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Background Early discharge (ED) after colectomy has become a target outcome for multiple reasons, but the factors associated with ED are not well characterized. This study investigated the factors associated with ED and evaluated the impact of ED on overall outcome. Methods Data from ACS-NSQIP were used to identify patients who underwent non-emergent colectomy from 2012 to 2021. ED was defined as length of stay ≤ 2 days. Unpaired t-tests, chi-square tests and adjusted multivariate logistic regression modeling were used to estimate associated factors for ED. Bounceback readmission was defined as readmission within 7 days of discharge. Results In this cohort of 282,490 patients, 43,137 (15.3%) met the criteria for ED. Robotic colectomy (OR 14.35; 95% CI [13.63-15.12]) was more strongly associated with ED than any other patient characteristic, including laparoscopic colectomy (6.82 [6.51-7.14], ref open colectomy). ED vs. non-ED patients had lower rates of 30-day (5.84 vs. 10.37%, p < 0.01) and bounceback (3.56 vs. 5.75%, p < 0.01) readmissions, overall complications (5.65 vs. 18.63%, p < 0.01) and post-discharge complications (4.21 vs. 7.49%, p < 0.01). Conclusions Robotic surgery was the variable most strongly associated with ED, with greater odds of ED compared to both laparoscopic and open colectomy. Patients who had ED after robotic surgery had lower rates of complications and readmission compared to non-ED patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Competing Interests: Declaration of competing interest Dr Joshua Wolf, clinical consult, Aroa Biosurgery No conflict of interest for other involved authors.

Introduction: Older and younger adults are offered similar analgesic options after hemorrhoid surgery (HS), but the differences in pain between the two populations are unknown. This study aims to compare postoperative pain outcomes after HS in older and younger individuals., Methods: This is a retrospective analysis of electronic medical records of patients who underwent HS between 2018 and 2023. Patients were excluded if additional anorectal procedures were performed at the time of HS. Data related to pain-related outcomes were compiled: (1) need for narcotic prescription refills; (2) documentation of a pain-related phone call within 30 d; (3) urgent postoperative office visit before regular scheduled follow-up; and (4) pain-related postoperative emergency department visits. Associations between age and pain-related outcomes were tested using Fisher's exact test, chi-square test, and covariate adjusted logistic regression modeling., Results: There were a total of 249 patients, 60 older adults, and 189 younger adults. Compared to younger patients, older adults demonstrated a reduced frequency of pain-related phone calls (10.3 versus 32.1%, P < 0.01) and opioid refills (0 versus 14.4%, P < 0.01). After adjusting for confounders, older age remained inversely associated with pain-related postoperative phone calls (odds ratio = 0.25, 95% confidence interval = [0.1-0.6], P = 0.003)., Conclusions: Older adults had better pain outcomes after HS in comparison to younger patients. These findings suggest that the postoperative analgesic needs of older patients after HS are lower than those of younger patients. Decisions regarding opioid prescription in older adults recovering from HS should be tailored to avoid narcotic-related complications., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Abstract: Mylott, JA, Potts, EM, Wolf, JH, Bullock, GS, and Nicholson, KF. Kinematic and kinetic differences between ball rotational exercises and the throwing motion in collegiate baseball athletes. J Strength Cond Res XX(X): 000-000, 2024-The purpose of this study was to observe the associations that medicine ball pushes and chops have on the lower extremities regarding ground reaction forces (GRF) and lead knee flexion angles and to compare these values with a regular baseball overhead throw. Lower extremity kinetics and kinematics were obtained via force plates and marker motion capture. Subjects (n = 35) included baseball players (age 19.7 ± 1.5 years). Five medicine ball movements of each type along with at least 3 pitches or 5 throws off the mound were recorded for data collection. Statistical parametric mapping, including analysis of variance and 2-way t-tests, was used to compare the variables of interest between the movements for continuous time data. All kinematic and kinetic variables were significantly different (p < 0.05) for some time during the motion between the different trial types of medicine ball exercises and throws. A medicine ball chop can increase peak drive leg GRF, whereas a push can help an athlete keep greater driver leg GRF and maintain ground connection into foot plant. A push helps train lead leg deficiencies in the delivery. Both the medicine ball chop and push have benefits for training lead leg stabilization and extension., (Copyright © 2024 National Strength and Conditioning Association.)

