Complicated Hospital Course Research Articles

Gastrostomy in the era of minimally invasive head and neck cancer surgery.

Minimally invasive transoral robotic surgery (TORS) is less likely to necessitate gastrostomy tube (GT) following resection of head and neck lesions versus conventional open procedures. However, the incidence of and indications for GT after TORS have not been reported in detail. This study defines the incidence of intra- and postoperative gastrostomy following robotic resection of advanced head and neck disease. It seeks to clarify the relevance of GT after TORS. Adult patients undergoing TORS and neck dissection from 2008 to 2014 were identified in the New York Statewide Planning and Research Cooperative System all-payer administrative database. Demographic data and timing of GT in relation to surgery were recorded. Emergency department (ED) visits and inpatient readmissions were compared with multivariable logistic analysis. Of the 441 included patients, immediate, delayed, and total GT incidence within the first postoperative year was 9.5%, 11.6%, and 21.1%, respectively. Gastrostomy tube complications resulted in 4.5% of 30-day ED visits, 3.3% of 30-day readmissions, and 3.5% of 90-day readmissions. Thirty-nine percent of 90-day readmissions were linked to poor postoperative oral intake. Delayed GT status was associated with an increase in 30-day ED visits, and 30- or 90-day readmissions attributable to poor oral intake (P = 0.10, P < 0.0001, 0.002, respectively). Even in the era of minimally invasive TORS, impaired oral intake is a significant postoperative burden to head and neck cancer patients with advanced disease. Attention to patient risk factors combined with a complicated hospital course may identify patients benefiting from early GT. 2c. Laryngoscope, 128:847-851, 2018.

Nutrition Support for Critically Ill Patients With Cancer.

Oncology patients often experience the classic signs of malnutrition-weight loss as well as fat and muscle wasting, which have been associated with poor tolerance to treatment and increased morbidity and mortality. Nutrition status may be an important factor in determining tolerance to treatment and outcomes associated with it. Thus, identification of those with preexisting malnutrition or who are at risk for developing malnutrition is crucial not only at time of cancer diagnosis but also throughout the treatment course so that nutrition interventions may be implemented to prevent development or worsening of malnutrition in this high-risk population. These patients often have extremely complicated hospital courses due to the aggressive nature of the disease and treatment, leading to intensive care unit admission and periods of critical illness. Critical illness is associated with catabolism, extreme stress on the body, and a state of systemic inflammation. During critical illness, it is important to provide adequate nutrition to prevent further break down of lean muscle mass and oxidative cellular injury and to regulate favorable immune responses. The purpose of this review is to discuss the importance of nutrition screening and assessment for the critically ill patient with cancer; to appropriately identify those at risk for, or who have developed, malnutrition; and to provide appropriate interventions to optimize nutrition status. This review also discusses the complications and difficulties associated with feeding this patient population and offers nutrition support recommendations.

Is bilateral internal thoracic artery grafting a safe option for chronic dialysis patients?

The use of bilateral internal thoracic artery (BITA) grafting has been proposed for dialysis patients with multivessel coronary artery disease, primarily because of hypothetical long-term survival benefits. To investigate the outcome of BITA grafting in dialysis patients. This was a retrospective analysis of the use of BITA grafting in 105consecutive patients with end-stage renal failure on chronic dialysis in three European centres with extensive experience in BITA. Baseline patient characteristics, operative data, early postoperative complications and late survival were reviewed. Outcomes of patients from one of the three centres who underwent either BITA (n=40) or single internal thoracic artery (SITA) grafting (n=19) were also analysed; a one-to-one propensity score (PS)-matched analysis was performed. There were 19 (18.1%) hospital deaths. Despite differences in preoperative patient characteristics and surgical features, in each centre, hospital mortality was greater than the 75th percentile of expected operative risk (EuroSCORE II). Diseased ascending aorta and extracardiac arteriopathy were found to be predictors of hospital death (odds ratio 9.7; P=0.006) and complicated hospital course (odds ratio 2.54; P=0.035), respectively. The 7-year non-parametric estimates of freedom from all-cause death and cardiac or cerebrovascular death were 59% (95% confidence interval: 52.3-65.7%) and 75.6% (95% confidence interval: 71.2-80%), respectively. There were no significant differences in early and late outcomes between BITA and SITA PS-matched groups. BITA grafting remains a risky operation for chronic dialysis patients, even when performed routinely. No long-term survival benefits for the use of BITA versus SITA were proven.

