Venous thromboembolism in COVID-19 patients and prediction model: a multicenter cohort study.

BACKGROUND: Patients with COVID-19 infection are commonly reported to have an increased risk of venous thrombosis. The choice of anti-thrombotic agents and doses are currently being studied in randomized controlled trials and retrospective studies. There exists a need for individualized risk stratification of venous thromboembolism (VTE) to assist clinicians in decision-making on anticoagulation. We sought to identify the risk factors of VTE in COVID-19 patients, which could help physicians in the prevention, early identification, and management of VTE in hospitalized COVID-19 patients and improve clinical outcomes in these patients. METHOD: This is a multicenter, retrospective database of four main health systems in Southeast Michigan, United States. We compiled comprehensive data for adult COVID-19 patients who were admitted between 1st March 2020 and 31st December 2020. Four models, including the random forest, multiple logistic regression, multilinear regression, and decision trees, were built on the primary outcome of in-hospital acute deep vein thrombosis (DVT) and pulmonary embolism (PE) and tested for performance. The study also reported hospital length of stay (LOS) and intensive care unit (ICU) LOS in the VTE and the non-VTE patients. Four models were assessed using the area under the receiver operating characteristic curve and confusion matrix. RESULTS: The cohort included 3531 admissions, 3526 had discharge diagnoses, and 6.68% of patients developed acute VTE (N = 236). VTE group had a longer hospital and ICU LOS than the non-VTE group (hospital LOS 12.2 days vs. 8.8 days, p < 0.001; ICU LOS 3.8 days vs. 1.9 days, p < 0.001). 9.8% of patients in the VTE group required more advanced oxygen support, compared to 2.7% of patients in the non-VTE group (p < 0.001). Among all four models, the random forest model had the best performance. The model suggested that blood pressure, electrolytes, renal function, hepatic enzymes, and inflammatory markers were predictors for in-hospital VTE in COVID-19 patients. CONCLUSIONS: Patients with COVID-19 have a high risk for VTE, and patients who developed VTE had a prolonged hospital and ICU stay. This random forest prediction model for VTE in COVID-19 patients identifies predictors which could aid physicians in making a clinical judgment on empirical dosages of anticoagulation.

Clinical correlates of CT imaging-derived phenotypes among lean and overweight patients with hepatic steatosis.

The objective of this study is to define CT imaging derived phenotypes for patients with hepatic steatosis, a common metabolic liver condition, and determine its association with patient data from a medical biobank. There is a need to further characterize hepatic steatosis in lean patients, as its epidemiology may differ from that in overweight patients. A deep learning method determined the spleen-hepatic attenuation difference (SHAD) in Hounsfield Units (HU) on abdominal CT scans as a quantitative measure of hepatic steatosis. The patient cohort was stratified by BMI with a threshold of 25 kg/m2 and hepatic steatosis with threshold SHAD ≥ - 1 HU or liver mean attenuation ≤ 40 HU. Patient characteristics, diagnoses, and laboratory results representing metabolism and liver function were investigated. A phenome-wide association study (PheWAS) was performed for the statistical interaction between SHAD and the binary characteristic LEAN. The cohort contained 8914 patients-lean patients with (N = 278, 3.1%) and without (N = 1867, 20.9%) steatosis, and overweight patients with (N = 1863, 20.9%) and without (N = 4906, 55.0%) steatosis. Among all lean patients, those with steatosis had increased rates of cardiovascular disease (41.7 vs 27.8%), hypertension (86.7 vs 49.8%), and type 2 diabetes mellitus (29.1 vs 15.7%) (all p < 0.0001). Ten phenotypes were significant in the PheWAS, including chronic kidney disease, renal failure, and cardiovascular disease. Hepatic steatosis was found to be associated with cardiovascular, kidney, and metabolic conditions, separate from overweight BMI.

Data of atrial arrhythmias in hospitalized COVID-19 and influenza patients.

