The Ultrasound Hepato-Jugular Reflux: Measuring the Hepato-Jugular Reflux with Ultrasound with Comparison to Invasive Right Heart Catheterization.

BACKGROUND: Ultrasound can overcome barriers to visualizing the internal jugular vein, allowing hepato-jugular reflux and jugular venous pressure measurement. We aimed to determine operating characteristics of the ultrasound hepato-jugular reflux and ultrasound jugular venous pressure predicting right atrial and pulmonary capillary occlusion pressures. METHODS: In a prospective observational cohort at three US academic hospitals the hepato-jugular reflux and jugular venous pressure were measured with ultrasound before right heart catheterization. Receiver operating curves, likelihood ratios, and regression models were utilized to compare the ultrasound hepato-jugular reflux and ultrasound jugular venous pressure to the right atrial and pulmonary capillary occlusion pressures. RESULTS: In 99 adults undergoing right heart catheterization, an ultrasound hepato-jugular reflux had a negative likelihood ratio of 0.4 if 0 cm and a positive likelihood ratio of 4.3 if ≥ 1.5 cm for predicting a pulmonary capillary occlusion pressure ≥ 15 mmHg. Regression modeling predicting pulmonary capillary occlusion pressure was not only improved by including the ultrasound hepato-jugular reflux (P < .001), it was the more impactful predictor compared with the ultrasound jugular venous pressure (adjusted odds ratio 2.6 vs 1.2). The ultrasound hepato-jugular reflux showed substantial agreement (kappa 0.76; 95% confidence interval, 0.30-1.21), with poor agreement for the ultrasound jugular venous pressure (kappa 0.11; 95% confidence interval, -0.37-0.58). CONCLUSION: In patients undergoing right heart catheterization, the ultrasound hepato-jugular reflux is reproducible, has modest impact on the probability of a normal pulmonary capillary occlusion pressure when 0 cm, and more substantial impact on the probability of an elevated pulmonary capillary occlusion pressure when ≥ 1.5 cm.

Prime time for chronic kidney disease.

Chronic kidney disease (CKD) represents a public health burden worldwide and is associated with significant morbidity and mortality. Most patients with CKD are managed by primary care practitioners and this educational series hope to improve knowledge and delivery of care to this high-risk patient population with CKD.

Diagnostic dilemma: drug-induced vasculitis versus systemic vasculitis.

Drug-induced vasculitis can rarely cause inflammation and necrosis of blood vessel walls of both kidney and lung tissue. Diagnosis is challenging because of the lack of difference between systemic and drug-induced vasculitis in clinical presentation, immunological workup and pathological findings. Tissue biopsy guides diagnosis and treatment. Pathological findings must be correlated with clinical information to arrive at a presumed diagnosis of drug-induced vasculitis. We present a patient with hydralazine-induced antineutrophil cytoplasmic antibodies-positive vasculitis with a pulmonary-renal syndrome manifesting as pauci-immune glomerulonephritis and alveolar haemorrhage.

Spontaneous Retroperitoneal Hematoma in Vitamin C Deficiency.

Retroperitoneal hematoma is rare but potentially life-threatening. It is commonly caused by traumatic or iatrogenic vascular injury, retroperitoneal neoplasm, coagulopathy, chronic anticoagulation, or fibrinolytic therapy. However, retroperitoneal hematoma due to vitamin C deficiency is rare. Here, we report a case of 40 years old man who developed retroperitoneal hematoma in context of very low vitamin C. To our knowledge, this is the second described case of retroperitoneal hematoma from vitamin C deficiency.

The Effect of Race and Socioeconomic Status on Hospitalized Patients with COVID-19 Infection.

