Uncomplicated Group Research Articles

Clinical and Laboratory Profile of COVID-19 Pneumonia Patients With a Complicated Post-Intensive Care Unit Hospital Course.

BackgroundCharacteristics of intensive care unit (ICU) downgrades who experience a complicated post-ICU ward course (ICU return or floor death) and the incidence of this phenomenon have not been examined in ICU survivors of coronavirus disease 2019 (COVID-19) pneumonia. The aim of the present study was to establish the rate of a complicated post-ICU ward course among survivors of COVID-19 pneumonia and describe the associated patient, ICU management, and serum biomarker characteristics. An additional aim was to compare these parameters between those who experienced a complicated post-ICU course and those who did not.MethodsThis was a retrospective study of patients who were admitted to the ICU with COVID-19 pneumonia and were downgraded to a hospital floor at the end of their initial ICU stay. Patients were divided based on a complicated or uncomplicated post-ICU course. Groups were compared with respect to relevant clinical variables. Serum biomarker levels were compared on day of ICU exit and were trended in the days preceding the downgrade. Ward stay of patients who had a complicated course was examined for notable floor events surrounding their decompensation.ResultsEighteen out of 99 downgraded patients (18%) experienced a complicated post-ICU course, among them there were 14 returns (14%) and four deaths (4%). They had higher Charlson Comorbidity Index, higher Acute Physiology and Chronic Health Evaluation (APACHE) IV score, as well as higher D-dimer and C-reactive protein (CRP) at ICU departure. They were less likely to have received therapeutic anticoagulation and convalescent plasma during their ICU stay. On multivariable analysis, these parameters except D-dimer remained independently associated with a complicated course. Review of biomarker trends preceding ICU exit demonstrated an upward trajectory of D-dimer, CRP, and lactate dehydrogenase (LDH) in the complicated course group not mirrored by the uncomplicated course group. Examination of notable floor events leading up to decompensation revealed that in 50% the ward course was characterized by new cardiac disturbances.ConclusionsOur rate of ward death among ICU downgrades was similar to pre-COVID data, but the rate of ICU return was higher. Complicated post-ICU course patients were exhibiting upward biomarker trends at ICU exit, and their ward stay was punctuated by acute cardiac abnormalities.

Relationship between second-trimester amniotic fluid and plasma levels of angiopoietin-2 and thrombomodulin with adverse pregnancy outcome

Our objective is to investigate maternal midtrimester plasma and amniotic fluid (AF) levels of angiopoietin-2 (Ang-2) and thrombomodulin (TM), which are involved in vascular remodelling and endothelium activation, in placental disorders including foetal growth restriction (FGR) and preeclampsia (PE). This prospective multiparametric pilot study was conducted at the Perinatology Division of Trakya University in a population undergoing genetic amniocentesis. Both AF and plasma aliquots were kept in –80 °C until ELISA assay. The pregnancies were followed up until the end of gestation in terms of obstetric results. Amniotic fluid and plasma aliquots from 127 pregnancies who underwent genetic amniocentesis between 16 and 24 weeks of gestation were analysed. During the final data evaluation, 39 were excluded with various reasons. Twelve subsequently developed FGR and 11 complicated with PE. The control group (n = 65) was consisted of women delivered >37th week with an uncomplicated outcome. The midtrimester maternal Ang-2 levels in both AF and plasma and also TM levels in plasma were found to be significantly increased in pregnancies who subsequently developed FGR or PE (p< .05). The midtrimester Ang-2, which rises in both plasma and AF and the midtrimester TM, which only significantly increase in plasma compartment in PE group, as compensatory mechanism may be the precursors of placental disorders including FGR and PE. Impact Statement What is already known on this subject? It is known that angiopoietin-2 (Ang-2) has important role in placental angiogenesis and vascular remodelling. TM which is a receptor for Ang-2 plays a protective role in pregnancy by preventing the uteroplacental circulation from thrombosis. What do the results of this study add? The present study demonstrates that both midtrimester maternal plasma Ang-2/TM and amniotic fluid (AF) Ang-2 levels were significantly higher in PE and FGR group than uncomplicated group. Midtrimester AF TM levels were not significantly higher in PE group than the control group. What the implications are of these findings for clinical practice and/or further research? In the clinical practice, high levels of midtrimester Ang-2 and TM in plasma may be used for the prediction of FGR and PE. Although amniocentesis is not practical in the clinical use, the levels of these two markers in both AF and plasma compartments may contribute to explain the pathophysiology of FGR and PE.

