Higher Blood Transfusion Rate Research Articles

Hepatectomy After Conversion Therapy for Initially Unresectable HCC: What is the Difference?

Conversion therapy gives some patients with initially unresectable hepatocellular carcinoma (HCC) access to surgery. The purpose of this study was to evaluate the safety and efficacy of hepatectomy after conversion therapy and how it differed from those who undergoing direct hepatectomy. From January 2018 to April 2022, 745 patients underwent hepatectomy for HCC were enrolled. Among them, 41 patients of unresectable HCC underwent hepatectomy after conversion therapy. A demographically and clinically comparable cohort was created from the remaining patients in a 1:1 ratio using propensity score matching. The median duration of conversion therapy was 108 (42-298) days, 8 patients achieved complete response (CR) and 33 achieved partial response (PR). Conversion therapy resulted in some degree of myelosuppression, but liver function index remained good. Compared with the direct hepatectomy group, the conversion group had more blood loss (600 mL vs 400 mL, p=0.015), longer operative time (270 min vs 240 min, p=0.02), higher blood transfusion rates, and longer hospital stay (8 days vs 11 days, p<0.001). Patients in the conversion group had significantly more complications of any grade (82.9% vs 51.2%, p=0.002) and grade 3/4 (26.8% vs 4.9%, p=0.013), and 6 patients developed post-hepatectomy liver failure (PHLF). There were no deaths in either group. All patients achieved R0 resection, 6 (6/41, 14.6%) achieved pathological complete response (pCR), 14 achieved major pathologic responses (MPR). During a median follow-up of 12.8 months, 14 patients in the conversion group experienced recurrence or metastasis, no deaths. Hepatectomy after conversion therapy was more difficult than direct hepatectomy, but accurate preoperative assessment could ensure the safety of the surgery. The damage of liver function after conversion therapy was more severe than expected, PHLF should be prevented and treated. Hepatectomy was effective and necessary, postoperative pathological examination could provide guidance for adjuvant therapy.

Mutliple Myeloma Increases the Mortality Rate in Patients Admitted for Upper GI Bleed: An Analysis of National Inpatient Database

Introduction Multiple myeloma is a malignant disease of terminally differentiated B cells presenting with bone lesions, renal abnormalities, electrolyte changes and infections. It can occasionally leave the bone medullary space and involve other systems like respiratory and gastrointestinal (GI) tract to form plasmacytomas. The extramedullary spread into the GI tract results in typical presentation of hematemesis and melena. There have been a few cases that have reported the same, but the true prevalence and mortality of these patients is not well known. The aim of the study was to evaluate role of multiple myeloma on the in-hospital outcomes in patients admitted for Upper GI bleed in the United States. Methodology We conducted retrospective analysis utilizing Nationwide Inpatient Database (NIS) from year 2016-2019. Patients with age 18 years or more admitted to the hospital due to non-variceal Upper GI bleed were included in our study and it was further divided based on presence (study group) or absence (control group) of underlying Multiple Myeloma. ICD-10 CM codes were used to identify patient population. Chi-square test was used to compare categorical variables and Wilcoxon rank sum test for continuous variables. Impact of multiple myeloma on the in-hospital outcomes and healthcare utilization was evaluated using multivariate logistic regression analysis. Results The sample size included 1,007,765 patients admitted for upper GI bleed, of which 0.31% had underlying multiple myeloma. Patients with underlying multiple myeloma were relatively older with mean age of 72 years compared to 65 years in group with no multiple myeloma (p<0.001). Females constituted 40.36% of the multiple myeloma group compared to 44.63% of patients without it. There was a higher mortality rate (5.03%) in those with multiple myeloma compared to those without it (1.9%) (adjusted OR=2.53, p<0.001). They also had a higher rate of blood transfusion (45.22% vs 33.91%) compared to those with no underlying multiple myeloma (adjusted OR=1.42, p<0.001). The adjusted mean total hospitalization charge was $14,531 higher and adjusted mean length of stay was 1.1 day more in those with underlying multiple myeloma compared to those without it, with p<0.001. Conclusion Our study showed that Multiple Myeloma increases the mortality rate by more than two and half fold in patients presenting with upper GI bleed. It also poses a significant burden on the healthcare and therefore, physicians should be more vigilant when encountered with such challenges. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Does pre-arthroplasty antiviral treatment for hepatitis C reduce complication rates after total shoulder arthroplasty? A matched cohort study.

