Sepsis and Septic Shock in Patients Undergoing Thyroidectomy: Incidence, Risk Factors, and Outcomes.

INTRODUCTION: Postoperative sepsis represents a rare complication following thyroidectomy. We aimed to explore the incidence, risk factors, sources, and outcomes of postoperative sepsis and septic shock among adult patients undergoing thyroidectomy. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program were used in this retrospective cohort study. Patients aged ≥18 y who underwent elective thyroidectomy between 2005 and 2019 were included. Multivariable binary logistic regression models were computed to explore risk factors and outcomes of 30-d sepsis and septic shock. RESULTS: Among the 180,373 included patients, 0.1% developed sepsis or septic shock. Male gender, low body mass index, American Society of Anesthesiologists classes 3-5, functional dependence, smoking, diabetes mellitus, pulmonary disease, inpatient surgery, malignant indication, clean-contaminated wound classification, and operation time ≥150 min were significant risk factors for development of sepsis or septic shock. Common infectious sources of sepsis included surgical site infections (29.6%), pneumonia (18.6%), urinary tract infections (16.2%), and multiple infections (6.9%). Patients with postoperative sepsis or septic shock were significantly more likely to develop complications, including wound disruption, stroke, cardiac and renal complications, thromboembolism, prolonged length of stay, unplanned reoperation, and mortality. CONCLUSIONS: Sepsis is rare following thyroidectomy. Our study provides insight into risk factors and procedural characteristics which may contribute to the development of postoperative sepsis or septic shock in this population.

The effect of preoperative steroids for at least 10 days on complications following craniotomy for tumor resection: A database, retrospective cohort study.

Introduction: The effect of chronic steroid therapy on postoperative outcomes after craniotomy for tumor resection remains understudied. Research question: This study aimed to fill this gap and to identify risk factors of postoperative morbidity and mortality among patients on chronic steroid use undergoing craniotomy for tumor resection. Materials and methods: Data from the American College of Surgeons National Surgical Quality Improvement Program were used. Patients who underwent craniotomy for tumor resection between 2011 and 2019 were included. Perioperative characteristics and complications were compared among patients with and without chronic steroid therapy, defined as steroid use for at least 10 days. Multivariable regression analyses were conducted to assess the impact of steroid therapy on postoperative outcomes. Subgroup analyses involving patients on steroid therapy were conducted to explore risk factors of postoperative morbidity and mortality. Results: Of 27,037 patients, 16.2% were on steroid therapy. On regression analyses, steroid use was significantly associated with any postoperative complication, infectious complication, urinary tract infection, septic shock, wound dehiscence, pneumonia, non-infectious, pulmonary, and thromboembolic complications, cardiac arrest, blood transfusion, unplanned reoperation, readmission, and mortality. On subgroup analysis, risk factors for postoperative morbidity and mortality among patients on steroid therapy included older age, higher American Society of Anesthesiology physical status, functional dependence, pulmonary and cardiovascular comorbidities, anemia, dirty/infected wounds, prolonged operative time, disseminated cancer, and a diagnosis of meningioma. Discussion and conclusion: Preoperative brain tumor patients on steroids for 10 or more days are at a relatively high risk of postoperative complications. We recommend a judicious use of steroids in brain tumor patients, both in terms of dosage and duration of treatment.

Association of Metabolic Syndrome with Stroke, Myocardial Infarction, and Other Postoperative Complications Following Carotid Endarterectomy: A Multicenter, Retrospective Cohort Study.

BACKGROUND: Metabolic syndrome (MetS) is a constellation of hypertension, insulin resistance, obesity, and dyslipidemia and is known to increase the risk of postoperative morbidity. This study aimed to assess the impact of MetS on stroke, myocardial infarction, mortality, and other complications following carotid endarterectomy (CEA). METHODS: We analyzed data from the National Surgical Quality Improvement Program. Patients undergoing elective CEA between 2011 and 2020 were included. Patients with American Society of Anesthesiologists status 5, preoperative length of stay (LOS) > 1 day, ventilator dependence, admission from nonhome location, and ipsilateral internal carotid artery stenosis of < 50% or 100% were excluded. A composite cardiovascular outcome for postoperative stroke, myocardial infarction, and mortality was generated. Multivariable binary logistic regression analyses were used to assess the association of MetS with the composite outcome and other perioperative complications. RESULTS: We included 25,226 patients (3,613, 14.3% with MetS). MetS was associated with postoperative stroke, unplanned readmission, and prolonged LOS on bivariate analysis. On multivariable analysis, MetS was significantly associated with the composite cardiovascular outcome (1.320 [1.061-1.642]), stroke (1.387 [1.039-1.852]), unplanned readmission (1.399 [1.210-1.619]), and prolonged LOS (1.378 [1.024-1.853]). Other clinico-demographic factors associated with the cardiovascular outcome included Black race, smoking status, anemia, leukocytosis, physiologic risk factors, symptomatic disease, preoperative beta-blocker use, and operative time ≥ 150 min. CONCLUSIONS: MetS is associated with cardiovascular complications, stroke, prolonged LOS, and unplanned readmissions following CEA. Surgeons should provide optimized care to this high-risk population and strive to reduce operative durations.