Background: A subset of patients in ACS-NCDB with stage-1 colon cancer received adjuvant chemotherapy (AC), in contrast to national guidelines. This study aimed to define this population and evaluate associations between AC and survival., Methods: Patients with T1-2N0 colon cancer from 2004 to 2016 were separated into AC and non-AC groups. Adverse pathological features (APF) included T2, poor differentiation, lymphovascular invasion, positive margin, and inadequate lymph nodes (<12). Cox proportional hazard models were used to estimate prognostic factors for overall survival (OS)., Results: A total of 1745 of 139,857 patients (1.2 %) received AC. Receiving AC was associated with male sex (p = 0.02), uninsured (p < 0.01), low income (p = 0.02), or having ≥2 APFs (p < 0.001). In the total cohort, AC was associated with increased mortality (HR 1.14 [1.04-1.24] P < 0.01). On subset analysis, AC was associated with improved OS for patients with ≥2 APFs (log-rank P=<0.001), and decreased mortality when adjusted for covariates (HR 0.81 [0.69-0.95] P=<0.01). The most significant predictor of mortality was old age (HR 3.78 [3.67, 3.89] p ≤ 0.01), followed by higher Charlson Comorbidity Index (HR 1.73 [1.69, 1.76] (p ≤ 0.01), and higher APF score (HR 1.46 [1.42, 15.2] p ≤ 0.01)., Conclusion: AC was associated with decreased survival in the total cohort of stage 1 colon cancer patients, but was associated with improved survival for patients with multiple APFs., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Investigations generally assess 30 days of perioperative outcomes with robotic-assisted and laparoscopic colectomy. Outcomes beyond 30 days serve as a quality metric of surgical services and an assessment of 90 days of outcomes may have greater clinical utility. The purpose of this study was to assess 90 days of outcomes, length of stay (LOS), and readmissions among patients who underwent a robotic-assisted versus laparoscopic colectomy using a national database. Patients undergoing either robotic-assisted or laparoscopic colectomy were identified using Current Procedural Terminology (CPT) codes within PearlDiver, a national, inpatient records database from 2010 to 2019. Outcomes were defined using the National Surgical Quality Improvement Program (NSQIP) risk calculator and identified using International Classification of Disease (ICD) diagnosis codes. Categorical variables were compared using chi-square tests, and continuous variables were compared using paired t tests. Covariate-adjusted regression models were also constructed to evaluate these associations while accounting for potential confounders. A total of 82,495 patients were assessed in this study. At 90 days, patients of the laparoscopic colectomy cohort experienced a higher rate of complications than patients who underwent robotic-assisted colectomy (9.5 vs. 6.6%, p < 0.001). There were no significant differences in LOS (6 vs. 6.5 days, p = 0.08) and readmissions (6.1 vs. 6.7%, p = 0.851) at 90 days. Patients undergoing robotic-assisted colectomy have a lower risk for morbidity at 90 days. Neither approach is superior for LOS nor 90 days of readmissions. Both techniques are effective minimally invasive procedures, yet patients may gain a greater risk benefit from robotic colectomy., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: The simplified frailty index (sFI) is a commonly used instrument to estimate postoperative risk, but its correlation with phenotypic frailty has been questioned. This study evaluates the relationship between sFI and phenotypic frailty, as measured by the Sinai Abbreviated Geriatric Evaluation (SAGE)., Methods: Charts were retrospectively reviewed from patients ≥75 years old who underwent surgery between 2012-2022. The sFI score was calculated by adding 1 point for hypertension, COPD, congestive heart failure, functional dependence, and diabetes (score 0-5). SAGE was calculated by adding 1 point for normal gait speed, normal Mini-Cog©, and independent activities of daily living (ADL) (0-3). Spearman rank correlation was used to test the relationship between sFI and SAGE. SAGE components were used as binary-dependent outcomes in covariate-adjusted logistic regression modeling to evaluate associations with sFI scores while adjusting for potential confounders., Results: 334 patients were assessed, with a mean age of 84.0. SAGE and sFI scores were significantly associated, with a modest inverse relationship (r=-0.24, p<0.0001). Each 1-point increase in sFI score was associated with increased odds of ADL deficit (OR 2.3, 95%CI [1.5-3.8], p<0.0001) and abnormal gait speed (OR 1.9, 95%CI 1.2-3.0, p<0.01). The sFI score was not associated with deficits in the Mini-Cog (OR 1.5, 95%CI [0.96-2.3], p=0.07)., Conclusion: Higher sFI was significantly associated with increased phenotypic frailty, particularly with the loss of physical condition and function but not associated with cognitive deficit. Therefore, sFI may not be an appropriate tool to estimate postoperative complications related to cognition, such as delirium risk., Competing Interests: Declaration of Competing Interest The authors in this study have no relevant conflicts of interest to disclose., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Purpose: Invasive surgical management of cryptoglandular perianal fistulas (PF) is challenging because of high recurrence rates and the potential for injury to the sphincter complex. In the present technical note, we introduce a minimally invasive treatment for PF using a perianal fistula implant (PAFI) comprising ovine forestomach matrix (OFM)., Methods: This retrospective observational case series highlights 14 patients who had undergone a PAFI procedure at a single center between 2020 and 2023. During the procedure, previously deployed setons were removed and tracts were de-epithelialized with curettage. OFM was rehydrated, rolled, passed through the debrided tract, and secured in place at both openings with absorbable suture. Primary outcome was fistula healing at 8 weeks, and secondary outcomes included recurrence or postoperative adverse events., Results: Fourteen patients underwent PAFI using OFM with a mean follow-up period of 37.6 ± 20.1 weeks. In follow-up, 64% (n = 9/14) had complete healing at 8 weeks and all remained healed, except one at last follow-up visit. Two patients underwent a second PAFI procedure and were healed with no recurrence at the last follow-up visit. Of all patients that healed during the study period (n = 11), the median time to healing was 3.6 (IQR 2.9-6.0) weeks. No postprocedural infections nor adverse events were noted., Conclusions: The minimally invasive OFM-based PAFI technique for PF treatment was demonstrated to be a safe and feasible option for patients with trans-sphincteric PF of cryptoglandular origin., (© 2023. The Author(s).)

Background: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes., Methods: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias., Results: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively., Conclusion: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Post-operative day zero (POD-0) discharge after laparoscopic appendectomy for uncomplicated appendicitis has been studied primarily in single-center or pediatric studies. A larger study from a national sample addressing high-yield outcomes can update and supplement current literature and evaluate early discharge rates. Methods: This is a retrospective, observational National Surgical Quality Improvement (NSQIP) database study of laparoscopic appendectomies for uncomplicated appendicitis performed 2016-2019, with discharge POD-0 or post-operative day one (POD-1). Study outcomes included any or serious complication, unplanned readmission, and unplanned return to operating room (OR). Unadjusted outcomes comparisons were estimated via chi-square tests. Multivariate logistic regression models were constructed to adjust for potential confounders (sex, ethnicity, frailty, ASA score, tobacco use and diabetes). Results: A total of 25,629 patients were included in this analysis. More patients were discharged POD-1 ( n  = 15,229) than POD-0 ( n  = 10,440). Rate of any or serious complication was lower in patients discharged POD-0 than POD-1 (any complication: 2.0 vs. 2.8, p  = 0.0002, serious complication: 1.4 vs. 2.1, p  < 0.0001). Unplanned return to OR and unplanned readmission rates were not different between POD-0 and POD-1 discharged groups ( p  = 0.9 and p  = 0.6, respectively). These findings were robust to adjustment for covariates in logistic regression modeling. Conclusions: This study found that unplanned readmission and other outcomes do not appear to be adversely affected by early discharge after laparoscopic appendectomy for uncomplicated appendicitis, confirming prior evidence on the topic in a large, national sample. It also found that early discharge does not appear to be used in most of these patients.

