Chronic Pancreatitis Patients Who Leave Against Medical Advice: Prevalence, Trend, and Predictors.

BACKGROUND AND AIMS: Leaving against medical advice (LAMA) is an unfortunate occurrence in 1-2% of all hospitalized patients and is associated with worse outcomes. While this has been investigated across multiple clinical conditions, studies on patients with chronic pancreatitis (CP) are lacking. We aimed to determine the prevalence and determinants of this event among patients with CP. METHODS: The Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (NIS), 2007-2014, was used in the study. Patients with LAMA were identified, and the temporal trend of LAMA was estimated and compared among patients with and without CP. We then extracted patients with a discharge diagnosis of CP from the recent years of HCUP-NIS (2012-2014) and described the characteristics of LAMA in these patients. Multivariate logistic regression models were used to evaluate predictors of LAMA. RESULTS: 3.39% of patients with CP discharged against medical advice. LAMA rate in CP patients was higher and increased more steeply at quadruple the rate of those without. More likely to self-discharge were patients who were young, males, non-privately insured, or engaged in alcohol and substance abuse, likewise were those with psychosis and those admitted on a weekend or non-electively. The northeast and for-profit hospitals also had higher odds of LAMA. However, patients transferred from other healthcare facilities have reduced LAMA odds. Among all patients with CP, those with LAMA had shorter length of stay (2.74 [2.62-2.85] days vs. 5.78 [5.71-5.83] days) and lower hospitalization cost $23,271 [$22,171-$24,370] versus $45,472 [$44,381-$46,562] compared to the no-LAMA group. CONCLUSION: LAMA occurs in approximately 1 in 29 patients with CP and is increasing at almost quadruple the rate of those without. Clinicians need to pay closer attention to the identified at-risk groups for ameliorative targeted interventions.

PTH assays in dialysis patients: Practical considerations.

Parathyroid hormone (PTH) 1-84 is the main biologically active hormone produced by the parathyroid cells. Circulating PTH molecules include the whole PTH 1-84 along with amino (N) and carboxyl (C) terminal fragments. While PTH is the best available noninvasive biomarker to assess bone turnover in dialysis patients, the biological roles of individual circulating PTH fragments are still not completely known. The understanding that there is an enormous variation in the target specificity of currently available PTH assays for different circulating forms of PTH has led to the evolution of assays from first to second then third generation. With a reduction in kidney function, there is a preferential increase in circulating C fragments and non-PTH 1-84 forms, resulting in a decrease in the ratio of PTH 1-84/non-PTH 1-84. However, there are also substantial differences in between-assay measurements, with several fold variations in results. Targets based on multiples of the upper limit of normal (ULN) should be used rather than PTH ranges using absolute iPTH values. To date, the second-generation PTH remains the most widely used assay. Current guidelines recommend following iPTH trends rather than absolute values. Herein, we highlight problems and challenges in PTH assays/measurements and their interpretations in dialysis patients.

Celiac Artery Compression Syndrome Presenting As Recurrent Diabetic Ketoacidosis: A Diagnostic Challenge.

Celiac artery compression syndrome (CACS), also known as median arcuate ligament syndrome, can sometimes represent a diagnostic challenge. Here, we present the case of a 29-year-old man who presented with recurrent diabetic ketoacidosis (DKA), abdominal pain, and vomiting thought to be due to cyclical vomiting syndrome. However, the lack of a clear precipitant for DKA, the presence of chronic gastrointestinal symptoms, and a revealing physical examination of abdominal bruit led to clinical suspicion of CACS and its diagnosis after appropriate investigations. While angiography has traditionally been considered the gold standard diagnostic test, hemodynamic and geometric ultrasound criteria can, however, be diagnostic. The patient was managed by releasing the celiac artery through robotic surgery and serial monitoring as an outpatient revealed resolution of his symptoms and no further readmissions for DKA. This case highlights how a presumptive and erroneous diagnosis (cyclical vomiting syndrome) can misguide clinicians, especially when dealing with a rare diagnosis of exclusion.