Hepatitis C virus (HCV) is associated with increased complications of risk after arthroplasty. The purpose of this study was to examine the impact of HCV and a pre-arthroplasty antiviral treatment on complications following total shoulder arthroplasty (TSA). A retrospective matched cohort study was conducted using an administrative claims database. Patients who underwent TSA were identified with Current Procedural Terminology -23472 and International Classification of Diseases procedural codes. A total of 1244 HCV patients were matched 1:3 with 3732 noninfected controls across age, sex, diabetes mellitus, tobacco use, and obesity. The HCV patients with treatment before TSA were identified by claims containing antiviral drug codes. Multivariable logistic regression was used to compare rates of 90-day medical complications and prosthesis-related complications within 2 years postoperatively for (1) HCV patients vs. controls, (2) antiviral-treated HCV patients vs. controls, and (3) antiviral-treated HCV patients vs. untreated HCV patients. Patients with HCV exhibited significantly higher rates of blood transfusion (OR 2.12), acute kidney injuries (OR 1.86), inpatient readmission (OR 2.06), revision TSA (OR 1.48), dislocation (OR 1.92), mechanical complications (OR 1.39), and prosthetic joint infection (OR 1.53) compared to controls. Antiviral-treated HCV patients exhibited a significantly lower rate of myocardial infarction (OR 0.27) and comparable rates of all other complications relative to controls (all P>.05). Compared to untreated HCV patients, antiviral-treated HCV patients exhibited significantly lower rates of 90-day medical complications (OR 0.57) and prosthetic joint infection (OR 0.36). HCV is associated with significantly increased complication rates after TSA. Antiviral treatment before TSA may reduce the risk of postoperative complications.

Endoscopic strip craniectomy with molding helmet therapy versus spring-assisted cranioplasty for nonsyndromic single-suture sagittal craniosynostosis: a systematic review.

Endoscopic strip craniectomy with postoperative molding helmet therapy (ESC-H) and spring-assisted cranioplasty (SAC) are commonly used minimally invasive techniques for correction of nonsyndromic sagittal craniosynostosis, but it is unclear which, if either, is superior. Therefore, the authors undertook a systematic review to compare ESC-H with SAC for the surgical management of nonsyndromic single-suture sagittal craniosynostosis. Studies were identified through a systematic and comprehensive search of four databases (Embase, MEDLINE, and two databases in the Cochrane Library). Databases were searched from inception until February 19, 2021. Pediatric patients undergoing either ESC-H or SAC for the management of nonsyndromic single-suture sagittal craniosynostosis were included. Systematic reviews and meta-analyses, single-patient case reports, mixed cohorts of nonsyndromic and syndromic patients, mixed cohorts of different craniosynostosis types, and studies in which no outcomes of interest were reported were excluded. Outcomes of interest included reoperations, blood transfusion, complications, postoperative intensive care unit (ICU) admission, operative time, estimated blood loss, length of hospital stay, and cephalic index. Pooled summary cohort characteristics were calculated for each outcome of interest. Methodological quality was assessed using the Newcastle-Ottawa Scale. The study was reported in accordance with the 2020 PRISMA statement. Twenty-two studies were eligible for inclusion in the review, including 1094 patients, of whom 605 (55.3%) underwent ESC-H and 489 (44.7%) underwent SAC for nonsyndromic sagittal craniosynostosis. There was no difference between the pooled estimates of the ESC-H and SAC groups for operative time, length of stay, estimated blood loss, and cephalic index. There was no difference between the groups for reoperation rate and complication rate. However, ESC-H was associated with a higher blood transfusion rate and higher postoperative ICU admission. The available literature does not demonstrate superiority of either ESC-H or SAC, and outcomes are broadly similar for the treatment of nonsyndromic sagittal craniosynostosis. However, the evidence is limited by single-center retrospective studies with low methodological quality. There is a need for international multicenter randomized controlled trials comparing both techniques to gain definitive and generalizable data.

Does the transfusion rate following reverse total shoulder arthroplasty warrant aggressive perioperative blood management? An indications-based analysis

HypothesisWe hypothesized that certain operative conditions are more likely to require transfusion after reverse total shoulder arthroplasty (RTSA), but found no data comparing transfusion rates for traumatic, post-traumatic, and non-traumatic indications. MethodsRetrospective review identified 1083 patients with RTSA. After exclusion of revision and tumor cases, 783 patients were divided into 3 groups as follows: traumatic (acute fractures, fracture-dislocations), post-traumatic (nonunions, malunions, chronic dislocations), or non-traumatic (chronic rotator cuff insufficiency, glenohumeral arthritis with advanced glenoid wear). Demographics, operative indications, preoperative hematocrit, postoperative hematocrit, change in hematocrit, estimated blood loss, operative time, and blood transfusion rates were compared. We constructed a logistic regression model to determine the risk factors predicting blood transfusion. ResultsIndications were acute trauma in 83 patients, post-traumatic sequelae in 65, and non-traumatic conditions in 635. There were no statistically significant differences regarding body mass index (P = .5) or American Society of Anesthesiologists score (P = .11). There were more females in the traumatic and post-traumatic cohorts than in the non-traumatic cohort (P < .001). Surgical age was younger in the post-traumatic cases (P = .002). The overall frequency of blood transfusion was 4.6% (36/783): traumatic, 19% (16/83); post-traumatic, 17% (11/65); and non-traumatic, 1.4% (9/635). Both the traumatic and post-traumatic groups had significantly higher rates of blood transfusion than non-traumatic cases (P < .001). Preoperative hematocrit was lower in the traumatic group and estimated blood loss was higher in the traumatic and post-traumatic groups (P = .001). Post-traumatic patients experienced the greatest drop in postoperative hematocrit from preoperative levels. The multivariate logistic regression model showed that traumatic and post-traumatic indications for surgery were each an independent risk factor for blood transfusion, as was change in hematocrit, body mass index, surgical age, estimated blood loss, and preoperative hematocrit. ConclusionsOur results suggest that acute trauma as the indication for RTSA is the strongest independent risk factor for blood transfusion followed by post-traumatic sequelae. Surgeons should be aware of the markedly increased risk of transfusion based purely on these 2 surgical indications especially when in combination with other predictors of transfusion.