A novel bud mutant of navel orange (Citrus sinensis) shows tolerance to chlorosis in acidic and magnesium-deficient soils.

Interveinal chlorosis in old leaves is a common occurrence in citrus orchards in southern China. The present study investigates the 'Langfeng' navel orange (LF, Citrus sinensis) grafted onto a Trifoliate orange (TO, Poncirus trifoliata) rootstock, which exhibits healthy green leaves, and the 'Newhall' navel orange (NHE, C. sinensis) grafted onto TO, which has typical magnesium (Mg) deficiency-induced chlorosis. Chemical analysis of the rhizosphere soil revealed that the pH values were around 3.92 and that both Mg and calcium (Ca) were significantly deficient in the rhizosphere soil of both grafting combinations (LF/TO and NHE/TO). Furthermore, the chlorotic leaves of NHE/TO had significantly lower levels of Mg, Ca, and phosphorus (P), and the green leaves of NHE/TO had significantly lower levels of Mg and Ca compared to the green leaves of the LF/TO. This suggests that Mg deficiency may be the primary cause of chlorosis in NHE/TO. A greenhouse study using the same graft combinations showed that the LF/TO plants had better growth than the NHE/TO, possibly by promoting Mg uptake and/or improving Mg distribution to leaves, thereby increasing carbon dioxide (CO2) assimilation and photosynthesis, optimizing carbohydrate distribution, and increasing plant biomass. This results in a phenotype that is tolerant to Mg deficiency. In conclusion, these findings suggest that the LF navel orange could be utilized in the development of new citrus varieties with improved Mg-use efficiency.

Ocular biodistribution of cysteamine delivered by a sustained release microsphere/thermoresponsive gel eyedrop.

The objective of the investigation was to determine the ocular biodistribution of cysteamine, a reducing agent used for treatment of cystine crystals in cystinosis, following topical administration of a sustained release formulation and traditional eyedrop formulation. To the right eye only, rabbits received a 50 µL drop of 0.44% cysteamine eyedrops at one drop per waking hour for 2, 6, 12, and 24 h. A second group received one 100 µL drop of a sustained release formulation containing encapsulated cysteamine microspheres suspended in a thermoresponsive gel. Upon serial sacrifice, ocular tissues from both eyes and plasma were obtained and quantified for cysteamine using LC-MS/MS. Cysteamine was detected in the cornea, aqueous humor and vitreous humor. Systemic plasma concentrations of cysteamine from treatment groups were below the limit of detection. As expected, 0.44% cysteamine eyedrops when administered hourly maintained drug concentrations within the cornea at a magnitude 5 times higher than a single dose of the sustained release formulation over 12 h. The sustained release formulation maintained cysteamine presentation across 12 h from a single drop. These studies demonstrate distribution of cysteamine to the eye following topical administration, including high drug uptake to the cornea and low systemic distribution.

A Comprehensive Assessment of Blood Transfusions in Elective Thyroidectomy Based on 180,483 Patients.

OBJECTIVES: To assess the incidence, risk factors, and complications of blood transfusions (BTs) in elective thyroidectomy patients. METHODS: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program. Adult patients who underwent elective thyroidectomy from 2005 to 2019 were divided into two cohorts based on whether they received BT or not. Multivariable binary logistic regression models were used to identify risk factors of BT and its impact on postoperative complications. RESULTS: Of 180,483 patients, 0.13% received BT. Risk factors for BT included underweight body mass index (BMI) (adjusted odds ratio [OR] 3.179, 95% confidence interval [CI] 1.444-6.996), bleeding disorders (OR 2.121, 95% CI 1.149-3.913), anemia (OR 4.730, 95% CI 3.472-6.445), preoperative transfusion (OR 7.230, 95% CI 1.454-35.946), American Society of Anesthesiology physical statuses 3-5 (OR 3.103, 95% CI 2.143-4.492), operative time >150 min (OR 4.390, 95% CI 1.996-9.654), and inpatient thyroidectomy (OR 5.791, 95% CI 3.816-8.787). In addition, transfusion was independently associated with any postoperative complication, non-infectious, cardiac, pulmonary, renal, vascular, or infectious complications, surgical site infection, sepsis, septic shock, wound disruption, pneumonia, unplanned reoperation, prolonged length of stay, and mortality. CONCLUSION: Recognition of risk factors of BT is imperative to identify at-risk patients and reduce transfusions by controlling modifiable risk factors such as anemia, operative time, and BMI. In cases where transfusions are still indicated, surgeons should optimize care to prevent or adequately manage transfusion-associated complications. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2078-2084, 2022.