Identification of Human Very Small Embryonic like Stem Cells (VSELS) in Human Heart Tissue Among Young and Old Individuals.

Very Small Embryonic-Like (VSEL) stem cells are a proposed pluripotent population, residing in adult tissues. VSELs have been described in multiple tissues including bone marrow, cord blood, and gonads. They exhibit multiple characteristics of embryonic stem cells including the ability to differentiate into cellular lineages of all three germ layers, including cardiomyocytes and vascular endothelial cells. However, their presence in adult solid organs such as heart in humans has not been established. VSELs are valuable source of stem cells for tissue regeneration and replacement of cells for turnover and usual wear-and-tear. The purpose of our study was to explore the existence of human VSELs (huVSELs) in human heart tissue and examine the changes in their prevalence with aging and cardiac disease. Human heart tissue, collected from healthy and ischemic heart disease subjects was examined for the prevalence of VSELS, defined as CD45-/CD133+/SSEA4+. Both epicardial and endocardial tissues were examined comparing VSEL numbers across different age groups. Our data confirm the existence of huVSELs in adult hearts with decreasing prevalence during aging. This is the first evidence of huVSELs in adult cardiac tissue. Cardiac huVSELs could be further explored in future studies to characterize their primitive potential and therapeutic potential in regenerative studies.

A Rare Case of Ipilimumab-induced Reversible Hypophysitis and Permanent Primary Hypothyroidism.

Ipilimumab is a monoclonal antibody targeting the cytotoxic T-lymphocyte antigen-4 receptor, which was originally approved for the treatment of metastatic melanoma. It is the first immune checkpoint inhibitor to enter clinical practice. Immune toxicity due to ipilimumab causing colitis, hepatitis, and dermatitis are well-described in literature. We report a case of hypophysitis resolving with corticosteroid treatment, following which the patient developed long-term primary thyroid impairment. This highlights the importance of vigilance for rarer immune-related toxicities as clinical utilization of ipilimumab becomes more widespread.

Ectopic Liver Tissue Mistakenly Diagnosed as a Right Atrial Myxoma.

Myxomas, metastatic tumors, thrombi, and vegetations top the differential diagnosis list of cardiac masses. We present a case of ectopic liver tissue, a far less common etiology of a right atrial mass, discovered incidentally on transthoracic echocardiography (TTE) of a 37-year-old female with multiple comorbidities who was referred to our facility for further management of left popliteal artery occlusion and right lower extremity cellulitis. We discuss further the categories, proposed pathogenesis, diagnostic approach, and potential complications of ectopic liver tissue.

Voriconazole-induced Myositis in a Double Lung Transplant Recipient.

Voriconazole is a triazole antifungal agent commercially approved in 2002. It is commonly used in immunocompromised patients as a therapeutic and prophylactic agent. We present the case of a 26-year-old Caucasian female who is a double lung transplant recipient who presented with complaints of generalized left lower extremity swelling and extreme tenderness of her left thigh. Although her muscle enzymes were not significantly elevated, inflammatory changes were noticed on T2-weighted fat-suppressed short-TI inversion recovery (STIR) sequence magnetic resonance imaging (MRI). These findings were later confirmed with tissue biopsy. We hereby present the case of drug-induced myositis as a rare complication of voriconazole used as chemoprophylaxis in a double lung transplant recipient patient.

Disseminated Mucormycosis with Extensive Cardiac Involvement.

Mucormycosis is an opportunistic fungal infection. Cardiac involvement is a rare, yet fatal, complication that can occur in disseminated disease. A strong index of suspicion is necessary for prompt treatment, especially in high-risk patients. We present a 62-year-old male patient with a history of diabetes and acute myeloid leukemia; he had pulmonary mucormycosis that was complicated by cardiac involvement as part of disseminated mucormycosis syndrome.

A Rare Case of Herpes Simplex Virus-2 Hepatitis with Negative Serology.

