Perforated peptic ulcer disease in transferred patients is associated with significant increase in length of stay.

BACKGROUND: Perforated peptic ulcer disease (PPUD) has a prevalence of 0.004-0.014% with mortality of 23.5% (Tarasconi et al. in World J Emerg Surg 15(PG-3):3, 2020). In this single center study, we examined the impact associated with patient transfer from outside facilities to our center for definitive surgical intervention (exploratory laparotomy). METHODS: Using EPIC report workbench, we identified 27 patients between 2018 and 2021 undergoing exploratory laparotomy with a concurrent diagnosis of peptic ulcer disease, nine of which were transferred to our institution for care. We queried this population for markers of disease severity including mortality, length of stay, intensive care unit (ICU) length of stay, and readmission rates. Manual chart reviews were performed to examine these outcomes in more detail and identify patients who had been transferred to our facility for surgery from an outside hospital. RESULTS: A total of 27 patients were identified undergoing exploratory laparotomy for definitive treatment of PPUD. The majority of patients queried underwent level A operations, the most urgent level of activation. In our institution, a Level A operation needs to go to the operating room within one hour of arrival to the hospital. Average mortality for this patient population was 14.8%. The readmission rate was 40.1%, and average length of ICU stay post-operatively was 16 days, with 83% of non-transfer patients requiring ICU admission and 100% of transfer patients requiring ICU admission, although this was not found to be statistically significant. Average length of hospital stay was 27 days overall. For non-transfer patients and transfer patients, LOS was 20 days and 41 days, respectively, which was statistically significant by one-sided t-test (p = 0.05). CONCLUSION: Patients transferred for definitive care of PPUD in a population otherwise notable for high mortality and high readmission rates: their average length of stay compared to non-transfer patients was over twice the length, which was statistically significant. Transferred patients also had higher rates of ICU care requirement although this was not statistically significant. Further inquiry to identify modifiable variables to facilitate the care of transferred patients is warranted, especially in the context of improving quality metrics known to enhance patient outcomes, satisfaction, and value.

Consenting patients for elective procedures during the pandemic: Are we consenting for risk of nosocomial COVID-19 infection.

Introduction: Nosocomial COVID-19 increases morbidity and mortality in patients undergoing surgical procedures. This study assesses the consenting process in patients admitted for surgical procedures with regard to risks of contracting nosocomial COVID-19 infection during the three lockdown periods in the United Kingdom.Methods: Retrospective review of consecutive surgical patients admitted to our tertiary referral centre for surgical procedures during the lockdown periods in the United Kingdom. Data from our hospital's electronic theatre database cross-referenced with the online surgical operative, admission and discharge records were reviewed by three independent reviewers.Discussion: A total of 180 patients (104 males and 76 females) were studied. No patients tested positive perioperatively for COVID-19. The first lockdown had a significantly larger proportion of consultants consenting (P < 0.001). Surgeons consented patients for risk of COVID-19 infection in 34.4% of cases, COVID-19-related illness in 33.9%, inpatient Intensive Care Unit (ITU) admission secondary to COVID-19 infection and risk of death due to COVID-19 in 0.0% and risk of death secondary to inpatient COVID infection in 1.1%.Conclusion: As surgical activity continues and COVID-19 persists, surgeons should be vigilant and ensure proper documentation for consent regarding COVID-19-related complications in line with the Royal College of Surgeons of England guidelines.

Maternal rotating night shift work before pregnancy and offspring stress markers.

BACKGROUND: Recent studies suggest an intergenerational influence of stress such that maternal exposure even before pregnancy could impact offspring health outcomes later in life. In humans, investigations on the impact of maternal stressors on offspring health outcomes, including stress-sensitive biomarkers, have largely been limited to extreme stressors. Prior studies have not addressed more moderate maternal stressors, such as rotating night shift work, on offspring stress markers in young adulthood. METHODS: We investigated the association between maternal rotating night shift work before conception and offspring salivary cortisol and alpha amylase (sAA) patterns in young adulthood among mothers enrolled in the Nurses' Health Study II (NHSII) and their offspring participating in the Growing Up Today Study 2 (GUTS2). Our sample included over 300 mother-child pairs where, between 2011 and 2014, the children provided 5 saliva samples over the course of one day. We used piecewise linear mixed models to compare awakening responses, overall slopes as well as several other diurnal patterns of cortisol and sAA between offspring born to shift working versus non-shift working mothers. RESULTS: Offspring born to shift working mothers had a flattened late decline in cortisol (percent differences in slope (%D): 2.1%; 95%CI: 0.3, 3.8) and their sAA awakening response was steeper (%D -37.4%; 95%CI: -59.0, -4.4), whereas sAA increase before bedtime appeared less pronounced (%D -35.9%; 95%CI: -55.3, -8.3), compared to offspring born to mothers without shift work. For cortisol, we observed a significant difference in the Area Under the Curve (AUC) (%D 1.5%; 95%CI: 0.3, 2.7) with higher AUC for offspring of mothers who worked rotating night shifts. In offspring-sex-stratified analyses we found differences primarily among males. CONCLUSION: Our results provide some - albeit modest - evidence that maternal rotating night shift work-a moderate stressor-influences offspring stress markers. Future studies with larger samples sizes, more detailed exposure assessment (particularly during maternal pregnancy), and multiple offspring biomarker assessments at different developmental stages are needed to further investigate these associations.