Impact of sarcopenia on outcomes of patients undergoing liver resection for hepatocellular carcinoma.

BackgroundPrevious studies have indicated that sarcopenia is associated with poor post‐operative outcomes in liver cancer patients, but the studies are limited by confounding from mixed diseases, retrospective data, and non‐standardized measurement methods. At present, there is no research with both muscle mass and strength as predictors for hepatocellular carcinoma (HCC) outcomes. We studied the impact of sarcopenia on post‐operative outcomes in HCC patients in a cohort study designed according to the European Working Group on Sarcopenia in Older People standards.MethodsA total of 781 consecutive patients admitted to our centre were registered from May 2020 to August 2021. All participants submitted questionnaires and underwent handgrip strength, chair stand test, physical performance, and computed tomographic evaluation. Then, they were divided into three groups according to muscle mass and strength: Group A (reduced muscle mass and strength), Group B (reduced muscle strength or reduced muscle mass), and Group C (normal muscle mass and strength). The baseline data and post‐operative outcomes were compared and analysed. The primary outcome variable in this study was the presence of a major post‐operative complication, and the secondary outcome was the 90‐day re‐admission rate.ResultsA total of 155 patients [median age, 60.00 (IQR, 51.00–66.00) years; 20 females (12.90%)] were included after strict exclusion. The mean (SD) BMI was 23.37 ± 0.23 kg/m2. The mean (SD) SMI of all participants was 47.05 ± 0.79 cm2/m2, and the mean (SD) handgrip strength was 32.84 ± 0.69 kg. Among them, 77 (49.68%) patients underwent laparoscopic hepatectomy, and 73 (47.10%) patients received major hepatectomy. Regarding the post‐operative results, Group A had a higher rate of major complications [40.91% (9 of 22) vs. 11.94% (8 of 67) in Group B and 6.06 (4 of 66) in Group C; P = 0.001], higher rate of blood transfusion (77.27% vs. 46.27% in Group B and 42.42% in Group C; P = 0.015), higher hospitalization expenses (P = 0.001), and longer hospital stay (P < 0.001). There was no difference in 90‐day re‐admission rates among the three groups. Sarcopenia (hazard ratio, 10.735; 95% CI, 2.547–45.244; P = 0.001) and open surgery (hazard ratio, 4.528; 95% CI, 1.425–14.387; P = 0.010) were independent risk factors associated with major complications.ConclusionsSarcopenia is associated with adverse outcomes after liver resection for HCC. It should be evaluated upon admission to classify high‐risk patients and reduce the risk of major complications.

Impact of Human Immunodeficiency Virus on Postoperative Outcomes following Osteonecrosis-Indicated Total Hip Arthroplasty

AbstractOsteonecrosis (ON) of the femoral head in human immunodeficiency virus (HIV)-positive patients is often treated with total hip arthroplasty (THA). The purpose of this study was to determine the effect that HIV positive status and acquired immunodeficiency syndrome (AIDS) have on postoperative complication rates and outcomes in patients with ON treated with THA. Patients who underwent primary ON-indicated THA with a minimum of 2-year follow-up were identified in a national database (PearlDiver Technologies) using Current Procedural Terminology and International Classification of Diseases codes. These patients were stratified into two cohorts: those who were HIV-positive and those who were HIV-negative (control). The HIV-positive cohort was further stratified into those with AIDS and those with asymptomatic HIV at the time of THA. Univariate and multivariate analyses were conducted to determine associations between the three cohorts and their 90-day, and 2-year outcomes were each compared with HIV-negative patients. In this study, 1,163 patients were in the HIV-positive cohort and 34,288 were in the HIV-negative cohort. In the HIV-positive cohort, there were significantly higher 90-day rates of renal failure (odds ratio [OR] = 1.874; p &lt; 0.001), pneumonia (OR = 1.682; p = 0.002), and sepsis (OR = 1.975; p &lt; 0.001). The asymptomatic HIV cohort and AIDS cohort followed similar associations as the HIV cohort; however, the AIDS cohort also had significantly higher rate of blood transfusion (OR = 1.692; p = 0.012) and deep vein thrombosis (OR = 1.765; p = 0.036). HIV infection, whether symptomatic or not, and AIDS are associated with a higher risk of short-term complications after THA. Physicians must consider this risk and discuss with their patients to reduce future complications.

