BaCKgRoUND aND aIMS: The coronavirus-19 disease (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 virus, is associated with significant morbidity and mortality attributable to pneumonia, acute respiratory distress syndrome, and multiorgan failure. Liver injury has been reported as a nonpulmonary manifestation of COVID-19, but characterization of liver test abnormalities and their association with clinical outcomes is incomplete. appRoaCH aND ReSUltS: We conducted a retrospective cohort study of 1,827 patients with confirmed COVID-19 who were hospitalized within the Yale-New Haven Health System between March 14, 2020 and April 23, 2020. Clinical characteristics, liver tests (aspartate aminotransferase [AST], alanine aminotransferase [ALT], alkaline phosphatase [ALP], total bilirubin [TBIL], and albumin) at three time points (preinfection baseline, admission, and peak hospitalization), and hospitalization outcomes (severe COVID-19, intensive care unit [ICU] admission, mechanical ventilation, and death) were analyzed. Abnormal liver tests were commonly observed in hospitalized patients with COVID-19, both at admission (AST 66.9%, ALT 41.6%, ALP 13.5%, and TBIL 4.3%) and peak hospitalization (AST 83.4%, ALT 61.6%, ALP 22.7%, and TBIL 16.1%). Most patients with abnormal liver tests at admission had minimal elevations 1-2× the upper limit of normal (ULN; AST 63.7%, ALT 63.5%, ALP 80.0%, and TBIL 75.7%). A significant proportion of these patients had abnormal liver tests prehospitalization (AST 25.9%, ALT 38.0%, ALP 56.8%, and TBIL 44.4%). Multivariate analysis revealed an association between abnormal liver tests and severe COVID-19, including ICU admission, mechanical ventilation, and death; associations with age, male sex, body mass index, and diabetes mellitus were also observed. Medications used in COVID-19 treatment (lopinavir/ritonavir, hydroxychloroquine, remdesivir, and tocilizumab) were associated with peak hospitalization liver transaminase elevations >5× ULN. CoNClUSIoNS: Abnormal liver tests occur in most hospitalized patients with COVID-19 and may be associated with poorer clinical outcomes. (Hepatology 2020;72:1169-1176). C oronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first described in December 2019 in patients with severe pneumonia in Wuhan, China. (1) The World Health Organization declared COVID-19 a global pandemic in March 2020. (2) Although the initial burden of disease was predominantly found in China, (1,3,4,5,6) the United States has reported the most cases of COVID-19 and COVID-19-related death globally since March 26, 2020 and April 11, 2020, respectively. (7) This infection is estimated to have resulted in >11 million cases and 500,000 deaths globally, including 3 million cases and 130,000 deaths in the United States as of July 8, 2020. (7) Whereas patients with COVID-19 typically present with fever and respiratory symptoms consistent

Background & Aims Bowel preparation is defined as adequate if it is sufficient for identification of polyps >5mm. However, adequate preparation has not been quantified. We performed a prospective observational study to provide an objective definition of adequate preparation, based on the Boston Bowel Prep Scale (BBPS, 0–3 points for each of 3 colon segments). Methods We collected data from 438 men who underwent screening or surveillance colonoscopies and then repeat colonoscopy examinations within 60 days by a different blinded endoscopist (1161 colon segments total) at the West Haven Veterans Affairs Medical Center from January, 2014 to February, 2015. Missed polyps were defined as those detected on the second examination of patients with the best possible bowel preparation (colon segment BBPS score of 3) on the second examination. The primary outcome was proportion of colon segments with adenomas >5mm that were missed in the first examination. We postulated that the miss rate was non-inferior for segments with BBPS scores of 2 vs those with BBPS scores of 3 (non-inferiority margin, <5%). Our secondary hypotheses were that miss rates were higher in segments with BBPS scores of 1 vs those with scores of 3 or of 2. Results The adjusted proportion with missed adenomas >5mm was non-inferior for segments with BBPS scores of 2 (5.2%) vs those with BBPS scores of 3 (5.6%) (a difference of −0.4%; 95% confidence interval [CI], −2.9% to 2.2%). Of study subjects, 347 (79.2%) had BBPS scores ≥2 in all segments on initial examination. A higher proportion of segments with BBPS scores of 1 had missed adenomas >5mm (15.9%) than segments with BBPS scores of 3 (5.6%) (a difference of 10.3%; 95% CI, 2.7%–17.9%) or 2 (5.2%) (a difference of 10.7%; 95% CI, 3.2–18.1%). Screening and surveillance intervals based solely on the findings at the first examination would have been incorrect for 16.3% of patients with BBPS scores of 3 in all segments, for 15.3% with BBPS scores of 2 or 3 in all segments, and 43.5% of patients with a BBPS score of 1 in 1 or more segments. Conclusions Patients with BBPS scores of 2 or 3 for all colon segments have adequate bowel preparation for detection of adenomas >5 mm and should return for screening or surveillance colonoscopy at standard guideline-recommended intervals. Colon segments with a BBPS score of 1 have a significantly higher rate of missed adenomas >5mm than segments with scores of 2 or 3. This finding supports a recommendation for early repeat colonoscopic evaluation in patients with a BBPS score of 0 or 1 in any colon segment.

