Characterization of urgent versus nonurgent early readmissions (<30 days) following primary bariatric surgery: a single-institution experience

BackgroundStudies on early postoperative readmissions after bariatric surgery (BS) have examined readmissions as a single entity, regardless of urgency. Strategies to lower nonurgent readmissions would reduce unnecessary hospital utilization.ObjectivesTo identify predictors of urgent readmissions (UR) versus nonurgent readmissions (NUR) at 30 days post-BS.SettingSingle academic institution.MethodsPatients undergoing primary BS over 2 years (n = 589) were retrospectively reviewed. Baseline demographic, medical, and hospitalization data were compared between readmitted patients, stratified by urgency, and nonreadmitted patients. Multivariate regression models of UR and NUR were created using variables with a P value ≤ .2 on univariate analyses. A P value ≤ .05 was considered statistically significant.ResultsThere were 39 documented instances of 30-day readmissions, of which 44% (n = 17) were NUR; NUR patients were more likely to be female (100% versus 78.2% male; P = .03) and trended toward being younger, experiencing ≥2 perioperative complications, and having a longer index hospital length of stay (LOS). Patients with URs had a higher baseline BMI (52.5 ± 11.4 kg/m² versus 48.7 ± 8.3 kg/m², respectively; P = .04), were more likely to have sleep apnea (77.3% versus 56.1%, respectively; P = .05), had a longer LOS (3 versus 2 d, respectively; P = .007), and were more likely to have ≥2 postoperative complications (46% versus 17.0%, respectively; P = .003) compared with those with an NUR. Independent predictors of NUR included public insurance (odds ratio [OR] = 3.7; 95% confidence interval [CI], 1.17–11.67; P = .03), younger age (OR = 1.05; 95% CI, 1–1.01; P = .04), and female sex, while URs were independently predicted by LOS (OR = 1.3; 95% CI, 1.04–1.5; P = .02).ConclusionsPublic insurance appears to be associated with NURs, while LOS predicts URs after BS. This suggests an important dichotomy within readmissions based on urgency, which has important implications for targeted quality initiatives.     

Gingival Swelling as the Initial Manifestation of Granulomatosis with Polyangiitis

We describe a case of granulomatosis with polyangiitis (GPA; formerly named Wegener granulomatosis) that presented initially as florid areas of gingival swelling. The patient also had upper respiratory symptoms that included sinus congestion and cough of recent onset. Clinical-pathologic correlation aided the interpretation of non-specific biopsy findings and immediate referral to an appropriate medical specialist. Treatment was rendered at an early stage of disease with a good response to date. Review of the literature indicates that gingival swelling, often with the characteristic appearance of “strawberry gingivitis” may represent the initial sign of disease in 2% of patients with GPA. Biopsy of gingival lesions often shows a non-specific histologic appearance that should be interpreted in the context of the clinical appearance and pertinent medical history. The clinical investigations that lead to definitive diagnosis and treatment are presented to facilitate the management of this uncommon but potentially fatal condition.     

Seasonal activity,size, and parity of Culicoides occidentalis (Diptera: Ceratopogonidae) in a coastal southern California salt marsh

Adult female Culicoides occidentalis Wirth and Jones were collected in a coastal salt marsh habitat in southern California over a period of 15 mo using CO2-baited suction traps. Adults were active year-round. Adult females overall were large based on wing length (1.86 mm). Because of coastal influences, daily and seasonal changes in air temperatures were greatly buffered, and mean temperatures ranged from 10 to 15 degrees C in winter to 19-21 degrees C in summer. Wing lengths varied inversely with air temperatures, with an average of 2.13 mm (February) to 1.6 mm (July). Parity was consistently low (3.6% overall) and may reflect poor host availability in this isolated salt marsh habitat.     

Distinct deoxyribonucleic acid polymerase activities associated with Dane particles and naked Dane cores.

Two distinct deoxyribonucleic acid polymerase activities were found associated with liver fractions containing Dane particles and Dane cores.     

Ferromagnetism and MR imaging: safety of carotid vascular clamps

Metallic extracranial carotid vascular clamps of the Selverstone, Crutchfield, Poppen-Blaylock, Salibi, Kindt, and tantalum varieties have been placed for treatment of large, giant, or inoperable intracranial aneurysms. To ascertain what adverse effect, if any, MR imaging would have on these clamps, magnetic deflection at 1.5 T was measured for various carotid clamps. Marked magnetic deflection (and torque) was displayed by stainless steel Poppen-Blaylock clamps. Relatively mild magnetic deflection was displayed by the stainless steel Selverstone, Salibi, Crutchfield, and Kindt clamps. Three patients with previously placed carotid clamps (two Selverstone, one Salibi) and one patient with a nonferromagnetic tantalum carotid clip had cranial or cervical MR studies at field strengths ranging from 0.35 to 0.60 T. No patient experienced any discomfort or neurologic sequelae as a result of MR imaging. Although the ferromagnetic clamps created severe "black-hole" artifacts and image distortion within the cervical and facial regions, no significant image degradation was apparent during spin-echo imaging of the brain. The tantalum clip created a far smaller MR artifact than did ferromagnetic clamps and allowed effective spin-echo and gradient-echo imaging in the cervical region. Our findings indicate that most patients with carotid vascular clamps (and nonferromagnetic clips) can probably be imaged safely with MR.     

