Disparities in colonoscopy utilization for lower gastrointestinal bleeding in rural vs urban settings in the United States.

BACKGROUND: Lower gastrointestinal bleeds (LGIB) is a very common inpatient condition in the United States. Gastrointestinal bleeds have a variety of presentations, from minor bleeding to severe hemorrhage and shock. Although previous studies investigated the efficacy of colonoscopy in hospitalized patients with LGIB, there is limited research that discusses disparities in colonoscopy utilization in patients with LGIB in urban and rural settings. AIM: To investigate the difference in utilization of colonoscopy in lower gastrointestinal bleeding between patients hospitalized in urban and rural hospitals. METHODS: This is a retrospective cohort study of 157748 patients using National Inpatient Sample data and the Healthcare Cost and Utilization Project provided by the Agency for Healthcare Research and Quality. It includes patients 18 years and older hospitalized with LGIB admitted between 2010 and 2016. This study does not differentiate between acute and chronic LGIB and both are included in this study. The primary outcome measure of this study was the utilization of colonoscopy among patients in rural and urban hospitals admitted for lower gastrointestinal bleeds; the secondary outcome measures were in-hospital mortality, length of stay, and costs involved in those receiving colonoscopy for LGIB. Statistical analyses were all performed using STATA software. Logistic regression was used to analyze the utilization of colonoscopy and mortality, and a generalized linear model was used to analyze the length of stay and cost. RESULTS: Our study found that 37.9% of LGIB patients at rural hospitals compared to approximately 45.1% at urban hospitals received colonoscopy, (OR = 0.730, 95%CI: 0.705-0.7, P > 0.0001). After controlling for covariates, colonoscopies were found to have a protective association with lower in-hospital mortality (OR = 0.498, 95%CI: 0.446-0.557, P < 0.0001), but a longer length of stay by 0.72 d (95%CI: 0.677-0.759 d, P < 0.0001) and approximately $2199 in increased costs. CONCLUSION: Although there was a lower percentage of LGIB patients that received colonoscopies in rural hospitals compared to urban hospitals, patients in both urban and rural hospitals with LGIB undergoing colonoscopy had decreased in-hospital mortality. In both settings, benefit came at a cost of extended stay, and higher total costs.

Atrial Fibrillation as a Possible Adverse Reaction to Evolocumab.

Evolocumab is a recently FDA-approved proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) that reduces the risk of myocardial infarction, stroke, and coronary revascularization in individuals with established atherosclerotic cardiovascular disease. We report an extremely rare possible side effect, atrial fibrillation (AF), encountered with evolocumab to increase the awareness among physicians of such a possibility.

Asymptomatic Spontaneous Pneumopericardium, Pneumomediastinum, and Subcutaneous Emphysema: A Case Report of an Incidental Rare Presentation.

Pneumopericardium (PP), pneumomediastinum (PM), epidural pneumatosis, and subcutaneous emphysema (SE) are identified by the existence of free air or gas in the associated spaces. They are normally self-limited unless tension pneumothorax, tension PM, cardiac herniation, air tamponade, and esophageal rupture accompany these disorders. PM and PP can be divided into "spontaneous" or "secondary" based on the preceding etiologies. Spontaneous PM is often extremely rare and benign in course. On the other hand, secondary PM and PP are more common and result from intrathoracic infections, trauma-related esophageal rupture, or tears along the tracheobronchial tree. Our patient presented four days after a fall from a chair and was found to have suffered a stroke, with complete left side paralysis. CT imaging on arrival was significant for PM, PP, and SE, the cause of which remains unclear. The patient was diagnosed with COVID-pneumonia approximately six months prior to presentation. As the COVID-19 pandemic has evolved, several scientific papers have been published reporting infected patients who had developed spontaneous PT, PM, or even PP, in the absence of invasive mechanical ventilation. Is it possible that the spontaneous findings in our patient were COVID-related? Or could the spontaneous PP, PM, and SE be a sequel to the trauma of her fall from a chair? The answer still remains unclear.