Given the low rates of both newly identified structural disease and morbidity after surgery for cN0 PTC, prohibitively large sample sizes would be required for sufficient statistical power to demonstrate significant differences in outcomes. Thus, a prospective randomized controlled trial of prophylactic central lymph node dissection in cN0 PTC is not readily feasible.

At most academic medical centers, promotion rates for Hispanic and Black were lower than those for White faculty. Equitable faculty promotion rates may reflect institutional climates that support the successful development of racial/ethnic minority trainees, ultimately improving healthcare access and quality for all patients.

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BaCKgRoUND aND aIMS: Recent evidence suggests that acute kidney injury (AKI) is the main predictor of postparacentesis bleeding in patients with cirrhosis. To assess the factors responsible for bleeding tendency in AKI, we performed a prospective study comparing all three aspects of hemostasis (platelets, coagulation, and fibrinolysis) in patients with decompensated cirrhosis with and without AKI. appRoaCH aND ReSUltS: Primary hemostasis assessment included platelet aggregation and secretion (platelet function markers) and von Willebrand factor. Secondary hemostasis assessment included pro-coagulant (factor VIII and factor XIII) and anti-coagulant (protein C, protein S, and antithrombin) factors and thrombin generation. Tertiary hemostasis assessment included fibrinolytic factors and plasmin-antiplasmin complex. Eighty patients with decompensated cirrhosis were recruited (40 each with and without AKI). Severity of cirrhosis and platelet count were comparable between groups. Median serum creatinine was 1.8 mg/dL and 0.8 mg/dL in patients with and without AKI, respectively. At baseline, patients with cirrhosis and AKI had lower platelet aggregation and secretion, indicative of impaired platelet function (increased bleeding tendency), without differences in von Willebrand factor. Regarding coagulation factors, factor VIII was higher, whereas protein C, protein S, and antithrombin were all lower, which, together with increased thrombin generation, indicate hypercoagulability. In contrast, factor XIII was lower in AKI (increased bleeding tendency). Finally, while both hypofibrinolytic and hyperfibrinolytic changes were present in AKI, a higher plasmin-antiplasmin complex indicated a hyperfibrinolytic state. After AKI resolution (n = 23 of 40), platelet function and coagulation improved to levels observed in patients with cirrhosis patients without AKI; however, fibrinolysis remained hyperactivated. CoNClUSIoNS: In patients with decompensated cirrhosis, AKI is associated with both hypocoagulable and hypercoagulable features that can potentially increase the risk of both bleeding and thrombosis. (Hepatology 2020;72:1327-1340). P atients with decompensated cirrhosis have multiple and complex alterations of hemostasis that predispose them to both bleeding and thrombotic complications. (1) Although patients with cirrhosis are traditionally considered to be at high risk of bleeding from procedures, data regarding the correlation between hemostatic

US National Institutes of Health.

Objective To estimate the association of age, medical comorbidities, functional status, and unintentional weight loss (as a marker of frailty) with postoperative complications in women undergoing major gynecologic surgery. Methods We conducted a cross-sectional analysis of the American College of Surgeons National Surgical Quality Improvement Program 2005-2009 participant use data files were used to analyze gynecologic procedures. The primary outcome was composite 30-day major postoperative complications. Results A total of 22,214 women were included in our final analysis. The overall prevalence of composite 30 day major postoperative complications was 3.7% (n=817). Age 80 years or older (adjusted odds ratio (OR)=1.8(95% Confidence Interval (CI) 1.25,2.58)), dependent functional status (adjusted OR= 2.37(95% CI 1.53,3.68)), and unintentional weight loss (adjusted OR = 2.49(95% CI 1.48,4.17)) were significantly associated with postoperative morbidity after adjusting for diabetes mellitus (adjusted OR= 1.44(95% CI 1.15,1.79)), known bleeding disorder (adjusted OR= 2.29 (95% 1.49,3.52)), morbid obesity (adjusted OR= 1.77(95% CI 1.45,2.17)), ascites (adjusted OR= 3.27(95% CI 2.18,4.90)), preoperative systemic infection (adjusted OR= 3.02(95% CI 2.03,4.48)), procedures for gynecologic cancer (adjusted OR= 1.60(95% CI 1.27,2.0)), disseminated cancer (adjusted OR= 2.57(95% CI 1.64,4.03)), emergency procedures (adjusted OR = 1.82(95% CI 1.18,2.79)), operative time greater than 4 hours vs. less than 1 hour (adjusted OR = 2.91(95%CI 2.18,3.89)) and wound class 4 vs. 1(adjusted OR= 4.28(95%CI 1.82,10.1). Conclusion Age 80 years or older, medical comorbidities, dependent functional status, and unintentional weight loss are associated with increased major postoperative complications after gynecologic procedures.