Impact of High-Risk Features and Timing of Repair for Acute Type B Aortic Dissections

The new Society for Vascular Surgery reporting standards for type B aortic dissection (TBAD) categorize clinical presentations of aortic dissection into uncomplicated, high-risk features (HRFs) and complicated groups. Although it is accepted that complicated dissections require immediate repair, the optimal timing of repair for those with HRFs has yet to be established. We aimed to identify the ideal timing of thoracic endovascular aortic repair (TEVAR) for HRFs and the outcomes associated with specific HRFs. The Vascular Quality Initiative was queried for TEVARs performed for acute and subacute TBAD with HRFs from 2014 to 2020. Rupture, malperfusion, and uncomplicated cases were excluded. HRFs were defined per the Society for Vascular Surgery guidelines as refractory hypertension, pain, and rapid aneurysm expansion or aneurysm size >40 mm. The primary outcomes were in-hospital or 30-day mortality and 1-year survival, with primary exposure variables of the interval (in days) from symptoms to repair and the number of HRFs. The secondary outcomes were spinal cord ischemia, myocardial infarction, stroke, and retrograde type A dissection. Of the 1100 patients who met the inclusion criteria, 811 had one HRF, 249 had two, and 40 had three. No significant differences were found in the primary or secondary outcomes according to the number of HRFs. Of the 1100 patients, 309 had undergone repair at 0 to 2 days, 262 at 3 to 6 days, 270 at 7 to 14 days, and 259 at ≥15 days. TEVAR performed at ≥15 days was independently associated with lower in-hospital and 30-day mortality (odds ratio, 0.38; P = .0388) and improved 1-year survival. Postoperative stroke was associated with earlier repair (0-2 days). No association was found between the timing of repair with myocardial infarction, spinal cord ischemia, retrograde type A dissection, or reintervention (Tables I and II). TEVAR for TBAD with HRFs delayed for ≥15 days from symptom onset was associated with improved survival, supporting the theory that it is best to delay TEVAR to the subacute phase. Additionally, TEVAR delayed ≥3 days was associated with a decrease in stroke. The presence of more than one HRF was not associated with worse outcomes. Because the classification of HRF is relatively new and without guidelines regarding repair, the present results highlight the risks of early intervention for patients with HRFs and suggest that these patients will benefit from at least a short stabilization period before TEVAR.Table IUnivariate analysis of impact of timing and HRFs on outcomes after TEVARVariableResultsP valueHRF1 (n = 811)2 (n = 249)3 (n = 40)NA Spinal cord ischemia42 (5.2)8 (3.2)3 (7.5).32 Myocardial infarction15 (1.9)1 (0.4)1 (2.5).17 Stroke49 (6)11 (4.4)2 (5).61 Retrograde type A dissection14 (1.7)4 (1.6)0 (0).99Interval to repair, days0-2 (n = 309)3-6 (n = 262)7-14 (n = 270)≥15 (n = 259) Spinal cord ischemia22 (7.1)8 (3.1)11 (4.1)12 (4.6).12 Myocardial infarction5 (1.6)4 (1.5)4 (1.5)4 (1.5).99 Stroke34 (11)11 (4.2)11 (4.1)6 (2.3)< .0001 Retrograde type A dissection4 (1.3)5 (1.9)3 (1.1)6 (2.3).69HRF, High-risk feature; TEVAR, thoracic endovascular aortic repair.Data presented as number (%).Boldface P values represent statistical significance. Open table in a new tab Table IIMultivariate analysis of impact of operative timing and HRFs on outcomesVariableRelated reinterventionIn-hospital/30-day mortalityOR95% CIP valueOR95% CIP valueInterval to repair 0-2 DaysRefRef 3-6 Days0.7440.38-1.455.38711.0150.499-2.063.9674 7-14 Days0.740.38-1.442.37690.4650.199-1.083.076 ≥15 Days0.5580.272-1.142.11040.380.152-0.951.0388HRFs 1RefRef 20.9840.54-1.79.9571.7250.9-3.307.1005 30.9310.21-4.121.92451.7890.465-6.876.3972CI, Confidence interval; HRF, high-risk feature; OR, odds ratio; Ref, reference.Boldface P values represent statistical significance. Open table in a new tab

TEVAR for complicated anduncomplicated type B aortic dissection-Systematic review and meta-analysis.

Type B aortic dissection (TBAD), is defined as a dissection involving the aorta distal to left subclavian artery with the ascending aorta and the aortic arch not affected. TBAD is classified due to the time frame and presence of complications. Complicated TBAD (co-TBAD) patients have a greater mortality rate than uncomplicated TBAD (un-TBAD) and thoracic endovascular aortic repair (TEVAR) is considered the gold-standard intervention for these clinical challenges. We undertook a systematic review of the literature regarding TEVAR intervention in co-TBAD and un-TBAD. A comprehensive search was undertaken across four major databases and was evaluated and assessed until June 2020. A total of 16,104 patients were included in the study (7772 patients co-TBAD and 8352 un-TBAD). A significantly higher proportion of comorbidities were seen in co-TBAD patients compared with un-TBAD. Acute dissection was more frequent in the co-TBAD group (73.55% vs. 66.91%), while chronic dissection was more common in un-TBAD patients (33.8% vs. 70.73%). Postprocedure stroke was higher in co-TBAD (5.85% vs. 3.92%; p < .01), while postprocedural renal failure was higher in un-TBAD patients (7.23 vs. 11.38%;p < .01). No difference was observed in in-hospital mortality however the 30 days mortality was higher in the co-TBAD group. One-year survival was higher in the uncomplicated group but this difference was not observed in the 5-year survival. In our analysis we can appreciate that despite significantly higher comorbidities in the co-TBAD cohort, there was no difference in in-hospital mortality between the two groups and the 5-year survival did not have any difference.

