Prospective Validation of PREDICT and Its Impact on the Transesophageal Echocardiography Use in Management of Staphylococcus aureus Bacteremia.

BACKGROUND: Infective endocarditis (IE) is the most feared complication of Staphylococcus aureus bacteremia (SAB). Transesophageal echocardiogram (TEE) is generally recommended for all patients with SAB; however, supporting data for this are limited. We previously developed a scoring system, "PREDICT," that quantifies the risk of IE and identifies patients who would most benefit most from undergoing TEE. The current prospective investigation aims to validate this score. METHODS: We prospectively screened all consecutive adults (≥18 years) hospitalized with SAB at 3 Mayo Clinic sites between January 2015 and March 2017. RESULTS: Of 220 patients screened, 199 with SAB met study criteria and were included in the investigation. Of them, 23 (11.6%) patients were diagnosed with definite IE within 12 weeks of initial presentation based on modified Duke's criteria. Using the previously derived PREDICT model, the day 1 score of ≥4 had a sensitivity of 30.4% and a specificity of 93.8%, whereas a day 5 score of ≤2 had a sensitivity and negative-predictive value of 100%. Additional factors including surgery or invasive procedure in the past 30 days, prosthetic heart valve, and higher number of positive blood culture bottles in the first set of cultures were associated with increased risk of IE independent of the day 5 risk score. CONCLUSIONS: We validated the previously developed PREDICT scoring tools for stratifying risk of IE, and the need for undergoing a TEE, among cases of SAB. We also identified other factors with predictive potential, although larger prospective studies are needed to further evaluate possible enhancements to the current scoring system.

Thyrotoxic Periodic Paralysis and Complicated Thyrotoxicosis, Two Presentations of Hyperthyroidism with Notable Differences in their Clinical Manifestations: An Experience from a Tertiary Care Hospital in the United States.

OBJECTIVE: Thyrotoxic periodic paralysis (TPP) is a muscular disorder characterized by sudden episodes of muscle weakness and hypokalemia in the setting of thyrotoxicosis. We aimed to report our experience with TPP in West Texas and compare its clinical presentation to that of patients admitted for complicated thyrotoxicosis. METHODS: Retrospective review of records of adult patients with admission diagnosis of hyperthyroidism, thyrotoxicosis, and/or discharge diagnosis of periodic paralysis seen at our institution in a 6-year period. RESULTS: Patients admitted for complicated thyrotoxicosis were more commonly females of a mean age of 44 years. Patients with TPP were more commonly Hispanic males of a mean age of 27 years. Despite no significantly different thyroid hormone levels, patients with TPP presented with less-severe signs and symptoms of hyperthyroidism, as reflected by lower Burch-Wartofsky score on admission (19 vs. 35; P<.001) and lower occurrence of atrial fibrillation in the TPP group (0% vs. 36%; P<.001). Finally, 89% of TPP patients presented with corrected QT (QTc) prolongation, whereas only 19% of thyrotoxic patient presented with a prolonged QTc. CONCLUSION: Hispanic patients with TTP seems to have relative resistance to the actions of thyroid hormones and commonly present with QTc prolongation, a risk factor for cardiac arrhythmias. ABBREVIATIONS: BWS = Burch-Wartofsky point scale; EKG = electrocardiogram; FT3 = free triiodothyronine; FT4 = free thyroxine; ICD = International Classification of Diseases; QTc = corrected QT; TPP = thyrotoxic periodic paralysis.

Mycobacterium abscessus infections in lung transplant recipients: 15-year experience from a single institution.

