Impact of cardiac troponin release and fluid resuscitation on outcomes of patients with sepsis.

BACKGROUND: Septic patients are predisposed to myocardial injury manifested as cardiac troponin release (TnR). Prognostic significance and management implications of TnR and its relationship to fluid resuscitation and outcomes in the intensive care unit (ICU) setting has not been fully elucidated. METHODS: A total of 24,778 patients with sepsis from eICU-CRD, MIMIC-III and MIMIC-IV databases were included in this retrospective study. In-hospital mortality and one-year survival were examined using multivariable regression analysis and Kaplan-Meier survival analysis with overlap weighting adjustment, as well as generalized additive models for fluid resuscitation. RESULTS: TnR on admission was associated with higher in-hospital mortality [adjusted odds ratios (OR) = 1.33; 95% confidence interval (CI) = 1.23-1.43; p < 0.001 in unweighted analysis and adjusted OR = 1.39; 95% CI = 1.29-1.50; P < 0.001 with overlap weighting]. One-year mortality was higher in patients with admission TnR (P = 0.002). A trend was noted for association between admission TnR and 1-year mortality [adjusted OR = 1.16; 95% CI = 0.99-1.37; P = 0.067 in unweighted analysis] while the association was statistically significant after overlap weighting (adjusted OR = 1.25; 95% CI = 1.06-1.47; P = 0.008). Patients with admission TnR were less likely to benefit from more liberal fluid resuscitation. Adequate fluid resuscitation (80 ml/kg in the first 24 h of ICU stay) was associated with lower in-hospital mortality in septic patients without TnR but not in those with admission TnR. CONCLUSIONS: Admission TnR is significantly associated with higher in-hospital mortality and 1-year mortality among septic patients. Adequate fluid resuscitation improves in-hospital mortality in septic patients without but not with admission TnR.

Is metformin use associated with low mortality in patients with type 2 diabetes mellitus hospitalized for COVID-19? a multivariable and propensity score-adjusted meta-analysis.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a new pandemic that the entire world is facing since December of 2019. Increasing evidence has shown that metformin is linked to favorable outcomes in patients with COVID-19. The aim of this study was to address whether outpatient or inpatient metformin therapy for type 2 diabetes mellitus is associated with low in-hospital mortality in patients hospitalized for COVID-19. METHODS: We searched studies published in PubMed, Embase, Google Scholar and Cochrane Library up to November 1, 2022. Raw event data extracted from individual study were pooled using the Mantel-Haenszel approach. Odds ratio (OR) or hazard ratio (HR) adjusted for covariates that potentially confound the association using multivariable regression or propensity score matching was pooled by the inverse-variance method. Random effect models were applied for meta-analysis due to variance among studies. RESULTS: Twenty-two retrospective observational studies were selected. The pooled unadjusted OR for outpatient metformin therapy and in-hospital mortality was 0.48 (95% CI, 0.37-0.62) and the pooled OR adjusted with multivariable regression or propensity score matching was 0.71 (95% CI, 0.50-0.99). The pooled unadjusted OR for inpatient metformin therapy and in-hospital mortality was 0.18 (95% CI, 0.10-0.31), whereas the pooled adjusted HR was 1.10 (95% CI, 0.38-3.15). CONCLUSIONS: Our results suggest that there is a significant association between the reduction of in-hospital mortality and outpatient metformin therapy for type 2 diabetes mellitus in patients hospitalized for COVID-19.

Kounis Syndrome: An Allergic Acute Coronary Syndrome Due to a Bee Sting.

Kounis syndrome, also known as allergic acute coronary syndrome, is defined as the occurrence of acute coronary syndrome (ACS) in the setting of an allergic or hypersensitivity reaction. Although Kounis syndrome is not an uncommon disease, many cases go undiagnosed or unrecognized. Patients with systemic allergic reactions associated with evidence of ACS should be suspected of Kounis syndrome because the outcome could be devastating if not treated promptly. The physician must be aware of Kounis syndrome because the treatment modality differs from traditional ACS.

Warfarin sensitivity is associated with increased hospital mortality in critically Ill patients.