Drug-induced parkinsonism: A case report.

Drug-induced parkinsonism is defined as the appearance of parkinsonism on treatment with pharmaceutical agents. Symptoms typically manifest within a few days, and 90% of cases emerge within 3 months. The patient was a 68-year-old white man with a past psychiatric history significant for bipolar I versus cyclothymic disorder. The patient presented with pressured speech, flight of ideas, distractibility, delusions, and disorganized thinking. He was started on risperidone and, due to a subclinical response, was cross-tapered from risperidone to olanzapine, and divalproex was started. The patient was then given paliperidone 234 mg long-acting injection (LAI) and a second loading dose of 156 mg 1 week later. The patient's cognitive and functional status subsequently declined, all neuroleptics were discontinued, and he was diagnosed with drug-induced parkinsonism. After a complicated hospital course the patient died approximately 5 months after the administration of paliperidone LAI. Although there are several confounding factors, due to the temporal relationship of events it is likely that paliperidone LAI was a contributing factor for the development of severe parkinsonism. Practitioners should be cognizant of the potential long-term consequences of paliperidone LAI.

Rare Presentation of Lupus Myocarditis With Acute Heart Failure—A Case Report

Systemic lupus erythematosus is an autoimmune disease with diffuse organ involvement. The cardiac complications include pericarditis, myocarditis, pulmonary hypertension, coronary vasculitis, and Libman-Sacks endocarditis. Symptomatic lupus myocarditis presenting with left ventricular dysfunction, acute heart failure, and pulmonary edema, although rare, is a life-threatening complication. We report the occurrence of acute lupus myocarditis in a 38-year-old postpartum female who had a cesarean section a week before presentation for preeclampsia. Initially she was managed for pneumonia but later found to have acute pericarditis and myocarditis related to systemic lupus erythematosus. She had a complicated hospital course including acute respiratory failure and cardiogenic shock. She was started on pulse dose steroids besides the treatment for heart failure and had a dramatic improvement within days.

Acute on Chronic Liver Failure and Urgent Orthotopic Liver Transplantation in an Adult with Alagille Syndrome

Alagille syndrome is an autosomal dominant syndrome marked by a paucity of interlobular bile ducts with cholestasis, and whose features can include butterfly vertebrae, dysmorphic facies, cardiac and ocular anomalies. Most patients are symptomatic during childhood. As adult patients may require elective liver transplant for cirrhosis and intractable pruritus, liver failure is uncommon in these patients. We present a case of liver failure in an adult with Alagille syndrome. A 32-year-old man with known Alagille syndrome was admitted to the hospital with progressive jaundice and RUQ pain. At that time his MELD was 24 and he was referred for liver transplant evaluation. A month later, he was admitted for hematemesis and hepatic encephalopathy. He had a complicated hospital course with worsening encephalopathy, hepatorenal syndrome (requiring dialysis), and septic shock due to Streptococcus viridans requiring pressors. His peak MELD score during this hospitalization was 42(total bilirubin 47.5, Cr 5, INR 2.0). A CDC high risk liver became available and he underwent an orthotopic liver transplant. This was complicated by bacterial peritonitis from an infected hematoma. However, he recovered well after treatment of his peritonitis, and LFTs were normal one month post-transplant. Allagile syndrome occurs in 1 in 70,000 live births from a JAG1 or NOTCH2 mutation. They have paucity or stenotic bile ducts with progressive cholestasis in 95%, and cirrhosis in more than 20% of cases. Initial treatment includes ursodeoxycholic acid, cholestyramine, fat soluble vitamins and nutrition support. However, 21-31% patients will require liver transplant for severe xanthomatosis, intractable pruritus, and portal hypertension. Most liver transplants are done in the pediatric group. Only 9.7% patients had their first liver transplant beyond 18 years old, and are done electively for cirrhosis and intractable pruritus. Only a few cases were reported due to acute liver failure requiring an urgent transplant, similar to our patient. Alagille syndrome patients may require liver transplantation, usually during childhood. In some cases, transplant may be required in adulthood due to liver cirrhosis and intractable pruritis, and is mostly elective. Liver failure is uncommon in these patients.

Gastroschisis: A Review of Management and Outcomes.

