Homelessness and Race are Mortality Predictors in US Veterans Undergoing CABG.

Coronary artery disease requiring surgical revascularization is prevalent in United States Veterans. We aimed to investigate preoperative predictors of 30-day mortality following coronary artery bypass grafting (CABG) in the Veteran population. The Veterans Affairs Surgical Quality Improvement (VASQIP) national database was queried for isolated CABG cases between 2008 and 2018. The primary outcome was 30-day mortality. A multivariable logistic regression was performed to assess for independent predictors of the primary outcome. A P-value of <0.05 was considered statistically significant. A total of 32,711 patients were included. The 30-day mortality rate was 1.37%. Multivariable analysis identified the following predictors of 30-day mortality: African-American race (OR 1.46, 95% CI 1.09-1.96); homelessness (OR 6.49, 95% CI 3.39-12.45); female sex (OR 2.15, 95% CI 1.08-4.30); preoperative myocardial infarction within 7 days (OR 1.49, 95% CI 1.06-2.10) or more than 7 days before CABG (OR 1.34, 95% CI 1.04-1.72); partially/fully dependent functional status (OR 1.44, 95% CI 1.07-1.93); chronic obstructive pulmonary disease (OR 1.54, 95% CI 1.24-1.92); mild (OR 1.48, 95% CI 1.04-2.11) and severe aortic stenosis (OR 2.06, 95% CI 1.37-3.09); moderate (OR 1.88, 95% CI 1.31-2.72), or severe (OR 2.99, 95% CI 1.71-5.22) mitral regurgitation; cardiomegaly (OR 1.73, 95% CI 1.35-2.22); NYHA Class III/IV heart failure (OR 2.05, 95% CI 1.10-3.83); and urgent/emergent operation (OR 1.42, 95% CI 1.08-1.87). The 30-day mortality rate in US Veterans undergoing isolated CABG between 2008 and 2018 was 1.37%. In addition to established clinical factors, African-American race and homelessness were independent demographic predictors of 30-day mortality.

Operative strokes after repair of acute type A dissections: predisposing factors and implications.

BACKGROUND: Type A aortic dissection is a surgical emergency with a high morbidity and mortality. Strokes occur in up to 25% and are among the most feared complications. This study aims to evaluate factors linked to stroke development and the implications of strokes on outcomes. METHODS: Patients from 2000-2014 were stratified based on the development of stroke. Factors were compared between the groups using chi-square or Fisher's exact tests for categorical variables, and independent two-group t-tests for continuous variables. Impact on survival at 30 days, 1 and 5 years were evaluated using the life-test method. RESULTS: Two hundred patients were analyzed. Forty (20%) developed a stroke. Preoperative factors associated with stroke were female gender (34% vs. 14% P=0.01), presentation with shock (32% vs. 17%; P=0.035), and history of stroke (64% vs. 17%; P<0.001). Femoral cannulation was the only technical variable associated with stroke (49% vs. 32%; P=0.035). Stroke patients had a higher rate of pneumonia (41% vs. 11%; P<0.001), respiratory failure (36% vs. 7%; P<0.001), hemodialysis requirement (38% vs. 16%; P=0.015), and longer hospital stay (23.9±17.8 days vs. 16.1±13.5 days; P=0.012). Stroke was associated with a lower survival probability at 30 days (0.73 vs. 0.89), 1 year (0.56 vs. 0.78), and 5 years (0.29 vs. 0.70) (P<0.001). CONCLUSIONS: Patients who developed stroke after type A dissection repair had higher complication rates and a higher mortality rate at 30 days, 1 year, and 5 years. Femoral cannulation was the only technical factor associated with a higher rate of strokes.

Early Goal-Directed Therapy: The History and Ongoing Impact on Management of Severe Sepsis and Septic Shock.

The use of early goal-directed therapy (EGDT) for the management of severe sepsis and septic shock, a practice put forth by Dr. Rivers et al. in 2001, ushered in a new era of targeted sepsis therapy. After its publication, several further studies helped validate the protocolized approach to sepsis management, ultimately leading to its incorporation into the Surviving Sepsis Campaign guidelines. Since that time, however, a trio of large multi-center randomized controlled trials have taken place to evaluate the efficacy of EGDT when compared with usual care and have demonstrated that strict adherence to the entirety of the original EGDT protocol is unnecessary for improved outcomes. Some recommendations, such as higher goal hemoglobin and hematocrit levels and liberal crystalloid fluid resuscitation, are likely harmful. Despite controversy over a number of the recommendations, early identification of sepsis, source control, and prompt empiric antibiotic administration remain the mainstay of treatment for patients with sepsis and septic shock.

Primary amyloidosis of the breast presenting as a solitary nodule: case report and review of the literature.

BACKGROUND: Amyloidosis of the breast is an unusual diagnosis. Overall, only 2 major case series have been published in the literature since the time amyloidosis was first reported in 1973, highlighting the rare nature of this disease. Clinically, the patient may present with a breast mass or simply increased breast density and skin thickening. As such, amyloidosis may mimic the appearance of a number of pathologies, both benign and malignant. CASE REPORT: We report a single case of a patient who presented with a breast mass and was ultimately diagnosed with primary amyloidosis of the breast. We also present a review of the literature to date. CONCLUSION: The main treatment for primary amyloidosis of the breast is surgical removal, most often accomplished with breast conservation via lumpectomy. In performing the lumpectomy, the goal should be to obtain negative surgical margins; however, no strong data exist to suggest that such lesions would recur with a microscopically positive margin.