Cerebral Venous Sinus Thrombosis After Lumbar Epidural Steroid Injection: A Case Report.

Cerebral venous sinus thrombosis (CVST) is an exceedingly rare complication of epidural anesthesia, with only a handful of known cases after epidural steroid injection (ESI). We report a case of CVST in a 33-year-old male patient that presented with headache after lumbar ESI. His clinical status initially improved on anticoagulation in the intensive care unit. However, he had a sudden worsening of cerebral edema that required an emergent hemicraniectomy. Ultimately, the patient was pronounced dead by neurologic criteria. This case highlights the importance of keeping this rare but potentially fatal diagnosis in the differential even in lower-risk patient populations.

Intraoperative Diagnosis of Sodium-Glucose Cotransporter 2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis: A Case Report.

The use of sodium-glucose cotransporter 2 (SGLT2) inhibitors is increasingly common in type 2 diabetes mellitus (DM) management. Patients taking an SGLT2 inhibitor are at risk for euglycemic diabetic ketoacidosis (EDKA). We report an intraoperative diagnosis of EDKA. The patient was found to have an arterial pH of 7.21 and serum beta-hydroxybutyrate of 88.8 mg/dL (normal: <3.0 mg/dL) with serum glucose <250 mg/dL. Acidosis resolved with insulin and glucose infusions. Perioperative specialists must recognize the potential for EDKA in patients taking SGLT2 inhibitors. Expert opinion suggests preoperative cessation for 2-3 days and intraoperative serum ketone concentration measurement for at-risk patients.

A Randomized Prospective Blinded Study Evaluating the Effect of Music on Novice Surgical Trainees' Ability to Perform a Simulated Surgical Task.

OBJECTIVE: To determine if playing music would affect novice surgical trainees' ability to perform a complex surgical task. BACKGROUND: The effect of music in the operating room (OR) is controversial. Some studies from the anesthesiology literature suggest that OR music is distracting and should be banned. Other nonblinded studies have indicated that music improves surgeons' efficiency with simple tasks. DESIGN/METHODS: A prospective, blinded, randomized trial of 19 novice surgical trainees was conducted using an in vitro model. Each trainee performed a baseline vascular anastomosis (VA) without music. Subsequently, they performed one VA with music (song validated to reduce anxiety) and one without, in random order and without prior knowledge of the study's purpose. The primary endpoint was a difference in differences from baseline with and without music with respect to time to completion, acceleration/deceleration (using a previously validated hand-tracking motion device), and video performance scoring (3 blinded experts using a validated scale). The participants completed a poststudy survey to gauge their opinions regarding music during tasks. RESULTS: Overall, 57 VAs by 19 trainees were evaluated. Average time to completion was 11.6 minutes. When compared to baseline, time to completion improved for both the music group (p = 0.01) and no-music group (p = 0.001). When comparing music to no music, there was no difference in time to completion (p = 0.7), acceleration/deceleration (p = 0.3), or video performance scorings (p = NS). Among participants, 89% responded that they enjoy listening to music while performing tasks. CONCLUSIONS: Using three outcome measures, relaxing music did not improve the performance of novice surgical trainees performing a complex surgical task, and the music did not make their performance worse. However, nearly all trainees reported enjoying listening to music while performing tasks.

Height mismatch: An overlooked component of adult heart transplant outcomes.

Heart transplantation guidelines recommend against matching donors with significant weight but not height discrepancies. This study analyzed the impact of donor-recipient height mismatch on mortality among heart transplant recipients. We retrospectively analyzed all adult patients in the United Network for Organ Sharing (UNOS) registry undergoing heart transplantation from 1990 to September 2016. Moderate and severe height mismatch were classified as >10% and >15% difference in donor height from recipient height, respectively. The primary outcome was 1-year mortality. Adjusted Cox hazards regression was performed, and Kaplan-Meier estimates illustrated 10-year survival. Of 44 877 transplants, 4822 (10.7%) were moderately height mismatched. Height-mismatched recipients were more frequently female (41.6% vs 21.8%, P < .001), sex mismatched (53.8% vs 24.9%, P < .001), and weight mismatched (4.9% vs 1.9%, P < .001). After adjustment, recipients of moderately (HR = 1.15 [1.02-1.30]) and severely (HR = 1.38 [1.10-1.74]) taller donor hearts were at increased risk of mortality at 1 year relative to height-matched recipients. Furthermore, of 1042 (21.6%) severe mismatches, recipients with taller (HR = 1.39 [1.11-1.74]) but not shorter (HR = 0.79 [0.44-1.43]) donors faced increased 10-year mortality. The effect was pronounced among re-transplant candidates (HR = 1.96 [1.07-3.59]). In conclusion, matching with moderately or severely taller donors is an independent predictor of mortality among primary and re-transplant candidates.