We performed an evidence-based review of the obstetrical management of gastroschisis. Gastroschisis is an abdominal wall defect, which has increased in frequency in recent decades. There is variation of prevalence by ethnicity and several known maternal risk factors. Herniated intestinal loops lacking a covering membrane can be identified with prenatal ultrasonography, and maternal serum α-fetoprotein level is commonly elevated. Because of the increased risk for growth restriction, amniotic fluid abnormalities, and fetal demise, antenatal testing is generally recommended. While many studies have aimed to identify antenatal predictors of neonatal outcome, accurate prognosis remains challenging. Delivery by 37 weeks appears reasonable, with cesarean delivery reserved for obstetric indications. Postnatal surgical management includes primary surgical closure, staged reduction with silo, or sutureless umbilical closure. Overall prognosis is good with low long-term morbidity in the majority of cases, but approximately 15% of cases are very complex with complicated hospital course, extensive intestinal loss, and early childhood death.

Surgical outcomes associated with postoperative atrial fibrillation after robotic-assisted pulmonary lobectomy: retrospective review of 208 consecutive cases.

In this study, we sought to investigate the effect of post-operative atrial fibrillation (POAF) after robotic-assisted video-thoracoscopic pulmonary lobectomy on comorbid postoperative complications, chest tube duration, and hospital length of stay (LOS). We retrospectively analyzed prospectively collected data from 208 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon for known or suspected lung cancer. Postoperatively, 39 (18.8%) of these patients experienced POAF during their hospital stay. The occurrence of postoperative complications other than POAF, chest tube duration, and hospital LOS were analyzed in patients with POAF and without POAF. Statistical significance (P≤0.05) was determined by unpaired Student's t-test or by Chi-square test. Of patients with POAF, 46% also had other concurrent postoperative complications, while only 31% of patients without POAF experienced complications. The average number of postoperative complications experienced by patients with POAF was significantly higher than that experienced by those without POAF (0.9 vs. 0.4, P<0.05). Median chest tube duration in POAF patients (6 days) was significantly higher than in patients without POAF (4 days). A similar result was also seen with hospital LOS, with the median hospital LOS of 8 days in POAF patients being significantly longer than in those without POAF, whose median hospital LOS was 4 days. No other significant difference was detected between the two groups of patients. This study demonstrated the association between the incidence of POAF and a more complicated hospital course. Further studies are needed to determine whether confounders were involved in this association.

Discharge Destination after Elective Femoropopliteal Bypass in Patients without Critical Ischemia

Femoropopliteal bypass (FPB) remains a widely accepted treatment option for symptomatic leg ischemia, even in patients without features of critical limb ischemia (CLI). These patients are revascularized to improve symptoms of exertional limb pain and the goal of such treatment is to increase their ability to ambulate within the community. Therefore, the anticipated initial discharge disposition for a patient without CLI undergoing FPB is back to their home. This study examined the disposition at initial discharge of such patients. Data from the 2012 National Surgical Quality Improvement Program registry was queried for all elective FPB performed in patients without CLI. Analysis was limited to patients surviving to initial discharge who were living independently at home before surgery. Initial disposition was defined as to HOME or to a FACILITY (either rehabilitation or skilled nursing); these constituting the study groups. Univariate analysis and multivariable logistic regression were performed to identify patient risk factors for failure to discharge to home. In-hospital and postoperative events were also recorded and compared. Significance was defined at P ≤ 0.05. In National Surgical Quality Improvement Program 2012, 1060 cases of elective FPB in patients without CLI were found. The mean± SD age of the population was 65 ± 9 years; 359 (34%) of patients were female; 198 (19%) had a reported race other than white; and most (893, 84%) had hypertension. 60 (6%) patients failed to discharge to home (26 to rehabilitation, 34 to skilled nursing). On univariate analysis, age (FACILITY 68 ± 11 years vs HOME 65 ± 9 years, P = 0.009), female gender (55% vs 37%, P < 0.001), nonwhite race (30% vs 18%, P = 0.007), and a history of diabetes (48% vs 33%, P = 0.01), dialysis (5% vs 1.3%, P = 0.02) congestive heart failure (5% vs 1.1%, P = 0.01), or a stroke (cerebrovascular accident, 5% vs 2.6%, P = 0.01) were found to predict failure to discharge to home. On multivariate analysis, female gender [odds ratio (OR) = 2.4, 95% confidence interval = 1.4-4.1, P = 0.002], and a history of congestive heart failure (OR = 4.7, 1.2-18, 0.03] or cerebrovascular accident (OR = 3.4, 1.9-9.4, 0.02) independently predicted failure to discharge to home. FACILITY patients had higher rates of infectious complications (8.3% vs 1.4%, P < 0.001), myocardial infarction (3.3% vs 0.8%, P = 0.05), operative transfusion (22% vs 5.8%, P < 0.001), and unplanned reoperation (17% vs 2.4%, P < 0.001) during their initial hospitalization. Elective FPB results in a low but not negligible failure of initial return to the community in patients without CLI. Female gender and serious comorbidities predict initial discharge to a facility, which is associated with a complicated hospital course. Careful patient selection is important to achieve good outcomes in this population and furthermore study into the specific preoperative functional and socioeconomic factors predicting failure of early return to the community is warranted.

