Acute coronary syndromes in the peri-operative period after kidney transplantation in United States.

INTRODUCTION: Chronic kidney disease is an independent risk factor for cardiovascular disease. Despite careful preoperative evaluation, there is a risk of acute coronary syndromes after kidney transplant. METHODS: The National Inpatient Sample for the years 2004-2013 was used for this retrospective cohort study. All adult patients undergoing kidney transplantation were identified using the appropriate ICD-9-CM codes. Multivariate logistic regression was used to identify predictors of acute coronary syndromes in the peri-operative period after kidney transplantation. RESULTS: A total of 147 431 kidney transplants were performed from 2004 through 2013 in the United States. The average peri-operative in-hospital mortality was 0.5%. Acute coronary syndrome occurred in 1.3% patients in the peri-operative period. Half of patients with acute coronary syndromes had pre-existing coronary artery disease. The strongest predictors of acute coronary syndromes included older age: 45-64 years. OR 3.28 95% CI (1.85-5.83), ≥65 years. OR 4.84 (2.59-9.05), race: African American, OR 0.66 (0.47-0.93) and pre-existing coronary artery disease OR 3.83 (2.84-5.15). The case fatality rates were 16.9% and 5.3% for STEMI and NSTEMI, respectively. The overall mortality for any ACS event was 7.1%. CONCLUSION: Acute coronary syndrome in the immediate peri-operative period after kidney transplantation is rare but is associated with high rates of mortality.

Steroids in COVID-19: An overview.

Most antiviral or immunomodulatory therapies investigated for use in patients with COVID-19 have failed to show any mortality benefit. Similar to the previous pandemics caused by respiratory viruses, the role and benefit of corticosteroids has been under debate in COVID-19-related pulmonary disease. In this consult, we discuss the evidence regarding the efficacy of corticosteroid use in hospitalized patients with COVID-19, including data from the first randomized controlled trial on this subject.

Impact of Palliative Care Utilization for Surgical Patients Receiving Prolonged Mechanical Ventilation: National Trends (2009-2013).

BACKGROUND: Patients requiring mechanical ventilation (MV) have high morbidity and mortality. Providing palliative care has been suggested as a way to improve comprehensive management. The objective of this retrospective cross-sectional study was to identify predictors for palliative care utilization and the association with hospital length of stay (LOS) among surgical patients requiring prolonged MV (≥ 96 consecutive hours). METHODS: National Inpatient Sample (NIS) data 2009-2013 was used to identify adults (age ≥ 18) who had a surgical procedure and required prolonged MV (≥ 96 consecutive hours), as well as patients who also had a palliative care encounter. Outcomes were palliative care utilization and association with hospital LOS. RESULTS: Utilization of palliative care among surgical patients with prolonged MV increased yearly, from 5.7% in 2009 to 11.0% in 2013 (p < 0.001). For prolonged MV surgical patients who died, palliative care increased from 15.8% in 2009 to 33.2% in 2013 (p < 0.001). Median hospital LOS for patients with and without palliative care was 16 and 18 days, respectively (p < 0.001). Patients discharged to either short or long term care facilities had a shorter LOS if palliative care was provided (20 vs. 24 days, p < 0.001). Factors associated with palliative care utilization included older age, malignancy, and teaching hospitals. Non-Caucasian race was associated with less palliative care utilization. CONCLUSIONS: Among surgical patients receiving prolonged MV, palliative care utilization is increasing, although it remains low. Palliative care is associated with shorter hospital LOS for patients discharged to short or long term care facilities.

A Case Report of Hypertensive Emergency and Intracranial Hemorrhage Due to Intracavernosal Phenylephrine.