National Study of Immediate and Delayed Readmissions After Colostomy Creation.

BACKGROUND: Readmissions after colorectal operations adversely impact patient recovery and are associated with about $300 million in additional health care expenditure in the United States alone. The present study aimed to characterize nonelective, short-term readmissions of colorectal surgery patients who underwent colostomy. METHODS: The Nationwide Readmissions Database was used to identify patients who received a colostomy from 2010 to 2015. Patients were stratified by discharge-to-readmission interval: immediate (within 7 d) and delayed (7-30 d). Nonparametric trend analysis and multivariable regression were performed to identify predictors of immediate and delayed readmission. RESULTS: Of an estimated 376,693 operations requiring colostomies during the study, in-hospital survival was 92.3%, with higher rates after elective compared with nonelective operations (96.5 versus 90.8%, P < 0.001). Overall, 15.3% patients undergoing elective and nonelective colostomy creation returned to the hospital within 30 d, with 41.6% of these readmissions occurring by the first week of discharge (immediate). Readmission rates and proportion of immediate and delayed groups did not significantly change over the 6-year study period. Nonhome discharge increased the odds of immediate (AOR 1.25, 95% CI 1.17-1.34) and delayed readmission (AOR 1.44, 95% CI 1.35-1.54). Annually, immediate and delayed rehospitalizations after colostomy creation were responsible for $64 and 82 million in excess costs, respectively. CONCLUSIONS: Colostomy creation is associated with a steady and high rate of rehospitalization. Nonhome discharge, in addition to several patient comorbidities, is associated with higher odds of readmission. Programs aimed at reduction of immediate readmission are warranted.

Abdominal Operations After Left Ventricular Assist Device Implantation and Heart Transplantation.

BACKGROUND: Left ventricular assist devices (LVADs) are increasingly used to supplant the limited number of orthotopic heart transplantation (OHT). The present study aimed to perform a contemporary analysis of emergency abdominal operations after LVAD and OHT at a national level. METHODS: The 2005-2015 National Impatient Sample, the largest all-payer hospitalization database in the United States, was used to identify all adult patients who had received LVAD or OHT. The primary outcome of interest was the rate of emergency general surgery (EGS), which included laparotomy, small or large bowel resection, peptic ulcer operation, adhesiolysis, and cholecystectomy, during the same hospitalization as LVAD or OHT. Logistic regression was used to determine risk factors for EGS as well as the association between EGS and mortality in both the LVAD and OHT populations. RESULTS: Of the estimated 19,395 OHT and 23,441 LVAD performed, 445 (2.3%) OHT and 719 (3.1%) LVAD patients required EGS. The incidence of EGS in LVAD decreased from 5.4 to 3.3%, whereas it increased among OHT patients from 1.9 to 3.7%, P = 0.003. Occurrence of EGS after OHT and LVAD was associated with significantly higher inpatient risk-adjusted mortality (OHT adjusted odds ratio, 3.0; P = 0.004; LVAD adjusted odds ratio, 2.5; P < 0.001), incremental hospitalization costs (OHT, $106,778; P < 0.001; LVAD, $61,965; P < 0.001), and length of stay (OHT, 27.9 d; P < 0.001; LVAD, 20.8 d; P < 0.001). CONCLUSIONS: EGS remains an infrequent but high mortality and cost complication of OHT and LVAD. Further investigation of the impact of immunosuppression, anticoagulation, and perfusion strategies on incidence of abdominal complications is warranted.

Association of Autoimmune Connective Tissue Disease and Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation.

Patients with autoimmune connective tissue disease (CTD) are at higher risk for developing aortic valve pathology, but the safety and value of transcatheter aortic valve implantation (TAVI) in this population has not been investigated. This study evaluated mortality, complication, and readmission rates along with length of stay and total costs after TAVI in patients with CTD. We retrospectively reviewed 47,216 patients who underwent TAVI from the National Readmissions Database between January 2011 and September 2015. Patients with systemic lupus erythematosus, scleroderma, rheumatoid arthritis, and other autoimmune CTD comprised the cohort. The primary outcome was mortality at index hospitalization. The 2,557 CTD patients (5.4%) had a higher Elixhauser co-morbidity index (7.1 vs 6.1, p <0.001) than non-CTD patients. CTD and non-CTD patients had similar mortality (2.8 vs 4.1%, p = 0.052), 30-day readmission (19.3 vs 17.0%, p = 0.077), length of stay (8.2 vs 8.3 days, p = 0.615), and total adjusted costs ($57,202 vs $58,309, p = 0.196), respectively. However, CTD patients were more frequently readmitted for postoperative infection (9.4 vs 5.6%, p = 0.042) and septicemia (8.2 vs 4.5%, p = 0.019). After multivariable adjustment, CTD patients faced lower mortality at index hospitalization (odds ratio [OR] 0.56 [0.38 to 0.82], p = 0.003) but were more frequently readmitted for septicemia (OR = 1.95 [1.10 to 3.45], p = 0.023) and postoperative infection (OR = 3.10 [1.01 to 9.52], p = 0.048) relative to non-CTD patients. In conclusion, CTD is not a risk factor for in-hospital mortality but is an independent risk factor for infectious complications post-TAVI.