PURPOSE: To evaluate our institutional experience with Mycobacterium abscessus infections occurring in lung transplant recipients (LTR). METHODS: We retrospectively reviewed our prospectively collected institutional adult lung transplant database from 2001 to 2015 to identify patients with M. abscessus or Mycobacterium chelonae/abscessus infection before or after transplantation. Untreated, colonized patients were excluded from the study. Electronic health records of nine out of 516 lung recipients (1.74%) with clinical infection were reviewed to determine outcomes. RESULTS: Seven patients acquired the infection after transplantation. Indications for transplantation were: idiopathic pulmonary fibrosis (in 6), chronic obstructive pulmonary disease (in 2), and cystic fibrosis (in 1). Five patients (55.5%) underwent bilateral lung transplantation; one patient required bilateral re-transplantation for complications from infection. M. abscessus was isolated from the respiratory tract with a median time of 7.5 months (range: 3 days to 13 months) from transplantation. All patients were treated using a multidrug regimen, with durations ranging from 3 days to 12 months. Complications from infection included death in one patient, bronchial anastomotic dehiscence in one patient, delayed bronchial occlusions in two patients, and osteomyelitis of the knee in one patient. Median survival time from transplantation was 39 months (range: 11-96 months) and from the date of first positive culture was 58 months (range: 3-91 months). Five patients (55.5%) were cured but two had re-infections >1 year later. CONCLUSIONS: Mycobacterium abscessus infection in LTR is rare and can lead to severe complications. Eradication is difficult and usually requires prolonged combination antibiotic therapy and occasionally surgical management.

Nontuberculous Mycobacterial Infections of the Upper Extremity: 15-Year Experience at a Tertiary Care Medical Center.

PURPOSE: To present our experience with culture-positive, nontuberculous mycobacterial infections (NTMI) of the upper extremity and to compare the clinical features and outcomes of treatment among immunocompetent and immunocompromised patients. METHODS: All patients at our medical center diagnosed with NTMI of the upper extremity from December 1, 2000, through December 31, 2015, were included. We performed a retrospective analysis of patient demographic characteristics, delay to diagnosis, risk factors, clinical presentation, specific location, diagnostic testing, treatment regimens, and outcomes. These variables were compared between immunocompetent and immunocompromised patients. RESULTS: Forty-four patients were identified with culture-positive NTMI of the upper extremity. Of the patients, 27 (61%) were men (median age, 59 years [range, 23-83 years]). Twenty (45%) patients were immunocompromised. Immunocompromised patients had fewer known inoculation injuries compared with immunocompetent patients (45% vs 92%). A significant difference existed in the treatment regimens selected for immunocompetent versus immunocompromised patients: immunocompetent patients were more often treated with both antibiotics and surgery (88% vs 50%), whereas immunocompromised patients were more often treated with antibiotics alone (45% vs 4%). Overall, 24% experienced treatment failure and 9% died. Outcomes were relatively similar between immunocompetent and immunocompromised patients. A shorter delay to diagnosis was associated with a lower failure rate. CONCLUSIONS: Diagnosis of upper-extremity NTMI is often delayed because of indolent presentation and lack of clinical suspicion. The clinical presentation, diagnostic delay, and diagnostic testing results are similar between immunocompetent and immunocompromised patients. Although treatment varied significantly between patient groups, outcomes were similar. Timely diagnosis has the greatest impact on patient outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The "July effect" on patients admitted with diabetes ketoacidosis: a national retrospective cohort study.

Background: Every July, new residents begin training across the United States, but it is unclear whether this affects the mortality rate of critically ill patients such as those with diabetes ketoacidosis (DKA). Methods: This national retrospective cohort study included patients aged 18 years or older admitted to acute care with DKA between 2016 and 2020. Data were obtained from the National Inpatient Sample Database. We compared patients admitted in July and August with those admitted during the remaining months and assessed the primary endpoint of all-cause inpatient mortality. We also obtained an odds ratio adjusted for confounders using multivariate logistic regression analysis. Secondary endpoints included length of hospital stay, total hospital charges, the crude rate of mechanical ventilation, acute kidney injury requiring hemodialysis, and vasopressor requirement. Hypothesis testing was conducted using the chi-square test for categorical variables and Student's t test for continuous variables. A two-tailed P value of < 0.05 was considered statistically significant. Results: Of the 269,095 hospitalizations identified over 5 years with a discharge diagnosis of DKA, 250,990 met the inclusion criteria. During July and August, 42,668 (17%) hospitalizations occurred, and 208,322 (83%) occurred during the remaining months. The mean age of the patients was 47 years, and there was no significant difference among the cohorts (P = 0.41). Female patients represented 54% of the total patients, and there was no difference between the cohorts (P = 0.68). Of the admitted patients, 61% were White, 21% were Black, and 11% were Hispanic, with no differences between the cohorts (P = 0.38). Medicare (35%) and Medicaid (30%) were the primary payers for most patients, and approximately 25% had private insurance. There were no differences between the cohorts in terms of primary payers (P = 0.49). The mean length of stay was 7 days, and the total hospitalization cost was $85,509. Admission in July or August did not increase the odds of inpatient mortality (adjusted odds ratio 0.96, P = 0.58). Conclusions: In this retrospective cohort study of patients admitted with DKA, inpatient care during July and August did not increase the odds of inpatient mortality.