Atrial arrhythmias (AA) are common in hospitalized COVID-19 patients with limited data on their association with COVID-19 infection, clinical and imaging outcomes. In the related research article using retrospective research data from one quaternary care and five community hospitals, patients aged 18 years and above with positive SARS-CoV-2 polymerase chain reaction test were included. 6927 patients met the inclusion criteria. The data in this article provides demographics, home medications, in-hospital events and COVID-19 treatments, multivariable generalized linear regression regression models using a log link with a Poisson distribution (multi-parameter regression [MPR]) to determine predictors of new-onset AA and mortality in COVID-19 patients, computerized tomography chest scan findings, echocardiographic findings, and International Classification of Diseases-Tenth Revision codes. The clinical outcomes were compared to a propensity-matched cohort of influenza patients. For influenza, data is reported on baseline demographics, comorbid conditions, and in-hospital events. Generalized linear regression models were built for COVID-19 patients using demographic characteristics, comorbid conditions, and presenting labs which were significantly different between the groups, and hypoxia in the emergency room. Statistical analysis was performed using R programming language (version 4, ggplot2 package). Multivariable generalized linear regression model showed that, relative to normal sinus rhythm, history of AA (adjusted relative risk [RR]: 1.38; 95% CI: 1.11-1.71; p = 0.003) and newly-detected AA (adjusted RR: 2.02 95% CI: 1.68-2.43; p < 0.001) were independently associated with higher in-hospital mortality. Age in increments of 10 years, male sex, White race, prior history of coronary artery disease, congestive heart failure, end-stage renal disease, presenting leukocytosis, hypermagnesemia, and hypomagnesemia were found to be independent predictors of new-onset AA in the MPR model. The dataset reported is related to the research article entitled "Incidence, Mortality, and Imaging Outcomes of Atrial Arrhythmias in COVID-19" [Jehangir et al. Incidence, Mortality, and Imaging Outcomes of Atrial Arrhythmias in COVID-19, American Journal of Cardiology] [1].

Increased Dephospho-uncarboxylated Matrix Gla-Protein Is Associated With Lower Axial Skeletal Muscle Mass in Patients With Hypertension.

BACKGROUND: Matrix Gla-protein (MGP) is a well-established inhibitor of vascular calcification that is activated by vitamin K-dependent carboxylation. In the setting of vitamin K2 deficiency, dephospho-uncarboxylated MGP (dpucMGP) levels increase, and have been associated with large artery stiffening. Vitamin K2 is also a mitochondrial electron carrier in muscle, but the relationship of vitamin K2 deficiency and dpucMGP with muscle mass is not well understood. We therefore aimed to examine the association of vitamin K2 deficiency and dpucMGP with skeletal muscle mass in patients with hypertension. METHODS: We studied 155 hypertensive adults without heart failure. Axial skeletal muscle mass was measured using magnetic resonance imaging from axial steady-state free precession images. DpucMGP was measured with ELISA. Carotid-femoral pulse wave velocity (CF-PWV) was measured from high-fidelity arterial tonometry recordings. RESULTS: We found an inverse relationship between dpucMGP levels and axial muscle mass, with progressively rising dpucMGP levels correlating with decreasing axial muscle mass. In an unadjusted linear regression model, correlates of dpucMGP included axial skeletal muscle area factor (ß = -0.32; P < 0.0001) and CF-PWV (ß = 0.31; P = 0.0008). In adjusted analyses, independent correlates of dpucMGP included axial skeletal muscle area factor (ß = -0.30; P = 0.0003) and CF-PWV (ß = 0.20; P = 0.019). CONCLUSIONS: In hypertensive adults, dpucMGP is independently associated with lower axial muscle mass, in addition to increased large artery stiffness. Further studies are required to investigate the role of vitamin K supplementation in this population.

3D-PAST: Risk Assessment Model for Predicting Venous Thromboembolism in COVID-19.