Background: Curative surgery for ulcerative colitis can be subdivided into restorative (with pouch and anastomosis) and non-restorative operations. Restorative surgery in older adults is controversial, due to concerns about surgical risk and long-term functional outcome. The goal of this study is to compare 30-day outcomes for restorative and non-restorative surgery in older adults with ulcerative colitis., Methods: Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from 2012-2018. Patients were included if they were >65 years old and had ulcerative colitis. Restorative and non-restorative surgeries were defined with procedure codes. Patient characteristics and adverse surgical outcomes were compared between restorative and non-restorative surgeries utilizing chi-square tests and Fisher's exact tests. Multivariate logistic regression models were constructed to evaluate the association of restorative versus non-restorative surgery with adverse surgical outcomes while adjusting for potential confounders., Results: Of 392 total patients, 95 had restorative and 297 had non-restorative surgery. Patients undergoing restorative surgery, compared to non-restorative surgery, were significantly younger (P<0.01), had lower incidences of steroid usage (P<0.001) and higher rates of readmission (P = 0.02). There were no differences in post-operative complications between the groups in both unadjusted analyses and covariate-adjusted regression analysis (P > 0.05)., Conclusion: In carefully selected older patients with ulcerative colitis, restorative surgery is associated with increased readmission, but otherwise similar rates of morbidity or mortality compared to non-restorative surgery. Data regarding postoperative functional outcome and quality of life are also needed to help select the most appropriate curative option for older adults., (Copyright © 2021. Published by Elsevier Inc.)

Aim: Emerging evidence has suggested that metformin may be protective against the development of human-papillomavirus-related cancers. Anal intraepithelial neoplasia (AIN) is highly associated with human papillomavirus infection and a precancerous status of anal cancer. The aim of this study was to investigate the relationship between metformin usage and the development of AIN in a large national sample., Methodology: The IBM MarketScan dataset was used to design a nested case-control study from 2010 to 2017. Patients aged 18-65 years with type 2 diabetes mellitus (DM) were evaluated, and cases of AIN were identified. Four controls were randomly selected in the risk set of each case by using incidence density sampling. The association between metformin usage and AIN was assessed using multivariate logistic regression modelling., Results: A total of 258 patients with type 2 DM were diagnosed with AIN during the study interval, and these were matched to 1032 control patients without a diagnosis of AIN. Patients who developed AIN had 38% lower odds of prior metformin use compared to those without a history of AIN (P < 0.01) and this finding remained robust after adjusting for age, sex, human immunodeficiency virus infection and DM complications (P = 0.02). Patients with AIN had 56% lower odds of long-term metformin use compared to control patients (P = 0.01)., Conclusions: An AIN diagnosis in patients with DM is associated with 56% lower likelihood of prior metformin use. This relationship suggests that metformin could potentially play a protective role against AIN. Prospective studies in non-diabetic patients are warranted to examine these findings further., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Background: Patients with Crohn's disease are particularly susceptible to preoperative frailty owing to the chronic nature of the illness and immunosuppressive therapy. The hypothesis in this study was that frailty would have a greater impact on postoperative outcome than age in older individuals with Crohn's disease., Methods: Data were obtained from the National Surgical Quality Improvement Program (NSQIP) from the years 2012 to 2018. Patients with Crohn's disease who underwent a bowel resection were identified from diagnostic and procedure codes. Frailty was assessed using the 5-point Simplified Frailty Index (0-not frail, 5-most frail). Age was defined as an ordinal variable with 3 age ranges (18-64, 65-79, >80 years). Aggregate morbidity was classified according to the standard NSQIP definitions. Simplified Frailty Index was evaluated as a potential predictor of morbidity and mortality using covariate-adjusted logistic regression modeling., Results: A total of 9,023 patients underwent bowel resection for Crohn's disease during the study period. Patient Simplified Frailty Index ranged from 0 to 3 (Simplified Frailty Index = 0, 82%; 1, 15%; 2, 2.5%; 3, 0.1%), and higher Simplified Frailty Index was associated with increased age (P < .01). In multivariate regression, a Simplified Frailty Index was significantly associated with postoperative morbidity (Simplified Frailty Index ≥ 2: odds ratio = 2.59, 95% confidence interval [1.84-3.63], P < .0001). In contrast, age was not found to be a significant predictor of morbidity when adjusted for Simplified Frailty Index and other covariates (P > .05)., Conclusion: Frailty is a stronger predictor than age for morbidity in Crohn's-related bowel resection. Functional assessments and vulnerability screening should be used to determine surgical candidacy rather than age alone., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background The study objectives were to transition in-person colorectal cancer multidisciplinary clinic (MDC) to a telehealth MDC (tele-MDC) format and to assess early outcomes.  Methods A colorectal tele-MDC was devised, in which patients used remote-access technology while supervised by a clinician. The team consisted of surgeons, medical oncologists, radiation oncologists, radiologists, and pathologists. Outcomes were assessed with patient and provider surveys, using a 5-point Likert scale (higher = more favorable). Results A total of 18 patients participated in the tele-MDC. Surveyed patients (n=18) and physicians (n=19) were satisfied with the quality of care (mean Likert = 4.93, 4.53, respectively), and low standard deviations (range 0-1.03) across all questions reflected homogeneity in satisfaction with the metrics surveyed. Conclusions This pilot study demonstrates that a functional colorectal cancer tele-MDC is a feasible alternative to in-person MDC during the coronavirus disease 2019 (COVID-19) pandemic, with the potential for a high degree of patient and physician satisfaction., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Aghedo et al.)