Cardiovascular Considerations of Experimental Hydroxychloroquine Therapy on Patients Diagnosed With COVID-19: A Case Series Review.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and its high virulence along with its variable presentation have generated a significant amount of interest within the medical community. The heterogeneous nature of the symptoms of the disease caused by SARS-CoV-2, coronavirus disease 2019 (COVID-19), ranging from being asymptomatic to severe acute respiratory distress syndrome (ARDS), has created significant interest in potential therapeutics. Given the lack of randomized controlled trials, most medications are experimental, and only anecdotal evidence is available so far regarding their efficacy. One medication that emerged as an early frontrunner as a promising therapeutic was hydroxychloroquine (HCQ), a common antimalarial and lupus drug. The adverse side effects that could result from its use did not gain much attention initially. We present the cases of two COVID-19-positive patients treated with HCQ at our institution, which showed adverse effects of the medication. While HCQ may have some therapeutic effect, it should be borne in mind that patients may experience more harm than benefit from its use.

A Rare Case of Severe Hypercalcemia Secondary to Atypical Parathyroid Cystic Adenoma with Negative Sestamibi Scan.

The two types of parathyroid cysts are functional and non-functional cysts. Cystic parathyroid lesions are a rare cause of hypercalcemia and often pose a diagnostic challenge due to the reduced detection on preoperative imaging studies. We, herein, present a rare case of an elderly female presenting to the emergency department with altered mental status associated with hypercalcemic crisis and a negative sestamibi scan. Following surgical resection, pathology revealed the diagnosis of cystic parathyroid adenoma and normalization of serum calcium levels.

Rhabdomyolysis as a rare paraneoplastic presentation of acute myeloid leukemia.

We present the case of a 56-year-old man who presented with rhabdomyolysis and was found to have acute myeloid leukemia (AML). Our case is the first to show an association of rhabdomyolysis with AML. Although rhabdomyolysis is likely a very rare clinical presentation of AML, our case raises awareness for workup for AML in patients who present with rhabdomyolysis and other suspicious findings. Both conditions are medical emergencies and require immediate treatment.

Diagnostic value of pleural fluid interferon-gamma and adenosine deaminase in patients with pleural tuberculosis in Qatar.

OBJECTIVE: To investigate the diagnostic utility of interferon-gamma (IFN-γ) and adenosine deaminase (ADA) in tuberculous pleural effusions by determining the best cutoff levels of these two markers for pleural tuberculosis, in the context of the local epidemiological settings in Qatar. METHODS: We prospectively studied IFN-γ and ADA levels in the pleural fluid of patients presenting to Hamad General Hospital between June 1, 2009 and May 31, 2010. RESULTS: We studied 103 patients with pleural effusions, 72 (69.9%) with pleural tuberculosis, and 31 (30.1%) with nontuberculous etiologies. The mean IFN-γ concentration for the group with tuberculous effusions was significantly higher than that in the group with nontuberculous effusions (1.98 ± 81 vs 0.26 ± 10 pg/mL [P < 0.0001]). The mean ADA activity for the tuberculous effusions group was significantly higher than that in group with nontuberculous effusions (41.30 ± 20.09 vs 14.93 ± 14.87 U/L [P < 0.0001]). By analysis of receiver operating characteristic (ROC) curves, the best cutoff values for IFN-γ and ADA were 0.5 pg/mL and 16.65 U/L, respectively. The results for IFN-γ vs ADA were: for sensitivity, 100% vs 86%, respectively; for specificity, 100% vs 74%, respectively; for positive predictive value, 100% vs 88.5%, respectively; and for negative predictive value, 100% vs 69.7%, respectively. CONCLUSION: IFN-γ and ADA could be used as valuable parameters for the differentiation of tuberculous from nontuberculous effusion, and IFN-γ was more sensitive and specific for tuberculous effusion than ADA.