BACKGROUND: Warfarin is a widely used anticoagulant with a narrow therapeutic index and large interpatient variability in the therapeutic dose. Warfarin sensitivity has been reported to be associated with increased incidence of international normalized ratio (INR) > 5. However, whether warfarin sensitivity is a risk factor for adverse outcomes in critically ill patients remains unknown. In the present study, we aimed to evaluate the utility of different machine learning algorithms for the prediction of warfarin sensitivity and to determine the impact of warfarin sensitivity on outcomes in critically ill patients. METHODS: Nine different machine learning algorithms for the prediction of warfarin sensitivity were tested in the International Warfarin Pharmacogenetic Consortium cohort and Easton cohort. Furthermore, a total of 7,647 critically ill patients was analyzed for warfarin sensitivity on in-hospital mortality by multivariable regression. Covariates that potentially confound the association were further adjusted using propensity score matching or inverse probability of treatment weighting. RESULTS: We found that logistic regression (AUC = 0.879, 95% CI: 0.834-0.924) was indistinguishable from support vector machine with a linear kernel, neural network, AdaBoost and light gradient boosting trees, and significantly outperformed all the other machine learning algorithms. Furthermore, we found that warfarin sensitivity predicted by the logistic regression model was significantly associated with worse in-hospital mortality in critically ill patients with an odds ratio (OR) of 1.33 (95% CI, 1.01-1.77). CONCLUSIONS: Our data suggest that the logistic regression model is the best model for the prediction of warfarin sensitivity clinically and that warfarin sensitivity is likely to be a risk factor for adverse outcomes in critically ill patients.

Metformin is associated with favorable outcomes in patients with COVID-19 and type 2 diabetes mellitus.

Coronavirus disease 2019 (COVID-19) is a new pandemic the entire world is facing since December of 2019. Several risk factors are identified in developing severe disease and one of which is preexisting type 2 diabetes mellitus. Metformin is known to have host-directed anti-viral and anti-inflammatory properties. However, whether these effects offer lower mortality remains unclear. In this retrospective study, we aim to address whether metformin use prior to admission decreases mortality in patients with COVID-19 and pre-existing type 2 diabetes mellitus. A total of 1356 hospitalized patients with COVID-19 and pre-existing type 2 diabetes mellitus was analyzed by multivariable regression. Covariates that potentially confound the association were further adjusted using propensity score matching or inverse probability of treatment weighting. We found that metformin therapy prior to admission in patients with COVID-19 and type 2 diabetes mellitus was significantly associated with less primary outcome events including in-hospital mortality and hospice care enrollment with an odds ratio (OR) of 0.25 (95% CI 0.06-0.74) and less in-hospital length of stay, compared to the non-metformin group. Our results provide supporting evidence that metformin may confer increased survival in patients with COVID-19 and type 2 diabetes mellitus treated with metformin prior to hospitalization.

Colon stenting in benign diverticular stricture - a case report and review of literature.

Background: Colonic stricture is a feared complication with varied etiology ranging from malignant obstruction to benign diseases. One such condition is recurrent diverticulitis-related strictures. Objectives & Methods: We report a case of a 48-year-old male patient with stricture of the sigmoid colon. The patient refused Sigmoid colon resection. He underwent stent placement and Two weeks later presented with constipation and abdominal discomfort. On Computed Tomography (CT) we discovered stent migration and consequent large bowel obstruction. Patient agreed on undergoing sigmoidectomy with a colostomy. Conclusion: Indication of SEMS for benign lesions remains unclear. Based on the current data, in benign colorectal obstructive lesions, SEMS is a viable option as a bridge to surgery when no other alternative option is available. However, the ASCRS 2020 guidelines did not point to SEMS as an option given the high rate of complications. Our patient was treated with a stent because he refused the resection surgery and found relief for a certain period before developing stent migration. Hence, the patients should be educated about the short and long-term potential effects of stenting before performing the procedure in benign strictures.

Wernicke's encephalopathy mimicking multiple sclerosis in a young female patient post-bariatric gastric sleeve surgery.

We describe a case of Wernicke's encephalopathy secondary to thiamine (B1) deficiency in a patient status post-bariatric sleeve gastrectomy. The presenting symptoms of new-onset weakness, diplopia, and confusion in a young female patient raised suspicion for multiple sclerosis (MS), but given a history of bariatric surgery, thiamine levels were checked, revealing significant Vitamin B1 (thiamine) deficiency. This case highlights the importance of thorough history taking, as a misdiagnosis of MS in this case could have resulted in irreversible neurological deterioration and hematological and infectious consequences associated with the inappropriate administration of disease-modifying therapies. It is also important to note that severe vitamin deficiency occurred despite medication compliance.

An unusual infection in an immunocompetent male from a non-endemic area: Lessons from a vacation.