Background: There are conflicting data regarding the relationship between pathologic complete response (pCR) and post-operative complications following rectal cancer resection. The objective of this study was to compare the rates of morbidity among pCR patients and non-pCR patients and to identify factors that predict pCR morbidity in a large national database., Methods: This is a retrospective study using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy data (2016-18). Patients with neoadjuvant chemoradiation therapy followed by proctectomy were included, and divided into pCR and non-pCR groups according to final stage. The groups were compared with Student's t-test, Chi-squared or Fisher's exact test. Multivariate logistic regression models were constructed to estimate the association between pCR status and post-operative morbidity while adjusting for key covariates., Results: 244 pCR and 1656 non-pCR patients were included. pCR patients had higher body mass index (28.1 ± 6.2 vs. 29.1 ± 5.9 kg/m 2 ; p = 0.01) and lower pre-operative stage (T stage, p = 0.03; N stage, p < 0.001). The groups were equivalent with respect to surgical approach, type of surgery, and operative time (p > 0.05). Post-operative complications in pCR patients were less frequent than in non-pCR patients (23.0% vs. 29.3%; p = 0.04). This association was robust to adjustment for confounders in logistic regression, as patients with pCR had decreased odds of post-operative morbidity (OR 0.66, CI [0.43, 0.96], p = 0.04)., Conclusion: pCR is associated with fewer post-operative complications compared to non-pCR, suggesting that pCR is not a marker of severe pelvic fibrosis. This difference may be due to underlying tumor biology, and associated increased technical challenges resecting larger, non-responsive tumors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Discharging older individuals to rehabilitation facilities is associated with adverse outcomes, including readmission or increased mortality rate. As preoperative functional status is an important factor impacting patient outcome, we hypothesized that this would be associated with patient disposition to nonhome locations., Materials and Methods: A retrospective analysis was performed using data from the 2013-2018 American College of Surgeons National Surgical Quality Improvement Program, including targeted variables from the Geriatric Pilot Project. Patients aged 65 and older in 33 institutions across the nation were included (n = 44,219). Preoperative functional status was categorized as independent, partially dependent, and dependent. The primary outcome was home versus nonhome disposition. Nonhome was defined as rehabilitation facility and nursing home. Descriptive analyses were performed. Variables associated with postoperative discharge to nonhome were identified using logistic regression., Results: The largest percentage of operations was orthopedics (40.8%), followed by general surgery (29.2%) and vascular operations (10.0%). The majority of the patients were independent before operations (93.1% independent, 6% partially dependent, and 0.9% totally dependent). In regression analyses, patients who were partially dependent preoperatively had five times higher odds of discharging to nonhome, compared to patients who were independent (odds ratio [OR] 5.04, p < 0.01). Similarly, patients who were totally dependent had 3.2 higher odds of discharging to nonhome than patients who were independent (OR 3.22, p < 0.01)., Conclusion: Better preoperative functional status is associated with patient discharge to home in older adults. Preoperative interventions aimed at improving functional status, such as prehabilitation, may be beneficial in improving patient outcomes., (© 2021 The American Geriatrics Society.)

Background: A subset of patients who undergo colon resection for suspected diverticulitis will unexpectedly be found to have cancer. We hypothesized that a subset of variables could be used to help predict a diagnosis of cancer preoperatively., Methods: National Surgical Quality Improvement Program data (2012-2018) were used to identify all patients with a preoperative diagnosis of diverticulitis who had unexpected cancer using postoperative staging data. Key characteristics of the study groups were compared with χ 2 tests and multivariate logistic regression modeling., Results: A total of 17,368 patients were identified with an operative indication of acute diverticulitis. Of these, 164 (0.94%) had an unexpected postoperative diagnosis of cancer. Most cancer patients had locally advanced tumors (T1-2: 15%; T3: 39%; T4: 45%), and 37.1% had positive lymph nodes. Rates of margin positivity and inadequate lymph node harvest were 1.2% and 15.9%, respectively. In bivariate analyses, cancer patients had increased age (P < .01), decreased albumin (P < .001), and increased rates of preoperative anemia (P = .01), sepsis (P < .01), and weight loss (>10% in 6 months) (P < .001). The only variables significantly associated with cancer in multivariate regression analysis were sepsis (odds ratio 2.14, 95% confidence interval [1.3-3.6]; P < .01), weight loss (odds ratio 2.31, 95% confidence interval [1.1-4.4]; P = .01), and preoperative albumin level (odds ratio 0.64, 95% confidence [0.45-0.92]; P < .01)., Conclusion: An unexpected postoperative diagnosis of cancer occurs in a small percentage of patients with suspected diverticulitis. Surgeons should have a high index of suspicion for cancer in patients with sepsis or malnutrition., (Copyright © 2020 Elsevier Inc. All rights reserved.)

While the physiology of biological events such as conception, birth, and breastfeeding are largely identical across time, geography, and culture, the practices that shape women's experiences of conception, birth, and breastfeeding differ across time and place according to the ever-changing emphases of medical and popular culture. In the United States, as in most other wealthy countries, birth and infant feeding practices have changed continually and significantly in the last two centuries. In this essay, I reflect on how those changes have affected my life, first as a witness to friends' births, and eventually as a mother and a grandmother. Foremost, however, I explain how my personal experience with changing birth and breastfeeding practices shaped my interests as a historian of medicine, and how my professional interests and knowledge eventually shaped my daughter's experience of conception and birth.