Background: Intracavernosal injection of phenylephrine is a commonly used therapy for ischemic priapism and is typically well tolerated with few severe adverse side effects. We report a case of intracranial hemorrhage related to hypertensive emergency due to intracavernosal phenylephrine. Case Report: A 43-year-old Caucasian man with history of hypertension, diabetes mellitus type I, end-stage renal disease status post a combination kidney-pancreas transplant, and recurrent idiopathic priapism presented to emergency department with an episode of priapism. His home medications were lisinopril, metoprolol tartrate, mycophenolate mofetil, prednisone, sulfamethoxazole-trimethoprim, and tacrolimus. After local injection of 2 rounds (1 hour apart) of 100 µg phenylephrine into each corpus cavernosa, priapism resolved. Within 5 minutes, the patient had headaches, dyspnea, and excruciating chest pain. His blood pressure (BP) was noted to be 240/130 mm Hg but normalized spontaneously within few minutes. During this period, he developed new-onset right arm and leg weakness and found to have intracranial hemorrhage in the midbrain. Conclusion: A careful review for pharmacologic interactions should be performed prior to intracavernosal phenylephrine administration, and close monitoring should occur after its administration.

In-Hospital Mortality and Major Adverse Cardiovascular Events after Kidney Transplantation in the United States.

BACKGROUND: Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease. Cardiovascular disease is a major determinant of morbidity and mortality in patients with KT. Temporal trends in perioperative cardiovascular outcomes after KT are understudied, especially in light of an aging KT waitlist population. METHODS: We performed a retrospective observational cohort study using the National Inpatient Sample for the years 2004-2013. All adult patients undergoing KT were identified using the appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes. Demographic and hospital characteristics, discharge disposition, payer status, and major adverse cardiovascular events (MACEs) were summarized using summary statistics. Multivariate logistic regression was used to identify predictors of MACEs in the perioperative period of KT. RESULTS: A total of 147,431 KTs were performed between 2004 and 2013. The mean age at KT went up from 48.1 to 51.8 years from 2004 to 2013. Medicare was the primary payer for 59.6% of the KTs. Overall average perioperative mortality was 0.5%, median length of stay was 5 days, and 6.5% of patients experienced an MACE, 78% of which were heart failures (HFs). Important predictors of perioperative MACEs were age ≥65 years (OR = 2.14), Medicare as primary payer (OR = 1.51), diabetes (OR = 1.46), recreational drug use (OR = 1.72), pulmonary circulation disorders (OR = 3.28), and malnutrition (OR = 1.91). CONCLUSION: Despite increases in age at the time of KT, the absolute risk of perioperative MACEs has remained stable from 2004 to 2013. HF is a major component of postoperative MACEs in KT. Malnutrition and pulmonary hypertension are major nontraditional predictors of perioperative MACE outcomes.

Optimizing the Approach to Patients With Pleural Effusion and Radiologic Findings Suspect for Cancer.

BACKGROUND: When patients present with pleural effusion and structural abnormalities consistent with malignancy on imaging, the traditional approach has been to perform a thoracentesis and await the results before proceeding to more invasive diagnostic procedures. The objective of this study was to evaluate whether concurrent thoracentesis and tissue biopsy is superior to sequential sampling. METHODS: Retrospective chart review was performed for patients who had a pleural cytology from May 2014 until January 2017. Patients without parenchymal, pleural, or mediastinal abnormalities and those with a prior primary thoracic malignancy were excluded. Patients with an effusion and additional suspect findings were grouped based upon whether initial approach was concurrent versus sequential. The following outcomes were documented: lag time to diagnosis from thoracentesis, lag time to hematology/oncology (HONC) service consult, time to molecular study results, lag time to therapy, and time to death. RESULTS: Of 565 cases, 45 met criteria, 28 (62%) having undergone concurrent and 17 (38%) sequential sampling. The median lag time to biopsy for the concurrent group, 3 days, was significantly shorter than the 9-day lag time for the sequential group (P=0.006). Five patients in the sequential group and one in the concurrent group were lost to follow-up. Patients in the concurrent group had earlier diagnosis and oncology visits (2 d, 7 d) than those in the sequential group (6.5 d, 16 d) (P<0.001 and <0.039, respectively). Time from diagnosis to death did not differ for the 2 groups. CONCLUSION: For patients presenting with pleural effusion accompanied by additional suspect findings, concurrent tissue sampling, and thoracentesis may both reduce loss to follow up and accelerate care.

