CT imaging determinants of persistent hypoxemia in acute intermediate-risk pulmonary embolism.

The factors associated with persistent hypoxemia after pulmonary embolus (PE) are not well understood. Predicting the need for oxygen post discharge at the time of diagnosis using available CT imaging will enable better discharge planning. To examine the relationship between CT derived imaging markers (automated computation of arterial small vessel fraction, pulmonary artery diameter to aortic diameter ratio (PA:A), right to left ventricular diameter ratio (RV:LV) and new oxygen requirement at the time of discharge in patients diagnosed with acute intermediate-risk PE. CT measurements were obtained in a retrospective cohort of patients with acute-intermediate risk PE admitted to Brigham and Women's Hospital between 2009 and 2017. Twenty one patients without a history of lung disease requiring home oxygen and 682 patients without discharge oxygen requirements were identified. There was an increased median PA:A ratio (0.98 vs. 0.92, p = 0.02) and arterial small vessel fraction (0.32 vs. 0.39, p = 0.001) in the oxygen-requiring group], but no difference in the median RV:LV ratio (1.20 vs. 1.20, p = 0.74). Being in the upper quantile for the arterial small vessel fraction was associated with decreased odds of oxygen requirement (OR 0.30 [0.10-0.78], p = 0.02). Loss of arterial small vessel volume as measured by arterial small vessel fraction and an increase in the PA:A ratio at the time of diagnosis were associated with the presence of persistent hypoxemia on discharge in acute intermediate-risk PE.

Impact of Pulmonary and Sleep Disorders on COVID-19 Infection Severity in a Large Clinical Biobank.

Rationale: Multiple pulmonary, sleep, and other disorders are associated with the severity of Covid-19 infections but may or may not directly affect the etiology of acute Covid-19 infection. Identifying the relative importance of concurrent risk factors may prioritize respiratory disease outbreaks research. Objectives: To identify associations of common preexisting pulmonary and sleep disease on acute Covid-19 infection severity, investigate the relative contributions of each disease and selected risk factors, identify sex-specific effects, and examine whether additional electronic health record (EHR) information would affect these associations. Methods: 45 pulmonary and 6 sleep diseases were examined in 37,020 patients with Covid-19. We analyzed three outcomes: death; a composite measure of mechanical ventilation and/or ICU admission; and inpatient admission. The relative contribution of pre-infection covariates including other diseases, laboratory tests, clinical procedures, and clinical note terms was calculated using LASSO. Each pulmonary/sleep disease model was then further adjusted for covariates. Measurements and main results: 37 pulmonary/sleep diseases were associated with at least one outcome at Bonferroni significance, 6 of which had increased relative risk in LASSO analyses. Multiple prospectively collected non-pulmonary/sleep diseases, EHR terms and laboratory results attenuated the associations between preexisting disease and Covid-19 infection severity. Adjustment for counts of prior "blood urea nitrogen" phrases in clinical notes attenuated the odds ratio point estimates of 12 pulmonary disease associations with death in women by ≥1. Conclusions: Pulmonary diseases are commonly associated with Covid-19 infection severity. Associations are partially attenuated by prospectively-collected EHR data, which may aid in risk stratification and physiological studies.

Sleep apnea phenotyping and relationship to disease in a large clinical biobank.

OBJECTIVE: Sleep apnea is associated with a broad range of pathophysiology. While electronic health record (EHR) information has the potential for revealing relationships between sleep apnea and associated risk factors and outcomes, practical challenges hinder its use. Our objectives were to develop a sleep apnea phenotyping algorithm that improves the precision of EHR case/control information using natural language processing (NLP); identify novel associations between sleep apnea and comorbidities in a large clinical biobank; and investigate the relationship between polysomnography statistics and comorbid disease using NLP phenotyping. MATERIALS AND METHODS: We performed clinical chart reviews on 300 participants putatively diagnosed with sleep apnea and applied International Classification of Sleep Disorders criteria to classify true cases and noncases. We evaluated 2 NLP and diagnosis code-only methods for their abilities to maximize phenotyping precision. The lead algorithm was used to identify incident and cross-sectional associations between sleep apnea and common comorbidities using 4876 NLP-defined sleep apnea cases and 3× matched controls. RESULTS: The optimal NLP phenotyping strategy had improved model precision (≥0.943) compared to the use of one diagnosis code (≤0.733). Of the tested diseases, 170 disorders had significant incidence odds ratios (ORs) between cases and controls, 8 of which were confirmed using polysomnography (n = 4544), and 281 disorders had significant prevalence OR between sleep apnea cases versus controls, 41 of which were confirmed using polysomnography data. DISCUSSION AND CONCLUSION: An NLP-informed algorithm can improve the accuracy of case-control sleep apnea ascertainment and thus improve the performance of phenome-wide, genetic, and other EHR analyses of a highly prevalent disorder.

