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Coronavirus disease 2019 (COVID-19) is thought to contribute to diabetic ketoacidosis (DKA) and worse outcomes in patients with diabetes. This study compared the cumulative insulin dose required to achieve DKA resolution in the intensive care unit among patients with type 2 diabetes and COVID-19 infection versus without COVID-19 infection.This retrospective cohort study evaluated 100 patients-50 patients with COVID-19 in cohort 1 and 50 patients without COVID-19 in cohort 2-treated with insulin infusions for DKA at a tertiary care teaching hospital. The primary outcome was to compare the cumulative insulin dose required to achieve DKA resolution in each cohort. The secondary outcomes included time to DKA resolution, mean insulin infusion rate, and mean weight-based cumulative insulin infusion dose required to achieve DKA resolution. All endpoints were adjusted for confounders.The mean cumulative insulin dose was 190.3 units in cohort 1 versus 116.4 units in cohort 2 (P = .0038). Patients receiving steroids had a mean time to DKA resolution of 35.9 hours in cohort 1 versus 15.6 hours in cohort 2 (P = .0014). In cohort 1 versus cohort 2, the mean insulin infusion rate was 7.1 units/hour versus 5.3 units/hour (P = .0025), whereas the mean weight-based cumulative insulin infusion dose was 2.1 units/kg versus 1.5 units/kg (P = .0437), respectively.COVID-19-infected patients required a significantly larger cumulative insulin dose, longer time to DKA resolution, higher insulin infusion rate, and higher weight-based insulin infusion dose to achieve DKA resolution versus non-COVID-19-infected patients with type 2 diabetes.

Background The decisions to routinely place a drain after pancreaticoduodenectomy and how long to leave the drain remain controversial due to conflicting evidence and significant variations in clinical practice. This study aims to address those questions by using a large national database and a rigorous analytical model. Methods The American College of Surgeons National Surgical Quality Improvement Program 2015-2016 Pancreatectomy Participant Use Data Files were used to identify patients who had undergone pancreaticoduodenectomy (n = 7583). Univariable and multivariable binomial regression analyses were performed to control for potential confounders and various preoperative risk factors. Cox regression with drain as a time-dependent covariate, conditional on having a drain placed, was used to examine the association between the drain remaining in place and morbidities. Results Of 7583 patients, drains were placed in 6666 (87.9%). Drain placement decreased the risk of developing serious morbidity (relative risk [RR] 0.73, 95% confidence interval [CI] 0.65-0.82), overall morbidity (RR 0.79, 95% CI 0.72-0.87), and organ space surgical site infection (RR 0.72, 95% CI 0.61-0.85). Drain placement did not change the risk of developing a clinically relevant postoperative pancreatic fistula (RR 0.96, 95% CI 0.78-1.19). However, for those with drains placed, length of drainage was independently associated with serious morbidity (hazard ratio [HR] 3.06, 95% CI 2.65-3.53), overall morbidity (HR 2.48, 95% CI 2.20-2.80), and organ space surgical site infection (HR 1.47, 95% CI 1.23-1.74). Conclusions Routine drain placement following pancreaticoduodenectomy may decrease postoperative complications, including serious morbidity, overall morbidity, and organ space surgical site infections; however, length of drainage was associated with increased risk of the previously-named complications. These results support the routine placement and early removal of intraoperative surgical drains in pancreaticoduodenectomy.

Predictors of operative outcome in patients with severely depressed left ventricular ejection fraction (LVEF) undergoing coronary artery bypass grafting (CABG) remain poorly defined. This study aims to identify preoperative variables that are associated with increased postoperative length of hospital stay or operative mortality in this patient population.Retrospective study.Single tertiary care university hospital.Patients undergoing isolated CABG between January 2012 and March 2017 with an LVEF ≤ 25%.Isolated CABG.Primary endpoint was a composite of prolonged length of stay, defined as postoperative length of stay7 days or operative mortality. Of the 201 patients, 99 (49.3%) met the primary endpoint. Patient comorbidities, clinical presentation, presence of Q-waves on electrocardiogram, and echocardiographic parameters including ventricular dimensions and right heart dysfunction were not associated with the primary endpoint. On multivariable analysis, patients who were not on preoperative beta-blockers, patients with preoperative albumin of3.5 g/dL, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score were associated with increased prolonged length of stay or death.More than half of patients with severely depressed LVEF undergoing isolated CABG are able to be discharged within 7 days postoperatively. The absence of preoperative beta-blockers, low preoperative albumin levels, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score are associated with more complicated or slower postoperative recovery after CABG in this patient population.

