Undetected Complications Research Articles

Discharge C-reactive protein predicts 90-day readmission after pancreatoduodenectomy: a conditional inference tree analysis

BackgroundThe aim of this study was to assess the predictive value of discharge C-reactive protein (CRP) and white blood cell (WBC) levels for 90-day readmission after pancreatoduodenectomy (PD). MethodsA two-centre, retrospective study was performed between 2008 and 2022. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive value of CRP level and WBC count at discharge. A conditional inference tree (CTREE) was constructed to identify combined risks within subgroups using variables associated with readmission. ResultsOf 438 patients, 54 (12%) were readmitted. The median WBC count at discharge was comparable between the readmitted and not readmitted groups (9.1 vs. 8.5 G/l). The CRP levels at discharge were predictive of 90-day readmission, with an area under the ROC curve (AUC) of 0.63 (95% CI: 0.55−0.63). A CRP concentration below 105 mg/l ruled out 90-day readmission, with a negative predictive value (NPV) of 90% (95% CI: 81%–95%). CTREE confirmed the diagnostic value of CRP at discharge (AUC = 0.68, 95% CI 0.60–0.68). CTREE additionally identified previous wound infection as a second risk factor for readmission in patients with CRP levels less than 101 mg/l (P = 0.003). ConclusionCRP levels below 105 mg/l at discharge allow for a safe discharge with a low 90-day readmission rate. Wound infection, but not WBC count, was a positive predictor of 90-day readmission with moderate accuracy, suggesting the need for predischarge imaging for undetected complications in this patient cohort. Trial registrationOur retrospective analysis did not require registration with a publicly accessible registry.

ISSUES IN CONTINUITY OF CARE AND COMPLICATIONS IN INDWELLING PLEURAL CATHETER PLACEMENT: A QUALITY IMPROVEMENT STUDY IN A THREE-HOSPITAL NY SYSTEM

ISSUES IN CONTINUITY OF CARE AND COMPLICATIONS IN INDWELLING PLEURAL CATHETER PLACEMENT: A QUALITY IMPROVEMENT STUDY IN A THREE-HOSPITAL NY SYSTEM

Native renal biopsy: outcomes with a 4-h observation period in low-risk outpatients.

Current practice guidelines recommend that 'low-risk' outpatients undergoing percutaneous native renal biopsy (PRB) are observed for 6-8 h to identify post-biopsy complications. We performed a retrospective review of 225 PRB procedures in low-risk outpatients who were observed for a 4-h period to determine the safety with regard to complication rate and timing. PRB was performed using a standardised protocol and under ultrasound guidance with a 16- or 18-gauge needle. Bleeding complications occurred in 7% (16/225) of patients, of which 88% (14/16) were detected within a 4-h period. The two undetected complications presented more than 72 h after the procedure. This suggests that a 4-h observation period may be safe and adequate in identifying the majority of patients who will experience significant complications in the first 24 h, with a potential saving of time and resources.

Evaluation of Spontaneous Swallow Frequency in Healthy People and Those With, or at Risk of Developing, Dysphagia: A Review

Dysphagia is a common and frequently undetected complication of many neurological disorders and of sarcopoenia in ageing persons. Spontaneous swallowing frequency (SSF) has been mooted as a possible tool to classify dysphagia risk. We conducted a review of the literature to describe SSF in both the healthy population and in disease-specific populations, in order to consider its utility as a screening tool to identify dysphagia. We searched Medline, Embase, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials databases. Metadata were extracted, collated and analysed to give quantitative insight. Three hundred and twelve articles were retrieved, with 19 meeting inclusion and quality criteria. Heterogeneity between studies was high (I2 = 99%). Mean SSF in healthy younger sub-groups was 0.98/min [CI: 0.67; 1.42]. In the Parkinson’s sub-group, mean SSF was 0.59/min [0.40; 0.87]. Mean SSF in healthy older, higher risk and dysphagic populations were similar (0.21/min [0.09; 0.52], 0.26/min [0.10; 0.72] and 0.30/min [0.16; 0.54], respectively). SSF is a novel, non-invasive clinical variable which warrants further exploration as to its potential to identify persons at risk of dysphagia. Larger, well-conducted studies are needed to develop objective, standardised methods for detecting SSF, and develop normative values in healthy populations.

Home Parenteral Nutrition in Patients with Intestinal Failure: Possible Undetected Complications.

Background: Septic pulmonary embolism (SPE) may be a frequently undetected complication of central venous catheter (CVC)-related bloodstream infections (CRBSIs). Materials and Methods: The incidence of SPE was evaluated in a cohort of non-oncological patients on home parenteral nutrition (HPN) who were hospitalized for a CRBSI from January 2013 to December 2017. The main clinical, microbiological, and radiological features and the therapeutic approach were also described. Results: Twenty-three infections over 51,563 days of HPN therapy were observed, corresponding to an infection rate of 0.45/1000. In 10 out of the 23 cases (43.5%), pulmonary lesions compatible with SPE were identified. Conclusion: Our results demonstrated that a CRBSI can produce asymptomatic SPE with lung infiltrates in 43.5% of the cases, suggesting the need to check for secondary lung infections to choose the most appropriate antimicrobial therapy.

