Predictors of 30-day readmission after outpatient thyroidectomy: An analysis of the 2011 NSQIP data set

Purpose

With enhancements in patient safety and improvements in anesthesia administration, outpatient thyroidectomy is now frequently undertaken as an outpatient procedure, with several peer-reviewed reports of safe implementation totaling over 4500 procedures since 2006. However, robust statistical analyses of predictors for readmission are lacking.

Methods

The 2011 NSQIP data set was queried to identify all patients undergoing thyroidectomy on an outpatient basis. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify the predictors of these events.

Results

In total 5121 patients were identified to have undergone an outpatient thyroidectomy in 2011. Overall 30-day morbidity was rare with only 47 patients (0.92%) experiencing any perioperative morbidity. One hundred eleven (2.17%) patients were readmitted within 30 days of the operation. A history of COPD was the only preoperative comorbid medical condition that significantly increased a patient's risk for readmission (OR 3.73 95% CI 1.57–8.85, p = 0.003). Patients with a surgical complication were more than 7 times as likely to be readmitted (OR 2.08–25.28, p = 0.002), and those with a medical complication were over 19 times as likely to be readmitted (OR 7.32–50.78, p < 0.001).

Conclusions

Readmission after outpatient thyroidectomy is infrequent, and compares well with other outpatient procedures. The main identified risks include preoperative COPD and any of the generic postoperative complications tracked in NSQIP. As procedures continue to transition into outpatient settings and financial penalties associated with readmission become a reality, these findings will serve to optimize outpatient surgery utilization.     

The extent of the perihemorrhagic perfusion zone correlates with hematoma volume in patients with lobar intracerebral hemorrhage

Introduction

Existing data on perfusion imaging assumes the perihemorrhagic zone (PHZ) in patients with intracerebral hemorrhage (ICH) to be size steady. This study investigates the size of the perihemorrhagic zone (PHZ) in patients with lobar ICH in relation to hematoma volume during the course of treatment using perfusion CT (PCT).

Methods

The present analysis is based on a previously reported cohort of 20 patients undergoing surgical evacuation for lobar SICH, with pre- and early postoperative PCT scanning. Time to peak of the residue function (T _max) was measured based on the 360° cortical banding method and singular value decomposition. The size of PHZ was determined before and after treatment and correlated with hematoma volume.

Results

Preoperative mean hematoma volume constituted 63.0 ml (interquartile ranges (IQR) 39.7–99.4 ml), which correlated significantly (r?=?0.563, p?=?0.010) with mean PHZ size (5.67 cm, IQR 5.44–8.17 cm). Following a surgical hematoma evacuation, mean hematoma volume was reduced to 2.5 ml IQR 0.0–9.5 ml, which also resulted in a significant reduction of PHZ size to 0.45 cm(IQR 0.0–1.36 cm; p?<?0.001). There was no association between postoperative hematoma volume and size of the PHZ.

Conclusion

Our findings illustrate that the extent of the PHZ cannot be generally assumed to be constant in size and that this differs significantly following hematoma reduction in patients with space occupying lobar SICH.     

The role of homeostatic regulation between tumor suppressor DAB2IP and oncogenic Skp2 in prostate cancer growth

Altered DAB2IP gene expression often detected in prostate cancer (PCa) is due to epigenetic silencing. In this study, we unveil a new mechanism leading to the loss of DAB2IP protein; an oncogenic S-phase kinase-associated protein-2 (Skp2) as E3 ubiquitin ligase plays a key regulator in DAB2IP degradation. In order to unveil the role of Skp2 in the turnover of DAB2IP protein, both prostate cell lines and prostate cancer specimens with a variety of molecular and cell biologic techniques were employed. We demonstrated that DAB2IP is regulated by Skp2-mediated proteasome degradation in the prostate cell lines. Further analyses identified the N-terminal DAB2IP containing the ubiquitination site. Immunohistochemical study exhibited an inverse correlation between DAB2IP and Skp2 protein expression in the prostate cancer tissue microarray. In contrast, DAB2IP can suppress Skp2 protein expression is mediated through Akt signaling. The reciprocal regulation between DAB2IP and Skp2 can impact on the growth of PCa cells. This reciprocal regulation between DAB2IP and Skp2 protein represents a unique homeostatic balance between tumor suppressor and oncoprotein in normal prostate epithelia, which is apparently altered in cancer cells. The outcome of this study has identified new potential targets for developing new therapeutic strategy for PCa.     

After you: conversations between patients and healthcare professionals in planning for end of life care

Background

This study explores with patients, carers and health care professionals if, when and how Advance Care Planning conversations about patients’ preferences for place of care (and death) were facilitated and documented.

Methods

The study adopted an exploratory case study design using qualitative interviews, across five services delivering palliative care to cancer and non-cancer patients within an urban and rural English region. The study recruited 18 cases made up of patients (N?=?18; 10 men; 8 women; median age 75); nominated relatives (N?=?11; 7 women; 4 men; median age 65) and healthcare professionals (N?=?15) caring for the patient. Data collection included: 18 initial interviews (nine separate interviews with patients and 9 joint interviews with patients and relatives) and follow up interviews in 6 cases (involving a total of 5 patients and 5 relatives) within one year of the first interview. Five group interviews were conducted with 15 healthcare professionals; 8 of whom also participated in follow up interviews to review their involvement with patients in our study.