Open Ankle Arthrodesis: A Retrospective Analysis Comparing Different Fixation Methods

A wide variation of surgical options, complications, and union rates are reported in the treatment of end-stage ankle arthritis. However, open ankle arthrodesis remains the golden standard for ankle arthritis. The purpose of this study was to evaluate the union rate and complication rate as well as identify potential risk factors for different methods of fixation in patients with end-stage ankle arthritis of different etiology. In total, 42 ankles of 41 patients with ankle osteoarthritis were included for this single-center retrospective study. The mean age was 50 years (range 22-75 years). Twenty patients were treated with screw-fixation, 14 with plate(s) and 8 with intramedullary nail. The results of this study showed an overall union rate of 97.6% (41 of the 42 operated ankles) and an overall complication rate of 21.4% (9 events). The mean follow-up time was 16 months (range 2.5-83.0 months). Complications consisted of 1 nonunion, 4 deep infections, 2 cases of wound dehiscence, 1 delayed union and 1 malalignment of the ankle joint. The plate-fixation group demonstrated significantly higher infections when compared with screw and intramedullary nail fixation (p = .017). There were no other significant variables for incidence of complications between patients in the uncomplicated and complicated group. This study achieved good clinical results for different methods of fixation in open ankle arthrodesis. In specific, the use of intramedullary nail provides excellent results for end-stage ankle arthritis with high union rate and a low complication rate.

Vertical Medial Thigh Lift with the 'Anchor L Liposculpture' Technique in Massive Weight Loss Patients: Preliminary results.

Among all post bariatric surgical procedures, vertical thigh lift has the highest complication rates. Many modifications have been described to achieve better aesthetic results and decrease complication rates. The study aimed to present ''Anchor L Liposculpture Technique'' and discuss the results in the light of current literature. Between 2016 and 2020, 33 patients were operated with the Anchor L Liposculpture technique. In this technique, liposuction is performed similarly with the other techniques, but the liposuction area is not extended to posterior or anterior compartments to prevent complications. The technique also used a deepithelized flap to anchor the superficial fascial system to the pubic arch periosteum. The patients' characteristics (age, sex, body mass index, smoking history, amount of weight loss, comorbidities) volume of liposuction and postoperative complications were recorded. Results were compared between uncomplicated (group A) and complicated patients (group B). Six (n=6, %18.2) out of 33 patients experienced complications (Group B). There were no major complication. The most common complications are wound dehiscence (n = 2) and lymphocele (n = 2). All complication cases managed conservatively. Age and amount of liposuction were found to be statistically associated with increased complications. Other comparisons between group A and B did not show any significant difference. Scar migration was not observed in any patient during follow-up. Anchor L Liposculpture technique is an easy-to-apply and reliable technique aimed better surgical results and lower complication rates. Surgeons especially at beginning of the learning curve or who experienced high complication rates can utilize this technique. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Inflammatory Markers and Duration of Symptoms Have a Close Connection With Diagnosis and Staging of Acute Appendicitis in Children.

Background: For children with acute appendicitis (AA), a clear diagnosis is a challenge. The purpose of this study is to explore whether inflammatory markers in the blood combined with symptom duration are helpful in the diagnosis of acute appendicitis and in predicting the severity of acute appendicitis.Methods: All the selected patients underwent appendectomy between November 10, 2011 and November 15, 2019, in whom preoperative WBCC, CRP, and NE% had been measured in a short time. All patients were divided into two groups: uncomplicated AA and complicated AA, postoperatively.Results: For our standards, 813 patients were selected, 442 of them had complicated AA. The mean [standard deviation (SD)] age for the uncomplicated AA group was 9.78 ± 2.02 years and for the complicated AA group was 9.69 ± 2.16 years (P = 0.55). Elevated WBCC, CRP, and NE% had a higher relatively sensitivity in complicated AA than uncomplicated AA especially when WBCC, CRP, and NE% were at normal levels, which had a sensitivity of 100% in uncomplicated AA, but this only applied to nine patients. CRP values were significantly different in three time groups, whether uncomplicated or complicated AA.Conclusion: The combination of WBCC, CRP, and NE% values is very sensitive for the diagnosis of acute appendicitis, and when we predict complicated AA using the CRP value, we also need to consider the time of symptom onset.