Endoscopic strip craniectomy with orthotic helmeting for safe improvement of head growth in children with Apert syndrome.

Bilateral coronal craniosynostosis in Apert syndrome is traditionally managed with open cranial vault remodeling procedures like fronto-orbital advancement (FOA). However, as minimally invasive procedures gain popularity, limited data exist to determine their efficacy in this syndromic population. This study examines whether endoscopic strip craniectomy (ESC) is inferior to FOA in correcting head growth in patients with Apert syndrome. The authors conducted a retrospective review of children with Apert syndrome over a 23-year period. Postoperative head circumferences until 24 months of age were compared for patients treated with ESC versus FOA by using normative growth curves. Intraoperative and postoperative morbidity was compared between groups. The median postoperative follow-up for the FOA (n = 14) and ESC (n = 16) groups was 40 and 28.5 months, the median age at operation was 12.8 and 2.7 months, and the median operative time was 285 and 65 minutes, respectively (p < 0.001). The FOA group had significantly higher rates of blood transfusion, ICU admission, and longer hospital length of stay (p < 0.01). There were no statistically significant differences in premature reossification rates, complications, need for further procedures, or complaints of asymmetry. Compared to normative growth curves, all patients in both groups had head circumferences comparable to or above the 85th percentile at last follow-up. Children with Apert syndrome and bilateral coronal craniosynostosis treated with ESC experience early normalization of head growth and cephalic index that is not inferior to those treated with FOA. Longer-term assessments are needed to determine long-term aesthetic results and the correlation between head growth and neurocognitive development in this population.

High rates of blood transfusion associated with Parkinson’s disease

BackgroundAs evidence continues to accumulate regarding the multi-organ dysfunction associated with Parkinson’s disease (PD), it is still unclear as to whether PD increases the risk of hematological pathology. In this study, the authors investigate the association between PD and hematological pathology risk factors.MethodsThis retrospective cohort analysis was conducted using 8 years of the National Readmission Database. All individuals diagnosed with PD were queried at the time of primary admission. Readmissions, complications, and risk factors were analyzed at 30-, 90-, 180-, and 300-day intervals. Statistical analysis included multivariate Gaussian-fitted modeling using age, sex, comorbidities, and discharge weights as covariates. Coefficients of model variables were exponentiated and interpreted as odds ratios.ResultsThe database query yielded 1,765,800 PD patients (mean age: 76.3 ± 10.4; 44.1% female). Rates of percutaneous blood transfusion in readmitted patients at 30, 90, 180, and 300 days were found to be 8.7%, 8.6%, 8.3%, and 8.3% respectively. Those with anti-parkinsonism medication side effects at the primary admission had increased rates of gastrointestinal (GI) hemorrhage (OR: 1.02; 95%CI: 1.01–1.03, p < 0.0001) and blood transfusion (OR: 1.06; 95%CI: 1.05–1.08, p < 0.0001) at all timepoints after readmission. PD patients who experienced GI hemorrhage of any etiology, including as a side effect of anti-parkinsonism medication, were found to have significantly higher rates of blood transfusion at all timepoints (OR: 1.14; 95%CI: 1.13–1.16, p < 0.0001).ConclusionsBlood transfusions were found to be significantly associated with anti-parkinsonism drug side effects and GI hemorrhage of any etiology.

Does Chronic Kidney Disease Really Affect the Complications and Prognosis After Liver Resection for Hepatocellular Carcinoma? A Meta-Analysis.