In-Hospital Mortality Benefit of Inferior Vena Cava Filters in Patients With Pulmonary Embolism and Congestive Heart Failure.

OBJECTIVE: Pulmonary embolism (PE) is associated with a higher mortality rate in patients with congestive heart failure (CHF) than in those without heart failure. The purpose of this study was to evaluate if inferior vena cava (IVC) filter placement provides any mortality benefit in patients admitted with CHF and PE. MATERIALS AND METHODS: The 2005-2014 Nationwide Inpatient Sample (NIS) was used for this study. Adults (≥ 18 years old) with PE were identified using International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) diagnosis codes. Patients with CHF were identified using the Elixhauser comorbidity variable (CM_CHF) in the NIS database. IVC filter placement was identified using the ICD-9-CM procedure code 38.7 (interruption of the vena cava). A multivariate logistic regression model was used to determine the association of IVC filter placement with in-hospital mortality. The model was adjusted for demographics, hospital characteristics, comorbidities, and PE severity indexes (pressor dependence, mechanical ventilation, nonseptic shock, and use of thrombolytic therapy). RESULTS: During the study years, 425,877 patients with a comorbidity of CHF were hospitalized with PE (44% male; mean age, 71.5 years old). Of them, 67,237 patients (15.8%) received an IVC filter during the admission, and 50,338 (11.8%) died during the hospital stay. The all-cause in-hospital mortality rate among patients who received an IVC filter was 9.7% (6541 of 67,237 patients) compared with 12.2% (43,796 of 358,638 patients) among those without an IVC filter (p < 0.001), with an absolute risk reduction of 2.5%. The multivariate adjusted hazard ratio of in-hospital mortality associated with IVC filter placement was 0.535 (95% CI, 0.518-0.551; p < 0.001). CONCLUSION: A lower all-cause mortality rate was observed in patients with CHF and PE who received an IVC filter while hospitalized. In the absence of data from randomized controlled trials, this study suggests that IVC filters could help prevent in-hospital death among patients admitted with PE and CHF.

National Trends (2009-2013) for Palliative Care Utilization for Patients Receiving Prolonged Mechanical Ventilation.

OBJECTIVES: Patients requiring mechanical ventilation have high morbidity and mortality. Providing palliative care services has been suggested as a way to improve comprehensive management of critically ill patients. We examined the trend in the utilization of palliative care among adults who require prolonged mechanical ventilation. Primary objectives were to determine the trend in palliative care utilization over time, predictors for palliative care utilization, and palliative care impact on hospital length of stay. DESIGN: Retrospective, cross-sectional study. SETTING: The National Inpatient Sample data between 2009 and 2013 was used for this study. PATIENTS: Adults (age ≥ 18 yr) who underwent prolonged mechanical ventilation (≥ 96 consecutive hr) were studied. MEASUREMENTS AND MAIN RESULTS: Palliative care and mechanical ventilation were identified using the corresponding International Classification of Diseases, 9th revision, Clinical Modification, codes. A total of 1,751,870 hospitalizations with prolonged mechanical ventilation were identified between 2009 and 2013. The utilization of palliative care increased yearly from 6.5% in 2009 to 13.1% in 2013 (p < 0.001). Among the mechanically ventilated patients who died, palliative care increased from 15.9% in 2009 to 33.3% in 2013 (p < 0.001). Median hospital length of stay for patients with and without palliative care was 13 and 17 days, respectively (p < 0.001). Patients discharged to either short- or long-term care facilities had a shorter length of stay if palliative care was provided (15 vs 19 d; p < 0.001). The factors associated with a higher palliative care utilization included older age, malignancy, larger hospitals in urban areas, and teaching hospitals. Non-Caucasian race was associated with lower palliative care utilization. CONCLUSIONS: Among patients who undergo prolonged mechanical ventilation, palliative care utilization is increasing, particularly in patients who die during hospitalization. Using palliative care for mechanically ventilated patients who are discharged to either short- or long-term care facilities is associated with a shorter hospital length of stay.