Gender Disparities in Hypertensive Emergency Admissions: A National Retrospective Cohort Study.

Background Hypertension is one of the most common conditions affecting almost one in every five adults globally and hypertensive emergency is a life-threatening complication of uncontrolled hypertension leading to significant disability. Despite advances in treatment, gender disparities are yet to be addressed. Methods This retrospective cohort study used nationally representative data from the Healthcare Cost and Utilization Project (HCUP), specifically the National Inpatient Sample, to study two cohorts divided by sex (males and females). The primary outcome was all-cause inpatient mortality. Multivariate logistic regression analysis yielded adjusted odds ratios (aORs) for confounders. Secondary outcomes included length of stay (LOS) and total hospital charges. Multivariate linear regression identified independent predictors. We described crude rates of mechanical ventilation, acute kidney injury (AKI) requiring hemodialysis (HD), and vasopressor requirements. Patient demographics were also presented. We used the chi-squared (χ2) test for categorical variables and Student's t-test for continuous variables. Statistical significance was defined as a two-tailed p-value<0.05. Results A total of 229,025 patients met the inclusion criteria, where 52% were male and 48% were female. The mean patient age was 58 years (55 for men and 62 for women, p <0.001). White patients represented 40% of hospitalizations (males: 37%; females: 42%), black patients represented 42% (males: 43%; females: 41%), and Hispanics 11% (males: 12%; females: 10%). Medicare was the primary payer 47% of the time (males: 38%; females: 56%), Medicaid in 21% (males: 23%; females: 18%), private insurance in 20% (males: 23%; females: 17%), and no insurance in 10% (males: 14%; females: 7%). Female patients had higher rates of chronic obstructive pulmonary disease (COPD) (21% for females vs. 15% for males), connective tissue disease (4.6% for females vs. 0.98% for males; p<0.001), and dementia (6% for females vs. 3% for males). Conversely, males had a higher rate of chronic kidney disease (CKD) (51% vs. 42% for females). Male sex was a predictor of mortality (aOR 1.39, p=0.036), along with age (aOR 1.02, p<0.001) and Charlson Comorbidity Index (http://mchp-appserv.cpe.umanitoba.ca/viewConcept.php?printer=Y&conceptID=1098) (aOR 1.20, p<0.001). Sex was not a predictor of length of stay (LOS) (p=0.496) or total hospital charges (p=0.192). Conclusions In an attempt to achieve better outcomes in patients affected by hypertensive emergency, our retrospective cohort study found that male patients who experienced hypertensive emergency had 39% higher odds of mortality than female patients. Age and Charlson Comorbidity Index were additionally found to be independent predictors of mortality.

Characteristics and outcomes of patients with sepsis who had cortisol level measurements or received hydrocortisone during their intensive care unit management: A retrospective single center study.

