Predictors of in-hospital appendiceal perforation in patients with non- perforated acute appendicitis with appendicolithiasis at presentation.

INTRODUCTION: Appendicolithiasis is a risk factor for perforated acute appendicitis. There is limited inpatient data on predictors of progression in appendicolithiasis-associated non-perforated acute appendicitis. METHODS: We identified adults presenting with appendicolithiasis-associated non-perforated acute appendicitis (on computed tomography) who underwent appendectomy. Logistic regression was used to investigate predictors of in-hospital perforation (on histopathology). RESULTS: 296 patients with appendicolithiasis-associated non-perforated acute appendicitis were identified; 48 (16.2%) had perforation on histopathology. Mean (standard deviation [SD]) age was 39 (14.9) years. The mean (SD) length of stay (LOS) was 1.5 (1.8) days. LOS was significantly longer with perforated (mean [SD]: 3.0 [3.1] days) vs. non-perforated (mean [SD]: 1.2 [1.2] days) appendicitis (p < 0.001). On multivariate analysis, in-hospital perforation was associated with age > 65 years (OR 5.4, 95% CI: 1.4- 22.2; p = 0.015), BMI > 30 kg/m2 (OR 3.5, 95% CI: 1.3-8.9; p = 0.011), hyponatremia (OR 3.6, 95% CI: 1.3-9.8; p = 0.012). There was no significant association with age 25-65 years, gender, race, steroids, time-to- surgery, neutrophil percentage, or leukocyte count. CONCLUSION: Geriatric age, obesity, and hyponatremia are associated with progression to perforation in appendicolithiasis-associated non-perforated acute appendicitis.

The First COVID-19 Pandemic Wave and the Effect on Health Care Trainees: A National Survey Study.

BACKGROUND: This study observes the trends and patterns among trainees during the coronavirus disease 2019 (COVID-19) pandemic and their response to resident education and hospital/program support. METHODS: An anonymous online 31-question survey was distributed to medical students and postgraduate year residents. Topics included were demographics, clinical responsibilities, educational/curricula changes, and trainee wellness. Descriptive analysis was performed for each set of demographic groupings as well as 2 and 3 group comparisons. RESULTS: Total 1051 surveys collected, 930 used for analysis: 373 (40.1%) male, 434 (46.6%) aged 30-34 years, 588 (63.2%) white, 417 (44.8%) married, 168 (18%) with children, and 323 (34.7%) from the Northeast region. The Northeast experienced difficulty sleeping, feelings of guilt, hopelessness, and changes in appetite (P = .0077). The pandemic interfered significantly with relationships and living situations (P < .0001). Trainees 18-34 years believed the pandemic affected residency training (P < .0001). Surgical residents were concerned about reaching numbers of operative procedures to graduate (P < .0001). Residency programs adhered to ACGME work restrictions (P < .0001). CONCLUSION: We aim to provide continued educational support for our trainees' clinical development and well-being during the COVID-19 pandemic.

Rapidly growing sclerosing angiomatoid nodular transformation of the spleen.

Sclerosing angiomatoid nodular transformation (SANT) of the spleen is a rare benign vascular lesion with unknown pathogenesis and no definitive pathognomonic radiological features. The majority of patients with SANT are asymptomatic, and the lesion is an incidental finding on cross-sectional imaging performed for unrelated reasons or during intra-abdominal surgery. However, in the symptomatic minority, abdominal pain is the most commonly reported symptom. SANT generally remains stable or has very slow growth, making it amenable to surveillance using serial cross-sectional imaging. Herein, we report the unusual case of SANT in a 30-year-old female with rapid growth from 6.0 × 5.6 × 4.4 cm to 8.0 × 6.6 × 7.2 cm over 21 months. Given the rapid growth, it was imperative to rule out malignancy. Thus, the patient underwent a laparoscopic total splenectomy. For SANT, splenectomy serves the dual purpose of diagnosis and definitive therapy.

Warfarin Use Is Associated with Increased Mortality at One Year in Patients with Idiopathic Pulmonary Fibrosis.