Prevalence and predictors of readmissions among adults with cystic fibrosis in the United States.

INTRODUCTION: Patients with Cystic Fibrosis (CF) have increasing rates of hospitalization. We analyzed the burden and predictors of thirty-day readmission among patients with CF in the U.S. MATERIAL AND METHODS: Nationwide Readmission Database (NRD) 2013 was used to identify adults with CF who were hospitalized. These individuals were followed to determine the prevalence of readmission within thirty days of index discharge. Cox proportional hazard regression was used to identify independent predictors of readmission. RESULTS: There were 14,616 index admissions of adults with CF in 2013. Of these, 2,606 (17.8%) patients were readmitted within 30 days of discharge. Female sex and chronic anemia were independent predictors of readmission. The most common causes of readmission were pulmonary exacerbation (31%), lung transplant complications (5.2%), and septicemia (3.4%). CONCLUSION: Readmissions are frequent among adults with CF and contribute to significant healthcare burden and cost among this population.

Out of proportion pulmonary hypertension in obstructive lung diseases.

PURPOSE OF REVIEW: Pulmonary hypertension is common (25-90%) in chronic obstructive pulmonary diseases (COPDs). Severe pulmonary hypertension, however, is quite rare (1-3%). The term 'out of proportion' pulmonary hypertension is still widely used. New guidelines instead propose to use the term 'Severe pulmonary hypertension' if mean pulmonary arterial pressure at least 35 mmHg or cardiac index (CI) is less than 2.0 l/min/m on right heart catheterization (RHC). Why only a minority of COPD patients develop severe pulmonary hypertension is unclear. RECENT FINDINGS: When present, severe pulmonary hypertension in COPD is associated with increased dyspnea and decreased survival and often does not closely correlate with degree of obstructive abnormality on pulmonary function testing. COPD patients with severe pulmonary hypertension experience circulatory limitation at maximum exercise, and not ventilatory limitation, which is typical for moderate-to-severe COPD patients with no or moderate pulmonary hypertension. SUMMARY: There is no conclusive evidence to support or completely reject the possibility of the use of specific pulmonary arterial hypertension (PAH) therapies in pulmonary hypertension associated with COPD. In mild-to-moderate COPD patients who have severe and progressive symptoms, and have evidence of severe pulmonary hypertension on RHC, specific PAH therapies may be used similar to WHO group-I PAH guidelines.

Highly Probable Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome Associated With Lenalidomide.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a life-threatening hypersensitivity reaction to medications. We report a case of a 75-year-old African American female who presented with generalized rash with desquamation and malodorous secretions. She was febrile and hypotensive, and required vasopressors for hemodynamic instability. Sepsis secondary to skin or soft tissue infection was considered initially. However, she recently was started on lenalidomide for treatment of her multiple myeloma, and her white blood cell count of 17 K/µL with 55% eosinophils along with peripheral smear showing eosinophilia suggested lenalidomide-induced rash. Lenalidomide was discontinued, and methylprednisolone was initiated. Four days after lenalidomide discontinuation, vasopressors were discontinued. Blood cultures did not exhibit any growth. The Niranjo Adverse Drug Reaction Probability Scale score of 9 suggests lenalidomide was a highly probable cause of DRESS syndrome. The temporal relation of lenalidomide administration and development of symptoms plus improvement of rash with the discontinuation of lenalidomide and reappearance on restarting lenalidomide in the follow-up clinic strengthens our suspicion of lenalidomide-induced DRESS syndrome. Cases of lenalidomide-induced DRESS syndrome are sparse; however, DRESS syndrome is fatal in approximately 10% of patients. Providers should be aware and keep a vigilant eye out for this adverse reaction with lenalidomide.

National Trends (2007-2013) of Clostridium difficile Infection in Patients with Septic Shock: Impact on Outcome.

