ST elevation myocardial infarction - national trend analysis with mortality differences in outcomes based on day of hospitalization.

BACKGROUND: Patientswho present with acute ST elevation myocardial infarction (STEMI) need emergent revascularization. Our study aims to investigate the outcomes in patients with STEMI admitted during weekends versus weekdays. METHODS: We conducted a retrospective analysis of the nationwide inpatient sample database. Patients with an admitting diagnosis of STEMI identified by the International Classification of Disease code for the year 2016 were analyzed. A weighted descriptive analysis was performed to generate national estimates. Patients admitted over the weekend were compared to those admitted over the weekday. Patients were stratified by demographic and clinical factors including the Elixhauser comorbidity index. The primary outcome was in-hospital mortality and secondary outcomes were percutaneous coronary intervention (PCI) utilization rate, rate of transfer-out, length of stay (LOS), and total hospital charges. Statistical analysis including linear and logistic regression was performed using STATA. RESULTS: A total of 163 715 adult patients were admitted with STEMI, of which 27.9% (45 635) were admitted over the weekend. There were 76.2% Caucasians, 9.3% African Americans, and 8.0% Hispanics. Mean age of the patients was 63.2 years (95% CI, 62.9-63.5) for the weekend group and 63.7 years (95% CI, 63.5-63.9) for weekday admissions. The majority of the patients in both groups had Medicare (43.7% and 45.8% on weekends and weekdays, respectively; P = 0.0047). After adjusting for age, sex, race, income, Elixhauser comorbidity index, PCI use, hospital location, teaching status, and bed size, mortality was not significantly different in weekend versus weekday admissions (odds ratios 1.04; P = 0.498; 95% CI, 0.93-1.16). There was no significant difference in mean total charge per admission during the weekend versus weekday admissions ($107 093 versus $106 869; P = 0.99.) Mean LOS was 4.1 days for both groups (P = 0.81). CONCLUSIONS: There were no significant differences in mortality, LOS, or total hospital charge in STEMI patients being admitted during the weekend versus weekdays.

Thirty-day readmission in patients with heart failure with preserved ejection fraction: Insights from the nationwide readmission database.

BACKGROUND: There are rising numbers of patients who have heart failure with preserved ejection fraction (HFpEF). Poorly understood pathophysiology of heart failure with preserved and reduced ejection fraction and due to a sparsity of studies, the management of HFpEF is challenging. AIM: To determine the hospital readmission rate within 30 d of acute or acute on chronic heart failure with preserved ejection fraction and its effect on mortality and burden on health care in the United States. METHODS: We performed a retrospective study using the Agency for Health-care Research and Quality Health-care Cost and Utilization Project, Nationwide Readmissions Database for the year 2017. We collected data on hospital readmissions of 60514 adults hospitalized for acute or acute on chronic HFpEF. The primary outcome was the rate of all-cause readmission within 30 d of discharge. Secondary outcomes were cause of readmission, mortality rate in readmitted and index patients, length of stay, total hospitalization costs and charges. Independent risk factors for readmission were identified using Cox regression analysis. RESULTS: The thirty day readmission rate was 21%. Approximately 9.17% of readmissions were in the setting of acute on chronic diastolic heart failure. Hypertensive chronic kidney disease with heart failure (1245; 9.7%) was the most common readmission diagnosis. Readmitted patients had higher in-hospital mortality (7.9% vs 2.9%, P = 0.000). Our study showed that Medicaid insurance, higher Charlson co-morbidity score, patient admitted to a teaching hospital and longer hospital stay were significant variables associated with higher readmission rates. Lower readmission rate was found in residents of small metropolitan or micropolitan areas, older age, female gender, and private insurance or no insurance were associated with lower risk of readmission. CONCLUSION: We found that patients hospitalized for acute or acute on chronic HFpEF, the thirty day readmission rate was 21%. Readmission cases had a higher mortality rate and increased healthcare resource utilization. The most common cause of readmission was cardio-renal syndrome.

Outcomes and Utilization of Therapeutic Hypothermia in Post-Cardiac Arrest Patients in Teaching Versus Non-Teaching Hospitals: Retrospective Study of the Nationwide Inpatient Sample Database (2016).

