Echocardiography and pulmonary hypertension in patients with chronic obstructive pulmonary disease undergoing lung transplantation evaluation

BACKGROUND

The use of echocardiography in pulmonary hypertension (PH) in advanced chronic obstructive pulmonary disease (COPD) is understudied. We aimed to compare the performance of echocardiography with right heart catheterization (RHC) in the diagnosis of PH in COPD patients undergoing lung transplant evaluation.

METHODS

We included 111 patients with severe COPD who underwent RHC in a single center as part of lung transplantation evaluation. COPD-PH and severe COPD-PH were defined based on RHC per the 6th world symposium on pulmonary hypertension. Echocardiographic probability of PH was described according to the European Society of Cardiology guidelines. Summary and univariate analyses were performed.

RESULTS

The mean age (±SD) was 62 (8) and 47% (n=52) were men. A total of 82 patients (74 %) had COPD-PH. The sensitivity, specificity, positive predictive, and negative predictive values of echocardiography in diagnosing COPD-PH were 43 %, 83 %, 88 %, and 34 % respectively and for severe COPD-PH were 67 %, 75 %, 50 %, and 86 % respectively. Echocardiography was consistent with RHC in ruling in/out PH in 53% (n=59) of patients. After controlling for age, sex. BMI, pack year, echocardiography-RHC time difference, GOLD class, FVC, and CT finding of emphysema, higher TLC decreased consistency (parameter estimate=-0.031; odds ratio: 0.97, 95%CI 0.94-0.99; p=0.037) and higher DLCO increased consistency (parameter estimate=0.070; odds ratio: 1.07, 95%CI 0.94-0.99; p=0.026).

CONCLUSIONS

Echocardiography has high specificity but low sensitivity for the diagnosis of PH in advanced COPD. Its performance improves when ruling out severe COPD-PH. This performance correlates inversely with lung hyperinflation.

Diagnostic and therapeutic practices of cardiac sarcoidosis in the United States: a nationwide questionnaire based study

BACKGROUND AND AIM

Cardiac sarcoidosis (CS) is the second most common cause of death in patients with sarcoidosis and data pertaining to its diagnosis and management is limited. We sought to describe diagnostic modalities and management of patients with CS in the United States, based on a national registry questionnaire.

METHODS

We conducted a retrospective study based on a national registry investigating 3,835 respondents to the Foundation for Sarcoidosis Research Questionnaire. The registry includes patient surveys completed between June 2014 and August 2019. Summary and univariate analyses were performed.

RESULTS

A total of 394 patients (10.3%) with CS were identified; 57% (n=223) were women and 81% (n=317) were white. The mean (±SD) age at diagnosis was 45 years (±13). CS was the initial presentation of sarcoidosis in 30%. Multiorgan involvement (≥3 organs) was present in 68%. Two-thirds of patients were admitted at least once to the hospital. Cardiac magnetic resonance imaging (74.4%) was the most common diagnostic modality used followed by positron emission tomography (PET) scan (59.3%) and cardiac biopsy (n=52, 13%).  Most patients received corticosteroids (86%) and steroid-sparing medications (61%) including methotrexate (26%) and tumor necrosis factor (TNF) inhibitors (19%). A combined cardioverter defibrillator and pacemaker (39%) was the most common cardiac device implanted.

CONCLUSIONS

The prevalence of CS in this cohort was higher than previously described. CS was a common initial presentation of sarcoidosis. The diagnosis was most likely made using cMRI. Steroids, methotrexate and infliximab are the most common medications used. Conduction abnormalities and arrhythmias often occurred.

Multiple lump and rogue wave for time fractional resonant nonlinear Schrödinger equation under parabolic law with weak nonlocal nonlinearity

This article retrieve lump, lump with one kink and rogue wave soliton for the time fractional resonant nonlinear Schrödinger equation with parabolic law having weak nonlocal nonlinearity. According to theory of dynamical systems, Schrödinger equation may be converted into plane systems. We use Hirota bilinear method to obtained these solutions. At the end, we present graphical representation of our results in various dimensions.

Management of humeral impending or pathological fractures with intramedullary nailing: reaming versus non reaming technique-a retrospective comparative study

PURPOSE

To compare reamed intramedullary nailing (RIM) versus un-reamed intramedullary nailing (URIM) for the treatment of impending and pathological fractures of the humeral shaft in terms of 24-h postoperative pain, blood transfusion requirements, surgical time, surgical complications, medical complications, length of stay and consolidation rates.

METHODS

A retrospective comparative study between January 2013 and December 2018 was conducted. Student's t test, Mann-Whitney U and Chi-square tests were used to detect differences within the two study groups. Multiple linear regression was done to adjust for possible confounders.

RESULTS

A total of 53 patients (33 RIM vs. 20 URIM) underwent humeral nailing. Fifteen (28%) were impending fractures (7 RIM vs. 8 URIM). Multiple myeloma (49%) and metastatic carcinoma (39.6%) were the most common etiologies. Pain score (5.13 ± 0.68 RIM vs. 6.78 ± 0.62 URIM; p = 0.082) and total dose of opioids (33.125 ± 27.6 RIM vs. 33.3 ± 22.28 URIM; p = 0.462) showed similar results. Blood transfusion was more prevalent within RIM group (34.48% RIM vs. 20% URIM; p = 0.044) with a clinical tendency of higher blood loss (207.86 ± 150.83RIM vs. 127.00 ± 179.98 URIM; p = 0.092). There was a consolidation rate of 71.05% (27/38) with no statistical difference (73.08% (19/26) RIM vs. 66.67% (8/12) URIM; p = 0.685).