Hypercoagulability is a recognized feature in SARS-CoV-2 infection. There exists a need for a dedicated risk assessment model (RAM) that can risk-stratify hospitalized COVID-19 patients for venous thromboembolism (VTE) and guide anticoagulation. We aimed to build a simple clinical model to predict VTE in COVID-19 patients. This large-cohort, retrospective study included adult patients admitted to four hospitals with PCR-confirmed SARS-CoV-2 infection. Model training was performed on 3531 patients hospitalized between March and December 2020 and validated on 2508 patients hospitalized between January and September 2021. Diagnosis of VTE was defined as acute deep vein thrombosis (DVT) or pulmonary embolism (PE). The novel RAM was based on commonly available parameters at hospital admission. LASSO regression and logistic regression were performed, risk scores were assigned to the significant variables, and cutoffs were derived. Seven variables with assigned scores were delineated as: DVT History = 2; High D-Dimer (>500−2000 ng/mL) = 2; Very High D-Dimer (>2000 ng/mL) = 5; PE History = 2; Low Albumin (<3.5 g/dL) = 1; Systolic Blood Pressure <120 mmHg = 1, Tachycardia (heart rate >100 bpm) = 1. The model had a sensitivity of 83% and specificity of 53%. This simple, robust clinical tool can help individualize thromboprophylaxis for COVID-19 patients based on their VTE risk category.

Incidence, Mortality, and Imaging Outcomes of Atrial Arrhythmias in COVID-19.

Atrial arrhythmias (AAs) are common in hospitalized patients with COVID-19; however, it remains uncertain if AAs are a poor prognostic factor in SARS-CoV-2 infection. In this retrospective cohort study from 2014 to 2021, we report in-hospital mortality in patients with new-onset AA and history of AA. The incidence of new-onset congestive heart failure (CHF), hospital length of stay and readmission rate, intensive care unit admission, arterial and venous thromboembolism, and imaging outcomes were also analyzed. We further compared the clinical outcomes with a propensity-matched influenza cohort. Generalized linear regression was performed to identify the association of AA with mortality and other outcomes, relative to those without an AA diagnosis. Predictors of new-onset AA were also modeled. A total of 6,927 patients with COVID-19 were included (626 with new-onset AA, 779 with history of AA). We found that history of AA (adjusted relative risk [aRR] 1.38, confidence interval [CI], 1.11 to 1.71, p = 0.003) and new-onset AA (aRR 2.02, 95% CI 1.68 to 2.43, p <0.001) were independent predictors of in-hospital mortality. The incidence of new-onset CHF was 6.3% in history of AA (odds ratio 1.91, 95% CI 1.30 to 2.79, p <0.001) and 11.3% in new-onset AA (odds ratio 4.01, 95% CI 3.00 to 5.35, p <0.001). New-onset AA was shown to be associated with worse clinical outcomes within the propensity-matched COVID-19 and influenza cohorts. The risk of new-onset AA was higher in patients with COVID-19 than influenza (aRR 2.02, 95% CI 1.76 to 2.32, p <0.0001), but mortality associated with new-onset AA was higher in influenza (aRR 12.58, 95% CI 4.27 to 37.06, p <0.0001) than COVID-19 (aRR 1.86, 95% CI 1.55 to 2.22, p <0.0001). In a subset of the patients with COVID-19 for which echocardiographic data were captured, abnormalities were common, including valvular abnormalities (40.9%), right ventricular dilation (29.6%), and elevated pulmonary artery systolic pressure (16.5%); although there was no evidence of a difference in incidence among the 3 groups. In conclusion, new-onset AAs are associated with poor clinical outcomes in patients with COVID-19.

SARS-COV-ATE risk assessment model for arterial thromboembolism in COVID-19.

Patients with SARS-CoV-2 infection are at an increased risk of cardiovascular and thrombotic complications conferring an extremely poor prognosis. COVID-19 infection is known to be an independent risk factor for acute ischemic stroke and myocardial infarction (MI). We developed a risk assessment model (RAM) to stratify hospitalized COVID-19 patients for arterial thromboembolism (ATE). This multicenter, retrospective study included adult COVID-19 patients admitted between 3/1/2020 and 9/5/2021. Among 3531 patients from the training cohort, 15.5% developed acute in-hospital ATE, including stroke, MI, and other ATE, compared to 13.4% in the validation cohort. The 16-item final score was named SARS-COV-ATE (Sex: male = 1, Age [40-59 = 2, > 60 = 4], Race: non-African American = 1, Smoking = 1 and Systolic blood pressure elevation = 1, Creatinine elevation = 1; Over the range: leukocytes/lactate dehydrogenase/interleukin-6, B-type natriuretic peptide = 1, Vascular disease (cardiovascular/cerebrovascular = 1), Aspartate aminotransferase = 1, Troponin-I [> 0.04 ng/mL = 1, troponin-I > 0.09 ng/mL = 3], Electrolytes derangement [magnesium/potassium = 1]). RAM had a good discrimination (training AUC 0.777, 0.756-0.797; validation AUC 0.766, 0.741-0.790). The validation cohort was stratified as low-risk (score 0-8), intermediate-risk (score 9-13), and high-risk groups (score ≥ 14), with the incidence of ATE 2.4%, 12.8%, and 33.8%, respectively. Our novel prediction model based on 16 standardized, commonly available parameters showed good performance in identifying COVID-19 patients at risk for ATE on admission.

