Effect of COVID-19 and its vaccines on surgical and postsurgical mortality, ICU admission and 90-day readmission for elective surgical procedures in a United States veteran population.

BACKGROUND: We investigated how COVID-19 infection and vaccination impact elective surgical outcomes. METHODS: We retrospectively compared pre-pandemic (P) veterans to those with COVID (C) more than three weeks preoperatively or no COVID (NC) history after carotid endarterectomy, CABG, hip replacement, or colectomy. Subgroup analysis considered vaccination. Age and sex propensity matching, and conditional logistic regression analyzed one-year-mortality, 90-day-readmission, and ICU requirements among 519 â€‹C, 1038 NC, and 2076 â€‹P, culled from 61,641 veterans. RESULTS: NC, C, and P had similar ICU requirements and mortality, although NC required fewer readmissions. However, NC immunized at least once were readmitted and died less commonly than C who received at least one immunization. CONCLUSIONS: SARS-CoV-2 history increased readmission without affecting ICU requirement or mortality. Further studies should evaluate whether the worse outcomes in postoperative patients with histories of both COVID infection and one vaccination reflect the effects of incomplete vaccination or dataset limitations.

Comparison of Cardiovascular Outcomes Between Statin Monotherapy and Fish Oil and Statin Combination Therapy in a Veteran Population.

A study that compared the use of statin therapies with and without fish oil in a veteran population found an insignificant difference between the 2 arms.

Atherosclerotic Plaque Tissue: Noninvasive Quantitative Assessment of Characteristics with Software-aided Measurements from Conventional CT Angiography.

Purpose To (a) evaluate whether plaque tissue characteristics determined with conventional computed tomographic (CT) angiography could be quantitated at higher levels of accuracy by using image processing algorithms that take characteristics of the image formation process coupled with biologic insights on tissue distributions into account by comparing in vivo results and ex vivo histologic findings and (b) assess reader variability. Materials and Methods Thirty-one consecutive patients aged 43-85 years (average age, 64 years) known to have or suspected of having atherosclerosis who underwent CT angiography and were referred for endarterectomy were enrolled. Surgical specimens were evaluated with histopathologic examination to serve as standard of reference. Two readers used lumen boundary to determine scanner blur and then optimized component densities and subvoxel boundaries to best fit the observed image by using semiautomatic software. The accuracy of the resulting in vivo quantitation of calcification, lipid-rich necrotic core (LRNC), and matrix was assessed with statistical estimates of bias and linearity relative to ex vivo histologic findings. Reader variability was assessed with statistical estimates of repeatability and reproducibility. Results A total of 239 cross sections obtained with CT angiography and histologic examination were matched. Performance on held-out data showed low levels of bias and high Pearson correlation coefficients for calcification (-0.096 mm2 and 0.973, respectively), LRNC (1.26 mm2 and 0.856), and matrix (-2.44 mm2 and 0.885). Intrareader variability was low (repeatability coefficient ranged from 1.50 mm2 to 1.83 mm2 among tissue characteristics), as was interreader variability (reproducibility coefficient ranged from 2.09 mm2 to 4.43 mm2). Conclusion There was high correlation and low bias between the in vivo software image analysis and ex vivo histopathologic quantitative measures of atherosclerotic plaque tissue characteristics, as well as low reader variability. Software algorithms can mitigate the blurring and partial volume effects of routine CT angiography acquisitions to produce accurate quantification to enhance current clinical practice. Clinical trial registration no. NCT02143102 © RSNA, 2017 Online supplemental material is available for this article. An earlier incorrect version of this article appeared online. This article was corrected on September 15, 2017.

The histopathologic reliability of tissue taken from cadavers within the gross anatomy laboratory.