Anticoagulation Management After Transcatheter and Surgical Valve Replacement

Valvular heart disease is associated with high morbidity and mortality, and its prevalence is rising as the population ages. Treatment of severe valvular disease has historically required surgical correction, which carries its own risks, but there have been significant advances in valve replacement technologies and techniques, most notably the development of percutaneous options for repair and replacement. While valve replacements alleviate the hemodynamic burden of valvular disease, the synthetic material comprising part or all of the replacement valve provides nidus for clot, necessitating antithrombotic therapy. Providing the right balance between thromboembolic and bleeding risk is made more challenging by the comorbidities that often co-exist with valve disease in the elderly patient. The backbone of anticoagulation regimens has been comprised of aspirin, warfarin, or both, but newer agents are gaining popularity due to improved convenience and safety profiles. The expanding medical arsenal brings not only more options but also more complexity with the increasing number of possible combinations of anticoagulants and valve types. In general, mechanical heart valves are thought to be the most durable option with the highest thrombotic risk, requiring anticoagulation with warfarin with the addition of aspirin. Bioprosthetic valves placed surgically or percutaneously are less likely to cause thrombus and have been successfully managed with antiplatelet agents alone. However, concerns about previously undetected complications coming to light with new imaging techniques have brought uncertainty about current practice. In order to provide optimal care for our patients, careful review of the current literature, guideline recommendations, and the thrombotic and bleeding risk unique to the individual patient and valve type is necessary.

Projection of prediabetes and diabetes population size in Singapore using a dynamic Markov model

The aim of the present study was to forecast the prevalence and number of adult Singapore residents with prediabetes and diabetes in 2035. A dynamic Markov model with nine mutually exclusive states was developed based on the clinical course of diabetes using time-dependent rates and probabilities. A 1-year cycle over a 25-year time horizon from 2010 to 2035 was used in the model. With publicly available data and a chronic disease register, the model forecast annual disease burden by simulating transition of cohorts across different health states using prevalence rates, incidence rates, mortality rates, disease transition, disease detection, and complication rates. An aging index was used in the model in anticipation of population aging to minimize risks of underestimating disease burden. From 2010 to 2035, the number of Singapore residents with prediabetes and diabetes is projected to more than double, from 434 685 to 903 596 and from 373 104 to 823 802, respectively. The prevalence of prediabetes and diabetes will rise steadily from 15.5% to 24.9% and from 13.3% to 22.7%, respectively. By 2035, a further estimate of 733 174 and 100 250 patients with prediabetes and uncomplicated diabetes, respectively, will remain undiagnosed. The prevalence of detected and undetected complications is forecast to rise from 60.0% in 2010 to 70.2% by 2035. By 2035, the prevalence of prediabetes and diabetes among Singapore residents aged 21+ years is expected to be one in four and one in five, respectively. There is an impetus to adopt more aggressive interventions to contain disease progression.

Acute Mastoiditis in Children: Necessity and Timing of Imaging.

Acute mastoiditis (AM) can be clinically diagnosed, with an option for supplemental imaging: computed tomography (CT) scan and magnetic resonance imaging (MRI). Debate widely exists whether clinical diagnosis alone is sufficient, in view of the risk of missing undetected complications. We sought to study the reasons leading to the performance of an imaging study during AM course. Medical records of children younger than 8 years who were admitted from 2005 to 2014 with AM were retrospectively reviewed. Data included medical history, signs and symptoms, laboratory results, imaging studies, treatment methods and final outcomes. Eighty-six children were diagnosed with 88 AM episodes. Of the AM episodes, 55 (63%) were in boys and 46 (52%) were in children younger than 2 years. All children were treated with parenteral antibiotics, and 82 (95%) underwent myringotomy on admission. Only 20 (23%) children underwent imaging studies, on the 6th median day. Of those, 20 (100%) children underwent CT scans, and 3 (15%) underwent additional MRI studies. The reasons for imaging studies included suspected subperiosteal abscess (9 of 20, 45%), lack of improvement despite adequate medical therapy (7, 35%) and focal neurological signs (4, 20%). Sixteen (16%) children underwent surgery for these pathologies: subperiosteal abscesses (n = 12,), jugular vein thrombosis (n = 2), perisinus empyema (n = 2), epidural abscess (n = 2) and Luc abscess (n = 1). Most children presenting with AM can be diagnosed clinically and do well with intravenous antibiotics and myringotomy. CT and MRI imaging should be reserved for children with suspected AM-related intracranial complications.

