Background

Thyroid storm is a rare but potentially lethal manifestation of thyrotoxicosis. Guidelines recommend nonoperative management of thyroid storm, but thyroidectomy can be performed if patients fail medical therapy or need immediate resolution of the storm. Outcomes of thyroidectomy for management of thyroid storm remain ill-defined.

Methods

Using the National Inpatient Sample from 2016 to 2020, a retrospective analysis was conducted of patients admitted with thyroid storm. Outcomes of interest included operative complications and mortality. Multivariable logistic regression was performed to assess factors associated with receiving thyroidectomy and mortality.

Results

An estimated 16,175 admissions had a diagnosis of thyroid storm. The incidence of thyroid storm increased from .91 per 100,000 people in 2016 to 1.03 per 100,000 people in 2020, with a concomitant increase in mortality from 2.9% to 5.3% (P < .001). Operative intervention was pursued in 635 (3.9%) cases with a perioperative complication rate of 30%. On multivariable regression, development of acute decompensated heart failure (adjusted odds ratio [AOR] 1.66, 95% Confidence Interval [CI] 1.03-2.68, P = .037) and acute renal failure (AOR 2.10, 95% CI 1.17-3.75, P = .013) increased odds of receiving surgery. The same multivariable model did not show a significant association between thyroidectomy and mortality.

Discussion

The incidence of thyroid storm and associated mortality increased during the study period. Thyroidectomy is rarely performed during the same admission, with an overall perioperative complication rate of 30% and no effect on mortality. Patients with acute decompensated heart failure and renal failure were more likely to receive an operative intervention.

Background

Lack of consensus remains about factors that may be associated with high resource use (HRU) in adult cardiac surgical patients. This study aimed to identify patient-related, hospital, and perioperative characteristics associated with HRU admissions involving elective cardiac operations.

Methods

Data from the National Inpatient Sample was used to identify patients who underwent coronary artery bypass graft, valve replacement, and valve repair operations between 2005 and 2016. Admissions with HRU were defined as those in the highest decile for total hospital costs. Multivariable regressions were used to identify factors associated with HRU.

Results

An estimated 1,750,253 hospitalizations coded for elective cardiac operations. The median hospitalization cost was $34,700 (interquartile range, $26,800- to $47,100), with the HRU (N = 175,025) cutoff at $66,029. Although HRU patients comprised 10% of admissions, they accounted for 25% of cumulative costs. On multivariable regression, patient-related characteristics predictive of HRU included female sex, older age, higher comorbidity burden, non-White race, and highest income quartile. Hospital factors associated with HRU were low-volume hospitals for both coronary artery bypass graft and valvular operations. Among postoperative outcomes, mortality, infectious complications, extracorporeal membrane oxygenation use, and hospitalization for more than 8 days were associated with greater odds of HRU.

Conclusions

In this nationwide study of elective cardiac surgical patients, several important patient-related and hospital factors, including patients' race, comorbidities, postoperative infectious complications, and low hospital operative volume were identified as predictors of HRU. These highly predictive factors may be used for benchmarking purposes and improvement in surgical planning.

Granulomatosis with polyangiitis (GPA) is one of three described anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). Early diagnosis and treatment of GPA is paramount, as it may help prevent irreversible end-organ damage, especially renal and pulmonary failure. A 72-year-old male with a past medical history of lung adenocarcinoma in remission, chronic sinusitis status-post multiple sinus surgeries, and coronary artery disease presented with shortness of breath, dark urine, and asymmetric polyarthralgias. He had an acute kidney injury, leukocytosis, with urinalysis demonstrating pyuria and hematuria, without casts. Chest imaging showed cavitary nodular opacities in addition to interval increase of existing nodules compared to the most recent scan one month prior. His acute kidney injury progressed to renal failure requiring hemodialysis, and he developed an inflammatory polyarthritis. GPA was suspected clinically so he was started on high-dose intravenous corticosteroids, and subsequently plasmapheresis and rituximab. Serology returned with highly positive proteinase-3 antibodies, and cytoplasmic ANCA positivity on immunofluorescence. Renal biopsy demonstrated severely active pauci-immune glomerulonephritis. Several months after discharge, the patient passed away from gram positive bacteremia. This patient's recurrent sinusitis, pulmonary nodules, and subsequent renal failure were highly suggestive of GPA. A biopsy is recommended to confirm the diagnosis of GPA, but treatment should not be delayed if there is a high index of suspicion for the disease. Induction therapy with corticosteroids combined with rituximab or cyclophosphamide has significantly decreased the mortality of patients with GPA. Patients with GPA often have preceding history of nasopharyngeal and upper airway disease, and can present with fluctuating pulmonary infiltrates. Early recognition and treatment of patients with GPA can prevent life-threatening complications and reduce mortality.