Bidirectional associations between alcohol consumption and health-related quality of life amongst young and middle-aged women.

BACKGROUND: Evidence from cross-sectional studies has suggested a positive association between moderate alcohol consumption and health-related quality of life but prospective data remain scarce. OBJECTIVES: To examine the bidirectional relationships between alcohol consumption and health-related quality of life using a longitudinal study design. METHODS: A total of 92 448 participants of the Nurses' Health Study II reported their alcohol consumption (in 1991, 1995, 1999 and 2003) and health-related quality of life (in 1993, 1997 and 2001). Using generalized estimating equations, we modelled the physical and mental component summary (PCS and MCS) scores as a function of alcohol consumption 2 years earlier (n = 88 363) and vice versa (n = 84 621). RESULTS: Greater alcohol consumption was associated with better PCS scores 2 years later in a dose-response manner up to ~1 serving daily [mean difference (ß) = 0.67 ± 0.06 PCS units, for moderate versus infrequent drinkers]. After adjustment for previous PCS, a similar but attenuated pattern was observed (ß = 0.33 ± 0.07). Moderate alcohol consumption was not related to MCS, whereas moderate-to-heavy alcohol consumption was associated with lower MCS scores (ß = -0.34 ± 0.15). Higher PCS scores were associated with greater alcohol consumption 2 years later, also after adjustment for previous alcohol consumption (ß = 0.53 ± 0.05 g day(-1) ). MCS was not associated with alcohol consumption 2 years later. CONCLUSION: Amongst young and middle-aged women, moderate alcohol intake was associated with a small improvement in physical health-related quality of life 2 years later and vice versa. Moderate alcohol consumption was not associated with mental health-related quality of life in either direction.

Risk of depression in women with psoriasis: a cohort study.

BACKGROUND: Psoriasis is a common, chronic and inflammatory disease of the skin, which has been associated with depression in cross-sectional studies with limited adjustment for confounders. OBJECTIVES: In this prospective cohort study, we investigated the risk of incident depression among individuals with psoriasis and psoriatic arthritis (PsA). METHODS: We included 50 750 US female nurses from the Nurses' Health Study who were free of depression at baseline in 2000. Those participants who had ever self-reported clinician-diagnosed depression or regular use of antidepressants, or had a Mental Health Inventory score of ≤ 52 were excluded. In 2008, we retrospectively asked participants if they had ever received a physician's diagnosis of psoriasis or PsA. We defined depression as self-report of clinician-diagnosed depression or regular use of antidepressant medication. Time-dependent Cox proportional hazard models were used to estimate age and multivariate-adjusted relative risks (RRs) of clinical depression. RESULTS: After adjusting for covariates including body mass index, physical activity, smoking and the presence of major chronic conditions, the multivariate-adjusted RRs of clinical depression were 1·29 [95% confidence interval (CI) 1·10-1·52] for women with psoriasis and 1·52 (95% CI 1·06-2·19) for women with psoriasis and concomitant PsA, compared with women without psoriasis. CONCLUSIONS: We found an increased risk of depression in US women with psoriasis compared with those without psoriasis. This risk was higher in those who reported concomitant PsA. Future studies are needed to confirm these findings in other populations and to identify pathophysiological mechanisms linking psoriasis to depression.

Long-term intake of nuts in relation to cognitive function in older women.