Abstract P170: Cardiovascular-related Pregnancy Complications: Associations With Health Behaviors And Mental Health During The Covid-19 Pandemic

Pregnancies with cardiovascular (CV) complications are more likely to involve additional complications, poorer short and long-term health, and worse fetal outcomes. Additionally, CV complications are associated with poorer mental health, lower socioeconomic status, and non-White race/ethnicity. The COVID-19 pandemic has had negative effects on mental well-being and disproportionately affects people of lower socioeconomic status and non-White race/ethnicity. Thus, we hypothesized that the pandemic would differentially affect pregnant people with and without CV complications. We performed a cross-sectional survey of 465 pregnant people in California from June 6 through July 29, 2020. Twenty-three participants reported CV complications (e.g., hypertensive disorders, gestational diabetes) and 29 participants reported non-CV complications. The CV group was 56.5% (13 of 23) Latinx and 43.5% (10 of 23) White versus the uncomplicated pregnancy group, which was 33.7% (137 of 407) Latinx and 66.3% (270 of 407) White (chi-square, p=0.03; 6 respondents did not answer). The CV complications group was 9.5% (2 of 21) African American and the uncomplicated pregnancy group was 4.9% (19 of 392) African American (Fisher’s Exact, p=0.053; 23 respondents did not answer). We assessed 64 health behaviors reported on a Likert scale with the Wilcoxon 2-Sample Test and found the CV group reported more health-promoting behaviors, including: less likely to eat sweets (p=0.004), more likely to sanitize frequently used areas in their homes and their groceries (p=0.049 and 0.069, respectively). However, they were also more likely to smoke cigarettes (p=0.02). While the two groups did not differ significantly on stress, depression, or anxiety, the CV group was more likely to worry that their babies may be hospitalized after birth (p=0.01) and their provider may be unavailable during delivery (p=0.047). Concerns for self and baby trended towards significance for the CV group, which reported being more likely to worry about getting sick (p=0.077) and their babies being born early (p=0.079) or getting sick (p=0.098). While preliminary, these data suggest that COVID-19 disproportionately affects pregnant people with prenatal CV complications. Given limited research on pregnancy during COVID-19 and the primary focus on biological outcomes, these findings indicate a clear need to address the pandemic’s influence on behavioral and emotional health during pregnancy - especially for those with CV complications who are at higher risk of poor maternal and fetal outcomes.

CT based Acute Appendicitis Severity Index for acute appendicitis and validate its effectiveness in predicting complicated appendicitis.

To propose a CT-based scoring system called Acute Appendicitis Severity Index (AASI) for diagnosis of acute appendicitis and validates its effectiveness in predicting complicated appendicitis. Retrospective analyses of CT images of 120 adult patients with pathologically proven uncomplicated (n = 64) and complicated (n = 56) acute appendicitis were performed. All patients had undergone a CT scan of the abdomen and pelvis using 320 multi-detectors computed tomography with Adaptive Iterative Dose Reduction 3D (AIDR 3D). CT image parameters were identified and used to develop a CT-based scoring system (AASI) to predict the severity of acute appendicitis and its outcome. All image analysis was performed by 2 radiologists and the total score was assigned to each patient based on the proposed CT scoring system. Validation of the effectiveness of the proposed scoring system (AASI) was done using statistical models. The mean and standard deviation of AASI was found to be significantly higher (P value = 0.001) in the complicated appendicitis group (observer 1 = 10.2 ± 1.6 and observer 2 = 9.63 ± 2.3) as compared to that in uncomplicated acute appendicitis group (observer 1 = 7.09 ± 2.2 and observer 2 = 6.38 ± 1.9). There was an excellent interobserver agreement of the Acute Appendicitis Severity Index for both the uncomplicated and complicated appendicitis groups (K = 0.89, 95% CI = 0.87-0.92, P = 0.001). The cutoff value for AASI used to predict complicated appendicitis was taken as 9.5 and 8.5. This resulted in an AUC of 0.877 and 0.848, accuracy of 83% and 81%, the sensitivity of 75% and 80%, the specificity of 90% and 81%, the positive predictive value of 87% and 78%, and a negative predictive value of 81% and 83% by both reviewers respectively. The proposed CT-based AASI is a reliable parameter for the prediction of complicated appendicitis.