PurposeThe purpose of this meta-analysis was to analyze whether chronic kidney disease (CKD) affected the complications and prognosis after liver resection for hepatocellular carcinoma.MethodsThe PubMed, Embase, and Cochrane Library databases were searched from inception to 22 February 2022 to find eligible studies. Complications, overall survival (OS), and disease-free survival (DFS) were collected, and this meta-analysis was performed with RevMan 5.3.ResultsA total of nine studies including 6,541 patients were included in this meta-analysis. After pooling all baseline information, the CKD group had a higher rate of Child-Pugh grade B than the Non-CKD group (OR = 1.58, 95% CI = 1.3 to 1.93, P < 0.00001). As for surgery-related information, the CKD group had larger blood loss (MD = −404.79, 95% CI = −509.70 to −299.88, P < 0.00001), and higher rate of blood transfusion (OR = 2.47, 95% CI = 1.85 to 3.3, P < 0.00001). In terms of complications, the CKD group had a higher rate of overall complications (OR = 2.1, 95% CI = 1.57 to 2.81, P < 0.00001) and a higher rate of ≥ grade III complications (OR = 2.04, 95% CI = 1.57 to 2.81, P = 0.0002). The CKD group had poor OS compared with the non-CKD group (HR = 1.28, 95% CI = 1.1 to 1.49, P = 0.001). However, in terms of DFS, no significant difference was found (HR = 1.11, 95% CI = 0.96 to 1.28, P = 0.16).ConclusionPreexisting CKD was associated with higher ratio of complications and poor OS.

Comparison of Extramedullary and Intramedullary Implants for Stable Intertrochanteric Fractures: Have We Swung the Pendulum Too Far the Other Way?

Although intramedullary implants are commonly used to treat stable intertrochanteric (IT) fractures, there is a lack of evidence to demonstrate their superiority over extramedullary implants in treating these fractures. The purpose of this study was to compare short-term outcomes (<30 days) between intramedullary and extramedullary implants in patients with closed nondisplaced stable IT fractures. Patients with closed nondisplaced stable IT fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program database between 2016 and 2019. Patients who either underwent extramedullary implant or intramedullary implant fixation were selected for this analysis. Postoperative outcomes included transfusion, surgical complications (stroke, myocardial infarction, venous thromboembolism, pneumonia, renal failure/insufficiency, surgical site infection, urinary tract infections, and sepsis), weight-bearing on postoperative day 1, discharge destination, place of residence at 30 days after the operation, days from operation to discharge, readmission related to the index procedure, any readmission, revision surgery, and mortality. Of the 3,244 cases identified for the study, 2,521 (77.7%) underwent intramedullary nailing (IMN). Based on adjusted multivariable analysis, surgical complications between the two intervention groups were not statistically significantly (odds ratio [OR] 1.142; confidence interval [CI], 0.838 to 1.558; P = 0.4). However, patients who underwent IMN were associated with higher rates of blood transfusions (OR, 1.35, CI, 1.042 to 1.748, P = 0.023), more likely discharged to a place other than home (OR, 1.372, CI, 1.106 to 1.700, P = 0.004), and more likely to get readmitted (OR, 1.783, CI, 1.157 to 2.75, P = 0.009). Patients treated with IMN were associated with lower postoperative length of stay (OR 0.982, CI 0.967 to 0.998, P = 0.030). Our study found that extramedullary implants were associated with lower transfusions rates, lower readmissions, and better patient disposition. We recommend surgeons to consider extramedullary implants when treating stable IT fractures, especially if the patient is anemic or at high risk for hospital readmission. Level III. Retrospective cohort study.

Risk factors for obstetric anal sphincter injury among adolescents

ObjectiveData regarding the risk factors for obstetrical anal sphincter injury (OASI) among nulliparous adolescent women are scarce. We aimed to evaluate these risk factors. Study designA retrospective case-control study of nulliparous women aged ≤ 21 who delivered vaginally between 3/2011 and 6/2021. Maternal and intrapartum characteristics were compared between OASI and no-OASI groups. ResultsOf 1,342 deliveries, 22 (1.6%) cases of OASI were diagnosed. Maternal anthropometric and demographic characteristics did not vary between study groups. Gestational comorbidity (diabetic and hypertensive disorders) was associated with an increased risk for an OASI [OR 95% CI 3.1 (1.1–8.6)]. The rate of prolonged second stage was associated with an OASI [OR 95% CI 2.5 (1.1–6.5)]. The mode of delivery was similar in both groups. There were no forceps deliveries in the OASI group. Birthweight and the proportion of newborns weighing more than 4,000 g were similar in both study groups. All sonographic biometric measurements did not vary between study groups. Women with an OASI had higher rate of blood transfusion [OR 95% CI 11.4 (3.1–42.0)].In a multivariable regression analysis, including birthweight, vacuum assisted delivery, prolonged second stage and gestational comorbidity - gestational comorbidity was the only independent factor associated with the occurrence of an OASI [adjusted OR 95% CI 2.9 (1.05–8.17)]. ConclusionGestational comorbidity is the only predictor of OASI among nulliparous adolescent women.

Effects of Iron Sucrose and Erythropoietin on Transfusion Requirements in Patients with Preoperative Iron Deficiency Anemia Undergoing on-Pump Coronary Artery Bypass Graft.