Objectives: The current guidelines for managing patients with sepsis include the early cultures, administration of antibiotics, and fluid resuscitation. Several clinical trials have tried to determine whether or not the administration of corticosteroids improves outcomes in these patients. This study analyzed the characteristics of a large group of critically ill patients who either had cortisol levels drawn during their intensive care unit management or had hydrocortisone administered during their management. Methods: A list of patients who had cortisol levels measured or who had hydrocortisone administered empirically for the treatment of sepsis was identified by the medical record department at University Medical Center in Lubbock, Texas. The primary outcome was in-hospital mortality. Secondary outcomes included the need for mechanical ventilation, the need for renal replacement therapy, the need for vasopressors, length of stay, and the development of nosocomial infections. Results: This study included 351 patients, including 194 women (55.3%). The mean age was 62.9 ± 16.1 years. The mean admission SOFA score was 9.3 ± 3.63, the mean APACHE 2 score was 18.15 ± 7.7, and the mean lactic acid level was 3.8 ± 4.0 mmol/L. One hundred sixty-two patients required intubation, 262 required vasopressors, 215 developed acute kidney injury, and 319 had cortisol levels measured. The mean length of stay was 11.5 ± 13.7 days; the mortality rate was 32.2%. Multiple variable analysis demonstrated that higher cortisol levels were associated with increased mortality (44.1% if cortisol ⩾20 µg/dL versus 17.5% if cortisol <20 µg/dL). One hundred forty-five patients received corticosteroids, and multivariable analysis demonstrated that these patients had increased mortality (40.0% versus 26.7%). Conclusion: In this study, higher cortisol levels were associated with increased mortality. The administration of hydrocortisone was associated with increased mortality possibly reflecting the use of this medication in patients who had a higher likelihood of poor outcomes.

Novel use of electromagnetic navigation for thoracostomy tube placement.

Management of recurrent pleural effusions can be challenging and may require multiple modalities for treatment. Advanced image guidance with ultrasound or computed tomography is often useful for increased accuracy. We demonstrate a novel application of a percutaneous image-guided technique using electromagnetic navigation to successfully place thoracostomy tubes.

Glucose and Lactate Levels at Admission as Predictors of In-hospital Mortality.

Objective Glucose and lactate levels in patients at the time of admission have been studied in diverse patient groups. Some studies suggest that elevated glucose levels at admission predict worse outcomes. Elevated Lactate levels have also been reported to be directly associated with increased mortality. We wanted to determine if the combination of admission glucose and lactate levels improves the predictability of inpatient mortality and length of stay (LOS). Methods This is a retrospective study. We included all adult patients admitted at an academic medical center from October 1, 2015 to September 30, 2016. We collected basic clinical information, including age, gender, admission glucose and lactate levels, LOS, and mortality. We separated outcomes based on glucose and lactate levels by dividing them into quartiles. We also stratified patients based on normal lactate (<2.0 mmol/L), high lactate (2.0-4.0 mmol/L), and very high lactate (>4 mmol/L) levels; and on normal glucose (60-140 mg/dl), high glucose (140-200 mg/dl), and very high glucose (>200 mg/dl) levels. Results A total of 5,436 adult patients were included in our study. The median age was 58 years, and 57% of the patients were male. The median LOS was 6 days, and the overall in-hospital mortality rate was 11%. When the patients were separated in quartiles based on admission glucose values, mortality was higher in the 4th quartile (≥173 mg/dL): 14.87%, probability value (p): <0.001. When the patients were separated in quartiles based on lactate levels, the mortality was higher in the 4th quartile (≥2.23 mmol/L): 21.95%, p: 0.001. When the patients were paired according to normal, high, or very high lactate and glucose levels, the groups that had higher mortality were as follows: normal glucose/very high lactate: 32.43%; high glucose/very high lactate: 34.04%; and very high glucose and very high lactate: 39.15%. The groups with very high glucose and very high lactate had increased odds of mortality when compared with the other groups (p: <0.001). Conclusions Admission glucose and lactate levels provide useful information in the estimation of inpatient mortality. The LOS was shortened in the groups with higher glucose, lactate, or both. The combination of glucose and lactate levels predicted mortality better than either value alone.

Risk factors and prevention of dabigatran-related gastrointestinal bleeding in patients with atrial fibrillation.