Background: Malnutrition has been associated with adverse surgical outcomes, but data regarding its impact specifically in rectal cancer are sparse. The goal of this study was to use national data to determine the effects of malnutrition on surgical outcomes in rectal cancer resection., Methods: Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from the years 2012-2015. Patients were included on the basis of International Classification of Disease 9/10 and Current Procedural Terminology codes for rectal cancer and proctectomy. Malnutrition was defined as body mass index <18.5 kg/m 2 , weight loss >10% in 6 mo, or preoperative albumin <3.5 mg/dL. Associations between malnutrition and postoperative outcomes were assessed by the Student t-test and chi-square test. Multivariate regression models were constructed to adjust for potential confounders of the association between malnutrition and surgical outcomes., Results: Of the 9289 patients with primary rectal cancer who underwent resection, 1425 (15%) were in a state of malnutrition at the time of surgery. Patients with malnutrition had longer mean length of stay (LOS), and higher rates of 30-d mortality, wound infection, organ-space infection, sepsis, reoperation, prolonged LOS (>30 d), failure to wean off ventilator, renal failure, and cardiac arrest. With the exception of LOS, renal failure, and organ-space infection, malnutrition was still significantly associated with higher rates of these adverse outcomes after adjustment for confounders in multivariate regression models., Conclusions: Malnutrition is a practical marker associated with a variety of adverse outcomes after rectal cancer surgery, and it represents a potential target for nutritional therapies to improve surgical outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

In 1900, 13% of infants in the United States died before their first birthday, most of dehydration from diarrhea. As part of a nationwide effort to "save the babies," pediatricians focused on several endeavors-experimenting with commercially made infant-food products; working with dairy farmers to clean up cows' milk; lobbying to pass municipal and state legislation regulating the dairy industry; and devising mathematical "formulas" that represented instructions to chemists on how to "humanize" cows' milk for the needs of a particular infant. Pediatricians dubbed the latter endeavor "percentage feeding" and, from the 1890s to the 1920s, they deemed percentage feeding a lifesaving scientific achievement. The complex, virtually infinite array of mathematical formulas that comprised this infant-feeding system is the origin of the word "formula" as used today to describe artificial baby milk.

Purpose: Health professional organizations recommend exclusive breastfeeding for 6 months, but there are mothers, such as those with a history of breast cancer, who are unable to exclusively provide their milk for their infants. Minimal research has been published on mothers' experience with lactation, breastfeeding, and bottle-feeding after breast cancer. This study explored mothers' perspectives of infant feeding after a history of breast cancer., Methods: Qualitative interviews were completed with 20 mothers who had experience with infant feeding after breast cancer, including exclusive breastfeeding, partial provision of human milk with formula supplementation, and exclusive formula feeding., Results: Mothers shared their perceptions, barriers, and experiences of infant feeding. Four themes were identified: miracle of motherhood after breast cancer, medical misinformation or no available information contributing to the exacerbation of mothers' worries, post-breast-cancer feeding challenges, and desire for infant-feeding support rather than pressure., Conclusions: Mothers who have had breast cancer and have since given birth face specific challenges to infant feeding which are compounded by limited resources and knowledge among healthcare providers. Findings of the study highlight the importance of healthcare professionals becoming more educated to provide adequate support and evidence-based information on lactation and infant feeding for women with a history of breast cancer., Implications for Cancer Survivors: Understanding the experiences of women who have given birth after breast cancer can help women in similar situations know that they are not alone, identify resources, access peer support, and seek evidence-based infant feeding advice from healthcare providers involved in their care.

BACKGROUND Post-streptococcal glomerulonephritis (PSGN) is a well-known cause of renal injury. This disease is caused by a prior infection with specific nephritogenic strains of group A beta-hemolytic streptococcus resulting in formation of immune complexes in the glomeruli. Clinical presentation can range from asymptomatic, microscopic hematuria to the nephritic syndrome which is defined by red to brown urine, nephrotic range proteinuria, edema, hypertension, and acute kidney injury. A few reports have described PSGN in kidney transplant recipients in the post-transplantation period. However, biopsy-proven, donor-derived, PSGN in kidney transplant recipients has not been described. CASE REPORT Kidneys were donated from a 25-year-old Caucasian female with no history of hypertension or diabetes who had anoxic brain death in the setting of sepsis due to group A Streptococcus pyogenes bacteremia. The recipients were a 55-year-old male and a 68-year-old female, both of whom had end stage renal disease (ESRD) secondary to hypertensive nephrosclerosis. The recipients had kidney biopsies, one at the time of implantation and the other on post-operative day (POD) 2. Both biopsies showed streptococcal-associated glomerulonephritis. The prompt recognition and treatment of this disease in the immediate post-operative period resulted in histological resolution of the disease as well as good graft outcomes. CONCLUSIONS Utilizing kidneys from donors with streptococcal bacteremia is possible while maintaining a high degree of suspicion for possible streptococcal-associated glomerulonephritis.

In the late 19th-century United States and Europe, infants died at high rates from diarrhea. Physicians and social justice advocates responded to the public health crisis with attempts to clean up the water and cows' milk supplies, as well as social welfare legislation and assorted educational efforts to help mothers better care for their children. Most visible among the educational efforts were breastfeeding campaigns. A century later in developing countries, physicians and activists were confronted with a similar problem-infants dying from diarrhea due to the unethical advertising and marketing practices of formula companies. I argue in this article that crusades for social justice at the most basic level-to ensure that children will live to adulthood-have long been connected with efforts to safeguard mothers' ability to adequately breastfeed their children.