Unique characteristics of the type B aortic dissection patients with malperfusion in the Vascular Quality Initiative

ObjectiveType B aortic dissection (TBAD) complicated by malperfusion carries high morbidity and mortality. The present study was undertaken to compare the characteristics of malperfusion and uncomplicated cohorts and to evaluate the long-term differences in survival using a granular, national registry. MethodsPatients with TBAD entered into the thoracic endovascular aortic repair/complex endovascular aortic repair module of the Vascular Quality Initiative from 2010 to 2019 were included. The demographic, radiographic, operative, postoperative, in-hospital, and long-term reintervention data were compared between the malperfusion and uncomplicated TBAD groups using t tests and χ2 analysis, as appropriate. Overall survival was compared using Cox regression to generate survival curves. ResultsOf the 2820 included patients, 2267 had uncomplicated TBAD and 553 had malperfusion. The patients with malperfusion were younger (age, 55.8 vs 61.2 years; P < .001), were more often male (79.7% vs 68.1%; P < .001), had a higher preoperative creatinine (1.8 vs 1.1 mg/dL; P < .001), had more often presented with an American Society of Anesthesiologists class of 4 or 5 (81.9% vs 58.4%; P < .001), and had more often presented with urgent status (77.4% vs 32.8%; P < .001). In contrast, the uncomplicated TBAD group had had more medical comorbidities, including coronary artery disease and chronic obstructive pulmonary disease, and a larger aortic diameter (4.0 cm vs 4.9 cm; P < .001). The malperfusion group more frequently had proximal zones of disease in zones 0 to 2 (38.6% vs 31.5%; P = .002) and distal zones of disease in zones 9 and above (78.7% vs 46.2%; P < .001), with a greater number of aortic zones traversed (7.7 vs 5.1; P < .001) and a greater frequency of dissection extension into branch vessels (61.8% vs 23.1%; P < .001). Patients with malperfusion also exhibited greater case complexity, with a greater need for branch vessel stenting and longer procedure times. The overall incidence of postoperative complications was greater in the malperfusion group (39.4% vs 17.1%; P < .001) and included a greater rate of spinal cord ischemia (6.3% vs 2.2%; P < .001), acute kidney injury (10.4% vs 0.9%; P < .001), and in-hospital mortality (11.6% vs 5.6%; P < .001). In-hospital reintervention was also greater for the malperfusion patients (14.5% vs 7.4%; P < .001), although the incidence of long-term reinterventions was similar between the two groups (8.7% vs 9.7%; P = .548). A proximal zone of disease in zone 0 to 2 was associated with decreased survival. In contrast, a distal zone of disease in 9 and above, in-hospital reintervention, and long-term follow-up were associated with increased survival. Despite these differences, long-term survival did not differ between the malperfusion and uncomplicated groups (P = .320.) ConclusionsPatients presenting with TBAD and malperfusion represent a unique cohort. Despite the greater need for branch vessel stenting and in-hospital reintervention, they had similar long-term reintervention rates and survival compared with those with uncomplicated TBAD. These data lend insight with regard to the observed differences between uncomplicated and malperfusion TBAD.

Clinical characteristics of health care workers infected with COVID-19 at the Single-Center Hospital in Turkey

Objectives: COVID-19 is a highly infectious disease characterized by different symptoms and varying severity from person to person. This study aims to identify the clinical characteristics of healthcare workers (HCWs) who have been infected with coronavirus and investigate which factors affect the disease’s severity. Materials and methods: In the presented study, 79 healthcare workers (HCWs) were recruited who had been infected with SARS-CoV-2, and working in a training and research hospital. Their data was examined in two groups as uncomplicated (without a computed tomography sign of pneumonia and respiratory rate &lt; 24 per minute, SpO2 &gt; 93% at room air) and pneumonia group in terms of the severity of the disease. The statistical analysis was performed by SPSS v.22.0 with a statistical significance of 0.05. Results: A total of 79 HCWs with a mean age of 33.37 ± 8.44 years were enrolled in the study. They consisted of 47 female and 32 male participants. There were 50 patients in uncomplicated and 29 patients in the pneumonia group. A total of 14 HCWs have been hospitalized with an average stay of 5.43 ± 1,5 days. The number of hospitalization between the groups was higher in the pneumonia group (n: 11) than in the uncomplicated group (n: 3) (38% vs. 6%; p &lt; 0.001). HCWs who work in areas in close contact with the patient (high-risk units) were more prone to be in the pneumonia group than those working in the other areas of the hospital [22/45 (48%) vs. 7/27 (25%); p = 0.019]. There wasn’t any significant difference between the groups in terms of age, gender, occupation, and the presence of chronic illness of workers (p &gt; 0.05). Sore throat and cough were the most common onset symptoms of the disease (34.2% and 31.6%, respectively). There was no difference between the groups in terms of biochemical parameters. (p &gt; 0.05). Conclusion: Healthcare workers are in the risk group for COVID-19 disease. HCWs working in high-risk units are more vulnerable.

