Unruptured aneurysmal clipping complicated by delayed and refractory vasospasm: case report.

BACKGROUND: Delayed symptomatic vasospasm is a rare complication following clipping of an unruptured intracranial saccular aneurysm. There have been ten reported cases of delayed symptomatic vasospasm and only two of these occurred after 2 weeks from initial intervention. Our case is the first to document the refractory nature of such vasospasm despite aggressive first line therapy. CASE PRESENTATION: Here, we present a 67-year-old female who had surgical clipping of a 10x7mm right middle cerebral artery (MCA) bifurcation aneurysm. Her surgery and initial postoperative course were uncomplicated, but she presented with acute left hemiparesis, dysarthria, headache and vomiting on post-op day 29 secondary to vasospasm of M2. She was initially stabilized with intra-arterial verapamil then managed with volume expansion, permissive hypertension, and nimodipine. She developed recurrent vasospasm of M2 the following day and was again treated with intra-arterial verapamil. Magnetic resonance imaging (MRI) brain showed an infarction involving the right basal ganglia, frontal lobe, and parietal lobe and her hospital course was complicated by super-refractory status epilepticus. At her follow up appointment she displayed continued left lower extremity weakness, left visual field defect, and left-sided neglect. CONCLUSIONS: Overall, cerebral vasospasms associated with unruptured aneurysms remain rare complications and are not often monitored for after initial recovery. Reviewing the documented cases highlights the unpredictability of when these events occur with our current knowledge. Current hypotheses for the mechanisms responsible for delayed and refractory vasospasms include: blood-derived breakdown products, mechanically induced vasospastic responses, and delayed reactions from the trigemino-cerebrovascular system (TCVS). The uncertainly of these events warrants further research and supports a strong argument for monitoring patients with initial surgical clipping up to a month out from their initial procedure.

Clinical profile of pterygium in patients seeking eye care in India: electronic medical records-driven big data analytics report III.

OBJECTIVE: To describe the clinical profile of pterygium in patients presenting to a multi-tier ophthalmology hospital network in India. METHODS: This cross-sectional hospital-based study included 1,610,843 new patients presenting between 2010 and 2019. Patients with a clinical diagnosis of pterygium in at least one eye were included as cases. The data were collected using an electronic medical record system. Multiple logistic regression analysis with odds ratios (OR) was performed to identify the associated risk factors. RESULTS: Overall, 168,807 (10.5%) new patients were diagnosed with pterygium, of which 43,692 (26%) patients complained about the lesion. The prevalence rates were 0.7% in children and 12.6% in adults. Majority of patients were female (54.5%) and had unilateral (57%) affliction. Among the 241,631 affected eyes, the pterygia were primary in 99.6%, nasally located in 94%, and were grade I-II in 84.8%. Four in 5 eyes did not have any cylindrical refractive error, and 44% had coexistent cataract. Pterygium surgery was indicated in 10.3% eyes. Female sex (OR 1.37), increasing age (OR 19.5), rural residence (OR 1.21), agriculture work (OR 2.19), manual labor (OR 2.05), low socioeconomic status (OR 2.14) and geographical location closer to the equator (OR 3.4) were identified as the risk factors for developing pterygium. CONCLUSION: About one-tenth of individuals seeking eye care in India have pterygium in at least one eye. It rarely impacts vision, is commonly unilateral and nasal and usually does not require surgery. It is associated with increasing age, females, outdoor work, low income and geographical location closer to the equator.

An analysis of 3,954 cases to determine surgical wound classification accuracy: Does your institution need a monday morning quarterback?

INTRODUCTION: Surgical site infections reporting has financial implications for institutions under Centers for Medicare and Medicaid Services (CMS) Pay-for-Performance programs. Surgical Wound Classification (SWC) is an important factor in performing risk adjustment and affects the accuracy of the Standardized Infection Ratio (SIR). This in turn leads to more accurate inter-hospital ratings and reimbursement. This study aims to measure (1) services and procedures associated with the highest rates of misclassification and (2) whether temporal factors influenced misclassification. METHODS: Accuracy of SWC was assessed by comparing the wound classification documented by the Operating Room (OR) nurse at the time of the operation to the actual SWC determined from in-depth chart review using Centers for Disease Control and Prevention (CDC) wound classification algorithm by a trained reviewer. Cases were reviewed once operative reports were available. RESULTS: Review of 3954 cases yielded an overall discordance rate of 22.15% (N = 876), with most cases being under-classified. Services with the highest rates of discordance include cardiothoracic (38.46%) and general surgery (37.86%), followed by general oncology (29.46%), OB-GYN (28.93%), urology (27.27%), and plastic surgery (27.14%). Procedures with the highest discordance rates are laparoscopic appendectomy (66.67%), cholecystectomy (52.90%), exploratory laparotomy (49.21%), and split-thickness skin graft (36.84%). Discordance rates were significantly higher (p = 0.0001) during weekends compared to weekdays, while operations starting after-hours during the week did not show a significant difference from daytime hours. CONCLUSION: At a level 1 trauma academic medical center, certain procedures were found to be misclassified in regards to SWC more often than other types of cases. The timing of the case, such that they occurred on the weekends also contributed to higher discordance rates between original and corrected wound classifications. Recognizing cases, services, and temporal factors frequently associated with misclassification of wound class can help allocate limited resources to maximize improvement of this important metric.