To determine the impact of postoperative hypothermia on outcomes in coronary artery bypass graft surgery (CABG) patients.A retrospective study was performed on patients who underwent isolated CABG between 2011 and 2014.Single-center study at a university hospital.All patients who underwent isolated CABG with cardiopulmonary bypass between 2011 and 2014.Patients underwent isolated CABG on cardiopulmonary bypass.Patients were propensity-score matched based on the likelihood of being hypothermic (36ºC) or normothermic (≥36ºC) on arrival to the cardiac surgery intensive care unit (ICU) from the operating room. Total transfusion requirements, composite in-hospital morbidity and/or mortality endpoint, total hours in the ICU, and length of hospital stay were compared between the 2 groups. Of the 1,030 patients undergoing isolated CABG, 529 (51.3%) were hypothermic on arrival to the ICU. The hypothermic cohort were older, had more females, had lower body mass indices, had lower starting hematocrit values, were cooled to lower temperatures while on cardiopulmonary bypass, and had longer cardiopulmonary bypass runs compared with the normothermic group. Of the 748 patients who were propensity matched, there were no differences in blood and blood product transfusion requirements, mortality and complication rates, time on the ventilator, length of ICU stay, and length of hospital stay between hypothermic and normothermic patients.Hypothermia at ICU admission after CABG was not associated with increased adverse outcomes, possibly suggesting that complete rewarming before separation from cardiopulmonary bypass may not be essential in all patients.

Objective The objective of this study was to determine the predictive value of 2 established risk models for surgical mortality in a contemporary cohort of patients undergoing repair of acute type-A aortic dissection. Design Retrospective analysis. Setting Single tertiary care hospital. Participants Seventy-nine consecutive patients undergoing emergent repair of acute type-A aortic dissection between 2008 and 2013. Intervention All patients underwent emergent repair of acute type-A aortic dissection. Measurements and Main Results The receiver operating characteristic curve was compared for each scoring system. Of the 79 patients undergoing emergent repair of acute type-A aortic dissection, 23 (29.1%) were above the age of 70. Seventeen (21.5%) patients presented with hypotension, 25 (31.6%) presented with limb ischemia, and 10 (12.7%) presented with evidence of visceral ischemia. Overall operative mortality was 16.5%. Increasing age was the only preoperative variable associated with increased operative mortality. The areas under the receiver operating characteristic curve for operative mortality was 0.62 and 0.66 for the scoring systems developed by Rampoldi et al and Centofanti et al, respectively. The area under the receiver operating characteristic curve for operative mortality for age was 0.67. The areas under the receiver operating characteristic curve for operative mortality between the 2 scoring systems and for age were not statistically different. Conclusions Existing predictive risk models for acute type-A aortic dissection provide moderate discriminatory power for operative mortality. Age as a single variable may provide equivalent discriminatory power for operative mortality as the established risk models.

Purpose The treatment of patients with medication-related osteonecrosis of the jaw (MRONJ) is challenging. The purpose of the present study was to estimate the frequency and identify the factors associated with clinical improvement during treatment. Patients and Methods We designed and implemented a retrospective cohort study and enrolled a sample of subjects diagnosed with MRONJ between 2004 and 2015. The primary predictor variables were a set of heterogeneous variables grouped into the following categories: demographic (age and gender) and clinical (location of necrosis, therapy duration, medication type, disease stage, and treatment type). The primary outcome variable was the treatment outcome, defined as stable or worse and improved or healed. The descriptive, bivariate, and multiple logistic statistics were computed, and statistical significance was defined as P < .05. Results The sample included 337 subjects with a mean age of 68.9 years. Of the 337 subjects, 256 were women (76%). A total of 143 patients (42.2%) experienced spontaneous necrosis. Twenty-four (7.1%) had had exposure to targeted antiangiogenic agents. Those with stage 1 or 2 disease were more likely to have better outcomes than those with stage 3 disease (stage 1, adjusted odds ratio [OR] 3.4, P = .005; stage 2, adjusted OR 2.2, P = .03). Treatment type was a significant variable. Subjects undergoing surgery were 28 times more likely to have a positive outcome than those receiving nonoperative therapy (adjusted OR 28.7, P < .0001). Conclusions Subjects with MRONJ who presented with less severe disease or who underwent operative treatment were most likely to have improvement or complete healing of their MRONJ-related lesions.