Background: Preoperative anemia is an independent risk factor for higher rates of blood transfusion in cardiac surgery. This study aimed to evaluate the effects of intravenous iron sucrose and erythropoietin on transfusion requirements in patients with preoperative iron deficiency anemia (IDA) undergoing on-pump coronary artery bypass graft (CABG) surgery. Methods: In this open-label, randomized clinical trial, patients with preoperative IDA who were candidates for on-pump CABG were randomized into intervention (iron plus erythropoietin) or control groups. Iron sucrose was administered as a 200 mg intravenous dose and erythropoietin as a 100 IU/kg bolus 1 to 2 days before surgery. The primary outcome was the amount of blood transfusion during the first 4 postoperative days. Results: The study population consisted of 114 patients. The mean age was 64.11±8.18 years in the intervention group and 63.35±8.70 years in the control group. Twenty-seven patients (47.4%) in the intervention group and 25 (43.9%) in the control group were males. The number of red blood cell units transfused per patient exhibited a significant fall in the intervention group compared with the control group (P˂0.001). The ferritin level showed a significant rise in the intervention group on postoperative day 7 (P=0.027). The length of stay in the intensive care unit and the hospital was significantly lower in the intervention arm (P=0.041 and P=0.006, respectively). No adverse events were reported in both groups. Conclusion: The use of erythropoietin and iron sucrose 1 to 2 days before surgery significantly decreased the need for blood transfusion in patients with IDA undergoing CABG without any significant adverse events.

Hydroxyethyl Starch for Fluid Management in Patients Undergoing Major Abdominal Surgery: A Systematic Review With Meta-analysis and Trial Sequential Analysis.

In critically ill patients, warnings about a risk of death and acute kidney injury (AKI) with hydroxyethyl starch (HES) solutions have been raised. However, HES solutions may yet have a role to play in major abdominal surgery. This meta-analysis and trial sequential analysis (TSA) aimed to investigate the effect of HES intravascular volume replacement on the risk of AKI, intraoperative blood transfusion, and postoperative intra-abdominal complications compared to crystalloid intravascular volume replacement. In this meta-analysis and TSA, we searched for randomized controlled trials (RCTs) comparing intraoperative HES intravascular volume replacement to crystalloid intravascular volume replacement in adult patients undergoing major abdominal surgery. Primary outcome was 30-day AKI, defined as a binary outcome according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, combining stages 1, 2, and 3 into an AKI category versus no AKI category (stage 0). Secondary outcomes included rates of intraoperative blood transfusion and postoperative intra-abdominal complications. We used random effects models to calculate summary estimates. We used relative risk (RR) as summary measure for dichotomous outcomes, with corresponding 95% confidence intervals (CIs) for the primary outcome (P value <.05 was considered statistically significant) and 99% CI after Bonferroni correction for the secondary outcomes (P value <.01 was considered statistically significant). Seven RCTs including 2398 patients were included. HES intravascular volume replacement was not associated with an increased risk of 30-day AKI (RR = 1.22, 95% CI, 0.94-1.59; P = .13), when compared to crystalloid intravascular volume replacement. According to TSA, this analysis was underpowered. HES intravascular volume replacement was associated with higher rates of blood transfusion (RR = 1.57 99% CI, 1.10-2.25; P = .001), and similar rates of postoperative intra-abdominal complications (RR = 0.76 99% CI, 0.57-1.02; P = .02). In this meta-analysis to focus on HES intravascular volume replacement in major abdominal surgery, HES intravascular volume replacement was not associated with a higher risk of 30-day AKI when compared to crystalloid intravascular volume replacement. However, CI and TSA do not exclude harmful effects of HES intravascular volume replacement on the renal function.

Regular feedback on inter-hospital transfer improved the clinical outcome and survival in patients with multiple trauma: a retrospective cohort study

BackgroundUndertriage of major trauma patients is unavoidable, especially in the trauma system of rural areas. Timely stabilization and transfer of critical trauma patients remains a great challenge for hospitals with limited resources. No definitive measure has been proven to improve the outcomes of patients transferred with major trauma. The current study hypothesized that regular feedback on inter-hospital transfer of patients with major trauma can improve quality of care and clinical outcomes.MethodThis retrospective cohort study retrieved data of transferred major trauma patients with an injury severity score (ISS) > 15 between January 2010 and December 2018 from the trauma registry databank of a tertiary medical center. Regular monthly feedback on inter-hospital transfers was initiated in 2014. The patients were divided into a without-feedback group and a with-feedback group. Demographic data, management before transfer, and outcomes after transfer were collected and analyzed.ResultsA total of 178 patients were included: 69 patients in the without-feedback group and 109 in the with-feedback group. The with-feedback group had a higher ISS (25 vs. 27; p = 0.049), more patients requiring massive transfusion (14.49% vs. 29.36%, p = 0.036), and less patients with Glasgow Coma Scale ≤8 (30.43% vs. 23.85%, p < 0.001). After adjusting for confounding factors, the with-feedback group was associated with a higher rate of blood transfusion before transfer (adjusted odds ratio [aOR]: 2.75; 95% confidence interval [CI]: 1.01–7.52; p = 0.049), shorter time span before blood transfusion (− 31.80 ± 15.14; p = 0.038), and marginally decreased mortality risk (aOR: 0.43; 95% CI: 0.17–1.09; p = 0.076).ConclusionThis study revealed that regular feedback on inter-hospital transfer improved the quality of blood transfusion.

