologists score of four or five. Myocutaneous or fasciocutaneous flaps were performed in 82 per cent of patients, local skin rearrangements in 17 per cent, and free flap in one patient. Complications were low with 1.9 per cent recurrence and 4.7 per cent reoperation rates. Higher American Society of Anesthesiologists was independently associated with mortality (odds ratio = 6.6) and steroid use correlated with flap failure (odds ratio = 15). No differences in complication profiles were identified based on technique, frailty, or contamination. Surgical closure can be considered reasonable in all patients fit for anesthesia.

Accessibility to Oral Antiviral Therapy for Patients with Chronic Hepatitis C in the United States

Background : Hepatitis C (HCV) direct acting antiviral agents (DAAs) are safe, effective, and tolerable. Most contraindications to interferon-based treatment are no long applicable. The aims of this study were to understand the predictors of approval to drug accessibility. Methods : We studied all consecutive patients with HCV prescribed DAAs between October 2014 and July 2015. Data on demographic, socio-economic status, comorbidities, baseline laboratory values, and assessment of liver disease severity, insurance, and specialty pharmacy type were collected. Multivariate analyses were performed to identify predictors of prescription approval. Results : In total, 410 patients were prescribed DAAs between October 2014 and July 2015. Of those, 332 (81%) patients were insurance approved for therapy. Of the 332 patients accepted, 251 were accepted after the first prescription attempt, and 38 were accepted after the second and third attempts. The number of attempts for the other 43 approved patients was unknown. Older age (p = 0.001), employment (p = 0.001), lack of comorbidities (p = 0.02), liver transplantation (p = 0.018), and advanced liver disease (p = 0.001) were more likely associated with obtaining approval. Household income was not associated with insurance approval. In the multivariate analysis, Medicare insurance (odds ratio [OR]) 2.67, 95% confidence interval [CI] 0.96-7.20), lack of nonliver comorbidities (OR 2.72, 95% CI 1.35-5.43), and the presence of advanced liver disease (OR 1.82, 95% CI 1.04-3.24) independently predicted drug approval. Conclusion : Despite the availability of DAAs for HCV, barriers from insurance carriers continue to impair widespread use. Patients with advanced liver disease, Medicare, and without comorbidities are most likely to be insurance approved for DAAs.

Curing Hepatitis C in Liver Transplant Recipients Is Associated with Changes in Immunosuppressant Use

BACKGROUND AND AIMS

All-oral interferon-free antivirals are highly effective in treating recurrent hepatitis C (HCV) infection in liver transplant (LT) recipients. The aim of the study was to assess immunosuppression needs after achieving a sustained viral response (SVR).

METHODS

We compared immunosuppression needs before and after achieving a SVR in adult LT recipients treated for recurrent HCV infection with all-oral direct acting agents.

RESULTS

We identified 52 liver LT treated recipients who achieved a SVR. The median (25th and 75th percentile interquartile range [IQR]) age was 62 years (57.75, 65). Most recipients received tacrolimus (TAC) for their immunosuppressant regimen. After achieving SVR, there was no statistically significant difference in daily dose of TAC unadjusted per weight (p > 0.05). However, there was a statistically significant decrease in daily dose of TAC adjusted per weight, serum levels of TAC, and the product of glomerular filtration rate and TAC. No statistically significant differences in cyclosporine unadjusted/adjusted per weight daily dose or serum levels were noted.

CONCLUSIONS

Immunosuppression needs were increased for those patients treated with TAC but not cyclosporine. LT recipients prescribed TAC require close monitoring after treatment completion to avoid potential risk of acute rejection.

Dabigatran Use Does Not Increase Intracranial Hemorrhage in Traumatic Geriatric Falls When Compared with Warfarin

Patients on anticoagulation are at increased risk for intracranial hemorrhage (ICH) after trauma. This is important for geriatric trauma patients, who are increasing in number, frequently fall, and often take anticoagulants. This study sought to evaluate whether prehospital use of dabigatran, a newer anticoagulant, is associated with outcome differences in geriatric trauma patients suffering falls when compared with warfarin. The registry of a Level II community trauma center was used to identify 247 patients aged 65 and older who sustained a fall while taking prehospital dabigatran or warfarin admitted between December 2010 and March 2014. Patients on warfarin were included if their International Normalized Ratio was therapeutic (2–3). About 176 of the 247 patients were then compared using coarsened exact matching. In the matched analysis, overall population means for age, Glasgow Coma Score, and Injury Severity Score were 83.5, 14.7, and 5.1, respectively. The overall rate of ICH was 12.5 per cent, with a mortality rate of 16.1 per cent for patients who sustained an ICH. There were no observed differences in ICH, hospital length of stay, intensive care unit length of stay, or mortality between patients taking prehospital warfarin or dabigatran.

Dabigatran Use Does Not Increase Intracranial Hemorrhage in Traumatic Geriatric Falls When Compared with Warfarin

Patients on anticoagulation are at increased risk for intracranial hemorrhage (ICH) after trauma. This is important for geriatric trauma patients, who are increasing in number, frequently fall, and often take anticoagulants. This study sought to evaluate whether prehospital use of dabigatran, a newer anticoagulant, is associated with outcome differences in geriatric trauma patients suffering falls when compared with warfarin. The registry of a Level II community trauma center was used to identify 247 patients aged 65 and older who sustained a fall while taking prehospital dabigatran or warfarin admitted between December 2010 and March 2014. Patients on warfarin were included if their International Normalized Ratio was therapeutic (2-3). About 176 of the 247 patients were then compared using coarsened exact matching. In the matched analysis, overall population means for age, Glasgow Coma Score, and Injury Severity Score were 83.5, 14.7, and 5.1, respectively. The overall rate of ICH was 12.5 per cent, with a mortality rate of 16.1 per cent for patients who sustained an ICH. There were no observed differences in ICH, hospital length of stay, intensive care unit length of stay, or mortality between patients taking prehospital warfarin or dabigatran.

Prophylactic Fresh Frozen Plasma Infusion is Ineffective in Reversing Warfarin Anticoagulation and Preventing Delayed Intracranial Hemorrhage After Falls

BACKGROUND

Elderly patients, with considerable fall risk, are increasingly anticoagulated to prevent thromboembolic disease. We hypothesized that a policy of prophylactic fresh frozen plasma (FFP) infusion in patients having falls would reverse vitamin K antagonists (VKAs) and that reversal would decrease delayed intracranial hemorrhage (ICH).

METHODS

A retrospective review of patients with trauma admitted to a level 2 community trauma center was performed from January 2010 until November 2012. Inclusion criteria were: ground level fall (GLF) with suspected head trauma, on VKA, an international normalized ratio (INR) of >1.5, and a negative head computed tomography (CT). Patients were transfused with FFP to a goal INR of <1.5 while observed. Patients were classified as reversed (REV) if the lowest INR achieved within 4 to 24 hours after initial INR was <1.5 or unreversed (NREV) if lowest INR achieved was >1.5. Chi-square and logistic regression were performed.

RESULTS

A total of 194 patients met the criteria. In all, 43 (22%) patients were able to be REV, and 151 (78%) patients remained NREV. Unreversed patients were male and younger (P < .05). There was no difference in mean FFP received. Unreversed patients had a higher initial INR of 3.0 compared to REV patients (2.5; P = .018). One patient developed a delayed ICH and belonged to the REV group.

CONCLUSION

The incidence of delayed hemorrhage was 0.5%. A strategy of prophylactic FFP infusion was ineffective in VKA reversal. We recommend against prophylactic infusion of FFP during a period of observation for patients on VKA with suspected head trauma and a negative initial CT.