To determine the incremental risk associated with each intraoperative red blood cell transfusion in cardiac surgery patients.Retrospective analysis on prospectively collected data.Single tertiary care hospital.Seven hundred forty-five patients undergoing on-pump cardiac surgery between January 2010 and June 2012 who received between 1 and 3 units of red blood cell transfusion intraoperatively.All patients received between 1 and 3 units of red blood cell transfusions. All transfusions were with leukoreduced blood that had been stored for14 days.Postoperative complications and length of intubation were associated with the number of red blood cell units transfused. Transfusion of each additional unit of red blood cells was associated with incrementally worse outcomes. Median length of intubation was 11 hours, 12 hours, and 13 hours in patients receiving 1, 2, and 3 units of red blood cell transfusions, respectively (p0.005). Similarly, each additional unit of red blood cell transfusion was associated with increasing postoperative septicemia (0% v 0.35% v 2.29%, p0.006) and postoperative pneumonia (0% v 0.70% v 2.29%, p0.013).There is a step-wise increase in length of postoperative intubation with each red blood cell transfusion in patients undergoing cardiac surgery. Each additional unit of intraoperative RBC transfusion also may increase postoperative infectious complications. Thus, even single-unit reductions in red blood cell transfusions may have significant impact on outcomes.

Introduction Acute kidney injury may be the presenting manifestation of multiple myeloma, although optimal use of immunofixation testing in this setting is incompletely defined. The authors attempted to determine clinical and laboratory predictors of positive immunofixation testing in patients with acute kidney injury. Patients and Methods The authors did a retrospective study of hospitalized patients with acute kidney injury who had immunofixation studies done. Various clinical and laboratory variables that may be predictive of the presence of multiple myeloma were evaluated and correlations with immunofixation test results determined. Results One hundred twenty-eight patients were studied. Thirteen had a monoclonal paraprotein detected by immunofixation testing (positive result). Patients with positive testing had higher total, ionized and corrected calcium levels, although the median total calcium in immunofixation-positive patients was normal at 9.7 mg/dL. Patients with positive testing also had lower hemoglobin and platelet counts. An anion gap of 4 g/dL were also associated with positive results. Conclusions In patients with acute kidney injury, relatively higher total, ionized and corrected calcium levels and lower hemoglobin and platelet counts may predict the presence of a monoclonal paraprotein. An anion gap of 4 g/dL may also be predictors. The metabolic consequences of acute kidney injury may attenuate some of these abnormalities as well. These findings may help guide optimal use of immunofixation testing and hence help potentially identify patients who may have multiple myeloma.

Study objective Long-term glycemic control can prevent or delay complications of diabetes. Although diabetes is a common comorbidity in emergency department (ED) patients, the adequacy of long-term control is not known. Our objectives are to determine the frequency of poorly controlled type 2 diabetes among adults presenting to an ED and to identify characteristics associated with poor control. Methods An A1C level was obtained for diabetic patients 18 years and older who presented to the ED for acute medical problems and had blood tests performed for usual medical care. Consecutive patients were screened for a total of 58 24-hour periods during a 10-week period. A1C values were stratified, with less than 7% defined as good control and greater than or equal to 7% poor long-term control. Logistic regression analysis was used to identify factors associated with poor control. Results Of the 500 patients with type 2 diabetes, 53.4% had inadequate long-term control. An increased ED glucose level was independently associated with an increased A1C level. If the ED glucose level was 126 to 149 mg/dL, the odds ratio (OR) for an increased A1C level relative to a glucose level less than 100 mg/dL was 2.3 (95% confidence interval [CI] 0.95, 5.68); the OR was 6.4 (95% CI 2.9, 14.1) for glucose levels 150 to 199 mg/dL, and for glucose level of 200 mg/dL or above, the OR for an increased A1C level was 21.2 (9.1, 49.3). Other factors independently associated with increased A1C level were black race, aged 40 to 59 years, and Medicaid insurance. Conclusion The high frequency of A1C levels more than 7% points to the ED as a potential source for identifying patients with poorly controlled type 2 diabetes.