Abstract WMP74: Admission Volume Depletion is Associated With Poor Outcome in Acute Ischemic Stroke

Background: Few large studies exist on volume depletion and its association with outcomes in acute ischemic stroke (AIS) patients. A common marker of volume status is the calculated blood urea nitrogen (BUN) to serum creatinine (SCr) ratio. We examined the association between admission volume depletion (BUN/SCr &gt; 15) and discharge outcome in AIS patients. Methods: Consecutive patients (March 2014 - April 2015) who presented with AIS to our Comprehensive Stroke Center (CSC) were retrospectively analyzed. Demographics, medical history, imaging, initial lab values, stroke severity (NIHSS), and discharge disposition were recorded. Patients with BUN/SCr &lt;= 15 and &gt; 15 were compared and good outcome defined as discharge home. We performed logistic regression adjusting for admission NIHSS and age. Results: We identified 776 patients who met inclusion criteria. Patients with BUN/SCr &gt;15, were older (median 61 vs. 68, p&lt;0.001), more often female (43.5 vs. 59.6%, p&lt;0.001), and had atrial fibrillation (9 vs. 16%, p=0.004). Greater proportions presented with a hyperdense artery sign (7.1 vs. 12.9%, p=0.010) and developed an in-hospital UTI (2.8 vs. 5.9%, p=0.034). Volume depleted patients had increased LOS (3 vs. 4 days, p=0.049) and higher in-hospital mortality (6.2 vs. 12.6%, p=0.003) with fewer discharged home (57.7 vs. 44.9%, p=0.001). A BUN/SCr &gt;15 was associated with lower odds of good outcome at discharge (OR=0.57, 0.42 - 0.78; p&lt; 0.001), this relationship persisted after adjusting for known predictors (OR=0.70, 0.49 -1.00; p=0.055). Conclusions: After controlling for age and NIHSS, volume depletion in AIS patients estimated by BUN/SCr ratio was associated with poor discharge outcome, complicated hospital course, increased LOS, and in-hospital mortality. This simple ratio can be used in the early evaluation and treatment of AIS. However, multi-center prospective studies are needed to determine if volume correction is confounding this association.

Crisis averted: a patient in cardiopulmonary arrest

Neuromuscular diseases are rare causes of acute hypercapnic respiratory failure due to respiratory muscle weakness and can be life-threatening if not recognized. We report a case of a 35-year-old man with worsening dyspnea, non-productive cough, and fever presenting in cardiopulmonary arrest requiring intubation and mechanical ventilation. After work-up for neuromuscular disease with a positive acetylcholine receptor antibody test, the source of his respiratory failure was discovered to be myasthenia gravis. He improved with acetylcholinesterase inhibitors, corticosteroids, and plasmapheresis therapy but had a long complicated hospital course. Computed tomography of the chest with intravenous contrast revealed an anterior mediastinal mass, which was later resected and confirmed to be a thymoma.

Intraoperative blood transfusion increases the incidence of acute kidney injury in elective off pump coronary artery surgery

Acute kidney injury (AKI) occurs in up to 30% of patients undergoing coronary artery bypass grafting. Development of kidney injury is associated with high overall mortality and a more complicated hospital course. Cardiopulmonary bypass is considered as one of the major risk factors for developing AKI. Off-pump coronary artery bypass (OPCAB) grafting eliminates the need for cardiopulmonary bypass and, as such, is assumed to reduce AKI. However, previous studies provided conflicting evidence to support this hypothesis.