The purpose of this study was to examine the histopathologic reliability of embalmed cadaveric tissue taken from the gross anatomy laboratory. Tissue samples from hearts, livers, lungs, and kidneys were collected after the medical students' dissection course was completed. All of the cadavers were embalmed in a formalin-based fixative solution. The tissue was processed, embedded in paraffin, sectioned at six micrometers, and stained with H&E. The microscope slides were evaluated by a board certified pathologist to determine whether the cellular components of the tissues were preserved at a high enough quality to allow for histopathologic diagnosis. There was a statistically significant relationship between ratings and organ groups. Across all organs, there was a smaller proportion of "poor" ratings. The lung group had the highest percentage of "poor" ratings (23.1%). The heart group had the least "poor" ratings (0.0%). The largest percentage of "satisfactory" ratings were in the lung group (52.8%), and the heart group contained the highest percentage of "good" ratings (58.5%) The lung group had the lowest percentage of "good" ratings (24.2%). These results indicate that heart tissue is more reliable than lung, kidney, or liver tissue when utilizing tissue from the gross anatomy laboratory for research and/or educational purposes. This information advises educators and researchers about the quality and histopathologic reliability of tissue samples obtained from the gross anatomy laboratory. Anat Sci Educ 11: 207-214. © 2017 American Association of Anatomists.

Pathology Image of the Month: Mitral Stenosis at Autopsy.

A 52-year-old woman decedent was presented to the hospital autopsy service for a coroner authorized complete autopsy following an admit urine toxicology screen that was positive for cannabinoids. Prior to admission, she was found unresponsive at home after a two month history of increasingly progressive shortness of breath. She was transported to the emergency department and resuscitated after prolonged arrest. She was then admitted to the intensive care unit and subsequently was documented to have significant anoxic brain injury. Care was withdrawn by the family and death was declared on hospital day five. Medical history was reported for type 2 diabetes mellitus, and bipolar schizoaffective disorder with multiple prior psychiatric admissions. Her medical record review revealed a transthoracic echocardiogram two months prior to admission that documented mild mitralregurgitation, moderate mitral valve stenosis and a thickened valvular and subvalvular mitral apparatus with restricted motion of the posterior leaflet. Left atrial enlargement was marked, left ventricular hypertrophy was moderate, and pulmonary hypertension was graded as severe. The ejection fraction was estimated at 70 percent. She was discharged with outpatient follow-up to the cardiology department but was noncompliant with recommendations.

Pathology case of the month: sudden unexplained death in a young adult with known alcohol abuse.

A 35-year-old, recently deceased woman with a medical history known only to include Hepatitis C and alcohol abuse was transferred to the autopsy service for an unrestricted autopsy under coroner authorization following a sudden unexplained death. External examination revealed marked scleral icterus and cutaneous jaundice. Internal examination was remarkable for 3 liters of ascitic fluid and established cirrhosis with a micronodular pattern (nodules all <0.3 cm in diameter). Numerous, small, firm vegetations were identified along the edges of the tricuspid, mitral, and aortic valves. There was no obvious necrosis or tissue destruction seen grossly. Zones of prominent myocardial discoloration and hemorrhage were seen in all regions (anterior, lateral, and posterior) of the left ventricular myocardium, as well as within the interventricular septal myocardium. Multiple punctate lesions, up to 2 cm in diameter with a greenish hue and associated with tissue necrosis were seen overlying the cerebral cortex, as well as within the intracerebral parenchyma. Tissues were fixed in formalin for subsequent microscopic examination, and representative images from the aortic valve, and from the cerebral cortex, are seen below.

Left ventricular noncompaction cardiomyopathy.

Isolated Left Ventricular Non Compaction Cardiomyopathy (LVNCC) is a rare genetic cardiomyopathy characterized by a thickened left ventricle with two distinct layers - an inner noncompacted (spongy) layer and an outer compact (dense) layer. The spongy layer is composed of deep intertrabecular recesses. Familial and sporadic forms are known to exist and there is significant genetic heterogeneity among the inherited forms. Symptoms vary and range from asymptomatic to severe heart failure and sudden death. The clinical diagnosis of LVNCC can be challenging partly because there is currently no consensus for diagnostic criteria. As such, many affected individuals are, inopportunely, first diagnosed at post-mortem examination.

Histopathological findings in fatal novel H1N1: an autopsy case series from September-November 2009 in New Orleans, Louisiana.

