Perforated peptic ulcer disease in transferred patients is associated with significant increase in length of stay

BACKGROUND

Perforated peptic ulcer disease (PPUD) has a prevalence of 0.004-0.014% with mortality of 23.5% (Tarasconi et al. in World J Emerg Surg 15(PG-3):3, 2020). In this single center study, we examined the impact associated with patient transfer from outside facilities to our center for definitive surgical intervention (exploratory laparotomy).

METHODS

Using EPIC report workbench, we identified 27 patients between 2018 and 2021 undergoing exploratory laparotomy with a concurrent diagnosis of peptic ulcer disease, nine of which were transferred to our institution for care. We queried this population for markers of disease severity including mortality, length of stay, intensive care unit (ICU) length of stay, and readmission rates. Manual chart reviews were performed to examine these outcomes in more detail and identify patients who had been transferred to our facility for surgery from an outside hospital.

RESULTS

A total of 27 patients were identified undergoing exploratory laparotomy for definitive treatment of PPUD. The majority of patients queried underwent level A operations, the most urgent level of activation. In our institution, a Level A operation needs to go to the operating room within one hour of arrival to the hospital. Average mortality for this patient population was 14.8%. The readmission rate was 40.1%, and average length of ICU stay post-operatively was 16 days, with 83% of non-transfer patients requiring ICU admission and 100% of transfer patients requiring ICU admission, although this was not found to be statistically significant. Average length of hospital stay was 27 days overall. For non-transfer patients and transfer patients, LOS was 20 days and 41 days, respectively, which was statistically significant by one-sided t-test (p = 0.05).

CONCLUSION

Patients transferred for definitive care of PPUD in a population otherwise notable for high mortality and high readmission rates: their average length of stay compared to non-transfer patients was over twice the length, which was statistically significant. Transferred patients also had higher rates of ICU care requirement although this was not statistically significant. Further inquiry to identify modifiable variables to facilitate the care of transferred patients is warranted, especially in the context of improving quality metrics known to enhance patient outcomes, satisfaction, and value.

Consenting patients for elective procedures during the pandemic: Are we consenting for risk of nosocomial COVID-19 infection

Introduction: Nosocomial COVID-19 increases morbidity and mortality in patients undergoing surgical procedures. This study assesses the consenting process in patients admitted for surgical procedures with regard to risks of contracting nosocomial COVID-19 infection during the three lockdown periods in the United Kingdom.Methods: Retrospective review of consecutive surgical patients admitted to our tertiary referral centre for surgical procedures during the lockdown periods in the United Kingdom. Data from our hospital's electronic theatre database cross-referenced with the online surgical operative, admission and discharge records were reviewed by three independent reviewers.Discussion: A total of 180 patients (104 males and 76 females) were studied. No patients tested positive perioperatively for COVID-19. The first lockdown had a significantly larger proportion of consultants consenting (P < 0.001). Surgeons consented patients for risk of COVID-19 infection in 34.4% of cases, COVID-19-related illness in 33.9%, inpatient Intensive Care Unit (ITU) admission secondary to COVID-19 infection and risk of death due to COVID-19 in 0.0% and risk of death secondary to inpatient COVID infection in 1.1%.Conclusion: As surgical activity continues and COVID-19 persists, surgeons should be vigilant and ensure proper documentation for consent regarding COVID-19-related complications in line with the Royal College of Surgeons of England guidelines.

Depression and Antidepressant Use in Relation to Breast Cancer Risk in the Nurses Health Study

Depression and antidepressant (AD) use have each been hypothesized to increase breast cancer risk, yet previous studies have not considered these exposures together. Thus, it is unclear whether increased risk due to depression may actually be attributable to AD use, or vice versa. Methods: We utilized data from 77,482 women enrolled in the prospective Nurses' Health Study cohort in which data on depression and AD use were collected simultaneously beginning in 2000. Women self-reported whether they had ever been diagnosed with depression by a clinician as well as their use of specific types of ADs. Self-reported breast cancer cases through 2012 were adjudicated and only confirmed invasive cases included as outcomes (N = 2,567). Logistic regression models were utilized to evaluate the effects of baseline depression and AD use, both independently and with mutual adjustment, on breast cancer risk. Results: The average age of participants was 66.2 (SD 7.1) years; 8.9% were clinically depressed and 8.7% used ADs. In separate models adjusted for age, body mass index, and menopausal status, we observed no statistically significant associations between depression (OR 0.94, 95% CI, 0.81–1.08) or AD use (OR 1.07, 95% CI, 0.93–1.22). When these exposures were included together in the same model, depression remained unassociated with breast cancer risk (OR 0.87, 95% CI, 0.74–1.03) while AD use exhibited a small, borderline significant increase in risk (OR 1.15, 95% CI, 0.98–1.35). The latter association remained consistent for selective serotonin reuptake inhibitors (SSRIs; OR 1.16, 95% CI, 0.96–1.39) but was not apparent for other classes of ADs (OR 1.07, 95% CI, 0.85–1.35). Conclusions: These initial results indicate that depression is not associated with breast cancer risk, while we could not exclude a slight increase in risk associated with SSRI use. Further analyses will update exposure information over follow-up and also evaluate whether associations differ by menopausal status or hormone receptor disease subtypes. Clarifying the effects of these exposures on breast cancer risk will provide critical information for the millions of women who are depressed and/or use ADs.