Herpes simplex virus-2 (HSV2) hepatitis represents a rare but serious complication of HSV2 infection that can progress to acute liver failure (ALF). We describe a case of a pregnant teenager who presented with four days of fever, headache, malaise, nausea, and vomiting. She was initially misdiagnosed with sepsis of unclear source and treated with broad-spectrum antibiotics. Empiric acyclovir was started one week into her hospitalization despite negative serologies while awaiting HSV2 PCR leading to complete resolution of symptoms. Given its high mortality and nonspecific presentation, clinicians should consider HSV hepatitis in all patients with acute hepatitis especially in high-risk population.

Acute Severe Hyponatremia as a Serious Health Implication of Herbal Detox Regimens.

Hyponatremia is a serious health problem and can cause substantial morbidity and mortality as a result of osmotically induced cerebral edema if left untreated. Also, inappropriate rapid correction of chronic cases of hyponatremia can lead to osmotic demyelination with neurological impairment and death as consequences. It is defined as a serum sodium concentration less than 135 mmol/L. Herbal detox regimens are gaining popularity with their easy access over the counter and not well studied adverse effects. We hereby present a case of a 67-year-old man who developed severe hyponatremia after starting a five-day kidney detox regime. This regime consisted of drinking over a gallon (128 oz) of fluid daily, herbal tea with Uva Ursi leaves, juniper berries and several other ingredients. On the last day of this detox regime, he presented to the emergency department with a critical serum sodium level of 111 mmol/L associated with neurological symptoms. The purpose of this case report is to highlight the potential serious adverse effects associated with what is considered benign herbal medicine.

Sickle cell disease is associated with higher mortality among patients hospitalized with ischemic bowel disease.

BACKGROUND: Sickle cell disease (SCD) is the most common inheritable hematologic disorder in the USA and is associated with ischemic organ diseases. SCD-associated ischemic bowel disease is increasing being recognized, and studies on the hospitalization outcomes of such patients are limited. OBJECTIVE: This study aimed to compare the inpatient outcomes of ischemic bowel disease among patients with SCD compared with patients without SCD. MATERIALS AND METHODS: This is a case-control study using data from the National Inpatient Sample Database (2007-2014). We analyzed and compared outcomes between cases (ischemic bowel disease with SCD) and controls (ischemic bowel disease without SCD), matched in a 1 : 5 ratio. The primary outcome was in-hospital mortality, and the secondary outcomes were healthcare resource utilization including mechanical ventilation, hemodialysis, transfusion, length of stay, and hospital charges. RESULTS: Of the 194 262 patients admitted with ischemic bowel disease, 98 had a diagnosis of SCD and were matched successfully to the controls. In multivariate analysis, patients with SCD had twice the mortality odds of those without (adjusted odds ratio=2.06, 95% confidence intervals: 1.13-3.74). They were more likely to require mechanical ventilation and blood transfusion, and to be discharged to secondary health facilities [1.68 (1.02-2.76), 3.32 (2.15-5.12), and 1.84 (1.02-3.35)]. Patients with SCD also had a higher frequency of pneumonia, acute respiratory failure, and hemodialysis for acute renal failure. There was no significant difference in the length of stay or the total hospital charge between the two groups. CONCLUSION: In patients hospitalized with ischemic bowel disease, SCD is associated with significantly increased mortality and healthcare burden.

Antibiotic-associated haemorrhagic colitis: not always Clostridium difficile.

Antibiotic-associated colitis is a gastrointestinal complication of antibiotic use commonly seen in hospitalised patients, with Clostridium difficile (C. difficile) colitis being the most common type. We present a case of haemorrhagic colitis secondary to Klebsiella oxytoca following self-initiated amoxicillin-clavulanic acid use. An 85-year-old woman presented to the emergency department with abdominal pain and mucobloody diarrhoea. History was notable for an ongoing 5-day course of amoxicillin-clavulanic acid use. The CT scan of her abdomen revealed extensive diffuse thickening of the ascending and transverse colon. Stool culture grew K. oxytoca, an established cause of haemorrhagic colitis. She declined colonoscopy but recovered with withdrawal of all antibiotics and conservative treatment. We should be vigilant to haemorrhagic colitis following antibiotic use which is not always C. difficile related.