OBJECTIVE: Nuts contain nutrients that may benefit brain health; thus, we examined long-term intake of nuts in relation to cognition in older women. DESIGN: Population-based prospective cohort study. SETTING: Academic research using data from the Nurses' Health Study. PARTICIPANTS: Nut intake was assessed in a food-frequency questionnaire beginning in1980, and approximately every four years thereafter. Between 1995-2001, 16,010 women age 70 or older (mean age = 74 years) without a history of stroke were administered 4 repeated telephone-based cognitive interviews over 6 years. Our final sample included 15,467 women who completed an initial cognitive interview and had complete information on nut intake. MAIN OUTCOME MEASURES: The Telephone Interview for Cognitive Status (TICS), a global score averaging the results of all tests (TICS, immediate and delayed verbal recall, category fluency, and attention), and a verbal memory score averaging the results of tests of verbal recall. RESULTS: In multivariable-adjusted linear regression models, higher long-term total nut intake was associated with better average cognitive status for all cognitive outcomes. For the global composite score combining all tests, women consuming at least 5 servings of nuts/week had higher scores than non-consumers (mean difference=0.08 standard units, 95% confidence interval 0.00-0.15; p-trend=0.003). This mean difference of 0.08 is equivalent to the mean difference we find between women 2 years apart in age. Long-term intake of nuts was not associated with rates of cognitive decline. CONCLUSIONS: Higher nut intake may be related to better overall cognition at older ages, and could be an easily-modifiable public health intervention.

Use of antidepressant medication and risk of type 2 diabetes: results from three cohorts of US adults.

AIMS/HYPOTHESIS: The results of several studies have suggested a potential positive association between use of antidepressant medication (ADM) and incident type 2 diabetes mellitus. We examined this association in three cohorts of US adults. METHODS: We followed 29,776 men in the Health Professionals Follow-up Study (HPFS, 1990-2006), 61,791 women in the Nurses' Health Study I (NHS I, 1996-2008) and 76,868 women in NHS II (1993-2005), who were free of diabetes mellitus, cardiovascular disease or cancer at baseline. The mean baseline ages for participants from the HPFS and NHS I and II were 56.4, 61.3 and 38.1 years, respectively. ADM use and other covariates were assessed at baseline and updated every 2 years. A time-dependent Cox proportional hazards model was used, and HRs were pooled together across the three cohorts. RESULTS: During 1,644,679 person-years of follow-up, we documented 6,641 new cases of type 2 diabetes. ADM use was associated with an increased risk of diabetes in all three cohorts in age-adjusted models (pooled HR 1.68 [95% CI 1.27, 2.23]). The association was attenuated after adjustment for diabetes risk factors and histories of high cholesterol and hypertension (1.30 [1.14, 1.49]), and further attenuated by controlling for updated BMI (1.17 [1.09, 1.25]). Use of selective serotonin reuptake inhibitors and other antidepressants (mainly tricyclic antidepressants) were both associated with an elevated risk of diabetes, with pooled multivariate-adjusted HRs of 1.10 (1.00, 1.22) and 1.26 (1.11, 1.42), respectively. CONCLUSIONS/INTERPRETATION: The results suggest that ADM users had a moderately elevated risk of type 2 diabetes mellitus compared with non-users, even after adjustment for BMI.

Bidirectional association between depression and obesity in middle-aged and older women.

OBJECTIVE: Although it has been hypothesized that the depression-obesity relation is bidirectional, few studies have addressed this hypothesis in a prospective setting. We aimed to examine the bidirectional relationship in middle-aged and elderly women. SUBJECTS: A total of 65 955 women aged 54-79 years in the Nurses' Health Study were prospectively followed from 1996 to 2006 with updated information on body weight, depression status and various covariates every 2 years. Depression was defined as self-report of physician-diagnosed depression and/or antidepressant use. Obesity was defined as a BMI ≥30.0 kg m(-2). The first three waves (1996-2000) were used as the baseline period and the last three waves (2002-2006) were used as the follow-up period. RESULTS: After adjusting for baseline age, physical activity, comorbidities, BMI and other covariates, depression at the baseline period was associated with an increased risk of obesity at the follow-up period in all women (multivariate-adjusted odds ratio (OR), 1.38; 95% confidence interval (95% CI), 1.24-1.53) and baseline non-obese women (OR, 1.51; 95% CI, 1.36-1.67). In the opposite direction, after adjusting for baseline age, physical activity, comorbidities, depression status and other covariates, obese women at baseline had a moderately increased risk of depression at the follow-up period compared with normal-weight women (OR, 1.11; 95% CI, 1.03-1.18), and this association was similar for new onset of depression (OR for obese versus normal weight women, 1.10; 95% CI, 1.02-1.20). CONCLUSIONS: Our results suggest a bidirectional association between depression and obesity in middle-aged and elderly women. Future studies are needed to confirm our findings in different populations, and investigate the potential mechanisms underlying this association. Our results underscore the importance of early detection and proper behavioral modifications to lower the burden of both conditions.

