Predictors of 30-day readmission following pancreatic surgery: A retrospective review.

BACKGROUND: Pancreatectomies have been identified as procedures with an increased risk of readmission. In surgical patients, readmissions within 30 days of discharge are usually procedure-related. We sought to determine predictors of 30-day readmission following pancreatic resections in a large healthcare system. METHODS: We retrospectively collected information from the records of 383 patients who underwent pancreatic resections from 2004-2013. To find the predictors of readmission in the 30 days after discharge, we performed a univariate screen of possible variables using the Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. Multivariate analysis was used to determine the independent factors. RESULTS: Fifty-eight (15.1%) patients were readmitted within 30 days of discharge. Of the patients readmitted, the most common diagnoses at readmission were sepsis (17.2%), and dehydration (8.6%). Multivariate logistic regression found that the development of intra-abdominal fluid collections (OR = 5.32, P < 0.0001), new thromboembolic events (OR = 4.08, P = 0.016), and pre-operative BMI (OR = 1.06, P = 0.040) were independent risk factors of readmission within 30 days of discharge. CONCLUSION: Our data demonstrate that factors predictive of 30-day readmission are a combination of patient characteristics and the development of post-operative complications. Targeted interventions may be used to reduce the risk of readmission.

Cardiovascular Risk Factors and Echocardiographic Findings in a Predominantly Black Population with Rheumatoid Arthritis and Heart Failure.

Among White rheumatoid arthritis (RA) cohorts, heart failure with preserved ejection fraction (HFpEF) is the most prevalent type of heart failure (HF). We aimed to assess the type of HF affecting Black RA patients. 64 patients with RA-HF were compared to age-, sex-, and race-matched RA patients without HF. Left ventricular ejection fraction (LVEF), wall motion abnormalities, left ventricle (LV) mass, and wall thickness were reviewed. 87.3% were Black, 84.4% were women, with a mean age of 69.6 ± 1.38 (± SEM) and BMI (kg/m 2) 29.6 ± 1.07. RA-HF patients had higher rates of hypertension (HTN), chronic kidney disease, and atrial fibrillation. 66.7% had ≥3 cardiovascular risk factors compared to RA patients without HF. 2D-echocardiograms of RA-HF revealed that 62.3% had LVEF ≥50%, 37% had diastolic dysfunction, and 43.1% had wall motion abnormalities. LV mass and relative wall thickness measurements indicated LV eccentric remodeling. The odds ratio for HF was 4.7 (1.5-14.53 CI), p<0.01, among RA-HTN group and 3.5 (1.091-11.7 CI) p<0.01 among smokers. In our predominantly Black RA-HF patients, HFpEF was the most common type of HF. HTN was associated with the highest OR for HF. Eccentric hypertrophic remodeling, a known poor prognostic indicator for cardiovascular events, was found. Further studies are required to confirm our findings.

COVID-19 on Chest CT: Translating Known Microscopic Findings to Imaging Observations.

PURPOSE: To describe the imaging findings of COVID-19 and correlate them with their known pathology observations. METHODS: This is an IRB-approved retrospective study performed at Columbia University Irving Medical Center (IRB # AAAS9652) that included symptomatic adult patients (21 years or older) who presented to our emergency room and tested positive for COVID-19 and were either admitted or discharged with at least one chest CT from 11 March 2020 through 1 July 2020. CT scans were ordered by the physicians caring for the patients; our COVID-19 care protocols did not specify the timing for chest CT scans. A scoring system was used to document the extent of pulmonary involvement. The total CT grade was the sum of the individual lobar grades and ranged from 0 (no involvement) to 16 (maximum involvement). The distribution of lung abnormalities was described as peripheral (involving the outer one-third of the lung), central (inner two-thirds of the lung), or both. Additional CT findings, including the presence of pleural fluid, atelectasis, fibrosis, cysts, and pneumothorax, were recorded. Contrast-enhanced CT scans were evaluated for the presence of a pulmonary embolism, while non-contrast chest CT scans were evaluated for hyperdense vessels. RESULTS: 209 patients with 232 CT scans met the inclusion criteria. The average age was 61 years (range 23-97 years), and 56% of the patients were male. The average score reflecting the extent of the disease on the CT was 10.2 (out of a potential grade of 16). Further, 73% of the patients received contrast, which allowed the identification of a pulmonary embolism in 21%. Of those without contrast, 33% had hyperdense vessels, which might suggest a chronic pulmonary embolism. Further, 47% had peripheral opacities and 9% had a Hampton's hump, and 78% of the patients had central consolidation, while 28% had round consolidations. Atelectasis was, overall, infrequent at 5%. Fibrosis was observed in 11% of those studied, with 6% having cysts and 3% pneumothorax. CONCLUSIONS: The CT manifestations of COVID-19 can be divided into findings related to endothelial and epithelial injury, as were seen on prior post-mortem reports. Endothelial injury may benefit from treatments to stabilize the endothelium. Epithelial injury is more prone to developing pulmonary fibrotic changes.