Long-term intake of nuts in relation to cognitive function in older women

OBJECTIVE

Nuts contain nutrients that may benefit brain health; thus, we examined long-term intake of nuts in relation to cognition in older women.

DESIGN

Population-based prospective cohort study.

SETTING

Academic research using data from the Nurses' Health Study.

PARTICIPANTS

Nut intake was assessed in a food-frequency questionnaire beginning in1980, and approximately every four years thereafter. Between 1995-2001, 16,010 women age 70 or older (mean age = 74 years) without a history of stroke were administered 4 repeated telephone-based cognitive interviews over 6 years. Our final sample included 15,467 women who completed an initial cognitive interview and had complete information on nut intake.

MAIN OUTCOME MEASURES

The Telephone Interview for Cognitive Status (TICS), a global score averaging the results of all tests (TICS, immediate and delayed verbal recall, category fluency, and attention), and a verbal memory score averaging the results of tests of verbal recall.

RESULTS

In multivariable-adjusted linear regression models, higher long-term total nut intake was associated with better average cognitive status for all cognitive outcomes. For the global composite score combining all tests, women consuming at least 5 servings of nuts/week had higher scores than non-consumers (mean difference=0.08 standard units, 95% confidence interval 0.00-0.15; p-trend=0.003). This mean difference of 0.08 is equivalent to the mean difference we find between women 2 years apart in age. Long-term intake of nuts was not associated with rates of cognitive decline.

CONCLUSIONS

Higher nut intake may be related to better overall cognition at older ages, and could be an easily-modifiable public health intervention.

Absence of an apolipoprotein E epsilon4 allele is associated with increased parietal regional cerebral blood flow asymmetry in Alzheimer disease

BACKGROUND

The apolipoprotein E (Apo E) epsilon4 allele has been associated with parietal metabolic abnormalities and asymmetries in asymptomatic subjects at risk for Alzheimer disease (AD). However, previous research has shown minimal effect of the epsilon4 allele on regional cerebral blood flow (rCBF) and metabolism in patients with probable AD.

OBJECTIVE

To determine whether the Apo E epsilon4 allele is associated with parietal rCBF abnormalities and asymmetries in patients with probable AD.

PATIENTS AND METHODS

Thirty patients with AD with the epsilon4 allele (epsilon4+ AD), 22 patients with AD without the epsilon4 allele (epsilon4- AD), and 14 healthy control subjects underwent single-photon emission computed tomography (SPECT) scanning with 740 MBq technetium Tc 99m hexamethylpropyleneamine oxime. Ratios of parietal-unaffected regions and a left-right parietal asymmetry index were compared between both patient groups.

RESULTS

The group with epsilon4- AD was younger (P = .005, Student t test) and had an earlier age of onset (P = .005) than the group with epsilon4+ AD. Analysis of covariance revealed no significant difference in the parietal rCBF ratio, controlling for age of onset and Mini-Mental State Examination score (F(1,48) = 0.06; P = .81). However, contrary to hypothesis, significantly greater parietal rCBF asymmetry was seen in patients with epsilon4- AD (mean +/- SD, 9.7% +/- 5.5%) than those with epsilon4+ AD (6.3% +/- 4.7%; F(1,50) = 5.89; P = .02; analysis of variance). When number of epsilon4 allele copies was considered, this effect appeared to accrue primarily from a difference between patients with 0 and with 2 epsilon4 allele copies. An exploratory analysis of multiple cortical structures suggested that this asymmetry extended to additional regions (superior temporal) and to combined association cortex.

CONCLUSIONS

Greater parietal rCBF asymmetry is involved in epsilon4- AD than in epsilon4+ AD. Lack of the epsilon4 allele may be associated with other (as yet undiscovered) genetic or environmental risk factors, which confer greater neuropathological asymmetry.