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Abstract
Abstract
Case
Symmetrical peripheral gangrene (SPG) is a relatively rare phenomenon characterized by symmetrical distal ischemic damage that leads to gangrene of 2 or more sites in the absence of large blood vessel obstruction, where vasoconstriction rather than thrombosis is implicated as the underlying pathophysiology. We present 2 cases of symmetrical peripheral gangrene (SPG) associated with the use of vasopressors to elevate blood pressure, resulting in four-limb amputation. Both patients had different backgrounds, and each presented to Accident and Emergency (A&E) with Streptococcal septicemia and subsequently septic shock, warranting ICU admission and the use of vasopressors to optimize blood pressure. Both patients then started to develop symmetrical peripheral gangrene of both the upper and lower limbs leading to staged amputations performed electively. Vasopressors including dopamine and norepinephrine are used frequently in the treatment of septic shock and its effectiveness is firmly established. However, it can result in peripheral gangrene due to the prolonged vasoconstrictive effect on peripheral blood vessels. Therefore, it is crucial that the astute physician consider the possibility of the development of peripheral gangrene and amputation when using vasopressors to treat septic shock.
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Affiliation(s)
| | - B Adjei
- Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - W Ken Vin
- Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - N Fumakia
- Aberdeen Royal Infirmary, Aberdeen, United Kingdom
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2
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Kirkwood KA, Gulack BC, Iribarne A, Bowdish ME, Greco G, Mayer ML, O'Sullivan K, Gelijns AC, Fumakia N, Ghanta RK, Raiten JM, Lala A, Ladowski JS, Blackstone EH, Parides MK, Moskowitz AJ, Horvath KA. A multi-institutional cohort study confirming the risks of Clostridium difficile infection associated with prolonged antibiotic prophylaxis. J Thorac Cardiovasc Surg 2018; 155:670-678.e1. [PMID: 29102205 PMCID: PMC5808431 DOI: 10.1016/j.jtcvs.2017.09.089] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/25/2017] [Accepted: 09/18/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The incidence and severity of Clostridium difficile infection (CDI) have increased rapidly over the past 2 decades, particularly in elderly patients with multiple comorbidities. This study sought to characterize the incidence and risks of these infections in cardiac surgery patients. METHODS A total of 5158 patients at 10 Cardiothoracic Surgical Trials Network sites in the US and Canada participated in a prospective study of major infections after cardiac surgery. Patients were followed for infection, readmission, reoperation, or death up to 65 days after surgery. We compared clinical and demographic characteristics, surgical data, management practices, and outcomes for patients with CDI and without CDI. RESULTS C difficile was the third most common infection observed (0.97%) and was more common in patients with preoperative comorbidities and complex operations. Antibiotic prophylaxis for >2 days, intensive care unit stay >2 days, and postoperative hyperglycemia were associated with increased risk of CDI. The median time to onset was 17 days; 48% of infections occurred after discharge. The additional length of stay due to infection was 12 days. The readmission and mortality rates were 3-fold and 5-fold higher, respectively, in patients with CDI compared with uninfected patients. CONCLUSIONS In this large multicenter prospective study of major infections following cardiac surgery, CDI was encountered in nearly 1% of patients, was frequently diagnosed postdischarge, and was associated with extended length of stay and substantially increased mortality. Patients with comorbidities, longer surgery time, extended antibiotic exposure, and/or hyperglycemic episodes were at increased risk for CDI.