Clot In Transit in a Patient with Protein S Deficiency.

Clot in transit (CIT) is a rare condition in which a venous thromboembolism becomes lodged in the right heart. It is seen in up to 18% of patients with massive pulmonary embolism, and if left untreated, mortality rates are between 80% and 100%. The identification and management of CIT are crucial. However, there are no current guidelines for the treatment of CIT. We present the case of a 44-year-old woman who was found to have CIT that was ultimately treated with medical management. LEARNING POINTS: Clot in transit (CIT) is a dangerous entity that must be promptly managed.Risk factors for CIT include a history of heart failure, a pre-existing central venous catheter and recent hospitalization.New interventions are emerging for the treatment of CIT.

When a stuffy nose won't go away: Rhabdomyosarcoma masquerading as adenoiditis.

Embryonal Rhabdomyosarcoma is a malignant mesenchymal proliferation of immature skeletal muscle and may arise in children in the orbit, middle ear, nasal cavity, paranasal sinuses, or nasopharynx. Clinical diagnosis may be difficult in a subset of patients who have no significant deformities or irregularities upon visual inspection of the oropharynx. Rhabdomyosarcoma in this setting may be mistaken for a more common underlying etiology such as an upper respiratory infection. We report a case of a 7-year-old male with embryonal variant rhabdomyosarcoma previously misdiagnosed by 3 different physicians to be adenoiditis based on clinical exam and laryngoscopy. This case highlights the capacity for rhabdomyosarcoma to mimic commonly encountered adenoiditis. It also serves as a reminder to maintain a high level of diagnostic vigilance and clinical suspicion of noninfectious etiologies when symptoms persist and are refractory to standard treatment.

Gliomatosis cerebri mimicking diffuse demyelinating disease: Case Report.

Gliomatosis Cerebri (GC) is a rareand rapidly progressive pattern of growth of diffusely infiltrating gliomas with limited treatment options. Imaging findings are usually nonspecific and can mimic other neurologic disorders, including demyelination, encephalitis, and multicentric/multifocal glioma. In this report, we describe a case of a 53-year-old female who presented with left hemiparesis, global headache, and gait ataxia with imaging features initially thought to represent demyelinating disease. A combination of conventional and advanced imaging findings with brain biopsy was utilized to make the diagnosis of GC. In patients with widespread abnormalities on brain imaging, GC should strongly be considered when cortical expansion, involvement of the septum pellucidum and elevated myoinositol levels are observed and the clinical and laboratory findings are atypical for demyelination or infection. Considering GC in such cases can facilitate early biopsy with prompt diagnosis and avoid delay in appropriate treatment.

Pineal glioblastoma: Case report and literature review of an exceedingly rare etiology for pineal region mass.

Pineal glioblastoma is an exceedingly rare potential etiology for a pineal region mass. The presentation, imaging appearance, and changes in treatment have been documented in a select number of cases since its first description in 1954. Through these cases, changes in treatment have shown to improve outcomes in select patients, some of which have had survival times over two or three years. We present a case of a 39 year old female with biopsy proven pineal glioblastoma who demonstrates improvement on imaging and survival >12 months after treatment with radiation therapy and chemotherapy. Our case and the prior reported cases enable future research into improving treatment, classification, and imaging recognition for this unlikely disease.

Association between elevated pre-operative glycosylated hemoglobin and post-operative infections after non-emergent surgery.

BACKGROUND: A chronic state of impaired glucose metabolism affects multiple components of the immune system, possibly leading to an increased incidence of post-operative infections. Such infections increase morbidity, length of stay, and overall cost. This study evaluates the correlation between elevated pre-operative glycosylated hemoglobin (HbA1c) and post-operative infections. STUDY DESIGN: Adult patients undergoing non-emergent procedures across all surgical subspecialties from January 2010 to July 2014 had a preoperative HbA1c measured as part of their routine pre-surgical assessment. 2200 patient charts (1100 < 6.5% HbA1c and1100 ≥ 6.5% HbA1c) were reviewed for evidence of post-operative infection (superficial surgical site infection, deep wound/surgical space abscess, pneumonia, and/or urinary tract infection as defined by Centers for Disease Control criteria) within 30 days of surgery. RESULTS: Patients with HbA1c < 6.5% and those with HbA1c ≥ 6.5% showed no statistically significant difference in overall infection rate (3.8% in the HbA1c < 6.5% group vs. 4.5% in the HbA1c ≥ 6.5% group, p = 0.39). Both linear regression and multivariate analysis did not identify HbA1c as an individual predictor of infection. Elevated HbA1c was, however, predictive of significantly increased risk of post-operative infection when associated with increased age (≥81 years of age) or dirty wounds. CONCLUSIONS: The risk factors of post-operative infection are multiple and likely synergistic. While pre-operative HbA1c level is not independently associated with risk of post-operative infection, there are scenarios and patient subgroups where pre-operative HbA1c is useful in predicting an increased risk of infectious complications in the post-operative period.