Background: There have been varying impacts of COVID-19 on racial, ethnic, and socioeconomic communities in the US. Recent literature suggests that Black Americans have the highest unadjusted and adjusted mortality rates from COVID-19, while White Americans have the lowest unadjusted and adjusted rates. However, the role of socioeconomic status and comorbidities in these disparities in health outcomes from COVID-19 are unclear. Thus, the purpose of this study is to evaluate how socioeconomic status and race impact COVID-19 outcomes in patients hospitalized with COVID-19 in a large health care system in the Mid-Atlantic region. Material and methods: We retrospectively analyzed the association of COVID-19 outcomes and race, ethnicity, and socioeconomic status using electronic medical records and the REDCap database from the time period of March 5, 2020 to June 3, 2020. The outcomes evaluated were intubation, ICU admission, and discharge destination. Multivariate logistic regression analysis was then performed to examine whether race and socioeconomic status were independent risk factors of mortality controlling for age, Charlson comorbidity index (CCI), and comorbidities. Results: Race was not found to be an independent predictor for COVID-19 inpatient mortality. Race was found to be an independent risk factor for ICU admission with odds of ICU admission for Black patients to be 1.5 times higher (odds ratio (OR) 1.4 1.07 to 2.04) compared to Non-Black/Non-White (72.4% identifying as Hispanic) but no difference between Black and White races. Race was found not to be an independent risk factor for intubation nor was race an independent risk factor for increased length of ICU LOS, hospital LOS or intubation days. Socioeconomic status was not an independent risk factor for inpatient mortality although high income groups were significantly less likely to be admitted to the ICU compared to middle income patients. Conclusion: Our cohort of patients in a large mid-Atlantic health system showed that there was no statistically significant difference between race or socioeconomic status and COVID-19 related inpatient mortality. However, Black patients and individuals in the lower to middle socioeconomic group had a higher rate of COVID-19 hospitalizations when accounting for age, sex, and comorbidities. With ongoing vaccination efforts, equitable administration of resources should focus on disproportionately affected populations.

Ruptured Sinus of Valsalva Aneurysm in Apert Syndrome: Case report.

Background: Sinus of Valsalva aneurysm (SOVA) is a rare anomaly of the aorta that can be congenital or acquired. It can be associated with syndromes such as Marfan syndrome and Ehlers-Danlos syndrome. However, to our knowledge, it has never been described in a patient with Apert syndrome. Although it often presents as an incidental finding on imaging, SOVA is associated with the risk of serious complications, including rupture. A possible connection between the conditions might be the FGFR2 gene mutation in Apert syndrome and the influence of a mutation in fibroblast growth factor 2 (FGF2) on heart development. Here we report a case of acute heart failure secondary to rupture of SOVA into the right atrium in a patient with Apert syndrome. Case presentation: A 47-year-old Caucasian woman with a history of Apert syndrome and rheumatoid arthritis presented with shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and progressive bilateral lower extremity edema for 2 weeks. She was diagnosed with acute right heart failure due to ruptured SOVA. The patient underwent surgical repair of the ruptured SOVA. Unfortunately, her postoperative course was complicated by a stroke leading to brain death. Conclusion: Ruptured SOVA is a quite rare but serious condition that can cause life-threatening complications. In this case, SOVA occurred in a patient with Apert syndrome. The case may suggest that these two conditions may be related through the FGFR2 gene mutation associated with Apert syndrome and the related growth factor FGF2 involved in heart development.

Improving Primary Care Delivery for Patients Receiving Maintenance Hemodialysis.

The beneficial impact of primary care, focused on all aspects of a patient's health (rather than a disease-specific focus) is well established. Recognized benefits include greater receipt of preventive care and counseling, lower use of emergency care and hospitalization for ambulatory care-sensitive conditions, and decreased early mortality. Although the importance of primary care and care coordination at the primary care/specialty interface is well recognized, the role of primary care within traditional and emerging care models for patients receiving in-center maintenance hemodialysis remains ill-defined. In this perspective article, we will describe: (1) the role of primary care for patients receiving maintenance hemodialysis and the current evidence regarding the receipt of primary care among these patients; (2) the key challenges to delivery of primary care in these complex cases, including suboptimal care coordination between nephrology and primary care providers, the intensity of dialysis care, and the limited capacity of nephrologists and primary care providers to meet the broad health needs of hemodialysis patients; (3) potential strategies for improving the delivery of primary care for patients receiving hemodialysis; and (4) future research requirements to improve primary care delivery for this high-risk population.

Catheter-Directed Therapy: Outcomes Versus Standard of Care and Evaluation of Current Practice.