Primary pulmonary histoplasmosis is found worldwide, and is particularly endemic in some areas of North America, usually those surrounding the Ohio and Mississippi river valleys. It is not common in the East Coast of the United States, and is in fact reportable in Pennsylvania. It has been rarely described in immunocompetent individuals residing in a non-endemic region. We present a case of a previously healthy middle-aged male, a Pennsylvania resident, who presented with mid-sternal chest discomfort, fatigue, chills and mild shortness of breath, and was diagnosed with primary pulmonary histoplasmosis.

Where there is sodium there may be sepsis.

Hypernatremia affects up to 9% of critically ill patients upon hospital admission, especially in elderly patients with thirst impairment. However, hypernatremia is not entirely explained by fluid imbalance. Recent studies suggest that sodium is an important enhancer of the immune system, raising the question of whether inflammatory states such as sepsis may contribute to hypernatremia. Although sepsis patients with hypernatremia face a greater mortality rate, there is a lack of studies examining a potential association between hypernatremia and sepsis. Motivated by the frequent concurrence of hypernatremia and sepsis observed at an eastern Pennsylvanian community hospital, the current study was conducted to evaluate whether hypernatremia on admission may serve as a potential surrogate marker for sepsis. The medical records of 153 patients with hypernatremia on admission (serum sodium > 145mEq/L) were retrospectively analyzed. The mean age of patients was 81.1. Sepsis was observed in 77.1% of patients, of which 86.2% had dementia. This study demonstrated a positive correlation between hypernatremia on admission and the presence of sepsis. We suggest that the existence of hypernatremia should prompt clinicians to further investigate for sources of infection, especially in the elderly and patients with dementia.

Critical Illness Associated Fatal Hypoglycemia in a Nondiabetic Male.

We present here the case of a 55-year-old male who presented to the emergency department with severe abdominal pain and respiratory distress secondary to mesenteric ischemia. His critical illness on preexisting chronic kidney disease, previously undiagnosed alcoholic cirrhosis, and congestive heart failure led to a rare yet fatal consequence of refractory hypoglycemia. Critical illness associated hypoglycemia generally occurs as a result of high metabolic consumption with relative insulin excess and insufficient nutritional intake that is seen frequently in critically ill patients. This, along with reduced hepatic and renal gluconeogenesis seen in preexisting liver and renal disease, can cumulate to life-threatening hypoglycemia and is seen as a poor prognostic factor in the ICU setting.

Triglyceride Levels Greater Than 10,000 mg/dL in a 49-Year-Old Female without Evidence of Pancreatitis.

We present a rare case of a 49-year-old female with very severe hypertriglyceridemia (HTG) having a total triglyceride (TG) count of > 10,000 mg/dL in the absence of pancreatitis. Based on literature review, this is one of the highest recorded TG counts in an adult without evidence of pancreatitis. HTG is a common occurrence in clinical practice, but rarely do numbers exceed 2000 mg/dl. It is crucial to evaluate and rapidly lower TG levels to prevent potentially life-threatening complications such as severe pancreatitis. Removal of potential predisposing medications, control of underlying diseases known to cause HTG, and maintenance therapies are essential to prevent reoccurrence.

Incidental descending thoracic aortic thrombus: the conundrum of medical versus surgical therapy.

Background: A mural thrombus in the descending thoracic aorta frequently leads to distal organ and acute limb ischemia, increasing overall morbidity and mortality. Early diagnosis is imperative as thrombi are usually discovered after end organ damage has taken place. The formation of a mural thrombus in descending aorta has not been fully explained; however, the principle of Virchow's triad for thrombogenesis (hypercoagulability, stasis of blood flow and endothelial injury) remains the likely pathophysiologic mechanism. Case Presentation: We present a case of a descending aortic thrombus incidentally detected on computed tomography scan in a 65-year-old female and successfully treated with anticoagulation, preventing subsequent complications. Conclusions: Suspicion for an aortic thrombus should arise when the origin is not known for acute onset distal limb or organ ischemia.

Left lower quadrant pain: an unlikely diagnosis in a case of acute abdomen.

Splenic infarct is an incredibly rare diagnosis for abdominal pain. One study involving two hospitals over ten years describes only 0.0037% of all hospital admissions presenting with splenic infarction. Our report describes a case of massive splenomegaly causing pain in a different location compared to the normal anatomical location of the spleen with an unexpected cause, lymphoma. High clinical suspicion for lymphoma as a cause of splenic infarction is critical because this disease can otherwise be clinically silent. This case emphasizes the importance of a thorough clinical workup and persistence in diagnostic pursuit.