Quantification of abdominal fat from computed tomography using deep learning and its association with electronic health records in an academic biobank.

OBJECTIVE: The objective was to develop a fully automated algorithm for abdominal fat segmentation and to deploy this method at scale in an academic biobank. MATERIALS AND METHODS: We built a fully automated image curation and labeling technique using deep learning and distributive computing to identify subcutaneous and visceral abdominal fat compartments from 52,844 computed tomography scans in 13,502 patients in the Penn Medicine Biobank (PMBB). A classification network identified the inferior and superior borders of the abdomen, and a segmentation network differentiated visceral and subcutaneous fat. Following technical evaluation of our method, we conducted studies to validate known relationships with visceral and subcutaneous fat. RESULTS: When compared with 100 manually annotated cases, the classification network was on average within one 5-mm slice for both the superior (0.4 ± 1.1 slice) and inferior (0.4 ± 0.6 slice) borders. The segmentation network also demonstrated excellent performance with intraclass correlation coefficients of 1.00 (P < 2 × 10-16) for subcutaneous and 1.00 (P < 2 × 10-16) for visceral fat on 100 testing cases. We performed integrative analyses of abdominal fat with the phenome extracted from the electronic health record and found highly significant associations with diabetes mellitus, hypertension, and renal failure, among other phenotypes. CONCLUSIONS: This work presents a fully automated and highly accurate method for the quantification of abdominal fat that can be applied to routine clinical imaging studies to fuel translational scientific discovery.

Body Composition, Natriuretic Peptides, and Adverse Outcomes in Heart Failure With Preserved and Reduced Ejection Fraction.

OBJECTIVES: The purpose of this study was to determine the relationship between body composition, N-terminal B-type natriuretic peptide (NT-proBNP) levels, and heart failure (HF) phenotypes and outcomes. BACKGROUND: Abnormalities in body composition can influence metabolic dysfunction and HF severity; however, data assessing fat distribution and skeletal muscle (SM) size in HF with reduced (HFrEF) and preserved EF (HFpEF) are limited. Further, whether NPs relate more closely to axial muscle mass than measures of adiposity is not well studied. METHODS: We studied 572 adults without HF (n = 367), with HFrEF (n = 113), or with HFpEF (n = 92). Cardiac magnetic resonance was used to assess subcutaneous and visceral abdominal fat, paracardial fat, and axial SM size. We measured NT-proBNP in 334 participants. We used Cox regression to analyze the relationship between body composition and mortality. RESULTS: Compared with controls, pericardial and subcutaneous fat thickness were significantly increased in HFpEF, whereas patients with HFrEF had reduced axial SM size after adjusting for age, sex, race, and body height (p < 0.05 for comparisons). Lower axial SM size, but not fat, was significantly predictive of death in unadjusted (standardized hazard ratio: 0.63; p < 0.0001) and multivariable-adjusted analyses (standardized hazard ratio = 0.72; p = 0.0007). NT-proBNP levels more closely related to lower axial SM rather than fat distribution or body mass index (BMI) in network analysis, and when simultaneously assessed, only SM (p = 0.0002) but not BMI (p = 0.18) was associated with NT-proBNP. However, both NT-proBNP and axial SM mass were independently predictive of death (p < 0.05). CONCLUSIONS: HFpEF and HFrEF have distinct abnormalities in body composition. Reduced axial SM, but not fat, independently predicts mortality. Greater axial SM more closely associates with lower NT-proBNP rather than adiposity. Lower NT-proBNP levels in HFpEF compared with HFrEF relate more closely to muscle mass rather than obesity.