PREOPERATIVE NEUTROPHIL TO LYMPHOCYTE RATIO AS A PREDICTOR OF THE SEVERITY OF ACUTE APPENDICITIS

Background: Neutrophil to lymphocyte ratio (NLR) is one of the tools to differentiate compli­cated and uncomplicated acute appendicitis (AA) preoperatively. However there is a consid­erable difference in the cutoff values of NLR in different studies. This study aimed to establish a cutoff value of NLR to distinguish complicated AA from uncomplicated AA preoperatively at our center. Methods: This was a prospective observational study conducted over 2 years from January 2017 to December 2019 in the department of surgery, Chitwan Medical College Bharatpur. Patients with a provisional diagnosis of AA and undergoing appendectomy were included in the study. The difference in NLR between the two groups was compared by Mann-Whitney U-test. The predictive ability of NLR was estimated by the receiver operating characteristic (ROC) curve analysis. Results: One hundred eighty-eight patients were included in the study, 112 patients were males and 76 were females. Among them, 29.2% (n=55) were complicated AA. Median NLR was signifi­cantly higher in the complicated AA group compared to the uncomplicated group (6.90 vs 4.27, P &lt;0.001). On ROC analysis, the predictive ability of NLR for complicated AA was acceptable (AUC: 0.705, p &lt;0.001). The optimal cut-off value of NLR to predict complicated acute appendicitis was 4.77, with sensitivity and specificity 74.5% and 65.4% respectively. Conclusions: NLR ≥ 4.77 can be a useful adjunct in predicting complicated AA preoperatively. But because of poor sensitivity and specificity, a lower value does not exclude complicated AA. and therefore other biochemical and radiological parameters have to be taken into consideration.

Chronic pain in parturients with an accidental dural puncture: A case-controlled prospective observational study.

We set out to examine incidence of chronic headache and back pain in women with PDPH after accidental dural puncture during labor. Chronic headache, backache, and disability were assessed 18-24months postpartum. Women with PDPH treated with epidural blood patch (PDPH-EBP) were identified and matched with women who had a PDPH without epidural blood patch (PDPH-no EBP), with women with uncomplicated epidural analgesia and with women without epidural analgesia. Our primary outcome was incidence of chronic headache and backache. Secondary outcome was the effect of epidural blood patch on chronic pain development. We used Chi-square or Fisher's exact test to calculate odds ratios. There was no statistically significant difference in demographic characteristics between groups. In the no epidural group, no women reported chronic headache and 2/116 (1.7%) reported chronic backache. In the uncomplicated epidural group, no women reported chronic headache and 7/116 (6.0%) reported chronic backache. In the PDPH-no EBP group, 9/56 (16.1%) women reported chronic headache and 10/56 (17.9%) reported chronic backache. In the PDPH-EBP group, 12/59 (20.3%) had chronic headache and 14/59 (23.7%) had chronic backache. No women in the no epidural or uncomplicated epidural group reported disability (chronic pain score of 3 or 4). High disability was reported by 8.9% of women in the PDPH-no EBP group and by 8.4% in the PDPH-EBP group. Women with PDPH had a high incidence of chronic headache, back pain, and disability. We did not find a statistically significant difference in chronic pain development between conservatively treated and EBP-treated patients.

Time to Unplanned Return to the Operating Room and Associated Risk Factors in Patients With Surgical Retinal Detachment Repair

To assess the incidence of unplanned return to the operating room (ROR) at ≤45 days or ≥46 days after primary retinal detachment (RD) surgery and correlate ROR with preoperative risk factors and visual outcomes. Retrospective cohort study. This was a retrospective review of patients with primary RD surgery to assess for unplanned ROR between January 1, 2012 and June 30, 2014, with follow-up of 90 days to 8 years (mean, 1.5 years). We assessed 268 patients receiving 270 primary rhegmatogenous RD surgeries between January 1, 2012 and June 30, 2014 in an academic tertiary referral center. Of the 270 RD surgeries, 82 were complicated (history of proliferative vitreoretinopathy or trauma-related RDs at presentation) and 188 were uncomplicated (RD unrelated to trauma or proliferative vitreoretinopathy at presentation). The ROR rate for all surgeries was 12.2% (33/270) over the follow-up period, with 51.5% (17/33) having reoperations within 45 days. The complicated detachment group had a ROR rate of 14.6% (12/82) over the follow-up period, and 50% of those (6/12) had reoperations within 45 days. The uncomplicated detachment group had a ROR rate of 11.2% (21/188) over the follow-up period. Of those, 52.4% (11/21) had reoperations within 45 days. Given that only 51.5% of all RORs occurred within 45 days, a 45-day ROR surgical quality metric that has been previously used may be of limited value for RD surgery. Factors such as age at presentation, number of retinal breaks, number of detached clock hours, use of silicone oil tamponade for pars plana vitrectomy, history of choroidal detachment, high myopia, ocular trauma, and open globe were associated with increasing risk of ROR. Implementing risk-adjusted metrics may provide a more accurate and useful quality improvement metric for evaluating quality of surgical care in vitreoretinal surgery. Am J Ophthalmol 2021;221:•••-•••. © 2021 Elsevier Inc. All rights reserved.