How to write a paper for Rapid Communications in Mass Spectrometry

How to write a paper for <i>Rapid Communications in Mass Spectrometry</i>

Letter by Dregelid Regarding Article, “Impact of Femoral Vascular Closure Devices and Antithrombotic Therapy on Access Site Bleeding in Acute Coronary Syndromes: The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) Trial”

HomeCirculation: Cardiovascular InterventionsVol. 3, No. 3Letter by Dregelid Regarding Article, “Impact of Femoral Vascular Closure Devices and Antithrombotic Therapy on Access Site Bleeding in Acute Coronary Syndromes: The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) Trial” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Dregelid Regarding Article, “Impact of Femoral Vascular Closure Devices and Antithrombotic Therapy on Access Site Bleeding in Acute Coronary Syndromes: The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) Trial” Einar Dregelid, MD Einar DregelidEinar Dregelid Search for more papers by this author Originally published1 Jun 2010https://doi.org/10.1161/CIRCINTERVENTIONS.110.954156Circulation: Cardiovascular Interventions. 2010;3:e12To the Editor:The study by Sanborn et al1 is a post hoc analysis in which multiple statistical tests have been made in an exploratory manner to examine the possible differences in access-site bleeding (ASB) with or without a vascular closure device (VCD). If P values <0.05 are used for statistical significance, a high false discovery rate for significant differences is to be expected.Patients with a major ASB were allotted to 7 end-point subgroups, but the sum of the patients in the subgroups is greater than the total number with major ASB. Therefore, many patients have been allotted to several subgroups and included in several analyses.The only end-point subgroup comparison showing a significant difference was the ≥5-cm-diameter hematoma end point, inconsequential concerning the need for intervention or surgical correction. The difference between the VCD and the no-VCD groups concerning requirement for interventional or surgical correction of ASB, with a P value of 0.048, may be because of chance.Patients who did not receive a VCD may have been more prone to develop an ASB because of a higher rate of hypertension and renal insufficiency. They may have received more intense platelet inhibition because of a higher rate of elevated biomarkers, and their higher rate of anemia may have increased the likelihood of intervention because of hemorrhage.VCD complications can result in permanent tissue malfunction or loss and severe infections.2,3 There is no proof to support the belief of the authors that contemporary VCD complication rates are decreasing. A realistic VCD complication rate on the order of 1:275 among the 4307 patients would result in 16 complications, most of them far more serious than the 16 ASBs in their study, requiring interventional, presumably transfusions, or surgical correction.3,4 In addition, late undetected complications may occur.2The use of a VCD has not been demonstrated to improve survival. In contrary, their use has been followed by serious complications. Although bleeding is a predictor of 30-day mortality in invasively managed patients, the implied assumption that VCD use can reduce the mortality is presently unfounded.Some of the authors may have a vested interest in the performance of firms producing VCDs.Einar Dregelid, MD Department of Vascular Surgery Haukeland University Hospital Bergen, NorwayDisclosuresNone.

Treatment of hypocalcemia in critical illness—part 1

Aberration in calcium homeostasis is an important but ften undetected complication in critically ill patients reeiving specialized nutritional support [1]. Severe hypocalemia, if left untreated, can lead to serious neurologic and ardiovascular complications [2,3]. The intent of this report part 1) is to review the pathogenesis, identification, and ncidence of hypocalcemia during critical illness. In addiion, the clinical relevance of hypocalcemia and a discussion f whether to treat or not is discussed. Treatment of acute ypocalcemia is discussed in part 2.

Hypoxemia Explained 36 Years Later

A 37-year-old man who had an atrial septal defect (ASD) corrected as an infant was found to be hypoxemic with a 22% shunt. An MRI scan revealed that the patient's inferior vena cava drained into his left rather than his right atrium, a previously undetected complication of his ASD repair 36 years before.

Postoperative Death and Malpractice Suits: Is Autopsy Useful?

Implications This report demonstrates the extremely high yield of autopsies performed in the case of postoperative death with suspicion of malpractice. They frequently identified undetected complications. They could also suggest faulty or negligent practice that would otherwise go unrecognized. This report supports the widespread use of autopsies to investigate perioperative death.

Postoperative death and malpractice suits: is autopsy useful?

This report demonstrates the extremely high yield of autopsies performed in the case of postoperative death with suspicion of malpractice. They frequently identified undetected complications. They could also suggest faulty or negligent practice that would otherwise go unrecognized. This report supports the widespread use of autopsies to investigate perioperative death.

Upper airway obstruction with hypoxaemia and sleep disruption in Down syndrome.

Six of 12 children with Down syndrome (DS) tested by means of long-term tape-recordings of oxygen saturation, breathing movements and expired CO2 were found to have previously undetected and severe upper airway obstruction during sleep. In five cases the obstruction occurred in the pharynx and in the sixth it was due to bilateral choanal stenosis. When compared with age-matched controls, overnight tape-recordings showed episodes of abnormal arterial hypoxaemia and an abnormally elevated end-tidal CO2. Episodes of obstruction were most marked during sleep associated with a non-regular breathing pattern. Abnormal episodes of hypoxaemia were associated with continued breathing movements. Sometimes there was no airflow (complete obstruction); at other times airflow continued normally or was reduced in amplitude (partial obstruction). During episodes of partial or complete airway obstruction the inspiratory waveform showed a characteristic shape. These results show sleep-related upper airway obstruction to be an often undetected complication of DS and all necessary measures should be taken to overcome the obstruction when it reaches the stage of producing abnormal hypoxaemia. Choanal dilatation and tracheostomy were successful in treating two of the children. Tonsillectomy and adenoidectomy were successful for one child, but only of marginal benefit for two others.