OBJECTIVES: We studied the safety and efficacy of warfarin compared to direct acting oral anticoagulant use in patients with IPF. METHODS: We conducted a retrospective cohort study of all patients with IPF who were prescribed warfarin or direct acting oral anticoagulants (DOACs) for cardiac or thromboembolic indications and followed at our institute for their care. Univariate tests and multivariable logistic regression analyses were used for assessing association of variables with outcomes. RESULTS: A total of 73 patients were included in the study with 28 and 45 patients in the warfarin and DOAC groups, respectively. Univariable analysis revealed a significant difference in mortality in one year between warfarin and DOAC groups (7/28 vs. 3/45, p value 0.027). Significantly more patients in the warfarin group suffered an exacerbation that required hospitalization within one year (9/28 vs. 5/45, p value 0.026). Multivariate logistic regression analysis showed that anticoagulation with warfarin was independently associated with mortality at one-year follow-up (OR: 77.4, 95% CI: 5.94-409.3, p value: 0.007). CONCLUSION: In our study of patients with IPF requiring anticoagulants, we noted statistically significant higher mortality with warfarin anticoagulation when compared to DOAC use. Further larger prospective studies are needed to confirm these findings.

Patients with idiopathic pulmonary fibrosis have poor clinical outcomes with COVID-19 disease: a propensity matched multicentre research network analysis.

INTRODUCTION: Outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients with pre-existing idiopathic pulmonary fibrosis (IPF) remain understudied, and it is unknown if IPF is an independent predictor of worse disease course. Herein, we report the clinical outcomes in a large cohort of 251 patients with COVID-19 in the setting of known IPF. Outcomes were compared with a propensity matched cohort of patients with COVID-19 without IPF. METHODS: Analysis of a federated multicentre research network TriNetX was performed including patients more than 16 years of age diagnosed with SARS-CoV-2 infection. Outcomes in patients diagnosed as positive for SARS-CoV-2 infection with concurrent IPF were compared with a propensity matched cohort of patients without IPF. RESULTS: A total of 311 060 patients with SARS-CoV-2 infection on the research network were identified, 251 patients (0.08%) carried a diagnosis of IPF. Mean age of patients with IPF was 68.30±12.20 years, with male predominance (n=143, 56.97%). Comorbidities including chronic lower respiratory diseases, diabetes mellitus, ischaemic heart disease and chronic kidney disease were more common in patients with IPF when compared with the non-IPF cohort. After propensity matching, higher rates of composite primary outcome (death or mechanical ventilation) at 30 and 60 days, as well as need for hospitalisation, critical care, and acute kidney injury were observed in the IPF cohort. CONCLUSION: Poor outcomes of COVID-19 disease were observed in patients with IPF after robust matching of confounders. Our data confirm that patients with IPF constitute a high-risk cohort for poor outcomes related to COVID-19 disease.

Increased mortality associated with a clonal outbreak of ceftazidime-resistant Klebsiella pneumoniae: a case-control study.

OBJECTIVES: To determine risk factors for ceftazidime-resistant Klebsiella pneumoniae infection and the effect of ceftazidime-resistant K. pneumoniae infection on mortality during an isolated outbreak. DESIGN: Case-control investigation using clinical and molecular epidemiology and prospective analysis of infection control interventions. SETTING: Surgical intensive care unit of a university-affiliated community hospital. PATIENTS: Fourteen case-patients infected with ceftazidime-resistant K. pneumoniae and 14 control-patients. RESULTS: Ten of 14 case-patients had identical strains by pulsed-field gel electrophoresis. Broad-spectrum antibiotic therapy before admission to the unit was strongly predictive of subsequent ceftazidime-resistant K. pneumoniae infection. In addition, patients with ceftazidime-resistant K. pneumoniae infection experienced increased mortality (odds ratio, 3.77). CONCLUSIONS: Cephalosporin restriction has been shown to decrease the incidence of nosocomial ceftazidime-resistant K. pneumoniae. However, isolated clonal outbreaks may occur due to lapses in infection control practices. Reinstatement of strict handwashing, thorough environmental cleaning, and repeat education led to termination of the outbreak. A distinct correlation between ceftazidime-resistant K. pneumoniae infection and mortality supports the important influence of antibiotic resistance on the outcome of serious bacterial infections.

Readmission within 30 days of discharge after hip fracture care.