Serum Albumin Is a Marker of Myocardial Fibrosis, Adverse Pulsatile Aortic Hemodynamics, and Prognosis in Heart Failure With Preserved Ejection Fraction.

Background Data regarding the phenotypic correlates and prognostic value of albumin in heart failure with preserved ejection fraction (HFpEF) are scarce. The goal of the current study is to determine phenotypic correlates (myocardial hypertrophy, myocardial fibrosis, detailed pulsatile hemodynamics, and skeletal muscle mass) and prognostic implications of serum albumin in HFpEF. Methods and Results We studied 118 adults with HFpEF. All-cause death or heart-failure-related hospitalization was ascertained over a median follow-up of 57.6 months. We measured left ventricular mass, myocardial extracellular volume, and axial muscle areas using magnetic resonance imaging. Pulsatile arterial hemodynamics were assessed with a combination of arterial tonometry and phase-contrast magnetic resonance imaging. Subjects with lower serum albumin exhibited a higher body mass index, and a greater proportion of black ethnicity and diabetes mellitus. A low serum albumin was associated with higher myocardial extracellular volume (52.3 versus 57.4 versus 39.3 mL in lowest to highest albumin tertile, respectively; P=0.0023) and greater N-terminal pro B-type natriuretic peptide levels, but not with a higher myocardial cellular volume (123 versus 114 versus 102 mL; P=0.13). Lower serum albumin was also associated with an increased forward wave amplitude and markedly increased pulsatile power in the aorta. Serum albumin was a strong predictor of death or heart failure hospitalization even after adjustment for N-terminal pro B-type natriuretic peptide levels and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score (adjusted standardized hazard ratio=0.56; 95% CI=0.37-0.83; P<0.0001). Conclusions Serum albumin is associated with myocardial fibrosis, adverse pulsatile aortic hemodynamics, and prognosis in HFpEF. This readily available clinical biomarker can enhance risk stratification in HFpEF and identifies a subgroup with specific pathophysiological abnormalities.

Recurrent Esophageal Stricture Secondary to Pemphigus Vulgaris: A Rare Diagnostic and Therapeutic Challenge.

Pemphigus vulgaris (PV) is an autoimmune blistering disorder of skin and mucous membranes, characterized by acantholysis, can be life threatening, and carries significant morbidity. Esophageal involvement is uncommon, and the diagnosis can often be delayed. Esophageal stricture secondary to PV is extremely rare, and there are no guidelines on the management of this complication. We present a case of recalcitrant esophageal stricture, secondary to PV, successfully treated with topical and intralesional steroids. Moreover, we review the literature pertaining to esophageal PV and the management of esophageal strictures.

Saphenous Vein Graft Pseudoaneurysm Repair with GraftMaster®.

Saphenous vein graft (SVG) pseudoaneurysm is a rare complication of coronary artery bypass graft (CABG) surgery. Despite the high mortality associated with SVG pseudoaneurysm, there is no consensus on the optimal management of these pseudoaneurysms as they are infrequently reported in the literature. We report a case of a 55-year-old man with prior CABG surgery who presented with cough associated with hemoptysis and chest pain, and was found to have SVG pseudoaneurysm. The pseudoaneurysm was successfully closed with polytetrafluoroethylene (PTFE)-covered Jostent GraftMaster® (Abbott Vascular, Santa Clara, CA). We propose that GraftMaster is an effective means of treating SVG pseudoaneurysms percutaneously.

A case report of emphysematous gastritis in a diabetic patient: favorable outcome with conservative measures.

Emphysematous gastritis (EG) is a rare cause of abdominal pain, which should be differentiated from gastric emphysema. It is hypothesized to result from air-producing microorganisms in patients with underlying predisposing factors. Because of the non-specific presentation of EG, it is diagnosed radiographically. CT scan is the diagnostic modality of choice that typically reveals irregular, mottled appearance of the air in the thickened gastric wall and in the portal vein in the liver. We report a rare case of EG in a male with a history of diabetes mellitus who presented to the emergency department with diarrhea, nausea, vomiting, and epigastric pain. On examination, he was hypotensive and had mild tenderness in the epigastrium. Laboratory tests revealed leukocytosis, elevated lactate, anion gap metabolic acidosis, and acute kidney injury. A non-contrast CT abdomen revealed findings consistent with EG. Even though mortality rate in access of 60% have been reported without prompt surgical intervention in EG, recent literature suggests favorable prognosis with conservative measures in patients without an overt surgical indication. Our patient was also managed conservatively with IV antibiotics and gradual advancement of diet and had complete resolution of symptoms over the ensuing few days. The factors that correlate with a poor prognosis include elevated serum lactate, serum creatinine, and concomitant pneumatosis in small bowel and colon.

