Risk Factors and Outcomes for Sepsis after Appendectomy in Adults.

Background: Sepsis is an uncommon occurrence after appendectomy, but the morbidity and mortality of patients who develop sepsis after appendectomy remains exceedingly high. The purpose of this study is to identify risk factors and adverse post-operative outcomes associated with sepsis after appendectomy in adults. Patients and Methods: The American College of Surgery National Surgical Quality Improvement Program participant user database was queried from 2012 to 2015. Patients who underwent appendectomy were identified and demographic data, intra-operative variables, and post-operative outcomes were collected. The primary outcome was post-operative sepsis after appendectomy, which was defined as the development of sepsis or septic shock post-operatively. Patients with a diagnosis of systemic inflammatory response syndrome (SIRS), sepsis, or septic shock within 48 hours prior to surgery or present at the time of surgery were excluded. Multivariable analyses (logistic and linear regression) were performed to assess for risk factors and adverse outcomes associated with sepsis. Results: Of the 72,538 patients who had appendectomies, 311 patients (0.43%) were identified as having post-operative sepsis. Of these, 17 patients (5.47%) died within 30 days. Age 60 years or more (odds ratio [OR] 1.51, 95% confidence interval [CI] 1.129-2.02), African American race (OR 1.951, 95% CI 1.399-2.722), morbid obesity (OR 1.784, 95% CI 1.264-2.516), acute renal failure or dialysis (OR 4.642, 95% CI 2.17-9.929), disseminated malignancy (OR 4.089, 95% CI 1.719-9.726), and open appendectomy (OR 2.607, 95% CI 2.003-3.393) were found to be associated with increased risk of post-operative sepsis; patients were also less likely to be female (OR 0.650, 95% CI 0.517-0.817). Patients who developed sepsis after appendectomy were more likely to return to the operating room (24.76 vs. 0.77%, p < 0.001), be re-admitted for any cause (53.38% vs. 2.70%, p < 0.0001), and die within 30 days of surgery (5.47% vs. 0.05%, p < 0.001). Conclusion: Patients who become septic after appendectomy are at risk for adverse post-operative morbidity and mortality. Age 60 years or more, African American race, morbid obesity, acute renal failure or dialysis, disseminated malignancy, and open appendectomy increase the risk for sepsis after appendectomy and sepsis-related morbidity and mortality. Given the remarkably large number of appendectomies that are performed each year, the findings of this study can assist in identifying at-risk patients, facilitate physician-patient discussion and shared decision-making, and guide appropriate care to further reduce the incidence of sepsis after appendectomy.

Healthcare-Associated Mycobacterium chimaera Infection Subsequent to Heater-Cooler Device Exposure During Cardiac Surgery.

A SERIES of reports in the United States and Europe have linked Mycobacterium chimaera infections to contaminated heater-cooler devices used during cardiac surgery. Heater-cooler devices commonly are used for cardiopulmonary bypass during cardiac surgery. M. chimaera is a slow-growing nontuberculous mycobacterium that has been shown to cause cardiac complications that can lead to fatal disease following cardiac surgery. Given that more than 250,000 cardiothoracic surgical procedures requiring cardiopulmonary bypass take place each year in the United States, the estimated number of patient exposures to M. chimaera has prompted a public health crisis. The goal of this review is to summarize the present status of the M. chimaera outbreak and provide cardiothoracic surgeons, cardiac anesthesiologists, and other clinicians with current approaches to patient management and to discuss risk mitigation.

Perioperative Patient Beliefs Regarding Potential Effectiveness of Marijuana (Cannabinoids) for Treatment of Pain: A Prospective Population Survey.

BACKGROUND AND OBJECTIVES: Cannabinoids have an expanding presence in medicine. Perioperative patients' perceptions of the effectiveness of these compounds, and acceptance if prescribed for pain, have not been previously described. Our primary objective was to describe patients' beliefs regarding the potential effectiveness of cannabinoids for the treatment of acute and chronic pain, as well as gauge patient acceptance of these compounds if prescribed by a physician. In addition, demographic and pain history data were collected to elucidate the predictors of the aforementioned patient attitudes. Secondarily, we sought to characterize the subgroup of patients who reported marijuana use. Predictors of marijuana use, effectiveness, and adverse effects were also reported for this subgroup. METHODS: An anonymous questionnaire was administered to 501 patients in the preoperative registration area at Mount Sinai Hospital, New York, New York. The questionnaire was designed to collect data on patient demographics, presence of pain, pain severity, use of pain medication, history of illicit-drug use, tobacco use, cannabis use, patient beliefs about the potential effectiveness of marijuana for acute and chronic pain and their willingness to use cannabis for pain, if prescribed by a physician. Normality of distributions for continuous variables was assessed with skewness and kurtosis measures. A logistic regression model was used to assess the demographic and medical characteristics of marijuana users compared with nonusers. The effectiveness of marijuana in dealing with pain and adverse effects associated with its use were examined using exploratory principal component analysis. RESULTS: More than 80% of this cohort of preoperative patients believed that marijuana could be at least somewhat effective for the treatment of pain after surgery and would be willing to use cannabinoid compounds if prescribed by their physician. Predictors of positive attitudes toward marijuana included history of marijuana use, pain history, and being a marijuana nonuser of white race. Approximately 27% of the respondents reported a history of marijuana use. Younger patients, those with higher levels of pain in the last 24 hours, and those who found standard therapies to be less effective for their pain were more likely to use marijuana. CONCLUSIONS: Patients generally believe that marijuana could be at least somewhat effective for the management of pain and are willing to use cannabinoid compounds for this indication, if prescribed by a physician.

Perioperative Pain Management of a Patient Taking Naltrexone HCl/Bupropion HCl (Contrave): A Case Report.

A 42-year-old obese woman (body mass index = 30.2 kg/m) presented for urgent anterior cervical diskectomy and fusion. She had been taking oral naltrexone-bupropion extended-release (Contrave, Orexigen Therapeutics Inc, La Jolla, CA) for the past 6 months and continued using it until 12 hours preoperatively. Despite discontinuation of this medication, and employing an intraoperative and postoperative multimodal analgesia strategy, immediate pain control was inadequately achieved. Patients taking opioid antagonists who present for surgery pose unique challenges to the anesthesiologist and require extensive preoperative interdisciplinary discussions and planning for pain control throughout the perioperative period.

Longitudinal imaging of HIV-1 spread in humanized mice with parallel 3D immunofluorescence and electron tomography.

Dissemination of HIV-1 throughout lymphoid tissues leads to systemic virus spread following infection. We combined tissue clearing, 3D-immunofluorescence, and electron tomography (ET) to longitudinally assess early HIV-1 spread in lymphoid tissues in humanized mice. Immunofluorescence revealed peak infection density in gut at 10-12 days post-infection when blood viral loads were low. Human CD4+ T-cells and HIV-1-infected cells localized predominantly to crypts and the lower third of intestinal villi. Free virions and infected cells were not readily detectable by ET at 5-days post-infection, whereas HIV-1-infected cells surrounded by pools of free virions were present in ~10% of intestinal crypts by 10-12 days. ET of spleen revealed thousands of virions released by individual cells and discreet cytoplasmic densities near sites of prolific virus production. These studies highlight the importance of multiscale imaging of HIV-1-infected tissues and are adaptable to other animal models and human patient samples.