Autopsy findings are presented on six patients in the greater New Orleans area with confirmed novel H1N1 in New Orleans, Louisiana, between the months of September to November 2009. Each case was reviewed for antemortem clinical data as well as pre-existing comorbidities. Results from postmortem gross, histological and bacteriologic analyses are detailed and support the assertion that pathologic findings associated with novel H1N1 are similar to those attributed to previous pandemics, though the rate of bacterial super-infection is variable and may depend on the analytical method of microbiologic testing. The current case series is also remarkable for the associated rate of pulmonary thromboemboli and acute renal failure as potential clinical associations with the current pandemic.

PDAY risk score predicts advanced coronary artery atherosclerosis in middle-aged persons as well as youth.

A risk score formula to estimate the probability of advanced atherosclerosis using coronary heart disease (CHD) risk factors was developed for persons 15-34 years of age by the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study. We applied the PDAY risk score to autopsied individuals from the Community Pathology Study (CPS), a different population that included middle-aged as well as young subjects. The PDAY risk score was associated with extent of raised lesions in the coronary arteries of CPS cases 15-34 years of age. The PDAY risk score computed from only the modifiable risk factors was associated with extent of raised lesions in the coronary arteries of subjects 35-54 years of age. The association of the PDAY risk score with lesions in 15-34 year old CPS subjects validates the PDAY risk score. The associations in both younger (15-34 years) and older (35-54 years) subjects suggest a seamless progression of the effects of the modifiable risk factors on atherosclerosis from 15 to 54 years of age. These results support the proposal that early control of risk factors is likely to prevent or delay the onset of CHD.

Attitudes toward the autopsy--an 8-state survey.

CONTEXT: National autopsy rates have declined for several decades, and the reasons for such decline remain contentious. OBJECTIVE: To elicit the opinions of one group of crucial decision makers as to the reasons for this decline and possible modes of reversal. DESIGN: A 2-part survey, composed of multiple choice questions and questions requesting specific data on autopsy rates and costs. SETTING: Illinois, Iowa, Louisiana, Minnesota, Nebraska, North Dakota, South Dakota, and Wisconsin. PARTICIPANTS: Hospital administrators within the 8 states. MAIN OUTCOME MEASURES: Six-point survey scale relating to reasons for autopsy decline and possible remedial measures, as well as estimates of autopsy rates and costs. RESULTS: The response rate was 43% and the median autopsy rate was 2.4% (mean 6.1%). The median cost of autopsy was estimated at $852 (mean $1275). Larger hospitals were associated with higher autopsy rates than smaller hospitals (9.6% vs 4.0%), and teaching hospitals had a significantly higher autopsy rate than nonteaching institutions (11.4% vs 3.8%). Autopsy rates also varied by type of hospital control, with federal government hospitals having the highest autopsy rate at 15.1%. Sixty-six percent of all respondents agreed that current autopsy rates were adequate. Of the respondents, the highest percent (86%) agreed that improved diagnostics contributed to the decline in autopsies, and the highest percent (78%) agreed that direct payment to pathologists for autopsies under the physician fee schedule might lead to an increase in autopsies. CONCLUSIONS: Our data support the conclusion that the decline in autopsy performance is multifactorial, although the variable that dominates in this analysis is the contentious perception that improved diagnostic technology renders the autopsy redundant. The rate of autopsy is conditional, at least in part, on individual hospital characteristics such as large hospital size, teaching status, and federal ownership. Three underlying factors may explain these associations: resources, mission, and case mix. An important factor in declining autopsy rates appears to be the changing economic landscape, with its increased focus on cost control within both the public and private healthcare sectors.

Cor triatriatum sinistrum: a rare congenital cardiac anomaly presenting in an adult with chronic atrial fibrillation.