Background Using therapeutic hypothermia (TH) reduces the core body temperature of survivors of cardiac arrest to minimize the neurological damage caused by severe hypoxia. The TH protocol is initiated following return of spontaneous circulation (ROSC) in non-responsive patients. Clinical trials examining this technique have shown significant improvement in neurological function among survivors of cardiac arrests. Though there is strong evidence to support TH use to improve the neurologic outcomes in shockable and nonshockable rhythms, predictors of TH utilization are not well-characterized. Our study tried to evaluate TH utilization, as well as the effect of the teaching status of hospitals, on outcomes, including mortality, length of stay, and total hospitalization charges. Method We conducted a retrospective analysis of the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS) database. Patients with an admitting diagnosis of cardiac arrest, as identified by the corresponding International Classification of Disease, 10th Revision (ICD-10) code for the year 2016 were analyzed. In addition, we identified TH using the ICD-10 procedure code. A weighted descriptive analysis was performed to generate national estimates. Groups of patients admitted to teaching hospitals were compared to those admitted in non-teaching hospitals. Patients were stratified by age, sex, race, and demographic and clinical data, including the Charlson Comorbidity Index (CCI), for these two groups, and statistical analysis was done for the primary outcome, in-hospital mortality, as well as the secondary outcomes, including length of stay (LOS) and total hospitalization charges. Fisher's exact test was used to compare proportions and student's t-test for continuous variables. Statistical analysis was completed by linear regression analysis. Results A total of 13,780 patients met the inclusion criteria for cardiac arrest admission. The number of patients with cardiac arrest admitted to a teaching hospital was 9285. A total of 670 patients received TH, with 495 admissions to teaching hospitals. The population of females in the hypothermia group was 270. The mean age of patients received TH was 59.4 years. In patients who received TH, 65% were Caucasians followed by Hispanics (16%), with no significant statistical racial differences in groups (p=0.30). The majority of patients with TH in both groups (teaching vs. non-teaching admissions) had Medicare (58.8% vs 49.5%; p=0.75). Hospitals in the southern region had the most admissions in both groups (45.7% and 31.3%), with the northeast region having the least non-teaching hospital admissions (8.5%) and approximately similar teaching hospital admissions in other regions (~22%) (p=0.27). The total number of deaths in this group was 510, out of which 370 were in a teaching hospital. After adjusting for age, sex, race, income, the CCI, hospital location, and bed size, mortality was not significantly different between these two groups (p=0.797). We found increased LOS in patients admitted to teaching hospitals (p=0.021). With a p-value of 0.097, there were no differences in total hospitalization charges in both groups. Conclusion There were no significant differences in mortality or total hospitalization charge between patients admitted with cardiac arrest to a teaching hospital and received TH as compared to a non-teaching hospital although patients admitted to teaching hospitals stayed longer.

Bilateral Earlobe Crease as a Marker of Premature Coronary Artery Disease.

Cardiovascular diseases, including heart disease and stroke, are the world's largest killers. More than 800,000 people die from cardiovascular disease each year in the United States (US). Heart disease is estimated to cost 200 billion US Dollars (USD) annually. Early identification of an inexpensive marker which allows for early intervention is the need of the hour. We present a case describing one such marker which can be easily appreciated on physical examination. Several studies have shown, not only the association between the presence of the diagonal earlobe crease (DELC) and coronary artery disease (CAD) but also a correlation with the extent and severity of CAD, independent of cardiovascular risk factors. Our patient who had no known CAD or risk factors presented with an acute coronary syndrome (ACS). On exam, he was noted to have bilateral DELC. Over the course of his workup, he was noted to have severe triple vessel disease and eventually underwent surgical revascularization. We seek to increase awareness of this valuable physical sign which has far-reaching consequences in the prognostication and risk stratification of patients.

Lyme Meningoencephalitis Masquerading as Normal Pressure Hydrocephalus.

Lyme disease is a tick-borne illness caused primarily by the spirochete Borrelia burgdorferi. The disease is most prevalent in forested areas endemic for Ixodes tick, which transmits the spirochete. Here, we describe a case of Lyme meningoencephalitis masquerading as normal pressure hydrocephalus (NPH) which initially presented with urinary incontinence, gait instability, and neurological decline. Due to its non-specific symptoms and low incidence, Lyme meningoencephalitis causing NPH like syndrome poses a diagnostic conundrum for clinicians. Awareness of this disease entity is key for prompt diagnosis and treatment.

Abdominal Angina Treated by Urgent Percutaneous Angioplasty: An Excellent Alternative to Surgical Revascularisation.

Chronic Mesenteric Ischemia (CMI) presenting as acute abdomen can be treated percutaneously. An endovascular intervention has surpassed surgical revascularization over the past decade due to its lesser perioperative complication rate. Trans-femoral approach of revascularising is limited by its difficulty in coaxial alignment of the guiding catheter and hence, brachial artery and recently the radial approach have been utilized for mesenteric artery revascularisation for over a decade. Here by we report a case of chronic mesenteric ischemia having total occlusion of two and 70% occlusion of one of the three mesenteric vessels. The patient had presented with acute abdomen which in turn was percutaneously revascularised via the left brachial artery for the two major abdominal visceral vessels being superior mesenteric artery and inferior mesenteric artery.