Lidocaine-Induced Cardiac Arrest in the Emergency Department: Effectiveness of Lipid Therapy

BackgroundLocal anesthetics are commonly used in the emergency department (ED). Overdoses can lead to disastrous complications including cardiac toxicity and arrest. Recognition of local anesthetic systemic toxicity (LAST) is important; however, prevention is even more critical. Knowledge of proper lidocaine dosage can prevent LAST. LAST may be effectively treated with lipid emulsion therapy. Although the mechanism is not well understood, its use may have a profound impact on morbidity and mortality. Case ReportFifty milliliters of 2% lidocaine was infiltrated for local anesthesia in a 35-year-old woman during the incision and drainage of a labial abscess. Following the procedure, the patient complained of vomiting, with rapid progression to an altered mental state and seizure requiring endotracheal intubation for airway protection. Suspecting lidocaine toxicity, intralipids were ordered. While waiting for the intralipids, the patient decompensated and suffered pulseless electrical activity (PEA) cardiac arrest. A 100-mL bolus of 20% intralipids was administered 3 minutes into the resuscitation, after which return of spontaneous circulation occurred. The intralipid bolus was then followed by a continuous infusion of 0.25 mL/kg/minute, for an infusion dose of 930 mL. Despite a complicated hospital course, the patient was discharged home neurologically intact. Why Should an Emergency Physician Be Aware of This?We believe this patient's cardiovascular collapse was secondary to an iatrogenic overdose of lidocaine. This is one of the first cases to support the efficacy of intravenous lipids in the treatment of LAST in humans in the ED.

Patterns and Predictors of Sensorineural Hearing Loss in Children With Congenital Diaphragmatic Hernia.

Although congenital diaphragmatic hernia (CDH) may be associated with sensorineural hearing loss (SNHL), to our knowledge, no studies have yet identified the pattern of this hearing loss or definitive independent risk factors that may place this population at higher risk. To characterize the type and degree or SNHL in CDH survivors and better characterize perinatal risk factors. This was a retrospective cohort study of CDH survivors who had a pure-tone audiogram available for review followed at a multidisciplinary clinic. Treatment for CDH at birth. Audiograms were used to calculate pure-tone average (PTA) for the most severely affected side and classify SNHL as normal (<20 dB), mild (20-39 dB), moderate (>40-59 dB), severe (≥60 dB), or profound (≥80 dB). Clinically significant SNHL was defined as a PTA of at least 40 dB. Perinatal data evaluated included demographics, characteristics of CDH and neonatal respiratory course, peak total and direct bilirubin levels, exposure to ototoxic drugs, need for supplemental oxygen at discharge, and results of newborn hearing screen. Univariate analysis was conducted to examine the relationship between these variables and (1) any SNHL or (2) significant SNHL. Fifty patients were included. Audiograms were performed at age 2.7 ± 2.3 years (range, 0.5-10.7 years). Of the 50 patients, 28 (56%) had any SNHL and 9 of the 28 (32%) had significant SNHL (PTA ≥ 40 dB). Any SNHL was not significantly different (P = .42) by newborn hearing screen results: 5 of 7 children (71%) who failed the screening were classified as having any SNHL, and 20 of 40 children (50%) who passed were classified as having any SNHL. While no variables were significantly associated with any SNHL, multiple significant associations were found with significant SNHL: extracorporeal membrane oxygenation support (P = .02), nonprimary CDH repair (P = .01), prolonged ventilation (≥14 days) (P = .001), and high neonatal furosemide exposure (P = .03). Sensorineural hearing loss is prevalent among children with CDH. As would be expected, significant SNHL (PTA ≥ 40 dB) in this cohort was associated with markers of more severe CDH with a more complicated neonatal hospital course. Overall close follow-up for hearing and speech development, including routine audiology testing, is indicated in children with CDH.