Group d salmonella urinary tract infection in an immunocompetent male.

A 62-year-old male with past medical history of benign prostatic hyperplasia presented to the emergency department with complaints of decreased urinary flow, inability to fully empty his bladder, and gross hematuria. Physical examination was unremarkable. Urinalysis revealed large amount of blood and more than 700 white blood cells suggesting a urinary tract infection. Urine culture grew group D Salmonella greater than 100,000 colony-forming units per mL. He was prescribed 6 weeks of trimethoprim/sulfamethoxazole and had resolution of symptoms. Retrospectively, he reported a 3-day history of watery diarrhea about a week prior to onset of urinary symptoms that was presumed to be the hematogenous source in this case. Urinary tract infection from nontyphoidal Salmonella (NTS) is rare and is usually associated with immunosuppression, chronic diseases, such as diabetes or structural abnormalities of the genitourinary tract. Genitourinary tract abnormalities previously reported in the literature that predispose to nontyphoidal Salmonella urinary tract infection include nephrolithiasis, chronic pyelonephritis, retrovesicular fistula, urethrorectal fistula, hydrocele, and post-TURP. We present an exceedingly uncommon case of 62-year-old male with group D Salmonella urinary tract infection predisposed by his history of benign prostatic hyperplasia.

IVC filter perforation through the duodenum found after years of abdominal pain.

BACKGROUND: The number of IVC filter-related complications has increased with their growing utilization; however, IVC filter perforation of the duodenum is rare. It can manifest with nonspecific abdominal pain, gastrointestinal bleeding, cava-duodenal fistula, or small bowel obstruction. CASE REPORT: A 67-year-old female presented with several years of right upper quadrant abdominal pain which was exacerbated by movement and food intake. She had a history of hepatic steatosis, cholecystectomy, and multiple DVTs with inferior vena cava filter placement. Physical exam was unremarkable. Laboratory tests demonstrated elevated alkaline phosphatase and transaminases. Esophagogastroduodenoscopy revealed a thin metallic foreign body embedded in the duodenal wall and protruding into the duodenal lumen with surrounding erythema and edema, but no active hemorrhage. Further evaluation with non-contrast CT scan revealed that one of the prongs of her IVC filter had perforated through the vena cava wall into the adjacent duodenum. Exploratory laparotomy was required for removal of the IVC filter and repair of the vena cava and duodenum. Her post-operative course was uneventful. CONCLUSIONS: In patients with history of IVC filter placement with non-specific abdominal pain, a high clinical suspicion of IVC filter perforation of the duodenum should be raised, as diagnosis may be challenging. CT scan and EGD are valuable in the diagnosis. Excellent outcomes have been reported with open surgical filter removal. Low retrieval rates of IVC filters have led to increased complications; hence, early removal should be undertaken as clinically indicated.

Thyroid follicular carcinoma presenting as metastatic skin nodules.

BACKGROUND: Follicular thyroid cancer (FTC) metastasizes most commonly to the lungs and non-cranial bones. Skull and skin are uncommon sites and usually manifest well after the diagnosis of primary malignancy. Metastasis to skull and skin as the presenting feature of FTC is infrequently reported in the literature. CASE PRESENTATION: A 65-year-old Caucasian woman with a history of thyroid nodule presented with the complaint of rapidly growing skull nodules which had been present for 3 years but were stable previously. She denied any fevers, chills, history of trauma, or weight loss. She denied any history of smoking or head and neck irradiation. On physical examination, she had two non-tender gray cystic lesions - one on her left temporal region and the other on the right parietal region. Biopsy was consistent with metastatic FTC. Magnetic resonance imaging of the brain demonstrated 7.1×3.8 cm and 3.7×4.5 cm fairly homogeneous, enhancing, relatively well-defined masses centered in the posterior and left anterior lateral calvarium with intracranial and extracranial extensions but without any vasogenic edema or mass effect on the brain. Thyroid ultrasound showed numerous nodules in both lobes. The patient underwent a total thyroidectomy. Histopathological studies of the thyroid gland revealed a well-differentiated FTC in the left lobe. Then she underwent resection of the tumor in multiple stages. She did not have any recurrence of the FTC or metastases during the follow-up period and will be receiving radioactive iodine treatment. CONCLUSION: Bone and lung are the common sites of metastasis from FTC, but involvement of skull or skin is unusual, particularly as the presenting feature. Metastases from FTC should be in the differential of patients with new osteolytic hypervascular skull lesions or cutaneous lesions in head and neck area.