INTRODUCTION: Dabigatran, as compared with warfarin, was associated with lower rates of stroke and systemic embolism with similar rates of major hemorrhage. But it has a significantly higher risk of gastrointestinal bleeding (GIB). There are limited data on how to prevent GIB from dabigatran and what are the risk factors. METHODS: We performed a retrospective cohort study of patients with atrial fibrillation who have ever taken dabigatran for thromboprophylaxis from October 2010 to February 2013. RESULTS: A total of 247 patients were identified. There were 10 (4%) patients who developed GIB (6 (6.5%) in PPI/H2RA users vs 4 (2.6%) in non-PPI/H2RA users; P = .184). History of GIB within 1 year prior to dabigatran initiation and HAS-BLED score ≥3 are independent risk factors for GIB, with odds ratio of 25.14 (95% CI, 2.85-221.47; P < .01) and 5.85 (95% CI, 1.31-26.15; P = .021), respectively. CONCLUSION: In this real-world cohort, PPI/H2RA use was not associated with reduced GIB events. HAS-BLED score ≥3 and prior history of GIB within 1 year are independent risk factors for GIB among dabigatran users.

Disseminated Mycobacterium interjectum Infection with Bacteremia, Hepatic and Pulmonary Involvement Associated with a Long-Term Catheter Infection.

We present a 49-year-old female with one year of intermittent fevers, chills, night sweats, and significant weight loss. Liver and lung biopsy showed evidence of a granulomatous process. Blood and liver biopsy cultures yielded growth of presumed Mycobacterium interjectum, thought to be related to a disseminated long-term central venous catheter infection. She successfully received one year of combined antimicrobial therapy after catheter removal without recurrence of disease. M. interjectum has been previously described as a cause of lymphadenitis in healthy children and associated with pulmonary disease in adults, although other localized infections have been reported. This is the first case described of a disseminated M. interjectum infection with bacteremia, hepatic and pulmonary involvement associated with a long-term catheter infection.

Toxoplasma Infection in an Immunocompetent Host: Possible Risk of Living with Multiple Cats.

A 32-year-old man presented with agitation, headache, and confusion. He was immunocompetent and had been living with multiple cats for many years. His vital signs were stable. He was afebrile. Multiple blood tests did not show any serious problem. Brain magnetic resonance imaging (MRI) revealed multiple ring-enhancing white matter lesions. Cerebrospinal fluid analysis did not show any signs of infection. Based on a presumptive diagnosis of multiple sclerosis, high-dose corticosteroid treatment was started. However, this caused worsening of the symptoms and increased the size of the lesions. Corticosteroids were discontinued and biopsy was done. Biopsy of the lesions confirmed Toxoplasma gondii infection, and treatment with pyrimethamine/sulfadiazine was initiated. Treatment decreased the size of the lesions dramatically. Toxoplasma infection of the central nervous system (CNS) is rare in immunocompetent hosts. Living with multiple cats is believed to be a risk factor for Toxoplasma infection in immunocompetent hosts.

Choriocarcinoma presenting with thyrotoxicosis.

We describe a 26-year-old man with metastatic choriocarcinoma who presented with hyperthyroidism associated with elevated ß-human chorionic gonadotropin (B-HCG) and respiratory failure secondary to diffuse lung metastasis. After the first cycle of chemotherapy, the concentration of B-HCG dramatically decreased and the patient became euthyroid, allowing us to discontinue antithyroid medications. The patient's hyperthyroidism was caused by stimulation of the thyroid gland by high B-HCG levels, as shown by the marked improvement of the patient's thyroid function panel after chemotherapy.

Coccidioidomycosis with diffuse miliary pneumonia.

Coccidioidomycosis is a well-known infection in the southwestern United States, and its occurrence is becoming more frequent in endemic areas. This disease can have a significant economic and medical impact; therefore, accurate diagnosis is crucial. In conjunction with patient symptoms, residence in or travel to an endemic area is essential for diagnosis. Diagnosis is usually made with serology, culture, or biopsy and confirmed with DNA probe technology. Pulmonary disease is the most common presentation and is seen in almost 95% of all cases. One-half to two-thirds of all Coccidioides infections are asymptomatic or subclinical. Most pulmonary infections are self-limited and do not require treatment except in special populations. When treatment is warranted, itraconazole and fluconazole are frequently used. Diffuse miliary pneumonia is uncommon and is especially rare in immunocompetent patients. Herein we describe a rare presentation of miliary coccidioidomycosis in a nonimmunocompromised patient.

High-flow nasal cannula oxygen in adult patients: a narrative review.