Impact of elective versus emergent admission on perioperative complications and resource utilization in lumbar fusion

BackgroundThe notion of higher complication rate and mortality in emergency surgeries is well established. There is a paucity of literature demonstrating the impact of emergent versus elective admissions for spinal surgery on the perioperative outcomes. We aim to evaluate the influence of the type of admission (elective or emergent) and day of surgery (same day versus other days within the emergent group) on the incidence, pattern of perioperative complications and hospital charges in the patients undergoing lumbar fusion for degenerative spine disease. MethodsData was obtained from the Nationwide Inpatient Sample (NIS) database between 2002 and 2011. We performed multivariate analysis to evaluate the impact of admission type and day of surgery on perioperative outcomes. ResultsA total of 266439 patients were identified. The majority of the admissions were elective (92.6%). Emergent admission comprised 7.4% of the total admission. Mean Charlson comorbidity index (CCI) was significantly higher in emergent and ‘other days’ (<0.001) groups. Emergent admission and surgery performed on the ‘other days’ were the independent risk factors for the higher incidence of the venous thromboembolic events, surgical site infection and wound dehiscence. The patients in the emergent and ‘other days’ surgery groups had a longer stay in the hospital (P<0.001). The mean total hospital charges were higher in the emergent admission and ‘other days’ surgery groups (P<0.001). Conclusions‘Emergent admission’ and surgery performed on the ‘other days’ in lumbar fusion are independent risk factors for the higher incidence of perioperative complications. Complicated hospital course and longer stay of the patients in the emergent admission and ‘other days’ group seems to be associated with higher total hospital charges.

Fibromuscular Dysplasia Leading to Spontaneous Coronary Artery Dissection with Sudden Cardiac Arrest.

A 30-year-old previously healthy female, who was six-week postpartum, experienced sudden collapse and tonic-clonic seizure. Emergency medicine services arrived at the scene and the patient was found to be in ventricular fibrillation. Advanced cardiovascular life support (ACLS) was initiated with return of spontaneous circulation. Afterwards, her initial EKG showed atrial fibrillation with rapid ventricular rate, ST elevation in leads II, III, and aVF, and ST depression in V2–V4. She was transferred to a tertiary care hospital where emergent angiogram was performed revealing obstruction of blood flow in the proximal and mid right coronary artery (RCA). A hazy and irregularly contoured appearance of the RCA was consistent with diagnosis of fibromuscular dysplasia. Subsequently, intravascular ultrasonogram (IVUS) was performed which confirmed the diagnosis of RCA dissection. Successful revascularization of the RCA was performed using two bare mental stents. After a complicated course in hospital, she was discharged in stable condition and did very well overall.

Timing of Discharge: a Key to Understanding the Reason for Readmission after Colorectal Surgery

PurposeThere is a growing interest in surgery regarding the balance between appropriate hospital length of stay (LOS) and prevention of unnecessary readmissions. This study examines the relationship between postoperative LOS and unplanned readmission after colorectal resection, exploring whether patients discharged earlier have different readmission risk profiles. MethodsPatients undergoing colorectal resection were selected by Common Procedural Terminology (CPT) code from the 2012 ACS National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by LOS quartile. Kaplan-Meier analysis was used to examine characteristics associated with 30-day unplanned readmission. Factors with a p < 0.1 were included in the Cox proportional hazards model. Subsequently, chi-square analysis compared LOS, patient, and perioperative factors with the primary reason for readmission. Factors with a p < 0.2 were included in a multivariable logistic regression for each readmission reason. ResultsFor 33,033 patients undergoing colorectal resection, the overall 30-day unplanned readmission rate was 11 %. After adjusting for patient and perioperative factors, a postoperative LOS ≥8 days was associated with a 55 % increase in the relative hazard of readmission. Patients with a ≤3-day LOS were more likely to be readmitted with ileus/obstruction (odds ratio (OR): 1.8, p = 0.001) and pain (OR: 2.2, p = 0.007). LOS was not significantly associated with readmission for intraabdominal infection or medical complications. ConclusionsPatients with longer LOS and complicated hospital courses continue to be high risk post-discharge, while straightforward early discharges have a different readmission risk profile. More targeted readmission prevention strategies are critical to focusing resource utilization for colorectal surgery patients.

Predictors and clinical implications of atrial fibrillation in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation.