Low serum calcium is associated with perioperative blood loss and transfusion rate in elderly patients with hip fracture: a retrospective study

BackgroundTo investigate whether hypocalcemia influenced total blood loss and transfusion rate in elderly patients with hip fracture.MethodsFrom our hip fracture database, patients were consecutively included between January 2014 and December 2020. Serum calcium level was corrected for albumin concentration, and hypocalcaemia was defined as corrected calcium < 2.11 mmol/L. Hemoglobin and hematocrit were obtained on admission day and postoperative day, and blood transfusions were collected. According to the combination formulas of Nadler and Gross, the total blood loss of each patient was calculated. Risk factors were further analyzed by multivariate linear regression.ResultsA total of 583 consecutive elderly hip fracture patients were finally included (mean age 79.32 ± 8.18 years, 68.61% female). On admission, the mean serum corrected calcium level was 2.17 ± 0.14 mmol/L, and the prevalence of hypocalcemia was 33.11% (95% CI: 29.42–37.02). When comparing patients with normal calcium, hypocalcemia patients exhibited a higher blood transfusion rate (7.69% vs 16.06%, P < 0.05), and significantly larger total blood loss (607.86 ± 497.07 ml vs 719.18 ± 569.98 ml, P < 0.05). Multivariate linear regression analysis showed that male, anemia on admission, time from injury to hospital, intertrochanteric fracture, blood transfusion and hypocalcemia were independently associated with increased total blood loss (P < 0.05).ConclusionHypocalcemia is common in elderly patients with hip fracture, and significantly associated with more total blood loss and blood transfusion. The other risk factors for increased total blood loss are male, anemia on admission, time from injury to hospital, intertrochanteric fracture, and blood transfusion.Level of evidenceLevel III, retrospective study.

Disparities in Craniosynostosis Outcomes by Race and Insurance Status.

Disparities in access to care for surgical intervention in craniosynostosis have been suggested as a cause in discrepancies between the surgical approach and consequently perioperative outcomes following surgery. This work aimed to investigate the influence of race, insurance status, and the presence of craniosynostosis-related conditions on the short-term outcomes after the surgical management of craniosynostosis. Using the National Inpatient Sample database for the years 2010 to 2012, sociodemographic predictors for 30-day postoperative complication rates and requirements for blood transfusion in craniosynostosis surgeries were identified. Medicaid patients were significantly more likely to experience complications (P = 0.013) and higher rates of blood transfusions (P = 0.011). Compared to those without any complications, patients who experienced postoperative complications and blood transfusions were older (191.5 versus 181.7 days old, P < 0.001), had a greater number of chronic diseases (P < 0.001), and had a longer average length of stay (P < 0.001). On multivariable regression, Medicaid patients were 1.7 times more likely to experience any postoperative complication compared to privately insured patients. White patients also experienced a 0.741 times lower likelihood of requiring a blood transfusion. At the hospital level, receiving surgery at government-operated hospitals was found to be a protective factor for postoperative complications compared to for-profit private (P = 0.016) and nonprofit private (P = 0.028). Healthcare providers and policy makers should be cognizant of these sociodemographic disparities and their potential causes to ensure equitable treatment for all patients regardless of insurance status and racial/ethnic background.

Changing Paradigms: Green Laser Vaporization for Prostates over 80 mL: A Comparative Study.

Introduction and Objectives: Benign prostatic enlargement (BPE) and big prostates are common. Photovaporization of the prostate (PVP) with Greenlight™ laser 180 W XPS is considered a reliable therapy for prostates <80 mL and an alternative for the treatment of bigger ones in selected cases. The aim of this study is to evaluate efficacy, safety, and functional outcomes of PVP among patients with prostates over and under 80 mL. Materials and Methods: After protocol approbation by our Institutional Ethics Committee, a cohort of 840 patients with BPE who underwent PVP with Greenlight laser between 2012 and 2019 in a single center was evaluated. Groups were stratified according to prostate volume, to less and greater than 80 mL (Groups 1 and 2, respectively). The primary outcomes were efficacy [prostate-specific antigen (PSA) drop, improvement of International Prostatic Symptom Score (IPSS), and quality of life] and variables regarding safety of the procedure. Peri- and postoperative outcomes were analyzed. Complications were assessed according to Clavien-Dindo classification. Overall patient satisfaction was evaluated with visual analog scale. Results: Preoperative variables showed no statistical difference among groups. Mean follow-up was 47 [interquartile range; IQR = 26-70] months. Longer operative time and a higher energy use was seen in bigger prostates (p < 0.001). Efficacy was similar between groups, with a reduction of ≥4 points in IPSS score in 83.1% and 89.5% in Groups 1 and 2 (p = 0.053), PSA drop was 1 ± 2.6 and 1.7 ± 4.7 (p = 0.32). Group 2 had a higher conversion rate (0.3% vs 4.9%, p < 0.001) and higher blood transfusion rate (0% vs 2.4%, p < 0.001). There were no differences in hospital stay, catheterization time, urethral stricture, or re-treatment rates. Conclusions: GreenLight PVP is a safe and effective procedure in prostates ≥80 mL. It shows the same advantages demonstrated for those under that volume, particularly short hospital stay and catheterization time. Surgeon's experience is important to avoid complications, such as conversion and transfusion. PVP should be considered a first-line alternative for the treatment of bigger prostates.