BACKGROUND: Clostridium difficile is the most common infectious cause of healthcare-associated diarrhea and is associated with worse outcomes and higher cost. Patients with septic shock (SS) are at increased risk of acquiring C. difficile infections (CDIs) during hospitalization, but little data are available on CDI complicating SS. OBJECTIVE: Prevalence of CDI in SS between 2007-2013 and impact of CDI on outcomes in SS. METHODS: Outcomes were prevalence of CDI in SS, effect on mortality, length of stay (LOS), and 30-day readmission. RESULTS: There were 2,031,739 hospitalizations with SS (2007-2013). CDI was present in 8.2% of SS. The in-hospital mortality of SS with and without CDI were comparable (37.1% vs 37.0%; 𝑃 = 0.48). Median LOS was longer for SS with CDI (13 days vs 9 days; 𝑃 < 0.001). LOS >75th percentile (>17 days) was 36.9% in SS with CDI vs 22.7% without CDI (𝑃 < 0.001). Similarly, LOS > 90th percentile (> 29 days) was 17.5% vs 9.1%, 𝑃 < 0.001. Odds of LOS >75% and >90% in SS were greater with CDI (odds ratio [OR] 2.11; 95% confidence interval [CI], 2.06-2.15; 𝑃 < 0.001 and OR 2.25; 95% CI, 2.22-2.28; 𝑃 < 0.001, respectively). Hospital readmission of SS with CDI was increased, adjusted OR 1.26 (95% CI, 1.22-1.31; 𝑃 < 0.001). CONCLUSIONS: CDI complicating SS is common and is associated with increased hospital LOS and 30-day hospital readmission. This represents a population in which a focus on prevention and treatment may improve clinical outcomes.

Impact of targeted educational interventions on appropriateness of stress ulcer prophylaxis in critically ill adults.

BACKGROUND: Acid suppression therapy (AST) is routinely used in critically ill patients to prevent stress-related mucosal bleeding (SRMB). OBJECTIVE: Our objective was to determine the impact of a structured educational intervention on AST used for prevention of SRMB on appropriateness of AST. METHODS: A single-center, retrospective, cohort study of appropriate use of AST in critically ill patients admitted to the medical intensive care unit (ICU) at an academic medical center between January to June of 2014 (no intervention) and January to June of 2015 (intervention) was conducted. The percentage of patients prescribed inappropriate AST, inappropriate AST at ICU transfer and hospital discharge, doses of inappropriate AST, and adverse effects associated with AST use were compared between periods using chi-square tests. RESULTS: Patients in the intervention group (n=118) were 5 years older than patients in the no intervention group (n=101). AST was inappropriately initiated more frequently in the no intervention group (23% vs. 11%, p=0.012). Continuation of inappropriate AST at ICU transfer and hospital discharge was similar between groups (60% vs. 53%, p=0.277 and 18% vs. 14%, p=0.368, respectively). CONCLUSION: Patients had appropriate AST initiated and inappropriate AST withheld more frequently when formal education was provided. This low-cost intervention strategy can be implemented easily at institutions where pharmacists interact with physicians on rounding services and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.

A rare case of community acquired serratia lung abscess in a patient with cardiac bronchus.

The incidence of lung abscess caused by Serratia marcescens is extremely low and is only reported in the immunocompromised population. We present a previously healthy woman with Serratia lung abscess in close proximity with an accessory cardiac bronchus. The patient was treated with appropriate antibiotics which led to complete resolution of the lesion. Our case highlights that individuals without medical co-morbidities may develop atypical lung infections like Serratia when associated with anatomic anomalies.

A bronchoscopic approach to benign subglottic stenosis.

OBJECTIVES: Subglottic stenosis is an abnormal narrowing of the tracheal lumen at the level of subglottis (the area in between the vocal cords and the cricoid cartilage). It can cause significant symptoms due to severe attenuation of airflow. We describe our experience in alleviating symptoms by addressing the stenosis using fibreoptic bronchoscopic methods. METHODS: We report all concurrent cases performed between September 2015 and July 2016. We use a combination of balloon dilation, electro-surgery knife to dilate and incise stenotic segments followed by steroid injection to modulate healing. RESULTS: We treated 10 patients in the study period, 8 of which were women. A total of 39 procedures were performed on these patients during this period. Gastro-esophageal reflux was the most common comorbidity associated with stenosis. The majority of the patients required more than 2 therapeutic procedures, but none required more than 4 procedures. There were no complications. CONCLUSION: Tracheal stenosis and in particular subglottic stenosis is a recurrent process and its management requires extensive collaboration amongst treating specialties. Our technique of steroid injection after dilation of the stenosis was effective in symptom control and decreased the number of repeat procedures.