Introduction

Cardiovascular complications are the leading cause of death after noncardiac surgery. Major abdominal operations represent the largest category of procedures considered to have an increased risk of cardiovascular complications. The current aim was to examine trends in the incidence of mortality, perioperative myocardial infarction, and cardiac arrest to determine the presence of potential volume-outcome relationships.

Methods

We performed a retrospective analysis of the Nationwide Inpatient Sample for patients undergoing elective, open abdominal esophagectomy, gastrectomy, pancreatectomy, nephrectomy, hepatectomy, splenectomy, and colectomy (major abdominal surgery) during 2008-2014. Univariate and multivariate analyses were performed to determine the impact of operative volume on rates of myocardial infarction, cardiac arrest, and mortality.

Results

Of the 962,754 elective admissions for major abdominal surgery, 1.4% experienced in-hospital mortality, 0.7% myocardial infarction, and 0.35% cardiac arrest. Myocardial infarction and cardiac arrest were associated with a 24-fold increase in risk of perioperative mortality. Compared with institutions that have a very low volume of operations, those hospitals with larger volumes of operations had a decreased risk of cardiac arrest and incident mortality after cardiovascular complications, but the odds of myocardial infarction were greatest at higher operative-volume hospitals. The annual all-cause mortality and myocardial infarction rates decreased over time, but the incidence of cardiac arrest increased.

Conclusion

Myocardial infarction or cardiac arrest after major abdominal surgery increased the odds of mortality with superior rescue after cardiovascular complications at higher volume institutions. Across all US hospitals performing major abdominal surgery, the rate of cardiac arrest increased without a concomitant increase in myocardial infarction or mortality. Novel targets for risk modification of myocardial infarction and cardiac arrest as well as investigation of processes that facilitate rescue after these complications at higher operative-volume hospitals are needed to delineate quality improvement opportunities.

BACKGROUND: Whether laparoscopic approach to gastrectomy for gastric cancer (GC) reduces the risk of pneumonia remains unknown. In this study, we compared pneumonia outcomes for patients with GC who underwent either laparoscopic gastrectomy (LG) or open gastrectomy (OG). METHODS: The ACS NSQIP database was queried to identify patients with GC who underwent LG or OG between Jan 2012 - Dec 2018. Outcomes were compared using regression models. A post-hoc analysis was performed for elderly patients. RESULTS: The study cohort included 2661 patients, 23.4 % undergoing LG. Laparoscopic approach lowered pneumonia risk (OR 0.47, p = .028) and reduced hospital length of stay, (5.3 vs 7.1 days, p < .001). Elderly patients undergoing LG demonstrated similar benefits. Risk factors for pneumonia included advanced age, dyspnea and weight-loss, whereas laparoscopic approach reduced this risk. CONCLUSIONS: LG in patients with GC has both statistically and clinically significant advantages over OG with respect to pneumonia. Further studies are needed to validate the relationship between postoperative pneumonia and surgical approach for gastrectomy.

Background

Atrial fibrillation (AF) is associated with left ventricular (LV) systolic dysfunction which may improve after AF ablation. We hypothesised that increased ventricular irregularity, as measured by R-R dispersion on the baseline ECG, would predict improvement in the left ventricular ejection fraction (LVEF) after AF ablation.

Methods

Patients with LVEF <50% at two US centres (2007-2016), having both a preablation and postablation echocardiogram or cardiac MRI, were included. LVEF improvement was defined as absolute increase in LVEF by >7.5%. Multivariable logistic regression (restricted to echocardiographic/ECG variables) was performed to evaluate predictors of LVEF improvement.

Results

Fifty-two patients were included in this study. LVEF improved in 30 patients (58%) and was unchanged/worsened in 22 patients (42%). Those with versus without LVEF improvement had an increased baseline R-R dispersion (645±155 ms vs 537±154 ms, p=0.02, respectively). The average baseline heart rate in all patients was 93 beats per minute. After multivariable logistic regression, increased R-R dispersion (OR 1.59, 95% CI 1.00 to 2.55, p=0.03) predicted LVEF improvement.

Conclusions

Increased R-R dispersion on ECG was independently associated with improved systolic function after AF ablation. This broadens the existing knowledge of arrhythmia-induced cardiomyopathy, demonstrating that irregular electrical activation (as measured by increased R-R dispersion on ECG) is associated with a cardiomyopathy capable of improving after AF ablation.