Pretransplant malignancy among lung transplant recipients in the modern era.

BACKGROUND: Malignancy is a relative contraindication in transplant candidates, given the increased neoplastic risk accompanying posttransplant immunosuppression. However, the number of patients receiving a lung transplant despite pretransplant malignancy is rising, and their outcomes remain unclear. Our purpose was to examine the outcomes of lung transplant recipients with pretransplant malignancy in the modern era. METHODS: We evaluated the United Network for Organ Sharing registry for adult lung transplants that were completed between June 2005 and September 2016. Transplant recipients were stratified by pretransplant malignancy, with subgroup analysis by sex and active malignancy. The primary outcome was 5-year survival and the secondary outcome was cause of death. Kaplan-Meier estimates illustrated 5-year survival and multivariable Cox proportional hazards regressions controlled for demographics and comorbidities. RESULTS: Of 18,032 transplant patients, 1,321 transplant recipients (7.3%) possessed a pretransplant malignancy. Patients with pretransplant malignancy faced significantly greater mortality within 5 years (36.0% vs 32.8%, P = .017), an effect greatest in men with pretransplant malignancy (39.2% vs 33.7%, P = .002). Patients with pretransplant malignancy also faced greater risk of death from posttransplant malignancy (15.6% vs 9.4%, P < .001), particularly for those with active malignancy at transplant (34.8% vs 9.8%, P < .001). Pretransplant malignancy remained a significant predictor of 5-year mortality in adjusted Cox regressions (hazard ratio: 1.16 [1.05-1.27], P = .003). CONCLUSION: Patients with pretransplant malignancy, and particularly men with pretransplant malignancy and those with active malignancy at transplant, are at an increased risk of 5-year mortality and posttransplant death from malignancy. Balancing individual risk of posttransplant malignancy with immunosuppressive care is necessary to optimize outcomes for pretransplant malignancy patients.

Clinical Outcomes of Infective Endocarditis in Injection Drug Users.

BACKGROUND: Rising rates of hospitalization for infective endocarditis (IE) have been increasingly tied to rising injection drug use (IDU) associated with the opioid epidemic. OBJECTIVES: This study analyzed recent trends in IDU-IE hospitalization and characterized outcomes and readmissions for IDU-IE patients. METHODS: The authors evaluated the National Readmissions Database (NRD) for IE cases between January 2010 and September 2015. Patients were stratified by IDU status and surgical versus medical management. Primary outcome was 30-day readmission and cause, with secondary outcomes including mortality, length of stay (LOS), adjusted costs, and 180-day readmission. The Kruskal-Wallis and chi-square tests were used to analyze baseline differences by IDU status. Multivariable regressions were used to analyze mortality, readmissions, LOS, and adjusted costs. RESULTS: The survey-weighted sample contained 96,344 (77.8%) non-IDU-IE and 27,432 (22.2%) IDU-IE cases. IDU-IE increased from 15.3% to 29.1% of IE cases between 2010 and 2015 (p < 0.001). At index hospitalization, IDU-IE was associated with reduced mortality (6.8% vs. 9.6%; p < 0.001) but not 30-day readmission (23.8% vs. 22.9%; p = 0.077) relative to non-IDU-IE. Medically managed IDU-IE patients had higher LOS (ß = 1.36 days; 95% confidence interval [CI]: 0.71 to 2.01), reduced costs (ß = -$4,427; 95% CI: -$7,093 to -$1,761), and increased readmission for endocarditis (18.1% vs. 5.6%; p < 0.001), septicemia (14.0% vs. 7.3%; p < 0.001), and drug abuse (4.3% vs. 0.7%; p < 0.001) compared with medically managed non-IDU-IE. Surgically managed IDU-IE patients had increased LOS (ß = 4.26 days; 95% CI: 2.73 to 5.80) and readmission for septicemia (15.6% vs. 5.2%; p < 0.001) and drug abuse (7.3% vs. 0.9%; p < 0.001) compared with non-IDU-IE. CONCLUSIONS: The incidence of IDU-IE continues to rise nationally. Given the increased readmission for endocarditis, septicemia, and drug abuse, IDU-IE presents a serious challenge to current management of IE.