Palpitations as a presenting feature of multisystem sarcoidosis.

Introduction: Sarcoidosis is described as a systemic condition characterized by non-caseating granulomas in multiple organs. In this report, we present an unusual manifestation of cardiac sarcoidosis and review management strategies. Case presentation: A 29-year-old African-American man presented with weight loss, fatigue, dyspnea, palpitations, night sweats, painless left eye redness and bilateral leg pain over the course of three months. His physical exam revealed left conjunctival congestion and bilateral crackles on auscultation. Computerized tomography of the chest showed severe parenchymal disease with bilateral fibrotic bands. Bronchoscopy and transbronchial biopsy revealed noncaseating granulomas and multinucleated giant cells, confirming sarcoidosis. Non-sustained ventricular tachycardia developed. Cardiac MRI showed myocardial delayed gadolinium enhancement. He responded to methotrexate and steroid therapy. An implantable cardioverter-defibrillator was placed. Discussion: Although cardiac sarcoidosis manifests in only 5% of sarcoidosis, autopsy reports indicate subclinical cardiac involvement in up to 30%. There are no established criteria for diagnosis of cardiac sarcoidosis. Conclusion: Early recognition and diagnosis of cardiac sarcoidosis is challenging but vital due to unpredictability and high risk for malignant cardiac involvement. Newer diagnostic imaging modalities have further aided in earlier identification and prevention of sudden cardiac death.

Necessity is the mother of invention: an innovative hospitalist-resident initiative for improving quality and reducing readmissions from skilled nursing facilities.

Background: Hospital readmissions have been a major challenge to the US health system. Medicare data shows that approximately 25% of Medicare skilled nursing facility (SNF) residents are readmitted back to the hospital within 30 days. Some of the major reasons for high readmission rates include fragmented information exchange during transitions of care and limited access to physicians round-the-clock in SNFs. These represent safety, quality, and health outcome concerns. Aim: The goal of the project was to reduce hospital readmission rates from SNFs by improving transition of care and increasing physician availability in SNFs (five to seven days a week physical presence with 24/7 accessibility by phone). Methods: We proposed a model whereby a hospitalist-led team, including the resident on the geriatrics rotation, followed patients discharged from the hospital to one SNF. Readmission rates pre- and post-implementation were compared. Study results: The period between January 2014 and June 2014 served as the baseline and showed readmission rate of 32.32% from the SNF back to the hospital. After we implemented the new hospitalist SNF model in June 2014, readmission rates decreased to 23.96% between July 2014 and December 2014. From January 2015 to June 2015, the overall readmission rate from the SNF reduced further to 16.06%. Statistical analysis revealed a post-intervention odds ratio of 0.403 (p < 0.001). Conclusion: The government is piloting several care models that incentivize value- based behavior. Our study strongly suggests that the hospitalist-resident continuity model of following patients to the SNFs can significantly decrease 30-days hospital readmission rates.

Reducing Error in Anticoagulant Dosing via Multidisciplinary Team Rounding at Point of Care.

The incorporation of a clinical pharmacist in daily rounding can help identify and correct errors related to anticoagulation dosing. Inappropriate anticoagulant dosing increases the risk of developing significant bleeding diathesis. Conversely, inappropriate dosing may also fail to produce a therapeutic response. We retrospectively reviewed electronic medical records of 41 patients to confirm and analyze the errors related to various anticoagulants. A clinical pharmacist in an integrated rounding between the period of February 2016 and April 2016 collected this data. We concluded that integrated rounding improves patient safety by recognizing anticoagulant dosage error used for the purpose of prophylaxis or treatment. It also allows us to make dose adjustments based on renal function of the patient. We think that it is prudent for physicians to pay particular attention to creatinine clearance when dosing anticoagulants in order to achieve the intended dosing effect and reduce the risk of adverse drug events.

Lyme disease presenting with facial palsy and myocarditis mimicking myocardial infarction.