When physicians performed cesarean sections in the nineteenth century, they customarily sought agreement from all present before proceeding. In contrast, after the introduction of electronic fetal monitoring in the late 1960s, obstetricians obtained permission for a cesarean by offering a choice that ensured consent-give birth by cesarean or give birth vaginally to a damaged or dead baby. This article argues that the manner in which physicians obtained consent for cesareans in the nineteenth century was one factor that kept the cesarean rate low, while the manner in which physicians obtained consent in the late twentieth and early twenty-first centuries was one factor driving up the cesarean rate. The dissimilar approaches to consent did serve a common purpose, however. Each preserved physicians' reputations. With the surgery likely to end in a woman's death in the nineteenth century, consensus ensured that a bad outcome would be a shared burden. And because the fetal monitor, in exaggerating the risks of vaginal birth, changed the nature of the malpractice climate for obstetricians, the late-twentieth-century approach to consent similarly protected physicians. As one early twenty-first-century obstetrician quipped, "You don't get sued for doing a C-section. You get sued for not doing a C-section.", (© The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The PREDICTS project-Projecting Responses of Ecological Diversity In Changing Terrestrial Systems (www.predicts.org.uk)-has collated from published studies a large, reasonably representative database of comparable samples of biodiversity from multiple sites that differ in the nature or intensity of human impacts relating to land use. We have used this evidence base to develop global and regional statistical models of how local biodiversity responds to these measures. We describe and make freely available this 2016 release of the database, containing more than 3.2 million records sampled at over 26,000 locations and representing over 47,000 species. We outline how the database can help in answering a range of questions in ecology and conservation biology. To our knowledge, this is the largest and most geographically and taxonomically representative database of spatial comparisons of biodiversity that has been collated to date; it will be useful to researchers and international efforts wishing to model and understand the global status of biodiversity.

Following living donor liver transplantation (LDLT; and unlike deceased donor liver transplantation [DDLT]), the liver must rapidly regenerate, and sometimes segmental graft dysfunction (SGD) is observed. Hepatic regeneration requires substantial de novo lipid synthesis, and we previously reported that expression of lipid-related genes is dysregulated in LDLT. Here, we compare serum lipid measurements in 41 LDLT recipients and 43 DDLT recipients at baseline and at serial posttransplant time points. In addition, we examined whether serum lipid/apolipoprotein (apo) levels correlate with the degree of liver regeneration (measured using percent volume increase [%VI] at 3 months) or SGD in LDLT recipients. In contrast to DDLT, lipid levels declined early after LDLT but returned to baseline by 30 days. The odds ratio (OR) for achieving robust regeneration (>90 %VI) was 2.53 (95% confidence interval [CI], 1.15-5.52) for every 1 mg/dL increase in serum apoE at 30 days. The OR of SGD for every year increase in donor age was 1.19 (95% CI, 1.02-1.39), and 0.61 for every 1 mg/dL increase in serum high-density lipoprotein cholesterol at 7 days (95% CI, 0.34-1.11). No associations were detected between preoperative serum lipids/apos in LDLT donors and SGD or %VI in recipients. In conclusion, we suggest that initiation of regeneration prevents the liver from participating fully in lipid transport and metabolism. Inability to meet systemic metabolic needs may result in compromised liver function and SGD. Certain serum lipid concentrations correlate with extent of liver regeneration and function., (© 2015 American Association for the Study of Liver Diseases.)

Unlabelled: Loss of liver mass and ischemia/reperfusion injury (IRI) are major contributors to postresectional liver failure and small-for-size syndrome. Mesenchymal stromal cell- (MSC-) secreted factors are described to stimulate regeneration after partial hepatectomy. This study investigates if liver-derived MSC-secreted factors also promote liver regeneration after resection in the presence of IRI. C57BL/6 mice underwent IRI of 70% of their liver mass, alone or combined with 50% partial hepatectomy (PH). Mice were treated with MSC-conditioned medium (MSC-CM) or unconditioned medium (UM) and sacrificed after 6 or 24 hours (IRI group) or after 48 hours (IRI + PH group). Blood and liver tissue were analyzed for tissue injury, hepatocyte proliferation, and gene expression. In the IRI alone model, serum ALT and AST levels, hepatic tissue damage, and inflammatory cytokine gene expression showed no significant differences between both treatment groups. In the IRI + PH model, significant reduction in hepatic tissue damage as well as a significant increase in hepatocyte proliferation was observed after MSC-CM treatment., Conclusion: Mesenchymal stromal cell-derived factors promote tissue regeneration of small-for-size livers exposed to ischemic conditions but do not protect against early ischemia and reperfusion injury itself. MSC-derived factors therefore represent a promising treatment strategy for small-for-size syndrome and postresectional liver failure.

Biodiversity continues to decline in the face of increasing anthropogenic pressures such as habitat destruction, exploitation, pollution and introduction of alien species. Existing global databases of species' threat status or population time series are dominated by charismatic species. The collation of datasets with broad taxonomic and biogeographic extents, and that support computation of a range of biodiversity indicators, is necessary to enable better understanding of historical declines and to project - and avert - future declines. We describe and assess a new database of more than 1.6 million samples from 78 countries representing over 28,000 species, collated from existing spatial comparisons of local-scale biodiversity exposed to different intensities and types of anthropogenic pressures, from terrestrial sites around the world. The database contains measurements taken in 208 (of 814) ecoregions, 13 (of 14) biomes, 25 (of 35) biodiversity hotspots and 16 (of 17) megadiverse countries. The database contains more than 1% of the total number of all species described, and more than 1% of the described species within many taxonomic groups - including flowering plants, gymnosperms, birds, mammals, reptiles, amphibians, beetles, lepidopterans and hymenopterans. The dataset, which is still being added to, is therefore already considerably larger and more representative than those used by previous quantitative models of biodiversity trends and responses. The database is being assembled as part of the PREDICTS project (Projecting Responses of Ecological Diversity In Changing Terrestrial Systems - http://www.predicts.org.uk). We make site-level summary data available alongside this article. The full database will be publicly available in 2015.