Background The links among smoking, inflammation, and cardiovascular disease (CVD) are well established. Several studies have demonstrated that quitting smoking reverses the risk of coronary heart disease within 5 to 10 years. However, the immediate effects of quitting smoking on inflammatory biomarkers associated with CVD risk have not been well described. Methods In this pilot study, we examined a panel of circulating inflammatory biomarkers associated with CVD in "at-risk" women during the smoking cessation program. Forty-six women enrolled in a smoking cessation program consented to attend four study visits over 6 to 7 weeks. Health/medical information and blood were collected at each visit. Circulating levels of C-reactive protein (CRP), tumor necrosis factor (TNF), interleukin (IL)-6, soluble TNF receptor (sTNFR)-I, sTNFR-II, and soluble vascular cell adhesion molecule (sVCAM)-1 were measured, and changes between baseline levels (visit 1, while smoking) and visits 2 through 4 were determined. Results Significant reductions in circulating levels of TNF, sTNFR-I, sTNFR-II, and sVCAM-1 were observed among participants over the course of the smoking cessation program. Serum levels of both IL-6 and CRP declined during the smoking cessation program; the changes were not statistically significant, however. Conclusions These findings suggest there are rapid consequences of smoking cessation on inflammatory biomarkers in women at risk for CVD. Additional, larger studies including diverse smokers desiring to quit are required to confirm changes in "measurable milestones" that could serve as motivating factors to assist smokers to quit.

Background Neurocognitive impairments have been documented in adolescents with early-onset schizophrenia (EOS; onset by age 18) and are important treatment targets. Information concerning the severity, pattern, and clinical correlates of these deficits in EOS remains limited. Methods Tests assessing motor skills, attention, memory, visuospatial abilities and executive functioning were administered to 54 clinically stabilized adolescents with EOS and 52 age- and sex-matched healthy controls. Childhood-onset patients (onset by age 13) were compared to those with an adolescent onset of illness. Patients' neurocognitive profiles were compared to those of controls. Relationships between neurocognitive deficits and demographic and clinical characteristics were explored. Results Neurocognitive profiles did not differ between childhood- and adolescent-onset participants. Patients showed a generalized neurocognitive deficit of 2.0 SDs compared to controls, with relative deficit in executive functioning and relative sparing of language and visuospatial abilities. Degree of generalized neurocognitive impairment was associated with premorbid adjustment and negative symptom severity (Adjusted R 2 = .39). Conclusions Results document both a significant generalized deficit and a relative deficit of executive functioning in adolescents with EOS. The overall pattern is similar to that observed in severely ill first-episode adult patients. The impairments across multiple neurocognitive domains suggest widespread brain dysfunction in EOS.

Clinical experience suggests that 6-mercaptopurine (6-MP) is effective therapy for children with active steroid-dependent Crohn's disease (CD). We report the results of a prospective, placebo-controlled, multicenter trial evaluating the combination of 6-MP and prednisone as therapy for children with newly diagnosed moderate-to-severe CD.Fifty-five children (age, 13+/-2 years) were randomized to treatment with 6-MP (1.5 mg x kg(-1) x day(-1)) or placebo within 8 weeks of initial diagnosis. Both groups also received prednisone (40 mg/day). Prednisone dosage adjustments were based on a defined schedule determined by the change in a subject's disease activity score, and steroid administration was discontinued as remission was achieved. Study treatment with 6-MP or placebo continued for 18 months.Groups were comparable for age, sex, and site and activity of disease. In the 6-MP group, the duration of steroid use was shorter (P0.001) and the cumulative steroid dose lower at 6, 12, and 18 months (P0.01). Although remission was induced in 89% of both groups, only 9% of the remitters in the 6-MP group relapsed compared with 47% of controls (P = 0.007). Growth was comparable in both groups. No clinically significant adverse events occurred, although mild leukopenia and increases in aminotransferase activity were noted in the 6-MP group.Addition of 6-MP to a regimen of corticosteroids significantly lessens the need for prednisone and improves maintenance of remission. 6-MP should be part of the initial treatment regimen for children with newly diagnosed moderate-to-severe CD.