A 45-year-old woman presented with a sudden episode of typical chest pain, radiating to her neck. The patient denied premature coronary artery disease in the family. Initial EKG showed normal sinus rhythm with a 1 mm ST-elevation involving lead II and lead aVF and a 1 mm ST-depression in lead V1 with associated T-wave inversion. Initial Troponin I (normal <0.4 ng/mL) and CK-MB (normal <7.7 ng/mL) were elevated at 7.82 ng/mL and 55.2 ng/mL, respectively. Six hours later, Troponin I increased to 13.44 ng/mL and CK-MB to 75.7 ng/mL. The patient underwent cardiac catheterization which did not show any significant obstructive coronary artery disease. Two days later the patient developed right-sided facial palsy. Diagnosis of Lyme disease was confirmed by ELISA with positive IgM and IgG antibodies. Treatment with intravenous ceftriaxone and oral steroids was started. Eventually resolution of symptoms and, normalization of cardiac markers and EKG changes, were achieved. This is a rare case of Lyme myocarditis associated with markedly elevated Troponin I, normal left ventricle function, and an absence of conduction abnormalities. To the best of our knowledge, Lyme myocarditis mimicking acute coronary syndrome with such high levels of Troponin I and neurologic compromise has not been previously described. Lyme myocarditis may be a challenging diagnosis in endemic areas especially in patients with coronary artery disease risk factors, presenting with typical chest pain, EKG changes and positive cardiac biomarkers. Therefore, it should be considered a differential diagnosis in patients presenting with clinical symptoms suggestive of acute coronary syndrome. Abbreviations AV: Atrioventricular; CK-MB: Creatinine Kinase-MB; EKG: Electrocardiogram; ELISA: Enzyme-Linked Immunosorbent Assay; IgG: Immunoglobulin G; IgM: Immunoglobulin M.

Necessity is the mother of invention: an innovative hospitalist-resident initiative for improving quality and reducing readmissions from skilled nursing facilities

Background: Hospital readmissions have been a major challenge to the US health system. Medicare data shows that approximately 25% of Medicare skilled nursing facility (SNF) residents are readmitted back to the hospital within 30 days. Some of the major reasons for high readmission rates include fragmented information exchange during transitions of care and limited access to physicians round-the-clock in SNFs. These represent safety, quality, and health outcome concerns. Aim: The goal of the project was to reduce hospital readmission rates from SNFs by improving transition of care and increasing physician availability in SNFs (five to seven days a week physical presence with 24/7 accessibility by phone). Methods: We proposed a model whereby a hospitalist-led team, including the resident on the geriatrics rotation, followed patients discharged from the hospital to one SNF. Readmission rates pre- and post-implementation were compared. Study results: The period between January 2014 and June 2014 served as the baseline and showed readmission rate of 32.32% from the SNF back to the hospital. After we implemented the new hospitalist SNF model in June 2014, readmission rates decreased to 23.96% between July 2014 and December 2014. From January 2015 to June 2015, the overall readmission rate from the SNF reduced further to 16.06%. Statistical analysis revealed a post-intervention odds ratio of 0.403 (p < 0.001). Conclusion: The government is piloting several care models that incentivize value- based behavior. Our study strongly suggests that the hospitalist-resident continuity model of following patients to the SNFs can significantly decrease 30-days hospital readmission rates.(AU)

Thyroid storm presenting as psychosis: masked by diabetic ketoacidosis.

INTRODUCTION: While extremely uncommon, diabetic ketoacidosis (DKA) and thyroid storm (TS) are endocrine emergencies that can coexist. We describe a case with a confounding clinical presentation that identifies these two emergencies within the setting of sepsis and influenza. CASE: A 69-year-old diabetic female was found by the paramedic staff to be disoriented. She demonstrated tachycardia and had a foul-smelling abdominal wound. Laboratory evaluation revealed DKA, leukocytosis, influenza B, and urinary tract infection. After appropriate management in the intensive care unit, the DKA resolved the following morning. However, the patient developed a fever, and her psychosis became more pronounced. Extensive analysis was performed but did not explain her mental status. The patient was found to have thyroid stimulating hormone of 0.06 mIU/mL, free T4 (thyroxine) of 2.38 ng/dL, and total T3 (triiodothyronine) of 72 ng/dL. Based on the Burch and Wartofsky criteria (score of 65), TS was diagnosed. Based on more recent diagnostic criteria suggested by Akamizu et al., the patient met criteria for TS grade 1. Within several hours of initiating treatment, the patient's mental state and tachycardia improved, and her psychosis resolved by the third day. CONCLUSION: This case highlights the importance of recognizing the clinical diagnosis of TS, as the magnitude of thyroid hormone derangements may not correlate with clinical severity. While rare, DKA and TS can simultaneously occur and are associated with increased morbidity and mortality if not promptly recognized and treated.