Results

Patients demonstrated varying degrees of reticence, evasion or reluctance to initiate any conversations about end of life care preferences. Most assumed that staff would initiate such conversations, while staff were often hesitant to do so. Staff-identified barriers included the perceived risks of taking away hope and issues of timing. Staff were often guided by cues from the patient or by intuition about when to initiate these discussions.

Conclusions

This study provides insights into the complexities surrounding the initiation of Advance Care Planning involving conversations about end of life care preferences with patients who are identified as having palliative care needs, in particular in relation to the risks inherent in the process of having conversations where mortality must be acknowledged. Future research is needed to examine how to develop interventions to help initiate conversations to develop person centred plans to manage the end of life.

     

2q34-qter duplication and 4q34.2-qter deletion in a patient with developmental delay

The 2q3 duplication and 4q3 deletion syndromes are two conditions with variable phenotypes including Pierre-Robin sequence (PRS), limb anomalies, congenital heart defects (CHD), developmental delays and intellectual disabilities. We describe a patient born to a mother with a balanced t(2; 4) translocation who combines both a 2q34-qter duplication and a 4q34.2-qter deletion through inheritance of the derivative chromosome 4 (der(4)). He showed developmental delay, growth retardation, hearing problems, minor facial and non-facial anomalies, such as bilateral fifth finger shortness and clinodactyly, but no PRS or CHD. The comparison of his features with those of 46 and 65 published cases of 2q3 duplication and 4q3 deletion, respectively, allows us to further restrict the size of the proposed critical intervals for PRS and CHD on chromosome 4.     

Comparison of 3,000 and 5,000 IU aXa/day certoparin in the prevention of deep-vein thrombosis after total hip replacement

Background

The aim was to investigate, whether 5,000 IUaXa/day certoparin lowers the incidence of deep vein thrombosis (DVT) in patients undergoing elective hip replacement surgery vs. 3,000 IUaXa/day. Double-blind, multicenter, randomised trial in 500 patients. Primary endpoint: incidence of symptomatic or asymptomatic DVT (bilateral ascending venography).

Results

Mean age was 71?±?10?years with a higher prevalence of previous DVT (8vs.4%) and pulmonary embolism (PE) (4vs.1%) in the high dose group. Mean duration of surgery was 82?±?32 and 85?±?36 min. DVT was detected in 28 (11.1%) of the low dose and 35 (14.1%) of the high dose group (p?=?n.s.). Combined distal-proximal DVT was observed in 5 (2%) and 4 (1.6%) patients respectively. No difference in bleeding events was found.

Conclusion

This trial confirms prior data showing that the conventional dosage of 3,000?IU aXa is effective and safe for the prevention of venous thromboembolic events after hip replacement surgery.     

Cutaneous cytomegalovirus infection in a child with hyper IgE and specific defects in antibody response to protein vaccines

Cytomegalovirus (CMV) infection is a common opportunistic systemic infection in immunocompromised patients, but skin involvement is rare. Herein, we report a 10 year-old girl from consanguineous parents who was referred to our center because of disseminated maculopapular rash. She had history of upper and lower respiratory tract infections. In immunological studies, increased serum IgE level and decreased responses to tetanus and diphtheria were detected. Polymerase chain reaction (PCR) examination of bronchoalveolar lavage and serum sample revealed the presence of CMV. Early diagnosis of cutaneous CMV and appropriate treatment are the key actions in management of patients with underlying immunodeficiencies to avoid further complications.     

Torque teno mini virus infection and multiple sclerosis

Multiple sclerosis (MS) is a disease of young adults which is characterized by autoimmune demyelination of the central nervous system. Interaction of genetics and environmental factors are required to cause MS. Among the proposed environmental factors for MS, viral infections are thought to play a role in the pathogenesis of the disease. Torque teno mini virus (TTMV), which has recently been shown to infect humans, is a member of circoviridae, and has a circular DNA with 2860 nucleotides. Since there are a few data about the pathogenicity of this virus, this study sought to investigate the presence of TTMV in sera from MS patients and healthy individuals. We studied 149 serum samples from MS patients and 150 sera of healthy individuals. Serum DNA was extracted using phenol-chloroform and was subjected to nested polymerase chain reaction. TTMV-DNA was detected in 24 (16%) sera of the healthy blood donors and in 21 (14.1%) samples of the MS patients, where the difference did not reach significance (p > .05). The result of this study could not establish an association between TTMV infection and MS.     

Identification of a novel mutation of MTP gene in a patient with abetalipoproteinemia

Abetalipoproteinemia (ABL), or Bassen-Kornzweig syndrome, is a rare autosomal recessive disorder of lipoprotein metabolism, characterized by fat malabsorption, hypocholesterolemia retinitis pigmentosa, progressive neuropathy and acanthocytosis from early infancy. We describe the clinical and molecular characterization of a 6-month-old infant born of consanguineous, apparently healthy parents from Iran. The patient was hospitalized because of failure to thrive, greasy stool and vomiting. The patient's serum lipid profile, the clinical phenotype and the duodenal histology suggested the clinical diagnosis of ABL. The MTP gene analysis by direct sequencing revealed a novel homozygous mutation (c.1586 A > G-H529R). The parents were heterozygotes for the same mutation and interestingly the father showed a lipid profile characterized by a slight reduction of total and LDL-cholesterol plasma levels.