Minimally invasive surgery for removal of a failed renal allograft has not previously been reported. Herein, we report the first robotic trans-abdominal transplant nephrectomy (TN). A 34-year-old male with Alport's syndrome lost function of his deceased donor allograft after 12 years and presented with fever, pain over his allograft and hematuria. The operation was performed intra-abdominally using the Da Vinci Robotic Surgical System with four trocars. The total operative time was 235 min and the estimated blood loss was less than 25 cm(3). There were no peri-operative complications observed and the patient was discharged to home less than 24 h postoperatively. The utilization of robotic technology facilitated the successful performance of a minimally invasive, trans-abdominal TN., (© Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Liver regeneration is a complex process that restores functional tissue after resection or injury, and it is accompanied by transient adenosine triphosphate depletion and metabolic stress in hepatic parenchymal cells. Heat shock protein 70 (Hsp70) functions as a chaperone during periods of cellular stress and induces the expression of several inflammatory cytokines identified as key players during early liver regeneration. We, therefore, hypothesized that Hsp70 is required for the initiation of regeneration. Investigations were carried out in a 70% partial hepatectomy mouse model with mice lacking inducible Hsp70 (Hsp70(-/-)). Liver regeneration was assessed postoperatively with the liver weight/body weight (LW/BW) ratio, and sera and tissues were collected for analysis. In addition, the expression of Hsp-related genes was assessed in a cohort of 23 human living donor liver transplantation donors. In mice, the absence of Hsp70 was associated with a reduced postoperative LW/BW ratio, Ki-67 staining, and tumor necrosis factor α (TNF-α) expression in comparison with wild-type mice. TNF-α expression was also reduced in livers from Hsp70(-/-) mice after induction with lipopolysaccharide (1 mg/kg). Clinically, the transcription of multiple Hsp genes (especially Hsp70 family members) was up-regulated after donor hepatectomy. Together, these results suggest that the early phase of successful liver regeneration requires the presence of Hsp70 to induce TNF-α. Further studies are required to determine whether Hsp70 contributes to liver regeneration as a chaperone by stabilizing specific interactions required for growth signaling or as a paracrine inflammatory signal, as can occur in models of shock., (© 2013 American Association for the Study of Liver Diseases.)

Context: When elderly patients face a terminal illness such as lung cancer, most are unaware that what we term in this article "the Lake Wobegon effect" taints the treatment advice imparted to them by their oncologists. In framing treatment plans, cancer specialists tend to intimate that elderly patients are like the children living in Garrison Keillor's mythical Lake Wobegon: above average and thus likely to exceed expectations. In this article, we use the story of our mother's death from lung cancer to investigate the consequences of elderly people's inability to reconcile the grave reality of their illness with the overly optimistic predictions of their physicians., Methods: In this narrative analysis, we examine the routine treatment of elderly, terminally ill cancer patients through alternating lenses: the lens of a historian of medicine who also teaches ethics to medical students and the lens of an actuary who is able to assess physicians' claims for the outcome of medical treatments., Findings: We recognize that a desire to instill hope in patients shapes physicians' messages. We argue, however, that the automatic optimism conveyed to elderly, dying patients by cancer specialists prompts those patients to choose treatment that is ineffective and debilitating. Rather than primarily prolong life, treatments most notably diminish patients' quality of life, weaken the ability of patients and their families to prepare for their deaths, and contribute significantly to the unsustainable costs of the U.S. health care system., Conclusions: The case described in this article suggests how physicians can better help elderly, terminally ill patients make medical decisions that are less damaging to them and less costly to the health care system., (© 2013 Milbank Memorial Fund.)

Simultaneous thoracic and abdominal (STA) transplantation is controversial because two organs are allocated to a single individual. We studied wait-list urgency, and whether transplantation led to successful outcomes. Candidates and recipients for heart-kidney (SHK), heart-liver (SHLi), lung-liver (SLuLi) and lung-kidney (SLuK) were identified through the United Network for Organ Sharing (UNOS) and outcomes were compared to single-organ transplantation. Since 1987, there were 1801 STA candidates and 836 recipients. Wait-list survival at 1- and 3 years for SHK (67.4%, 40.8%; N = 1420), SHLi (65.7%, 43.6%; N = 218) and SLuLi (65.7%, 41.0%; N = 122), was lower than controls (p < 0.001), whereas for SLuK (65.0%, 51.6%; N = 41) it was comparable (p = 0.34). All STA groups demonstrated similar 1- and 5 years posttransplant survival to thoracic controls. Compared to abdominal controls, 1- and 5 years posttransplant survival in SHK (85.3%, 74.0%; N = 684), SLuLi (75.5%, 59.0%; N= 42) and SLuK (66.7%, 55.6%; N = 18) was decreased (p < 0.01), but SHLi (85.9%, 74.3%; N = 92) was comparable (p = 0.81). In summary, STA candidates had greater risk of wait-list mortality compared to single-organ candidates. STA outcomes were similar to thoracic transplantation; however, outcomes were similar to abdominal transplantation for SHLi only. Although select patients benefit from STA, risk-exposure variables for decreased survival should be identified, aiming to eliminate futile transplantation., (© Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Early allograft dysfunction (EAD) occurring in the first week post-liver transplantation is associated with increased graft failure and mortality and is believed to be largely due to ischemia/reperfusion injury. We anticipated that the presence of EAD would be reflected by alterations in expression of serum proteins associated with an inflammatory response in the peri-operative period, and hypothesized that a specific pattern of expression might correlate with the development of EAD. The serum levels of 25 cytokines, chemokines, and immunoreceptors were measured by Luminex multiplex assays pre- and post-liver transplantation. Levels of each cytokine biomarker were compared in adult recipients with or without EAD at serial time points using samples collected pre-operatively and at 1, 7, 14, and 30 days post-transplant. EAD was defined according to standard criteria as maximum alanine transferase (ALT) or aspartate transferase (AST) levels on days 1-7 of >2000 U/ml, day 7 bilirubin level ≥10 mg/dl, or a day 7 international normalized ratio (INR) ≥1.7. Multivariable analyses showed that patients experiencing EAD had lower pre-operative IL-6 and higher IL-2R levels. Patients with EAD also showed higher MCP-1 (CCL2), IL-8 (CXCL8), and RANTES (CCL5) chemokine levels in the early post-operative period, suggesting up-regulation of the NF-kB pathway, in addition to higher levels of chemokines and cytokines associated with T cell immunity, including MIG (CXCL9), IP-10 (CXCL10) and IL-2R. These findings identify several possible biomarkers and pathways associated with EAD, that may guide future validation studies and investigation of specific cellular and molecular mechanisms of graft dysfunction. Furthermore, if validated, our findings may contribute to perioperative prediction of the occurrence of EAD and ultimately lead to identification of potential interventional therapies., (Copyright © 2011 American Association for the Study of Liver Diseases.)