Absence of an apolipoprotein E epsilon4 allele is associated with increased parietal regional cerebral blood flow asymmetry in Alzheimer disease.

BACKGROUND: The apolipoprotein E (Apo E) epsilon4 allele has been associated with parietal metabolic abnormalities and asymmetries in asymptomatic subjects at risk for Alzheimer disease (AD). However, previous research has shown minimal effect of the epsilon4 allele on regional cerebral blood flow (rCBF) and metabolism in patients with probable AD. OBJECTIVE: To determine whether the Apo E epsilon4 allele is associated with parietal rCBF abnormalities and asymmetries in patients with probable AD. PATIENTS AND METHODS: Thirty patients with AD with the epsilon4 allele (epsilon4+ AD), 22 patients with AD without the epsilon4 allele (epsilon4- AD), and 14 healthy control subjects underwent single-photon emission computed tomography (SPECT) scanning with 740 MBq technetium Tc 99m hexamethylpropyleneamine oxime. Ratios of parietal-unaffected regions and a left-right parietal asymmetry index were compared between both patient groups. RESULTS: The group with epsilon4- AD was younger (P = .005, Student t test) and had an earlier age of onset (P = .005) than the group with epsilon4+ AD. Analysis of covariance revealed no significant difference in the parietal rCBF ratio, controlling for age of onset and Mini-Mental State Examination score (F(1,48) = 0.06; P = .81). However, contrary to hypothesis, significantly greater parietal rCBF asymmetry was seen in patients with epsilon4- AD (mean +/- SD, 9.7% +/- 5.5%) than those with epsilon4+ AD (6.3% +/- 4.7%; F(1,50) = 5.89; P = .02; analysis of variance). When number of epsilon4 allele copies was considered, this effect appeared to accrue primarily from a difference between patients with 0 and with 2 epsilon4 allele copies. An exploratory analysis of multiple cortical structures suggested that this asymmetry extended to additional regions (superior temporal) and to combined association cortex. CONCLUSIONS: Greater parietal rCBF asymmetry is involved in epsilon4- AD than in epsilon4+ AD. Lack of the epsilon4 allele may be associated with other (as yet undiscovered) genetic or environmental risk factors, which confer greater neuropathological asymmetry.

Heart transplantation in an 8-month-old girl. 10th anniversary report.

In 1984, Dr. Denton A. Cooley led a surgical team that implanted a cardiac allograft in an 8-month-old girl who had end-stage cardiac disease secondary to endocardial fibroelastosis. At that time, experience with cardiac transplantation in infants was limited, and the long-term effects of the procedure were cause for concern. Ten years later, our patient is a healthy 4th-grade student who enjoys a remarkably normal life. She has grown and developed quite satisfactorily, and her heart has enlarged in proportion to her overall somatic growth. Long-term immunosuppression has produced no adverse effects, and the child's medical problems have differed little from those of her peers. This landmark case has yielded preliminary answers to a number of important questions about cardiac transplantation in infants and has confirmed our original opinion that the procedure is well warranted in selected patients.

Radical excision of invasive thymoma with intracardiac extension.

A patient with a low grade malignant thymoma who also had pleural, pericardial and cardiac invasion with intracardiac extension, presented with signs of superior vena cava obstruction, moderate hepatosplenomegaly and a mediastinal mass on a plain chest radiograph. Radical excision requiring cardiopulmonary bypass for the removal of the intracardiac extension into the right atrium was performed. Despite the patient's failure to receive radiotherapy treatment, he was alive one year after surgery. This case is reported because this mode of presentation of intracardiac extension of a thymoma is uncommon and because only this method of radical excision could ensure near-total removal of the mass and prevent early death from cardiovascular complications.

Sustainable urban development and human health: septic tank as a major breeding habitat of mosquito vectors of human diseases in south-eastern Nigeria.