Maternal and neonatal risk factors for neonatal respiratory distress syndrome in term neonates in Cyprus: a prospective case\u2013control study

BackgroundNeonatal respiratory distress syndrome (NRDS) is strongly associated with premature birth, but it can also affect term neonates. Unlike the extent of research in preterm neonates, risk factors associated with incidence and severity of NRDS in term neonates are not well studied. In this study, we examined the association of maternal and neonatal risk factors with the incidence and severity of NRDS in term neonates admitted to Neonatal Intensive Care Unit (NICU) in Cyprus.MethodsIn a prospective, case-control design we recruited term neonates with NRDS and non-NRDS admitted to the NICU of Archbishop Makarios III hospital, the only neonatal tertiary centre in Cyprus, between April 2017–October 2018. Clinical data were obtained from patients’ files. We used univariate and multivariate logistic and linear regression models to analyse binary and continuous outcomes respectively.ResultsDuring the 18-month study period, 134 term neonates admitted to NICU were recruited, 55 (41%) with NRDS diagnosis and 79 with non-NRDS as controls. In multivariate adjusted analysis, male gender (OR: 4.35, 95% CI: 1.03–18.39, p = 0.045) and elective caesarean section (OR: 11.92, 95% CI: 1.80–78.95, p = 0.01) were identified as independent predictors of NRDS. Among neonates with NRDS, early-onset infection tended to be associated with increased administration of surfactant (β:0.75, 95% CI: − 0.02-1.52, p = 0.055). Incidence of pulmonary hypertension or systemic hypotension were associated with longer duration of parenteral nutrition (pulmonary hypertension: 11Vs 5 days, p < 0.001, systemic hypotension: 7 Vs 4 days, p = 0.01) and higher rate of blood transfusion (pulmonary hypertension: 100% Vs 67%, p = 0.045, systemic hypotension: 85% Vs 55%, p = 0.013).ConclusionsThis study highlights the role of elective caesarean section and male gender as independent risk factors for NRDS in term neonates. Certain therapeutic interventions are associated with complications during the course of disease. These findings can inform the development of evidence-based recommendations for improved perinatal care.

Comparison of safety and efficacy between single-tract and multiple-tract percutaneous nephrolithotomy treatment of complex renal calculi: a systematic review and meta-analysis.

A systematic review and meta-analysis was conducted to explore the safety and efficacy of single-tract and multiple-tract percutaneous nephrolithotomy (PCNL) in complex renal calculi treatment. PubMed, Web of Science, Embase, EBSCO, and Cochrane library databases (updated November 2020) were searched for studies assessing the effect of different numbers of tracts on cases that underwent PCNL. The search strategy and study selection process were managed according to the PRISMA statement. Five comparative studies were included in the meta-analysis. The multiple-tract PCNL group had a significantly increased total complications rate than the single-tract group (OR=2.35, 95% CI=1.71, 3.25; P<0.00001) with insignificant heterogeneity (I2=0%, P=0.52). Subgroup analysis showed there were different incidence of complications, mainly because the multiple-tract PCNL group was significantly associated with a higher rate of blood transfusion (OR=2.99, 95% CI=1.95, 4.57; P<0.00001) with insignificant heterogeneity (I2=9%, P=0.35). There were no differences in operation time (MD=12.04, 95% CI=6.36, 17.72; P<0.0001) or hospitalization (MD=0.54, 95% CI=0.14, 0.95, P=0.008). However, the single-tract group had a higher stone-free rate (OR=0.37, 95% CI=0.19, 0.74; P=0.005) with heterogeneity (I2=51%, P=0.08), as stones in the single-tract group were smaller than those in the multiple-tract group. The current research did not find that the multiple-tract group had a higher stone-free rate. Additionally, multiple-tract PCNL was associated with a higher incidence of blood transfusion and negative impact on renal function.