Decreasing Utilization of Inferior Vena Cava Filters in Post-FDA Warning Era: Insights From 2005 to 2014 Nationwide Inpatient Sample.

BACKGROUND: To determine the impact, if any, of the 2010 FDA safety communication on the rate of inferior vena cava filter (IVCF) placement over time. METHODS: The Nationwide Inpatient Sample was interrogated for the most recent years preceding and after the FDA safety communication-from 2005 to 2014. IVCF placements and associated diagnoses were identified using corresponding International Classification of Diseases, version nine codes. Trends in number of IVCF placement were evaluated in aggregate and by associated diagnoses, both of which were further stratified by hospital geographic cluster, hospital teaching status, and patient demographics. Generalized linear regression models were used to determine statistical significance of trends over time. RESULTS: IVCF placements steadily increased between 2005 and 2010 (100,434 in 2005 versus 129,614 in 2010, growth rate 5.81%). Aggregate IVCF placements subsequently declined between 2010 and 2014 (96,005 in 2014, decline rate -6.48%). IVCF placements peaked in 2010, the year of the FDA advisory. The proportion of filter placements for therapeutic indication of venous thromboembolism increased significantly during the study period (69.8% in 2005 versus 80.4% in 2014, P < .001). Neither trend varied significantly by patient demographics or hospital characteristics. CONCLUSIONS: IVCF placements have declined significantly since 2010, when the FDA advisory was released. The proportion of IVCFs placed in patients with venous thromboembolism, as opposed to prophylactic indications, is increasing.

Impact of end stage kidney disease on costs and outcomes of Clostridium difficile infection.

OBJECTIVES: To assess the impact of end stage kidney disease (ESKD) on the outcomes of Clostridium difficile infection (CDI), including complications of infection, length of hospital stay, overall mortality, and healthcare burden. METHODS: The National Inpatient Sample (NIS) database created by the Agency of Healthcare Research and Quality (AHRQ) was used, covering the years 2009 through 2013. Manufacturer-provided sampling weights were used to produce national estimates. RESULTS: All-cause unadjusted in-hospital mortality was significantly higher for patients with CDI and ESKD than for patients without ESKD (11.6% vs. 7.7%, p<0.001). The in-hospital mortality remained higher even after adjusting for age, sex, race, and Charlson index group using multivariate logistic regression (odds ratio 1.47, confidence interval 1.41-1.53). The median length of stay was found to be longer by 2days in the ESKD group (9 vs. 7 days, p<0.001). The average cost of hospitalization for patients with CDI and ESKD was also significantly higher compared to the non-ESKD group (USD $35 588 vs. $23 505, in terms of the 2013 value of the USD, p<0.001). CONCLUSIONS: The presence of end stage kidney disease in hospitalized patients with Clostridium difficile infection is associated with higher mortality, a longer length of stay, and a higher cost of hospitalization.

Iatrogenic Right-Sided Pneumothorax Presenting as ST-Segment Elevation: A Rare Case Report and Review of Literature.

Pneumothorax is a well-recognized complication of central venous line insertion (CVL). Rarely, pneumothorax can lead to electrocardiogram (ECG) findings mimicking ST-segment elevation myocardial infarction. We present a 63-year-old man with iatrogenic right-sided pneumothorax who developed ST-segment elevation on a 12-lead ECG suggestive of myocardial infarction. The ECG findings completely resolved after needle decompression and chest tube placement. This case points up this rare electrocardiographic finding with discussion of possible mechanisms and differential diagnosis.