Salt and Mesophase Formation in Aqueous Suspensions of Lauric Acid

The solubility and solution behavior of lauric acid (LA) and its 1:1 acid soap (potassium hydrogen dilaurate) were investigated at 32°C over a pH range of 2.5–8.5 and at varying KC1 concentrations to examine the self-association of this long-chain carboxylic acid under these conditions. LA's solubility in water exhibited the classical pH dependence of a monocarboxylic acid with no evidence of self-association. In 0.1 M KC1 between pH 6.3 and pH 7.3, filtered samples were turbid, suggesting the presence of high molecular weight aggregates (mesophase), which could be removed by ultrafiltration. The apparent LA solubility vs pH profile in ultrafiltered samples was consistent with a solid phase consisting of either the free acid (pH < 6.5) or potassium hydrogen dilaurate (pH > 6.5), again with no evidence of self-association to form low molecular weight species (dimers, etc.). Quasi-elastic light scattering (QLS) studies and mannitol trapping experiments indicated that vesicles were present in samples containing mesophase. The mesophase composition was characterized and a mass-action law for mesophase formation was developed to describe the apparent LA solubility versus pH in the mesophase region in terms of three parameters. The index of cooperativity, , indicated that the mesophase consists of approximately 25 molecules of LA with an acid:anion ratio, , of 1.7. The standard free energy of mesophase formation per mole of monomer was determined to be –6.3 kcal/mol. The aggregate size determined thermodynamically is several orders of magnitude less than that of the mesophase particle size determined by QLS measurements, suggesting that the LA monomer concentration in equilibrium with mesophase may be governed by a small unit domain of the vesicle. These observations may have a bearing on the thermodynamics of self-assembly of lipid bilayer membranes.     

Solubilization and Stabilization of an Anti-HIV Thiocarbamate,NSC 629243, for Parenteral Delivery,Using Extemporaneous Emulsions

The O-alkyl-N-aryl thiocarbamate, I, (2-chloro-5-[[(l-methyl-ethoxy)thioxomethyl]amino]benzoic acid, 1-methylethylester, NSC 629243, also known as Uniroyal Jr.) is an experimental anti-HIV drug with very low water solubility (1.5 µg/mL). Early clinical studies required an injectable solution at 15 mg/mL, representing a solubility increase of 10⁴-fold. Adequate solubilization of this hydrophobic drug was achieved in 20% lipid emulsions. Extemporaneous emulsions were prepared by adding a concentrated drug solution to a commercially available parenteral emulsion. Various methods of preparation to minimize drug precipitation during its addition and enhance redissolution of precipitated drug were evaluated. The stability and mechanism(s) of decomposition of NSC 629243 in both 20% lipid emulsions and in natural oil vehicles were examined. In lipid emulsions, the shelf life at 25°C varied from 1 to >10 weeks, depending on the extent to which air was excluded from the preparation. The shelf life of 50 mg/mL solutions in natural oils at 25°C varied from <1 to >100 days depending on the oil and its supplier. A qualitative correlation was found between the initial rate of oxidation and the peroxide concentration in the oil. The primary degradation product in both systems was shown to be a disulfide dimer, II, formed via oxidation. Oxidation was inhibited by vacuum-sealing of emulsion formulations or incorporation of an oil-soluble thiol, thioglycolic acid (TGA), into oil formulations. TGA may inhibit oxidation by consuming free radicals or peroxide initiators or by reacting with the disulfide, II, to regenerate the starting drug.     

Physical attractiveness of boys with gender identity disorder

University students blind to group status rated boys with gender identity disorder and clinical control boys regarding their physical attractiveness. Ratings were made of the face and upper torso from photographs taken at the time of clinical assessment ( age, 8.1 years). On all five adjectives (attractive, beautiful, cute, handsome, and pretty), boys with gender identity disorder were judged to be more attractive than were the clinical control boys. Attractiveness correlated with extent of behavioral femininity in the clinical control group, but not in the group of boys with gender identity disorder. The extent to which the group differences in attractiveness were due to objective, structural differences in facial attractiveness vs. socially created, or subjective, processes is discussed.A version of this article was presented at the meeting of the International Academy of Sex Research, Sigtuna, Sweden, August 1990.