Septic tank mosquitoes in Abia State University Okigwe, south-eastern Nigeria were studied using exit traps between November 1988 and April 1989. The results were revealing and striking. Apart from the common septic tank mosquitoes, Culex p. quinquefasciatus, Cu. cinereus and Aedes aegypti, which have been previously commonly found breeding in ammonia and nitrate-rich waters of latrines and septic tanks, the other species, Cu. horridus, Cu. tigripes and Aedes vittatus, have not been commonly reported as colonizing septic tanks in Nigeria. Three out of these six mosquito species observed are vectors of human diseases: Aedes aegypti and Aedes vittatus are vectors of Yellow fever and Cu. p. quinquefasciatus is a potential vector of Bancroftian filariasis and a world-wide vector of various arboviruses. The fact that these mosquito vectors are able to breed in highly polluted waters of septic tanks during the harsh dry months when most surface water bodies are dry is epidemiologically important. The breeding of these mosquito vectors of human diseases around human dwellings indicates an intense man-vector contact creating a high level risk to the crowded urban population. The public health implications of this urbanization/modernization problem and solutions are discussed.

Occlusive coronary arteritis: a cause of early death in a cardiac transplant patient.

A patient died 5 months after undergoing cardiac transplantation. Endomyocardial biopsies performed prior to death showed no evidence of severe rejection. At autopsy, nonnecrotizing occlusive coronary arteritis was present. The intima of the coronary arteries contained numerous lymphocytes and plasma cells. Chronic rejection appeared to be responsible for the arteritis. The onset of coronary occlusive disease is insidious, and recognition depends on the performance of coronary arteriography, which is usually not done until the one-year follow-up. Early coronary arteriography is suggested to rule out occlusive coronary arteritis when cardiac allograft function is not satisfactory, even when the endomyocardial biopsy shows no evidence of rejection.

Cardiac transplantation in a patient with septicemia after prolonged intraaortic balloon pump support: implications for staged transplantation.

After initial support with an intraaortic balloon pump, and since the introduction of cyclosporine for immunosuppression, five patients have undergone cardiac transplantation in our institution with good results. Not one of these patients died of sepsis in the immediate postoperative period. We report the clinical course of one such patient to show the advantage of cyclosporine immunosuppression and the value of circulatory support devices in patients awaiting suitable cardiac donors. A 22-year-old mother of two children was transferred to our institution with progressive cardiac failure. An intraaortic balloon (IABP) was inserted after she had become hypotensive, obtunded and acidotic, with severe congestive heart failure. However, she failed to improve and we performed a cardiac transplantation. After major problems with infections-a leading cause of death among cardiac transplant recipients-and episodes of convulsions that were controlled with Dilantin, along with other complications, she slowly but progressively improved and was discharged 7 weeks post-transplantation. She had one episode of allograft rejection, which was reversed with a short course of Solu Medrol. She is alive and well 18 months post-transplantation. In conclusion, cardiac transplantation in patients with sepsis can be expected to have a favorable outcome if cyclosporine is used for immunosuppression. When IABP or any other circulatory assist device is used as a bridge to cardiac transplantation, it is still possible to control infection in such patients, especially when cyclosporine is used as the major immunosuppressive.

Congenital diverticulum of the ventricle.

Ten cases of ventricular diverticula were seen at the Texas Heart Institute between 1965 and 1984. Operations were performed on nine of the 10 patients with no operative mortality. The tenth patient, a 3-month-old infant with multiple abnormalities, was not returned after the initial evaluation. Most diverticular in our series were unsuspected and diagnosed during cardiac catheterization. Symptoms were related mainly to associated malformations, including intracardiac, midline thoracic, diaphragmatic, and abdominal wall defects. The surgical techniques employed in each case varied according to the size and site of the diverticulum and the associated cardiac defects. We recommend surgery for all diagnosed ventricular diverticula, especially when associated with other intracardiac defects.

Heart transplantation: a therapeutic alternative for patients with end-stage cardiac disease; the Texas Heart Institute experience

El transplante del corazón es una modalidad terapéutica aceptada para aquellos pacientes que sufren de enfermedad cardíaca terminal y cuya condición no es corregible mediante los tratamientos médicos o quirúrgicos convencionales. Desde julio de 1982, el "Texas Heart Institute" ha llevado a cabo 74 transplantes cardíacos usando la Ciclosporina como agente inmunosupresivo con una sobrevivencia de 73%. Los diagnósticos antes del transplante incluyeron cardiomiopatía idiopática (36.4%), miocarditis viral (8.1%). La fibroelastosis endocárdica, las enfermedades congénitas y reumática cardíaca completaron el restante 15% de los casos. En nuestra serie, las infecciones y episodios de rechazo constituyeron las mayores causas de mortalidad y morbilidad. Las mejoras y avances en los criterios de selección de donantes y recipientes, en la preservación de órganos y en la inmunosuperión postoperatoria han contibuido a mejores resultados y mayor sobrevivencia