Purulent Streptococcus intermedius Pericarditis in the Setting of Histoplasma Mediastinal Lymphadenitis: A Case Report and Literature Review.

Purulent pericarditis is a rare and potentially life-threatening condition characterized by infection of the pericardial space. We describe a case of purulent bacterial pericarditis in a 41-year-old male with no significant medical or surgical history who had concomitant pulmonary Histoplasma infection. Streptococcus intermedius was the bacteria directly responsible for the pericardial infection, though co-infection with histoplasmosis likely predisposed him to develop purulent pericarditis. We hypothesize histoplasmosis caused mediastinal lymphadenopathy, facilitating contact between a necrotic lymph node and the pericardium and contiguous suppuration of bacteria to the pericardial space. We treated S. intermedius and Histoplasma capsulatum with ceftriaxone and amphotericin B, respectively. Additionally, the patient presented in cardiac tamponade requiring emergent pericardiocentesis and drain placement. His course was also complicated by pericardial constriction. Cardiac magnetic resonance confirmed this, showing inflamed pericardium and abnormal septal motion with inspiration, and he had symptoms refractory to antimicrobials and anti-inflammatories. As such, he required pericardiectomy. This case demonstrates maintaining suspicion for secondary infectious foci as a contributor to the pathogenesis of purulent pericarditis is important, as pulmonary histoplasmosis played a pivotal role in allowing S. intermedius to spread to the pericardium but was not the primary infection. It also highlights the multifaceted evaluation and management of purulent pericarditis, highlighting the role of echocardiography and emergent pericardial drainage if cardiac tamponade is present, the importance of targeted antimicrobial therapy, the superior ability of cardiac magnetic resonance to identify pericardial constriction as a sequela of purulent pericarditis, and indications for pericardiectomy.

National Use and Short-term Outcomes of Video and Robot-Assisted Thoracoscopic Thymectomies.

BACKGROUND: Transsternal open thymectomy has long been the most widely used approach for thymectomy, but recent decades have seen the introduction of minimally invasive surgery (MIS), such as video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) thymectomy. This retrospective cohort study provides a national comparison of trends, outcomes, and resource utilization of open, VATS, and RATS thymectomy. METHODS: Admissions for thymectomies from 2008 to 2014 were identified in the National Inpatient Sample. Patients were identified as undergoing open, VATS, or RATS thymectomy. Propensity score-matched analyses were used to compare overall complication rates, length of stay (LOS), and cost of VATS and RATS thymectomies. RESULTS: An estimated 23,087 patients underwent thymectomy during the study period: open in 16,025 (69%) and MIS in 7217 (31%). Of the MIS cohort, 4119 (18%) underwent VATS and 3097 (13%) underwent RATS. Performance of RATS and VATS thymectomy increased while that of open thymectomy declined. Baseline characteristics between VATS and RATS were similar, except more women underwent VATS thymectomy. No differences in LOS or overall complication rates were appreciable in this study. VATS was associated with the lowest cost of the 3 approaches. CONCLUSIONS: Our findings demonstrate the increasing adoption of MIS and declining use of the open surgical approach for thymectomy. There are no differences in overall complication rates between RATS and VATS thymectomy, but RATS is associated with greater cost and lower cardiac complication rates.

Risk factors for penile fracture compared with a surgical control cohort in the United States: the role of substance abuse.

Penile fracture (PF) is a surgical emergency. Given its rarity, we queried a national cohort over an 11-year period to study the temporal and demographic variations in presentation, evaluation, and management of patients with PF compared with a cohort of control patients. The National Inpatient Sample was queried between the years 2005 and 2016 for patients with a diagnosis of PF. Appendectomy patients were selected as a control cohort, given the non-discriminatory nature of this disease. Clinical and demographic data of the patients were compared with that of controls. Presenting symptoms, rates of surgical repair, and rates of associated surgical procedures were evaluated in the PF cohort. During the study period, 5802 patients were hospitalized for PF. The annual incidence of PF remained unchanged at 1.0-1.8 cases per 100 000 hospitalizations over the study period. Compared with the control cohort, PF patients were more likely to be younger (38.7 years vs 41.2 years, P ≤ 0.001), have lower rates of comorbidities except erectile dysfunction (1.4% vs 0.1%, P ≤ 0.001), and were more likely of Black race (25.4% vs 6.2%, P ≤ 0.001). Notably, PF patients had significantly higher rates of substance abuse (26.4% vs 18.1%, P ≤ 0.001), despite no difference in the diagnosed psychiatric disorders. PF rarely presented with hematuria (3.5%); however, urethral evaluation was performed in 23.1%, most commonly with cystoscopy (19.2%). PF occurs more commonly in a younger, healthier male population, and among minorities. Importantly, rates of substance abuse appear to be higher in the PF cohort compared with those of controls.

Nonalcoholic Fatty Liver Disease and Diabetes Mellitus Are Associated With Post-Transjugular Intrahepatic Portosystemic Shunt Renal Dysfunction: An Advancing Liver Therapeutic Approaches Group Study.