Pediatric HIV infection is characterized by a progressive decline in CD4 T lymphocytes and faster disease progression than is typically seen in adults. Apoptosis, possibly mediated through the CD95 antigen, has been proposed as a mechanism for cell loss which eventually leads to immune dysfunction. In this study of peripheral blood lymphocytes from HIV-infected children, classified according to CDC immunologic categories, we found that the percentage of CD4 and CD8 T cells expressing CD95 and the percentage of lymphocytes undergoing apoptosis were increased in children with HIV infection and were greater in children from immunologic Category III as compared to those in Category I. Most striking was our observation that an increased percentage of CD95-positive cells appeared as early as 3 months of age, at a time when these children did not have elevated levels of apoptosis. These data demonstrate early upregulation of CD95 expression in HIV-infected infants, an abberation which may have profound implications for the pathogenesis of perinatally acquired HIV disease.

Background/purpose: In baseball pitching is a much less visually demanding task than hitting is. We sought to find a stronger relationship between visual function (as measured by stereopsis) and hitting a baseball than between stereopsis and pitching skill. Methods: Multiple parameters including near and distance stereopsis (as a measure of visual function) were measured in 23 returning college baseball players (with a prior year's record). Their level of stereopsis (measured at distance with use of the B-VAT II BVS Binocular Vision Testing System) was compared with their batting statistics (in the case of the 14 position players) or their pitching statistics (for the 9 pitchers). Batting average and slugging percentage were used as measures of hitting skill, and earned run average, "out percentage" (1.000 — Opposing players' batting average) and "strike-out percentage" (frequency of batters struck out) were used as pitching parameters. Results: As a group, visual parameters were excellent in these college athletes. Although the newer test of distance stereopsis correlated with the standard near stereo test (Spearman coefficients), there was no correlation between distance stereopsis and any of the pitching or hitting performance parameters. Conclusions: The nature of the visual demands required of successful baseball hitters may have yet to be determined or are difficult to identify among a population homogeneous for excellent visual function, true for most groups of competitive athletes. In addition, simpler parameters such as plain visual acuity may be the most important factor(s).

Introduction The objective of this study was to evaluate the role of intraoperative frozen section (IFS) in determining the course of surgery in thyroid nodules with a prior fine needle aspiration (FNA) biopsy diagnosis. In addition, reliability of FNA interpretation to guide surgical management without IFS was investigated. Material and Methods This is a retrospective study of all patients who had a FNA biopsy, IFS, and final pathology performed on a thyroid nodule over a 9 month period. The extent of surgery at the time of the IFS was recorded. Subsequent change in surgical procedure following the IFS diagnosis was noted in each of the Bethesda diagnostic categories. Results 55% of the cases were deferred at IFS overall, with 68 and 86% in Bethesda III and IV categories, respectively. Overall, there was a change in management in 6% of cases. Conclusions Our study does not support the use of IFS for nodules with prior FNA interpretation of Bethesda II, III, IV and VI as management was not significantly changed. IFS is of value for nodules with prior FNA diagnosis of Bethesda I for interpretation of nodule, and Bethesda V for planning surgery. A confirmatory diagnosis could not be rendered at IFS for lesions with follicular architecture, which comprised most of the cases in Bethesda III and IV.

Methods: 64 patients were enrolled in the study. 45 patients [11 males, 34 females; mean age 51.3 years; with confirmed PAH (WHO Group I), and 19 patients [9 males, 10 females; mean age 69.8 years] with WHO Group III. Patients completed Medical Outcomes Study Short–Form 36 V2 to measure generic HRQOL, Modified Medical Research Council [mMRC] Dyspnea Scale and Zung Depression scale. Physical Health Composite Scores [PCS] and Mental Health Composite Scores [MCS] were derived from SF36V2. For each scale, Mann-Whitney test was used to examine the association between WHO Groups (Group I or Group III) and that scale. The Spearman correlation coefficient was computed to determine the degree of correlation between each pair of scales. Summary statistics are reported as medians and 25 th percentile (Q1) to 75 th percentile (Q3).