BACKGROUND: Small studies have noted benefit with the use of catheter-directed therapy (CDT) versus standard of care in treatment of pulmonary embolism, but none have focused on the variability of clinical practice with this modality. METHODS: International Classification of Diseases (ICD) codes were used to retrospectively identify consecutive adult patients admitted to an intensive care unit (ICU) with pulmonary embolism over a 2-year period. We evaluated inpatient mortality and major bleeding and assessed treatment variation. RESULTS: Of 284 patients included, 46 underwent CDT (9 massive pulmonary embolism, 37 submassive pulmonary embolism). Significantly more patients who underwent standard treatment had a history of congestive heart failure and diabetes. Obesity, higher troponin levels, and right heart strain were significantly more likely in the CDT group. No significant difference in inpatient mortality or major bleeding events was observed between the treatment groups. Tissue plasminogen activator use varied widely in the CDT group, and inferior vena cava filter utilization was significantly more common in the CDT group (18; 41%) compared with the standard group (40; 17%) (P < 0.01). CONCLUSIONS: In this study, no significant difference in inpatient mortality or major bleeding was found in patients in the intensive care unit with pulmonary embolism who underwent CDT compared with standard care. It may be beneficial to standardize this procedure given the potential benefit of CDT in patients with submassive pulmonary embolism.

A rare case of spontaneous tumor lysis syndrome in multiple myeloma.

Spontaneous tumor lysis syndrome is an uncommon oncologic emergency. It occurs when a massive number of malignant cells release their contents to the blood stream without previous cancer treatment. TLS carries a mortality rate exceeding 15%. Because of the high mortality rate, the key to the management of TLS continues to be early recognition of high-risk patients and using prophylactic measures to prevent its occurrence. However, it remains difficult to completely eradicate TLS, as a small proportion of patients with aggressive tumors develop spontaneous TLS prior to receiving any therapy. We present a case of 58-year-old male with recently diagnosed multiple myeloma. He was found to have hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, elevated LDH levels, and acute renal failure, fulfilling the criteria of clinical TLS. He was treated with rasburicase, continuous renal replacement therapy, and dexamethasone.

High Scan Volume with Low Positive Scan Rate in Highest Utilizers: Computed Tomography Pulmonary Angiography in the Emergency Department.

BACKGROUND: We examined utilization patterns and predictors of computed tomography pulmonary angiography (CTPA) results in the emergency department (ED). OBJECTIVES: We retrospectively determined ED CTPA positive scan rate (PSR) among ED attendings based on a system that grouped attendings into scan quantity categories through >100. METHODS: We manually reviewed all scans ordered in 2017 in EDs in a multisite medical system. RESULTS: Of 10,032 ED CTPAs, 6168 were ordered by 153 ED attendings. Most attendings (123/153; 80%) ordered 60 or fewer scans with relatively high PSR (259/2927, PSR 8.8%; 95% confidence interval 7.8-9.9%). Of the ED attendings, 13 (3%) ordered more than 100 scans each (1981 scans; 32% of all scans), with PSR of 5.5% (95% confidence interval 4.5-6.5%). CONCLUSION: Most ED attendings were low- to mid-volume utilizers of CTPA and had a relatively high PSR. However, the small percentage of attendings who ordered more than 100 scans each accounted for a large percentage of the total scan volume and had a relatively low PSR. These findings suggest that sharing of performance feedback and best practices in the highest utilizers could help to improve CTPA PSR in the ED.

ACE inhibitor angioedema: characterization and treatment versus non-ACE angioedema in acute hospitalized patients.

Background: ACE angioedema has not been characterized in comparison with angioedema from other causes in acute hospitalized patients. Methods: We retrospectively compared ACE-angioedema and non-ACE angioedema patients from January 2013 to May 2017. Results: Of 855 cases screened, 575 met the inclusion criteria of angioedema diagnosis and an electronic medical record. Of these, 297 (51.7%) had ACE angioedema and 278 had angioedema from other causes, of these 31 who were taking an ACE inhibitor that was not considered to be the cause of angioedema (ACE other cause). At least 80% of cases in all groups were African American. Epinephrine was prescribed in 21% of ACE angioedema cases. One-third of patients in all groups were admitted to the ICU, and about 25% required intubation. Previous history of ACE inhibitor-induced angioedema was found in 63 of 278 non-ACE cause angioedema patients (23%) and in 23 (8%) in the ACE cause group. Conclusion: ACE angioedema was the cause of half of angioedema admissions over a 4.5-year period. Mortality, morbidity, and treatment did not differ between the groups. Patients on ACE inhibitors were often treated with medications known not to be effective for ACE angioedema. Over one-fourth of patients not taking an ACE inhibitor had a previous history of ACE angioedema, and 31 patients taking ACE inhibitors were diagnosed with non-ACE angioedema. Regardless of the etiology of angioedema, 25% of patients required airway protection in the form of intubation.