To assess the prevalence at baseline, postprocedural incidence, and clinical impact of atrial fibrillation (AF) on consecutive patients undergoing transcatheter aortic valve implantation (TAVI). AF in patients with aortic stenosis (AS) is an independent risk factor for adverse outcome. Despite the evidence for high AF prevalence and the increased risk in surgical series, there are limited data with regard to AF and its impact on outcome after TAVI. Consecutive patients with symptomatic, severe AS were analyzed and categorized according to prevalence of AF on initial admission (baseline AF) and according to the development of new AF postprocedure (postprocedure AF). A total of 371 patients were included in the analysis; of them, 143 (39%) had AF at baseline. No difference in procedural and hospital outcome was found between groups; however, baseline AF patients did have higher 1-year mortality (28.8 vs. 18%, P = 0.01). Of the patients with no baseline AF, 46 patients (20%) developed new, postprocedural AF during their hospital stay. Inhospital death was twice as frequent in patients with new, postprocedure AF, however, this difference did not reach statistical significance (13 vs. 6.7%, P = 0.22). Procedure hemodynamic instability (OR 9.3; 95% CI 1.5-59), and transapical access (OR 4.96, 95% CI 1.9-13.2) were independent predictors for development of new AF. Baseline and postprocedure AF are common in AS patients undergoing TAVI. However, only postprocedure AF is associated with a prolonged and more complicated hospital course. AF is associated with poor long-term, but not short-term, mortality.

A Rare Case of Malignant Melanoma to the Jejunem, Diagnosed on Small Bowel Enteroscopy

Introduction: A 63-year-old male was transferred to our center from an outside hospital after presenting with complaints of left hand numbness and dizziness, which had been ongoing for a few days. A head CT revealed 2 masses, which led to his transfer in order to evaluate for a likely malignancy and subsequently, a metastatic work-up. The patient denied any nausea, vomiting, diarrhea, constipation, abdominal pain, fevers, melena, and hematochezia. He also denied any prior endoscopic procedures. The patient had a contrast CT of the chest, abdomen, and pelvis, which revealed a 4 x 5-cm right atrial mass (later thought to be a thrombus based on MRI), and a 9 x 7-cm mid small bowel mass with surrounding lymphadenopathy and fat stranding, concerning for a primary small intestinal malignancy. Small bowel enteroscopy was performed and a large circumferential, fungating, ulcerated, and infiltrated mass with no bleeding was found in the proximal jejunum at 50-60 cm from the pylorus. This was biopsied and pathology returned positive for metastatic melanoma. After further evaluation, the patient was also found to have a lesion on the skin of his back, which was also biopsied and returned positive for melanoma in situ. The patient was then started on whole brain radiation and trametinib for palliative therapy. The patient underwent a complicated hospital course, which ultimately resulted in comfort care measures and ultimately, expiration. Small bowel tumors only account for 3-6% of all GI tumors, and only 1.5-4% of GI metastases from cutaneous melanoma are ever diagnosed in a patient’s lifetime. Our case highlights a rare presentation that lent itself to diagnosis via push enteroscopy. While there is some suggestion of the possibility for primary GI melanoma, some authors have suggested that there is no such entity and that they all result from a non-GI primary site, such as a regressed cutaneous source. The gold standard for therapy at this time remains surgical resection of metastatic bowel, but as a means of palliation and not cure. Newer systemic chemotherapies and immunotherapies are being FDA-approved in recent years, which may show promise in the coming future.

Independent risk factors for a complicated hospital course in intensive care unit overdose patients.

The purpose of the present study was to identify risk factors associated with a complicated hospital course in overdose patients admitted to the intensive care unit. A total of 335 overdose patients were retrospectively studied in the surgical and medical intensive care unit of an academic tertiary hospital. Factors possibly associated with a complicated hospital course were evaluated. Complicated hospital course was defined as the occurrence of pneumonia, rhabdomyolysis, decubitus ulcer, nerve palsy, prolonged intubation, prolonged hospitalization, or death. Of the 335 overdose patients, 93 (27.8%) had a complicated hospital course. Complicated hospital course was found to be associated with a high number of ingested pills (median, 135 [interquartile range, 78-240] versus 84 [53-134] tablets, P < 0.0001), low Glasgow Coma Scale score on admission (7 [3-11] versus 13 [8-15], P < 0.0001), and a high serum lactate level on admission (1.8 [1.0-3.0] versus 1.4 [0.9-2.0] mg/dL, P < 0.01) on univariate analysis of these factors in patients with and without a complicated hospital course. The independent risk factors for a complicated hospital course identified on multivariate analysis were a high number of ingested pills (≥100 tablets), low admission Glasgow Coma Scale score (<9), and high serum lactate on admission (≥2.0 mg/dL). The probability of a complicated hospital course for patients with 0, 1, 2, or all 3 independent risk factors were 7%, 22%, 40%, and 81%, respectively. The total number of ingested pills, admission Glasgow Coma Scale score, and serum lactate level on admission are predictive of a complicated hospital course in overdose patients admitted to the intensive care unit.