Risk factors of orbital complications in outpatients presenting with severe rhinosinusitis: A case-control study.

We assessed associations of potential factors with orbital complications in acute rhinosinusitis (ARS) patients. An unmatched case-control study. A tertiary referral hospital in Thailand. Consecutive outpatients of any age with severe ARS (visual analog scale≥7) with and without orbital complications. Patients were enrolled from January 2013 to December 2018. Forty-three ARS patients (55.8% female, median age 45.6, (range 2.0-93.0) years) were included, with 19 patients in the complicated group and 24 in the uncomplicated group. Patient characteristics (gender, age, diabetes, immune status), symptoms and signs, site of infection and type of pathogenic bacteria were recorded and assessed their associations with orbital complications by univariable and multivariable logistic regression analyses. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The most common orbital complication was subperiosteal abscess (42.1%), followed by orbital cellulitis (15.8%) and cavernous sinus thrombosis (10.5%). Multivariable logistic regression analysis demonstrated a positive association with orbital complications (pseudo R2 0.4) for ethmoid sinusitis (OR 31.1, 95% CI [2.3-430.6]) and a short duration of symptoms (OR 0.9, 95% CI [0.8-0.9]). Orbital complications were associated with ethmoid sinusitis with a short duration of ARS symptoms.

Thrombocytosis and Hyponatremia as Predictors of Complicated Acute Appendicitis: Predictors of Appendicitis

BackgroundMultiple serologic markers have been studied to predict complicated acute appendicitis (CAA) (C-reactive protein and procalcitonin); these increase health care costs and are not always available in medical centers in Mexico. There is a need for low-cost serologic markers to predict CAA and guide the preoperative management of patients. Our objective was to analyze the predictive value of hyponatremia and thrombocytosis for complicated acute appendicitis. MethodsWe analyzed 274 patients with AA surgically treated and divided them into two groups: the CAA group and the uncomplicated AA group. We compared the serum values of sodium and platelet blood counts on presentation in the emergency room between the two groups and the proportion of patients with hyponatremia and/or thrombocytosis. Receiver operating characteristic analysis was performed for the two biochemical markers. Sensitivity, specificity, and positive and negative predictive values were calculated for complicated appendicitis in the presence of hyponatremia and thrombocytosis. ResultsWe found 87 patients with CAA and 187 with uncomplicated acute appendicitis. Patients with CAA presented with lower serum sodium values and higher platelet counts than uncomplicated patients. Hyponatremia was found in 54.8% of complicated patients and 29.2% in the uncomplicated group. Thrombocytosis was present in 11.6% of the complicated group and 3.2% in uncomplicated patients. We found a specificity and positive predictive value of 100% for complicated appendicitis in patients with hyponatremia and thrombocytosis. ConclusionsIn patients with abdominal pain and suspected acute appendicitis, the presence of hyponatremia and thrombocytosis is a strong predictive tool for the complicated disease. This is the first study to analyze the association between thrombocytosis and complicated appendicitis.

ROLE OF HYPERBILIRUBINEMIA, ELEVATED CREACTIVE PROTEIN AND LEUCOCYTE COUNT AS A PREDICTIVE FACTOR FOR APPENDICEAL PERFORATION IN ACUTE APPENDICITIS

Background: Appendiceal perforation in patients with acute appendicitis may cause a variety of potentially life-threatening complications. Escherichia coli endotoxin has been shown to impact physiological bile flow in vivo. This had led to the theory that hyperbilirubinemia and elevated CRP in patients with appendicitis may have a predictive potential for the preoperative diagnosis of appendiceal perforation. Objectives: The aim of this retrospective study was to investigate the diagnostic value of hyperbilirubinemia and elevated CRP as a preoperative laboratory marker for appendiceal perforation in patients with acute appendicitis. Thus a new marker for appendiceal perforation would be welcomed. Thus, the need for the study is to conclude whether the Serum Bilirubin or CRP can be considered as a new laboratory marker to aid in the diagnosis of Appendicular Perforation. Materials and methods: All patients admitted with clinical diagnosis of "Acute Appendicitis" or "Appendicular Perforation" and undergoing surgery in General Surgery Dept in Tertiary Care Teaching Hospital were taken as Subjects for this study. The primary data for this study were the blood investigations of the patients. 200 patients with concerned consent and meeting the inclusion criteria were included in the study. The necessary clinical and lab details were obtained in a prewritten format. The intraoperative findings were noted and documented precisely. Upon completion of data collection the preoperative bilirubin levels of the perforated and uncomplicated groups wereOther clinical and lab parameters obtained during the study were compared between the two groups. All parameters were subjected to statistical analysis and evaluated critically. Results: A total of 200 patients participated in the study. Of the 200 patients studied 132 patients were males and 68 patients were females. The youngest patient was 13 years old and the oldest 64 years. Among all the patients operated with a diagnosis of Acute Appendicitis 92 were found to have a perforated appendix, and 108 were found to have a non-perforated appendix. It was observed that among 92 patients with perforated appendix 86 patients showed a raised CRP levels and 58 patients had a raised Bilirubin levels. However in case of non-perforated cases it was found that among the 108 cases 82 patients had a raised CRP levels and 36 patients showed raised bilirubin levels. Conclusion: Hence Logistic Regression technique revealed that the C- reactive protein and Hyperbilirubinemia can be used to predict the appendicular perforation preoperatively and that their roles are comparable and that there is no definitive advantage of one over the other for the same.