The Impact of Door to Diuretic Time in Acute Heart Failure on Hospital Length of Stay and In-Patient Mortality.

Background Acute heart failure (AHF) can be life-threatening if not treated promptly and can significantly increase the number of annual emergency department (ED) encounters in the United States. Achieving adequate and prompt euvolemic state in AHF patients using intravenous (IV) diuretics is the cornerstone of treatment, which not only reduces in-hospital stay and mortality but also decreases healthcare expenditures. Surprisingly, the door to diuretic (D2D) time in AHF patients has always been a debatable issue among physicians worldwide, and so far, there are no set guidelines. This study examines a large cohort of AHF patients to determine the association between diuretics use within 90 minutes of ED admission and hospital length of stay (LOS) and patient mortality.  Methods Retrospective institutional data of AHF patients receiving IV diuretics following ED admission were extracted from 2016 to 2017. A total of 7,751 patients treated for AHF exacerbation were included, which were further divided into two groups based on the timing of diuretics administration (<90 minutes vs. ≥90 minutes). The primary outcomes were LOS between the two groups and hospital mortality. The standard statistical methodology was used for data analysis. Results  A total of 7,751 AHF cases receiving IV diuretics were identified. Almost 1,432 patients (18.5%) received IV diuretics within 90 minutes of ER admission (group 1) while 6,319 patients (81.5%) patients received IV diuretics after 90 minutes (group 2). Furthermore, among group 1 patients, average LOS was noted to be associated with shorter hospitalization (average of 1.423 days less as compared to group 2 patients (confidence interval (CI) =1.02-1.82; p<0.05). Finally, after controlling for other mortality risk factors, patients in group 2 were 1.435 times more likely to have died compared to patients in group 1 (CI=1.03-1.98; p<0.05). Conclusions  D2D time in AHF patients has always been a crucial judgmental decision. The current study successfully demonstrated the relation between IV diuretics administration within 90 minutes of ED admission, favorable clinical outcomes, and decreased mortality rates. More adequately powered studies are needed to validate the results of our current study further.

Loss of Pulmonary Vascular Volume as a Predictor of Right Ventricular Dysfunction and Mortality in Acute Pulmonary Embolism.

BACKGROUND: In acute pulmonary embolism, chest computed tomography angiography derived metrics, such as the right ventricle (RV): left ventricle ratio are routinely used for risk stratification. Paucity of intraparenchymal blood vessels has previously been described, but their association with clinical biomarkers and outcomes has not been studied. We sought to determine if small vascular volumes measured on computed tomography scans were associated with an abnormal RV on echocardiography and mortality. We hypothesized that decreased small venous volume would be associated with greater RV dysfunction and increased mortality. METHODS: A retrospective cohort of patients with intermediate risk pulmonary embolism admitted to Brigham and Women's Hospital between 2009 and 2017 was assembled, and clinical and radiographic data were obtained. We performed 3-dimensional reconstructions of vasculature to assess intraparenchymal vascular volumes. Statistical analyses were performed using multivariable regression and cox proportional hazards models, adjusting for age, sex, lung volume, and small arterial volume. RESULTS: Seven hundred twenty-two subjects were identified of whom 573 had documented echocardiography. A 50% reduction in small venous volume was associated with an increased risk of RV dilation (relative risk: 1.38 [95% CI, 1.18-1.63], P<0.001), RV dysfunction (relative risk: 1.62 [95% CI, 1.36-1.95], P<0.001), and RV strain (relative risk: 1.67 [95% CI, 1.37-2.04], P<0.001); increased cardiac biomarkers, and higher 30-day and 90-day mortality (hazard ratio: 2.50 [95% CI, 1.33-4.67], P=0.004 and hazard ratio: 1.84 [95% CI, 1.11-3.04], P=0.019, respectively). CONCLUSIONS: Loss of small venous volume quantified from computed tomography angiography is associated with increased risk of abnormal RV on echocardiography, abnormal cardiac biomarkers, and higher risk of 30- and 90-day mortality. Small venous volume may be a useful marker for assessing disease severity in acute pulmonary embolism.

Brain metastasis in colorectal cancer presenting as refractory hypertension.