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Affiliation(s)
- Katherine A Kirkwood
- International Center for Health Outcomes and Innovation Research (InCHOIR) and Center for Biostatistics in the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Brian C Gulack
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke Health, Durham, NC
| | | | - Michael E Bowdish
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Giampaolo Greco
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mary Lou Mayer
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Karen O'Sullivan
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Annetine C Gelijns
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Nishit Fumakia
- Division of Cardiovascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Jesse M Raiten
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine, New York, NY
| | | | | | - Michael K Parides
- International Center for Health Outcomes and Innovation Research (InCHOIR) and Center for Biostatistics in the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alan J Moskowitz
- International Center for Health Outcomes and Innovation Research, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith A Horvath
- Clinical Transformation, Association of American Medical Colleges, Washington, DC
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3
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Perrault LP, Kirkwood KA, Chang HL, Mullen JC, Gulack BC, Argenziano M, Gelijns AC, Ghanta RK, Whitson BA, Williams DL, Sledz-Joyce NM, Lima B, Greco G, Fumakia N, Rose EA, Puskas JD, Blackstone EH, Weisel RD, Bowdish ME. A Prospective Multi-Institutional Cohort Study of Mediastinal Infections After Cardiac Operations. Ann Thorac Surg 2017; 105:461-468. [PMID: 29223421 DOI: 10.1016/j.athoracsur.2017.06.078] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 05/23/2017] [Accepted: 06/28/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Mediastinal infections are a potentially devastating complication of cardiac operations. This study analyzed the frequency, risk factors, and perioperative outcomes of mediastinal infections after cardiac operations. METHODS In 2010, 5,158 patients enrolled in a prospective study evaluating infections after cardiac operations and their effect on readmissions and mortality for up to 65 days after the procedure. Clinical and demographic characteristics, operative variables, management practices, and outcomes were compared for patients with and without mediastinal infections, defined as deep sternal wound infection, myocarditis, pericarditis, or mediastinitis. RESULTS There were 43 mediastinal infections in 41 patients (cumulative incidence, 0.79%; 95% confidence interval [CI] 0.60% to 1.06%). Median time to infection was 20.0 days, with 65% of infections occurring after the index hospitalization discharge. Higher body mass index (hazard ratio [HR] 1.06; 95% CI, 1.01 to 1.10), higher creatinine (HR, 1.25; 95% CI, 1.13 to 1.38), peripheral vascular disease (HR, 2.47; 95% CI, 1.21 to 5.05), preoperative corticosteroid use (HR, 3.33; 95% CI, 1.27 to 8.76), and ventricular assist device or transplant surgery (HR, 5.81; 95% CI, 2.36 to 14.33) were associated with increased risk of mediastinal infection. Postoperative hyperglycemia (HR, 3.15; 95% CI, 1.32 to 7.51) was associated with increased risk of infection in nondiabetic patients. Additional length of stay attributable to mediastinal infection was 11.5 days (bootstrap 95% CI, 1.88 to 21.11). Readmission rates and mortality were five times higher in patients with mediastinal infection than in patients without mediastinal infection. CONCLUSIONS Mediastinal infection after a cardiac operation is associated with substantial increases in length of stay, readmissions, and death. Reducing these infections remains a high priority, and improving post-operative glycemic management may reduce their risk in patients without diabetes.
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Affiliation(s)
- Louis P Perrault
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Katherine A Kirkwood
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Helena L Chang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John C Mullen
- Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Brian C Gulack
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke Health, Durham, North Carolina
| | - Michael Argenziano
- Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, New York
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Ravi K Ghanta
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, Ohio State University, Columbus, Ohio
| | - Deborah L Williams
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nancy M Sledz-Joyce
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brian Lima
- Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Giampaolo Greco
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nishit Fumakia
- Division of Cardiovascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eric A Rose
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John D Puskas
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Richard D Weisel
- Division of Cardiovascular Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Michael E Bowdish
- Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
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Abstract
Background “Brain drain” is a colloquial term used to describe the migration of health care workers from low-income and middle-income countries to higher-income countries. The consequences of this migration can be significant for donor countries where physician densities are already low. In addition, a significant number of migrating physicians fall victim to “brain waste” upon arrival in higher-income countries, with their skills either underutilized or not utilized at all. In order to better understand the phenomena of brain drain and brain waste, we conducted an anonymous online survey of international medical graduates (IMGs) from low-income and middle-income countries who were actively pursuing a medical residency position in Ontario, Canada. Methods Approximately 6,000 physicians were contacted by email and asked to fill out an online survey consisting of closed-ended and open-ended questions. The data collected were analyzed using both descriptive statistics and a thematic analysis approach. Results A total of 483 IMGs responded to our survey and 462 were eligible for participation. Many were older physicians who had spent a considerable amount of time and money trying to obtain a medical residency position. The top five reasons for respondents choosing to emigrate from their home country were: socioeconomic or political situations in their home countries; better education for children; concerns about where to raise children; quality of facilities and equipment; and opportunities for professional advancement. These same reasons were the top five reasons given for choosing to immigrate to Canada. Themes that emerged from the qualitative responses pertaining to brain waste included feelings of anger, shame, desperation, and regret. Conclusion Respondents overwhelmingly held the view that there are not enough residency positions available in Ontario and that this information is not clearly communicated to incoming IMGs. Brain waste appears common among IMGs who immigrate to Canada and should be made a priority for Canadian policy-makers.
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Affiliation(s)
- Aisha Lofters
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada ; Department of Family and Community Medicine, St Michael's Hospital, Toronto, ON, Canada ; Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada ; Canadian Institutes of Health Research Strategic Training Fellowship, Transdisciplinary Understanding and Training on Research - Primary Health Care Program, London
| | - Morgan Slater
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Nishit Fumakia
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Naomi Thulien
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
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