Biomarkers and Their Relation to Cardiac Function Late After Peripartum Cardiomyopathy

BackgroundAngiogenic imbalance involving the placental protein soluble Fms-like tyrosine kinase-1 (sFlt-1) and cleavage of the nursing-hormone prolactin by the enzyme cathepsin D (CD) both play a role in the pathogenesis of peripartum cardiomyopathy (PPCM). We hypothesized that angiogenic imbalance and increased activity of CD have a long-lasting impact in women with PPCM. Methods and ResultsA nationwide Danish cohort of women with PPCM (PPCM group, n = 28), age matched women with previous preeclampsia (n = 28) and uncomplicated pregnancies (n = 28) participated in a follow-up study including biomarker analysis, exercise testing and cardiac magnetic resonance imaging. The median time to follow-up was 91 months (range 27–137 months) for the PPCM group. Levels of sFlt-1, placental growth factor, N-terminal pro-natriuretic brain peptide, and copeptin were all significantly higher in the PPCM group. More women in the PPCM group had detectable CD activity (68%) compared with the preeclampsia group (29%) and uncomplicated pregnancies group (36%) (P = .0002). Levels of angiogenic factors and biomarkers correlated inversely with maximal exercise capacity and cardiac functional parameters assessed with cardiac magnetic resonance imaging. ConclusionsWomen with PPCM had higher biomarker levels and CD activity up to 7 years after diagnosis. Higher biomarker levels correlated inversely with maximal exercise capacity and markers of cardiac dysfunction suggesting that persistent angiogenic imbalance and increased CD activity is associated with residual cardiac dysfunction.

ASSOCIATION OF MATERNAL CHARACTERISTICS WITH COMPLICATIONS OF PREGNANCY: A CROSS-SECTIONAL STUDY AMONG MIDDLE SOCIOECONOMIC PREGNANT WOMEN

Objective: The objective of the study was to determine the association of maternal characteristics with complications of pregnancy among middle socioeconomic women.&#x0D; Methods: The enrolled subjects were divided into two groups as complicated and uncomplicated group based on the occurrence of complications in current pregnancy and their sociodemographic details along with present and past medical and medication history was collected.&#x0D; Results: The mean age of the study subjects was 25.33±4.22 years. Maternal characteristics such as age, parity, body mass index, maternal education, and employment status did not have a statistically significant association with the complications of pregnancy at p&lt;0.05. However, the first antenatal visit at the gestational age &lt;8 weeks had a statistically significant association with the complications of pregnancy at p=0.02.&#x0D; Conclusion: Early initiation of antenatal care along with adequate antenatal visits may reduce the risk of complications of pregnancy.

Acute respiratory distress syndrome and pneumothorax in COVID-19 patients

Background: Spontaneous pneumothorax is known as a fatal complication in patients with COVID-19. However, the exact pathogenesis of the spontaneous pneumothorax occurrence and its cause remains unknown. Accordingly, the present study examined 30 patients with acute COVID-19-induced respiratory failure who were under biphasic positive airway pressure (BIPAP) and medical ventilator machines. Methods: This study is a retrospective study and was performed on patients with COVID-19-induced acute respiratory failure who were admitted to the intensive care unit. The study population included 30 patients (10 patients with pneumothorax complication and 20 other patients without this complication). All study patient demographic data and device parameters (physiological parameters observed by the device) were collected and compared with each other. Results: Overall, 30 patients with COVID-19 and acute respiratory distress syndrome (ARDS) were selected during the 3 months from April to July 2020, with complications of spontaneous pneumothorax and emphysema detected in the collected chest X-ray images of 10 patients. In general, the results showed that p-plateau and p-peak parameters in the group with pneumothorax were significantly higher than the other group. Alternately, it was observed that static compliance for the group with pneumothorax was significantly lower than the uncomplicated group. Further, the mortality rates obtained were equal to 80% for the group with pneumothorax complication and 55% for the other group. Conclusion: Spontaneous pneumothorax in patients with ARDS and COVID-19 is a rare complication with a high mortality rate that occurs even in patients without intubation and patients undergoing BIPAP. Hence, if low static compliance and high pulmonary pressures are observed for patients, physicians should seek the complication diagnosis and treatment following changes in patients' symptoms.