The Affordable Care Act currently requires hospitals to report 30-day readmission rates for certain medical conditions. It has been suggested that surveillance will expand to include hip and knee surgery-related readmissions in the future. To ensure quality of care and avoid penalties, readmissions related to hip fractures require further investigation. The goal of this study was to evaluate factors associated with 30-day hospital readmission after hip fracture at a level I trauma center. This retrospective cohort study included 1486 patients who were 65 years or older and had a surgical procedure performed to treat a femoral neck, intertrochanteric, and/or subtrochanteric hip fracture during an 8-year period. Analysis of these patients showed a 30-day readmission rate of 9.35% (n=139). Patients in the readmission group had a significantly higher rate of pre-existing diabetes and pulmonary disease and a longer initial hospital length of stay. Readmissions were primarily the result of medical complications, with only one-fourth occurring secondary to orthopedic surgical failure. Pre-existing pulmonary disease (odds ratio [OR], 1.885; 95% confidence interval [CI], 1.305-2.724), initial hospitalization of 8 days or longer (OR, 1.853; 95% CI, 1.223-2.807), and discharge to a skilled nursing facility (OR, 1.586; 95% CI, 1.043-2.413) were determined to be predictors of readmission. Accordingly, patient management should be consistently geared toward optimizing chronic disease states while concomitantly working to minimize the duration of initial hospitalization and decrease readmission rates

Radiologic case study. Dialysis-related amyloidosis.

A 59-year-old woman presented with worsening bilateral hip pain for 6 months. She had been receiving hemodialysis for 12 years.

Adenocarcinoma arising at ileostomy sites: Two cases and a review of the literature.

Total colectomy with ileostomy placement is a treatment for patients with inflammatory bowel disease or familial adenomatous polyposis (FAP). A rare and late complication of this treatment is carcinoma arising at the ileostomy site. We describe two such cases: a 78-year-old male 30 years after subtotal colectomy and ileostomy for FAP, and an 85-year-old male 50 years after colectomy and ileostomy for ulcerative colitis. The long latency period between creation of the ileostomies and development of carcinoma suggests a chronic metaplasia due to an irritating/inflammatory causative factor. Surgical excision of the mass and relocation of the stoma is the mainstay of therapy, with possible benefits from adjuvant chemotherapy. Newly developed lesions at stoma sites should be biopsied to rule out the possibility of this rare ileostomy complication.

Use of an "antibiotic plate" for infected periprosthetic fracture in total hip arthroplasty.

Periprosthetic fracture and infection are dreaded complications after total hip arthroplasty. We present the case of a 50-year-old man who suffered an early postoperative Vancouver B1 periprosthetic fracture, which was further complicated by concurrent infection after open reduction and internal fixation. We report the novel use of an antibiotic-impregnated cement coated locking plate during the staged treatment of concomitant periprosthetic fracture and chronic total hip arthroplasty infection. At 1-year follow-up, the patient is pain free and ambulating independently with full range of motion.

Distal third femur fractures treated with retrograde femoral nailing and blocking screws.

Retrograde femoral nailing is a widely used treatment for fractures involving the distal third of the femur. Angular malunion of these fractures after retrograde intramedullary nailing is a known complication. We report our surgical technique and experience using blocking screws to aid in reduction and augment the stability of the fixation when using a retrograde intramedullary nail for distal femoral fractures.

Extent of initial corneal injury as the mechanistic basis for ocular irritation: key findings and recommendations for the development of alternative assays.

Currently, there are no recognized alternative tests to eliminate the use of animals in ocular irritation testing. A major reason no replacement alternatives have been developed is that the current in vivo data set provides no perspective regarding the critical cellular and molecular changes involved in initial ocular injury, subsequent responses, and repair processes in standard in vivo tests. Without this perspective, mechanistically based replacement tests cannot be developed and validated. We have proposed that the level of ocular irritation is related to the extent of initial injury, and that regardless of the processes leading to tissue damage, the extent of initial injury is the principal factor determining the outcome of ocular irritation. This article summarizes the results from our studies of various surfactants and nonsurfactants of differing irritancy that support our hypothesis. Our findings indicate that a mechanistically based alternative to in vivo ocular irritation tests would be the microscopic or biochemical measurement of initial injury using either ex vivo or in vitro corneal equivalent systems composed of corneal epithelial, stromal keratocyte, and corneal endothelial cell layers. This work also provides a well-characterized panel of materials of varying types and irritation for use in developing and validating alternative tests.