An acute care surgery dilemma: emergent laparoscopic cholecystectomy in patients on aspirin therapy.

BACKGROUND: The current literature regarding hemorrhagic complications in patients on long-term antiplatelet therapy undergoing emergent laparoscopic cholecystectomy is limited. The aim of our study was to describe hemorrhagic complications in patients on prehospital aspirin (ASP) therapy undergoing emergent cholecystectomy. METHODS: We performed a 1-year retrospective analysis of our prospectively maintained acute care surgery database. The 2 groups (ASP group vs No ASP group) were matched in a 1:1 ratio for age, sex, previous abdominal surgeries, and comorbidities. Primary outcome measures were intraoperative hemorrhage, postoperative anemia, need for blood transfusion, and conversion to open cholecystectomy. Intraoperative hemorrhage was defined as intraoperative blood loss of ≥ 100 mL; postoperative anemia was defined by ≥ 2 g/dL drop in hemoglobin. RESULTS: A total of 112 (ASP: 56, no ASP: 56) patients were included in the analysis. The mean age was 65.9 ± 10 years, and 50% were male. There was no difference in age (P = .9), sex (P = .9), and comorbidities (P = .7) between the 2 groups. There was no difference in intraoperative blood loss >100 mL (P = .5), postoperative anemia (P = .8), blood transfusion requirement (P = .9), and conversion to open surgery (P = .7) between patients on American Society of Anesthesiologists therapy and patients not on American Society of Anesthesiologists therapy. CONCLUSIONS: Emergent laparoscopic cholecystectomy is a safe procedure in patients on long-term ASP. Prehospital use of ASP as an independent factor should not be used to delay emergent cholecystectomy.

Transforming hemoglobin measurement in trauma patients: noninvasive spot check hemoglobin.

BACKGROUND: Technological advances now allow for noninvasive Hbg measurements. Previous studies have reported on the efficacy of continuous noninvasive Hgb devices. Recently, a new device, Pronto-7, a spot check pulse CO-oximeter has become available. The aim of our study was to assess noninvasive Hgb measurement in trauma patients. METHODS: We performed a prospective cohort analysis of all trauma patients presenting to our Level I trauma center. Invasive Hgb and spot check Hgb measurements were obtained simultaneously at presentation. Spot check was measured 2 times with each invasive Hgb value. Normal Hgb was defined as >8 mg/dL. Spearman correlation and Bland-Altman analysis was performed. RESULTS: A total of 525 patients had attempted spot check Hgb measurements with a success rate of 86% (n = 450). A total of 450 invasive and 1,350 spot check Hgb measurements were obtained. Mean ± SD age was 41 ± 21 years, 74% were male, and mean Injury Severity Score was 21 ± 13. Thirty-eight percent (n = 173) of patients had Hgb ≤8 mg/dL at presentation. Mean invasive Hgb was 11.5 ± 4.36 g/dL, mean spot check Hgb 11.1 ± 3.60 g/dL, and mean difference was 0.3 ± 1.3 g/dL. Spot check Hgb values had strong correlation with invasive Hgb measurements (R(2) = 0.77; R = 0.86; p = 0.04) with 76% accuracy and 95.4% sensitivity. CONCLUSIONS: Spot check Hgb monitoring had excellent correlation with invasive Hgb measurements. Application of spot check has more clinical use as compared with previous continuous Hgb monitoring. This novel technology allows immediate and accurate Hgb measurements in trauma patients.