Current Understandings on Magnesium Deficiency and Future Outlooks for Sustainable Agriculture.

The productivity of agricultural produce is fairly dependent on the availability of nutrients and efficient use. Magnesium (Mg2+) is an essential macronutrient of living cells and is the second most prevalent free divalent cation in plants. Mg2+ plays a role in several physiological processes that support plant growth and development. However, it has been largely forgotten in fertilization management strategies to increase crop production, which leads to severe reductions in plant growth and yield. In this review, we discuss how the Mg2+ shortage induces several responses in plants at different levels: morphological, physiological, biochemical and molecular. Additionally, the Mg2+ uptake and transport mechanisms in different cellular organelles and the role of Mg2+ transporters in regulating Mg2+ homeostasis are also discussed. Overall, in this review, we critically summarize the available information about the responses of Mg deficiency on plant growth and development, which would facilitate plant scientists to create Mg2+-deficiency-resilient crops through agronomic and genetic biofortification.

Quality-of-life indicators and falls due to vitamin D deficiency.

OBJECTIVE: To determine whether the number of falls and quality-of-life indicators relate to serum levels of vitamin D, parathyroid hormone (PTH), and calcium levels. DESIGN: A prospective study. PARTICIPANTS: Patients being admitted with a fall with or without sustaining a fragility fracture post fall. MEASUREMENTS: Measured frequency of falling, SF-12 questionnaire, serum concentrations of 25-hydroxyvitamin D, calcium, and PTH levels before and after treatment with vitamin D supplementation. RESULTS: The mean age (N=38) of the cohort was 80.2±12. In all, 76.3% of the cohort had sustained a fragility fracture after the fall. The cohort was vitamin D deficient with the pretreatment mean value of 24.2±17 nmol/L and posttreatment mean value of 99±40 nmol/L with a statistically significant mean difference of 74.7 nmol/L (confidence interval [CI] 61.27-88.3), P=0.001. The levels of calcium and PTH were statistically significant after treatment with a mean difference of 0.16 (CI 0.1-0.2), P=0.001, and 3.7 (CI -4.8 to -2.5), P=0.001, respectively. After treatment, the mean difference of physical component score (PCS) and mental component score for the whole cohort was 2.9 (CI -0.69 to 6.6), P=0.10, and 1.05 (CI -2.6 to 4.7), P=0.56, respectively. However, a subgroup analysis for cohort aged ≤70 years provided a statistically significant effect on PCS with a mean difference of 8.9 (CI 1.3-16.4), P=0.03, but a statistically insignificant improvement in mental component score with a mean difference of 6.0 (CI -17 to -5.0), P=0.20. However, a statistically significant improvement in PCS SF-12 was observed in patients ≤70 years of age 2.9 (1.3-16.4), P=0.03. The mean number of falls for the whole cohort pre- and posttreatment was 1.11±0.92 vs 0.97±0.99 (P=0.68), respectively. CONCLUSION: Patients who had fallen and sustained fragility fracture had lower serum 25-dihydroxyvitamin D and higher serum PTH levels. Our study demonstrates that there is no statistically significant improvement in the number of falls after treatment with vitamin D. Overall, vitamin D levels improved significantly, this is despite quality-of-life indicators showing a mean increase in PCS but not a statistically significant improvement. However, statistically significant improvement in PCS was observed in group aged ≤70 years after vitamin D supplementation.

Current and future therapy for pulmonary hypertension in patients with right and left heart failure.

Pulmonary hypertension (PH) is a devastating condition that without proper management can deteriorate progressively. Elevated pulmonary artery pressure without an identifiable etiology is called IPAH. PH resulting from a specific disease is referred to as secondary PH; left-sided cardiac disease can lead to an increase in pulmonary artery pressure resulting in increased vascular resistance and subsequent structural remodeling. If left-sided failure progresses to right-sided failure with high pulmonary artery pressure, the outcome is ominous. It has been clearly proven that early diagnosis and effective medical therapy can markedly decrease morbidity and mortality. In this review, we discuss the current treatment modalities and their limitations for PH secondary to heart failure. Conventional therapy in patients with pulmonary arterial hypertension as well as recent advances in the medical management of PH in general, are also described. Last, the surgical management of these patients and other promising interventional modalities are reviewed.

Osteonecrosis and bisphosphonates in oral and maxillofacial surgery.

Bisphosphonates are a class of compounds approved for the treatment of multiple myeloma, hypercalcemia of malignancy, osteolytic lesions of metastatic disease, Paget's disease, and most commonly, osteoporosis. Recently, these drugs have been associated with a new clinical entity, bisphosphonate related osteonecrosis (BRON) which is characterized by jaw necrosis that typically presents following dentoalveolar surgery. The pathogenesis for this complication appears to related to bisphosphonate mediated inhibition of osteoclast function and normal bone remodeling. This complication can have a significant impact on the quality of life for those patients with advanced stages of necrosis.