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for portal hypertensive complications, but its effect on renal function is not well characterized. Here we describe renal function and characteristics associated with renal dysfunction at 30 days post-TIPS. Adults with cirrhosis who underwent TIPS at 9 hospitals in the United States from 2010 to 2015 were included. We defined "post-TIPS renal dysfunction" as a change in estimated glomerular filtration rate (ΔeGFR) ≤-15 and eGFR ≤ 60 mL/min/1.73 m2 or new renal replacement therapy (RRT) at day 30. We identified the characteristics associated with post-TIPS renal dysfunction by logistic regression and evaluated survival using adjusted competing risk regressions. Of the 673 patients, the median age was 57 years, 38% of the patients were female, 26% had diabetes mellitus, and the median MELD-Na was 17. After 30 days post-TIPS, 66 (10%) had renal dysfunction, of which 23 (35%) required new RRT. Patients with post-TIPS renal dysfunction, compared with those with stable renal function, were more likely to have nonalcoholic fatty liver disease (NAFLD; 33% versus 17%; P = 0.01) and comorbid diabetes mellitus (42% versus 24%; P = 0.001). Multivariate logistic regressions showed NAFLD (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.00-4.17; P = 0.05), serum sodium (Na; OR, 1.06 per mEq/L; 95% CI, 1.01-1.12; P = 0.03), and diabetes mellitus (OR, 2.04; 95% CI, 1.16-3.61; P = 0.01) were associated with post-TIPS renal dysfunction. Competing risk regressions showed that those with post-TIPS renal dysfunction were at a higher subhazard of death (subhazard ratio, 1.74; 95% CI, 1.18-2.56; P = 0.01). In this large, multicenter cohort, we found NAFLD, diabetes mellitus, and baseline Na associated with post-TIPS renal dysfunction. This study suggests that patients with NAFLD and diabetes mellitus undergoing TIPS evaluation may require additional attention to cardiac and renal comorbidities before proceeding with the procedure.

The impact of obesity on outcomes in patients receiving extracorporeal life support.

Extracorporeal life support (ECLS) has been increasingly utilized to manage cardiac and pulmonary dysfunction. The impact of obesity on outcomes of ECLS is poorly defined. The purpose of the study was to compare in-hospital mortality, resource use, complications, and readmissions in obese versus non-obese patients receiving ECLS. We performed a retrospective cohort study of all adult ECLS patients with and without an obesity diagnosis using the 2010-2016 Nationwide Readmissions Database (NRD). Mortality, length of stay (LOS), hospital charges, complications, and readmissions were evaluated using multivariable logistic and linear regression. Of 23 876, patients who received ECLS, 1924 (8.1%) were obese. Obese patients received ECLS more frequently for respiratory failure (29.5% vs. 23.7%, P = .001). After adjustment for patient and hospital factors, obesity was not associated with increased odds of mortality (AOR = 1.06, P = .44) and was associated with decreased LOS (13.7 vs. 21.2 days, P < .001), hospital charges ($171 866 vs. $211 445, P < .001), and 30-day readmission (AOR = 0.71, P = .03). Obesity was also associated with reduced odds of hemorrhage (AOR = 0.43, P < .001), neurologic complications (AOR = 0.55, P = .004), and acute kidney injury (AOR=0.83, P = .04). After stratification by ECLS indication, obesity remained predictive of shorter LOS (AOR range: 0.53-0.78, all P < .05 ) and did not impact mortality (all P > .05). Respiratory support remains the most common indication for ECLS among obese patients. Among all patients, as well as by individual ECLS indication, obesity was not associated with increased odds of mortality. These findings suggest that obesity should not be considered a high-risk contraindication to ECLS.

Impact of Malnutrition on Outcomes Following Transcatheter Aortic Valve Implantation (from a National Cohort).

Malnutrition is associated with increased mortality in open cardiac surgery, but its impact on transcatheter aortic valve implantation (TAVI) is unknown. This study utilized the National Readmissions Database to evaluate the impact of malnutrition on mortality, complications, length of stay (LOS), 30-day readmission, and total charges following TAVI. Adult patients undergoing isolated TAVI for severe aortic stenosis were identified using the 2011 to 2016 National Readmissions Database, which accounts for 56.6% of all US hospitalizations. The malnourished cohort included patients with nutritional neglect, cachexia, protein calorie malnutrition, postsurgical nonabsorption, weight loss, and underweight status. Multivariable models were utilized to evaluate the impact of malnutrition on selected outcomes. Of 105,603 patients, 5,280 (5%) were malnourished. Malnourished patients experienced greater mortality (10.4% vs 2.2%, p <0.001), postoperative complications (49.2% vs 22.6%, p <0.001), 30-day readmission rates (21.4 vs 14.9%, p <0.001), index hospitalization charges ($331,637 vs $208,082, p <0.001), and LOS (16.4 vs 6.2 days, p <0.001) relative to their nourished counterparts. On multivariable analysis, malnutrition remained a significant, independent predictor of increased index mortality (Adjusted odds ratio (AOR) = 2.68, p <0.001), complications (AOR = 2.09, p <0.001), and 30-day readmission rates (AOR = 1.34, p <0.001). Malnutrition was most significantly associated with infectious complications at index hospitalization (AOR = 3.88, p <0.001) and at 30-day readmission (AOR = 1.43, p <0.027). In conclusion, malnutrition is independently associated with increased mortality, complications, readmission, and resource utilization in patients undergoing TAVI. Preoperative risk stratification and malnutrition modification may improve outcomes in this vulnerable population.

Hepatocellular cancer pain: impact and management challenges.

Hepatocellular carcinoma (HCC) remains the most common primary liver malignancy. Pain comprises one of the most pervasive and troubling symptoms of HCC and may have severely negative effects on patient's quality of life. Furthermore, because HCC frequently arises in the setting of cirrhosis, treating pain related to this malignancy poses a clinical challenge. This article summarizes manifestations of hepatocellular cancer pain, common obstacles to treatment, and practical HCC pain management.