Background: Brain metastasis (BM) from colorectal cancer (CRC) is rare with the incidence ranging from 0.6% to 3.2%. There is also an increased incidence of BM with rectal primaries and is consistent with this patient's presentation. Overall, there is scarce literature on the symptoms of patients who present with CRC BMs. Objectives: We present a case of brain metastasis in colorectal cancer presenting with hypertensive urgency and severe headache. Methods and results: This case highlights that neurological deficits are not necessary for BMs in patients with CRC and summarizes and reviews the associated literature regarding BM in CRC. A 57-year-old female with a past medical history of recently diagnosed stage IV moderately differentiated distal rectal adenocarcinoma with liver and lung metastasis was admitted with the primary complaint of hypertensive urgency, severe headache, intractable nausea and vomiting, and diarrhea. Magnetic resonance imaging brain showed a left cerebellar lesion measuring 3.6 × 3.2 × 2.9 cm, ipsilateral transtentorial herniation, and obliteration of the fourth ventricle. The patient was started on steroids and transferred for an urgent neurosurgical intervention to a tertiary care center. Conclusions: Even though BMs are rare in CRC, clinicians should have a high index of suspicion with complaints like hypertensive urgency, headache, nausea, vomiting, vertigo, and blurring of vision triggering imaging studies to rule out BM. The approach to BM has become increasingly individualized as surgical and radiosurgical therapies have continued to evolve Abbreviations: CRC: Colorectal cancer; BM: Brain metastasis; FOLFOX: Folinic acid, fluorouracil and oxaliplatin; CT: Computed tomography; IV: Intravenous; PO: By mouth; BAER: Brain auditory evoked response hearing testing; SSEP's: Somatosensory evoked potentials; BMFI: Brain metastasis free interval; WBRT: Whole-brain radiation therapy; SRS: Stereotactic radiosurgery.

Adult idiopathic hypertrophic pyloric stenosis - a common presentation with an uncommon diagnosis.

Background and Objectives: Adult Idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare but well-defined entity in adults with only 200-300 cases reported so far in the literature.We describe a case of AIHPS and the relevant literature review. Methods and Results: The patient presented with acute onset upper abdominal pain associated with nausea, vomiting, foul-smelling black tarry stools, and anorexia. On the Esophagogastroduodenoscopy (EGD), pylorus demonstrated a unique "cervix sign." The patient had multiple endoscopic dilations with minimal relief. She then underwent a distal partial gastrectomy with a Billroth 1 gastroduodenostomy with considerable  improvement in her symptoms on follow up. Conclusion: Adult Idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare disease which is also underreported due to a difficulty in diagnosis. The most common symptoms of AIHPS are postprandial nausea, vomiting, early satiety, and epigastric pain as seen in our patient. Endoscopy usually shows ?Cervix sign? a unique sign showing a fixed, markedly narrowed pylorus with a smooth border. Multiple treatments have been proposed for AIHPS, including endoscopic dilation, pyloromyotomy with or without pyloroplasty, gastrectomy with a Billroth 1 gastroduodenostomy. Currently, there is no evidence of one surgical technique being superior to another. Further research needs to be done on AIHPS before one technique can be standardized as the standard of care.

A confusing manifestation: a case report of neurosarcoidosis presenting with confusion.

Introduction: Sarcoidosis is an inflammatory granulomatous multisystem disease with an unknown etiology. Neurosarcoidosis is a cryptogenic neuroinflammatory manifestation of sarcoidosis. Case report: We describe a case of neurosarcoidosis with initial presentation as confusion. Our patient fits the picture of probable neurosarcoidosis as per the Zajicek et al criteria, with the clinical presentation of neurosarcoidosis, evidence of inflammation in the CNS, evidence of systemic sarcoidosis and exclusion of other diseases. He was started on steroids with subsequent improvement in mental status. Discussion and conclusion: The diagnosis of neurosarcoidosis becomes challenging when neurosarcoidosis presents as isolated clinical neurological symptoms. We want to highlight the highly variable nature of neurosarcoidosis and underscore the fact that for cryptogenic neuroinflammatory diseases, neurosarcoidosis should be considered after excluding common infections and autoimmune causes. Abbreviations: CXR: Chest X-ray; CTA: Computed tomography angiography; PCR: Polymerase chain reaction; DNA: Deoxyribonucleic acid; MRI: Magnetic resonance imaging; ACE: Angiotensin converting enzyme; HRCT: High Resolution computed tomography.

An assessment of the level of awareness and reported complaints regarding occupational health hazards and the utilization of personal protective equipments among the welders of Lahore, Pakistan.

Objective To assess the level of awareness and reported complaints of occupational health hazards among the welders of Lahore. Methods A cross-sectional descriptive study of 70 welders. An interview questionnaire was employed to assess awareness and complaints, the possession and utilization of protective personal equipment (PPE), and socio-demographic characteristics. Results All of the respondents were male with a mean age of 25.7 years. 54.3% of the respondents were aware of welding as a risk to their health. 98.6% possessed at least 1 PPE. There was an association between the level of education and the awareness of a health risk (χ2 = 6.885; p = 0.032). The most frequent complaint was foreign body in the eye (47.1%) followed by arc eye injury (45.7%), cuts and injuries (50.0%), and burns (48.6%). Conclusion The findings suggest that welders had low level of awareness and reported many complaints of occupational health hazards. Preventive initiatives are recommended.