Cor triatriatum is a rare congenital cardiac anomaly in which the left atrium is divided into proximal (dorsal or upper) and distal (ventral or lower) chambers by a fibromuscular septum. The upper chamber receives the pulmonary veins and the lower chamber contains the atrial appendage and the mitral valve. The 2 chambers communicate through a defect in the membrane. Cor triatriatum is often associated with other congenital cardiac anomalies. Most frequently, the upper chamber communicates with the right atrium through a patent foramen ovale or atrial septal defect, and the clinical symptoms simulate anomalous pulmonary venous return. Less commonly, the foramen ovale communicates with the distal chamber and the clinical features mimic mitral stenosis. When cor triatriatum is the only abnormality, the clinical findings are also similar to mitral stenosis with development of pulmonary hypertension and subsequent right ventricular hypertrophy and atrial enlargement. The diagnosis is usually made in infancy or childhood, and the lack of treatment results in death in 75% of patients. We report the case of a woman who presented much later in life. The patient was a 57-year-old female with a clinical history of chronic atrial fibrillation who presented to the emergency department because of a "funny sensation" in her chest, though she denied chest pain, nausea, vomiting, or diaphoresis. EKG revealed atrial fibrillation with a rapid ventricular response and a tachycardic rate of 157. She had a therapeutic level of digoxin, and cardiac enzymes were normal. The patient was admitted and placed on Cardizem drip. Serial EKGs remained normal and heart rate control was achieved. On hospital day 2, the patient became dyspneic and cyanotic. She went into cardiac arrest and died.Autopsy revealed cardiomegaly (610 g) with 4-chamber dilatation. A septum divided the left atrium into 2 chambers. The defect in the dividing membrane measured 1 cm in diameter. No other congenital defects were noted. The large size of the defect in the membrane likely accounted for the late onset of symptoms that allowed this patient to survive into adulthood without previous diagnosis or surgical intervention (which is usually required in childhood).

ACE insert/delete polymorphism and atherosclerosis.

We report on the results of a large autopsy study focusing upon the hypothesis that deletion of the Alu insert in the angiotensin converting enzyme (ACE) gene is associated with: (a) greater prevalence or extent of atherosclerosis in the aorta and coronary arteries; and (b) microscopic qualities of established atherosclerotic plaques in the coronary arteries. This study was conducted in young US black (n=290) and white (n=379) males using available materials and data from the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study, a multi-center cooperative autopsy study organized in 1985 to explore the relationships of known cardiovascular risk factors to atherosclerosis in victims of accidents, homicides, or suicides in the age range of 15-34 years. The results provide strong evidence that ACE genotype may not be a predictor of either the prevalence or the extent of the lesions of atherosclerosis in the right coronary artery or the aorta of young adults, an observation that confirms previous studies that estimated the prevalence and extent of atherosclerosis using coronary angiography. In addition, the results suggest that ACE genotype does not contribute to the formation of atherosclerotic lesions that have the characteristics of vulnerable plaques in the left anterior descending coronary artery of young adults.

Cardiovascular complications associated with cocaine use.

Cocaine use in North America has reached epidemic proportions becoming one of the top causes of drug-related visits to US emergency rooms. The number of users has increased due to the popularity and accessibility of crack cocaine. The pharmacokinetic properties and effects of cocaine on the cardiovascular system can lead to serious complications. Cocaine is known to induce angina and precipitate myocardial infarction. Cocaine use has been associated with the development of dilated cardiomyopathy, left ventricular dysfunction, and can also predispose a patient to a variety of cardiac arrhythmias including sudden cardiac death. Additionally, cocaine use has been associated with spontaneous aortic and coronary dissection, mesenteric ischemia, stroke, venous thrombosis, and a variety of pulmonary complications. This review article focuses on the effects and complications of cocaine upon the cardiovascular system.

Atherosclerosis in coronary arteries and aorta among Greenlanders: an autopsy study.

In a cross-sectional autopsy study of 107 Inuit in Greenland, the extent of arterial surface involvement with atherosclerosis was evaluated in the presence of known or estimated environmental risk factors for coronary heart disease (CHD): age, gender, obesity, serum lipids, smoking, and hypertension. Mean, median, and range values for all of the risk factor variables and for the extent of atherosclerosis in the thoracic aorta, abdominal aorta, right coronary artery, and left anterior descending coronary artery are reported by age strata, along with the results of covariant analysis of the dependence of the extent of atherosclerosis upon the risk factors. No significant differences between females and males were found in either the risk factors or prevalence and extent of atherosclerosis in the aorta and in the coronary arteries. It appears that the extent of advanced atherosclerotic lesions in Greenlanders appears to be the same as that previously reported in a similar study in Alaska Natives.