Receptor tyrosine kinase signaling cooperates with WNT/β-catenin signaling in regulating many biological processes, but the mechanisms of their interaction remain poorly defined. We describe a potent activation of WNT/β-catenin by FGFR2, FGFR3, EGFR and TRKA kinases, which is independent of the PI3K/AKT pathway. Instead, this phenotype depends on ERK MAP kinase-mediated phosphorylation of WNT co-receptor LRP6 at Ser1490 and Thr1572 during its Golgi network-based maturation process. This phosphorylation dramatically increases the cellular response to WNT. Moreover, FGFR2, FGFR3, EGFR and TRKA directly phosphorylate β-catenin at Tyr142, which is known to increase cytoplasmic β-catenin concentration via release of β-catenin from membranous cadherin complexes. We conclude that signaling via ERK/LRP6 pathway and direct β-catenin phosphorylation at Tyr142 represent two mechanisms used by various receptor tyrosine kinase systems to activate canonical WNT signaling.

The OPTN defines high risk donors (HRDs), colloquially known as 'CDC high risk donors', as those thought to carry an increased risk of HIV window period (WP) infection prior to serologic detectability. However, the true risk of such infection remains unknown. To quantify the risk of WP infection in each HRD behavior category, we performed a systematic review and meta-analysis of studies of HIV prevalence and incidence. Of 3476 abstracts reviewed, 27 eligible studies of HIV infection in HRD populations were identified. Pooled HIV incidence estimates were calculated for each category of HRD behavior and used to calculate the risk of WP HIV infection. Risks ranged from 0.09-12.1 per 10 000 donors based on WP for ELISA and 0.04-4.9 based on nucleic acid testing (NAT), with NAT reducing WP risk by over 50% in each category. Injection drug users had the greatest risk of WP infection (4.9 per 10 000 donors by NAT WP), followed by men who have sex with men (4.2:10 000), commercial sex workers (2.7:10 000), incarcerated donors (0.9:10 000), donors exposed to HIV through blood (0.6:10 000), donors engaging in high-risk sex (0.3:10 000) and hemophiliacs (0.035:10 000). These estimates can help inform patient and provider decision making regarding HRDs., (©2010 The Authors Journal compilation©2010 The American Society of Transplantation and the American Society of Transplant Surgeons.)

The OPTN classifies high infectious risk donors (HRDs) based on criteria originally intended to identify people at risk for HIV infection. These donors are sometimes referred to as 'CDC high risk donors' in reference to the CDC-published guidelines adopted by the OPTN. However, these guidelines are also being used to identify deceased donors at increased risk of window period (WP) hepatitis C virus (HCV) infection, although not designed for this purpose. The actual risk of WP HCV infection in HRDs is unknown. We performed a systematic review of 3476 abstracts and identified 37 eligible estimates of HCV incidence in HRD populations in the United States/Canada. Pooled HCV incidence was derived and used to estimate the risk of WP infection for each HRD category. Risks ranged from 0.26 to 300.6 per 10,000 donors based on WP for ELISA and 0.027 to 32.4 based on nucleic acid testing (NAT). Injection drug users were at highest risk (32.4 per 10,000 donors by NAT WP), followed by commercial sex workers and donors exhibiting high risk sexual behavior (12.3 per 10,000), men who have sex with men (3.5 per 10,000), incarcerated donors (0.8 per 10,000), donors exposed to HIV infected blood (0.4 per 10,000) and hemophiliacs (0.027 per 10,000). NAT reduced WP risk by approximately 10-fold in each category., (©2011 The Authors Journal compilation©2011 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Purpose. The purpose of this study was to compare the surgical and pathological variables which impact rate of re-excision following breast conserving therapy (BCS) with or without concurrent additional margin excision (AM). Methods. The pathology database was queried for all patients with DCIS from January 2004 to September 2008. Pathologic assessment included volume of excision, subtype, size, distance from margin, grade, necrosis, multifocality, calcifications, and ER/PR status. Results. 405 cases were identified and 201 underwent BCS, 151-BCS-AM, and 53-mastectomy. Among the 201 BCS patients, 190 underwent re-excision for close or involved margins. 129 of these were treated with BCS and 61 with BCS-AM (P < .0001). The incidence of residual DCIS in the re-excision specimens was 32% (n = 65) for BCS and 22% (n = 33) for BCS-AM (P < .05). For both the BCS and the BCS-AM cohorts, volume of tissue excised is inversely correlated to the rate of re-excision (P = .0284). Multifocality (P = .0002) and ER status (P = .0382) were also significant predictors for rate of re-excision and variation in surgical technique was insignificant. Conclusions. The rate of positive margins, re-excision, and residual disease was significantly higher in patients with lower volume of excision. The performance of concurrent additional margin excision increases the efficacy of BCS for DCIS.

The American focus on the sexual purpose of breasts, rather than the physiological function of breasts, has serious public health consequences. Discomfort with breastfeeding in public lowers breastfeeding rates, which in turn negatively affects women's and children's short- and long-term health.