High-flow nasal cannula oxygen (HFNC) is a relatively new therapeutic innovation being used in adults with severe respiratory disease. It delivers heated humidified oxygen through short nasal prongs and supplies much higher flow rates than traditional nasal cannula systems. These higher flows match patient flow demands better, reduce anatomic dead space and provide a slightly positive pressure in the upper airway. Randomized trials, nonrandomized prospective trials and case series using HFNC in adults were identified in the PubMed, Google Scholar and Cochrane databases for the period of June 1981 to December 2013. Fifteen studies meeting our inclusion criteria were analyzed; 5 were randomized controlled studies. These studies included 943 patients managed in intensive care units. Common clinical diagnoses included postoperative status, cancer and pneumonia. These studies demonstrated that HFNC provided better or comparable oxygenation when compared with conventional face masks and nasal cannulas. Side effects included epistaxis, nasal discomfort and dryness. No unexpected side effects were reported in the studies reviewed. Current studies demonstrate that HFNC can improve oxygenation adults with hypoxemic respiratory failure. In some patients, it is superior to traditional oxygen delivery systems and may obviate the need for positive pressure ventilation. More studies are needed to compare HFNC with noninvasive ventilation.

High Flow Nasal Cannulas for Oxygenation: An Audit of Its Use in a Tertiary Care Hospital.

BACKGROUND: High flow nasal cannulas (HFNCs) provide humidified oxygen at higher flow rates and higher FiO2s than conventional delivery devices and are typically used in special care units. There is limited information on their use in general hospital settings. METHODS: The medical records of all patients who were treated with HFNC during the calendar year 2014 were retrospectively reviewed to collect information on age, sex, indications, arterial blood gases when available, O2 saturations and outcomes. RESULTS: One hundred six patients received oxygen supplementation by HFNC in their hospital in 2014. The average age was 61.6 ± 16.2 years; 62 patients were men. The indications for HFNC included dyspnea (1 patient), hypoxemic respiratory failure (101 patients) and hypercapneic respiratory failure (4 patients). The PaO2 increased from 68.2 ± 16.3 mm Hg to 83.1 ± 32.2 mm Hg (N = 32, P = 0.02) with the change to HFNC. The O2 saturation increased from 93.1 ± 4.5% to 95.1 ± 3.0% (N = 106, P = 0.00015). The mean duration of use was 4.3 ± 3.7 days. Sixty-five patients did not require intubation or noninvasive ventilation (NIV). Sixteen required NIV, 16 required intubation and 9 required both. The overall mortality was 15%. CONCLUSIONS: HFNC oxygen therapy is used relatively frequently in their hospital on surgical and medical services. PaO2s and O2 saturations improved when patients were switched to this mode of oxygenation, but some patients subsequently required NIV and/or intubation. Patients on HFNC need careful monitoring for deterioration in their respiratory status.

Carcinoma of the lungs causing enlarged kidneys.

Bilateral enlarged kidneys can be caused by a number of conditions. Renal metastasis is included in the differential diagnosis. We report a case of a 67-year-old woman with a 6-month history of productive cough and unintentional weight loss. Cavitary pulmonary lesions and bilateral enlarged kidneys were noted on imaging studies. Hematuria, azotemia, and proteinuria were present. Renal biopsy showed squamous carcinoma cells invading normal-appearing glomeruli and atrophic tubules. The invasive squamous cells stained negative for CK7 and CK 20. Lung biopsy confirmed squamous cell carcinoma. Our case shows that in patients with renal enlargement, even with the absence of a focal mass, renal metastasis should be considered, especially in those with suspected or diagnosed malignancy elsewhere.

Newly diagnosed acromegaly presenting with hypertriglyceridemic pancreatitis with normal amylase and lipase levels.

The incidence of hypertriglyceridemia in acromegaly is three times higher than in the normal population, and it is the most common dyslipidemia in acromegaly. We present a case of hypertriglyceridemic pancreatitis confirmed by imaging, with normal pancreatic enzymes. Hypertriglyceridemia in this patient was likely secondary to acromegaly. The hypertriglyceridemic pancreatitis appears to be secondary to somatotrophic pituitary adenoma.