Fatal intoxication with N-ethylpentylone: a case report.

Synthetic cathinones represent the latest genre of new drugs of abuse, which are increasing in popularity in part because they are readily available and because they are not detected by routine drug testing. They provide a cheaper substitute to stimulants such as methamphetamine and cocaine and are sold on the internet and in retail establishments as 'bath salts,' 'plant food,' or 'research chemicals.' We report a case involving a 21-year-old male who suffered arrest-related death due to intoxication with N-ethylpentylone, a new cathinone derivative. He reportedly left his house to smoke marijuana and returned displaying extremely odd behavior. The patient was unresponsive upon presentation to the emergency room and was intubated after suffering cardiac arrest. Clinical laboratory values revealed elevated lactic acidosis, hyperkalemia, rhabdomyolysis, and renal injury. His condition continued to worsen despite medical management. Sudden cardiac arrest occurred again 72 hours into his hospital stay and the patient was pronounced dead. Post-mortem toxicology testing with gas chromatography and mass spectrometry determined the presence of N-ethylpentylone in the urine. This case report details the behavior effects, clinical presentation, and autopsy findings for N-ethylpentylone drug intoxication.

Pylephlebitis: a rare complication of an intra-abdominal infection.

Pylephlebitis is defined as an inflamed thrombosis of the portal vein. It is a rare complication of an intra-abdominal infection, and the diagnosis is often missed due to its nonspecific clinical presentation. Symptoms may include abdominal pain, fever, chills, fatigue, nausea, and vomiting. It is important to consider this differential when a patient presents with signs of abdominal sepsis since it has a high mortality rate and is often diagnosed postmortem. Pylephlebitis can be diagnosed via abdominal ultrasound or CT demonstrating a thrombus in the portal vein, and it must be treated early and aggressively with broad-spectrum antibiotics. We are presenting a case of pylephlebitis as well as discussing the diagnosis and treatment of this potentially lethal condition.

A medical resident post-discharge phone call study.

BACKGROUND: Several studies have identified the post-discharge period as a time of vulnerability for patients, and an opportunity exists to improve patient care. Adverse drug events are the most common events leading to complications during the post-discharge period. Recent studies have shown that using a scripted medication reconciliation process improves the quality of patient care. OBJECTIVE: Does a phone call from a medical resident within 72 hours after hospital discharge improve patient satisfaction and quality of care? Does this exercise result in improved attitudes and competence for practice-based learning, and improvement and system-based practice of participating residents? MATERIALS AND METHODS: This was a prospective randomized study comparing 1 group of patients that received a medication reconciliation phone call from a medical resident within 72 hours after discharge with a control group that did not receive a call. Adult patients aged ≥ 18 years on a medical resident service for ≥ 2 days and being discharged to home were invited to participate. The primary endpoint of the study was patient satisfaction. Secondary endpoints included readmission rates, emergency department visits, follow-up with the primary care provider, and resident attitudes and competence. RESULTS: The primary and secondary endpoints did not reach statistical significance. However, a medication reconciliation error occurred in 48% of patients, and 93% of residents agreed that the phone call was beneficial to patient care. CONCLUSION: Although patient satisfaction was not improved from this exercise, a follow-up call to patients after hospital discharge can identify otherwise missed medication reconciliation errors. Medical residents found the phone call to be worthwhile and gained valuable insight into their own discharge practices as demonstrated by self-reflection and intended change in discharge practices.

Flexible titanium nailing for the treatment of the unstable pediatric tibial fracture.

Tibia fractures in the skeletally immature patient can usually be treated without surgery. The purpose of this study was to assess the use of flexible titanium nails in the tibia that requires operative stabilization. Over a 5-year period, 16 unstable tibia fractures in 14 patients were treated with flexible titanium intramedullary nails. All charts and radiographs were reviewed. The average age was 10 years 4 months. There were three open fractures. All fractures healed. Closed injuries obtained union by an average of 8 weeks, open fractures by an average of 15 weeks. There were no malunions. The average follow-up was 1 year 5 months. There were no instances of growth arrest, remanipulations, or refracture. In the unstable pediatric tibia fracture, flexible titanium nails are an effective treatment to obtain and maintain alignment and stability.