CONCLUSION

Our study suggests possible benefit of URIM in terms of less blood transfusions with no difference in consolidation rates. Even though without significance, a tendency to less blood loss, less events of systemic complication and lower length of stay was observed with URIM. Despite its limitations, this study can be used to design future prospective ventures that quantify patient-reported outcomes and provide more clear evidence.

The Impact of a New Best Practice Advisory on the Management of Diabetic Ketoacidosis

BACKGROUND

According to the Center for Disease Control and Prevention, diabetic ketoacidosis (DKA) hospitalization rates have been steadily increasing. Due to the increasing incidence and the economic impact associated with its morbidity and treatment, effective management is key. We aimed to streamline the management of DKA in our intensive care units (ICU) by implementing a Best-Practice Advisory (BPA) that notifies providers when DKA has resolved.

METHODS

A BPA was implemented on 9/15/2018. We conducted a retrospective review of patients admitted to the ICU with DKA a year before and after 9/15/2018. Adults (≥18 age) meeting DKA criteria on admission and treated with continuous insulin infusion (CII) were included. Pre-intervention group included patients admitted before BPA implementation and post-intervention group included patients admitted after. Summary and univariate analyses were performed.

RESULTS

A total of 282 patients were included; 162 (57%) pre-intervention and 120 (43%) post-intervention. Mean (±SD) age of the patients was 44 (±17) years. There was no significant difference in baseline characteristics such as age, sex, race, BMI, HbA1c, initial blood glucose, anion gap or bicarbonate concentration between both the groups (p>0.05). Mean (±SD) total time on CII in hours was significantly lower in the post-intervention group {14.8 (±7.7) vs. 17.5 (±14.3) p=0.041, 95% CI: 0.11-5.3}. The incidence of hypoglycemia was lower in the post-intervention group {n=4 (3%) vs. 17 (10%), p=0.024}. There was no significant difference in hypokalemia, mortality, LOS or ICU stay between both the groups (p>0.05).

CONCLUSION

The BPA introduced in our DKA management algorithm successfully reduced the total time on insulin and the incidence of hypoglycemia.

The Use of Direct Oral Anticoagulants in the Management of Venous Thromboembolism in Patients With Obesity

Introduction

The use of direct oral anticoagulants (DOACs) has gained significant traction given the lack of therapeutic monitoring and the need for anticoagulant bridging. There is a paucity of data on their effectiveness in obese patients with venous thromboembolism (VTE). Preliminary subgroup and pharmacokinetic analyses suggest reduced efficacy in those with a bodyweight >120 kg or body mass index (BMI) ≥40 kg per m² and it is currently not recommended that these agents be used as first-line agents. We aimed to assess the rate of VTE recurrence in obese patients diagnosed with VTE and treated with DOAC therapy.

Methods

We utilized the Health Facts Center National Data Warehouse (Cerner) to perform a retrospective analysis of patients with VTE (acute deep venous thrombosis (DVT) or pulmonary embolism) that presented to the hospital between 2010 and 2016 and were managed with DOACs. The cohort of patients diagnosed with DVT or PE were identified using International Classification of Disease (ICD-9-CM, ICD-10-CM). Patients were divided into two groups based on their weight: 1) weight <120 kg or 2) weight>120 kg. Six-month VTE recurrence rates were recorded. Summary and univariate statistics were performed.

Results

A total of 18,147 patients with a mean (±SD) age of 62 (17) years were included; 48% (n=8732) were male. A total of 2,419 (13%) patients weighed >120 kg while the rest (N=15,728, 87%) weighed <120 kg. There were significantly more female patients weighing<120 kg (54% vs 42%, p<0.0001); otherwise, there was no significant difference in age or tobacco use between both groups (p>0.05). There was no significant difference in six-month readmission rates for VTE recurrence in patients that weighed <120 kg (34%) in comparison with patients >120 kg (36%) (p=0.08).

Conclusion

Our study suggests that the use of DOACs in obese patients is equally efficacious with similar VTE recurrence rates in comparison with non-obese patients. This study paves the way for prospective multi-institutional randomized control trials to further reinforce the safe use of such agents in this patient population.

A Rare Case of Multipathogenic Pneumonia in a Patient With Human Immunodeficiency Virus

The incidence of acquired immunodeficiency syndrome (AIDS)-related opportunistic infections has declined dramatically following the introduction of potent antiretroviral therapy (ART). However, pulmonary infections remain a significant cause of morbidity and mortality. The spectrum of pulmonary disease that can affect patients with human immunodeficiency virus (HIV) is wide and includes opportunistic infections with many bacterial, fungal, viral, and parasitic organisms. In this case, we present a 65-year-old woman with HIV, non-compliant with ART, who presented with subacute melena, fatigue, dyspnea, and hemoptysis. After extensive evaluation, she was found to have pneumonia caused by four different pathogens: Strongyloides stercoralis, Pneumocystis jirovecii, Cytomegalovirus (CMV), and Pseudomonas aeruginosa. She received trimethoprim-sulfamethoxazole, steroids, and ivermectin. However, her clinical condition did not improve and she passed away.

The role of adjuvant chemotherapy in the management of surgically resected primary pulmonary salivary gland-type carcinomas

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Background: Primary pulmonary salivary gland-type carcinomas (PSGC) are rare tumors. There are limited data on the role of adjuvant chemotherapy after surgical resection of these tumors. Here, we examine the role of adjuvant chemotherapy in the management of resected PSGC. Methods: The National Cancer Database was queried to identify patients with PSGC who underwent surgical resection. Histology codes 8200- adenoid cystic carcinoma (ACC), 8430- mucoepidermoid carcinoma (MEC), 8550- acinic cell carcinoma (AIC) and 8551- adenocarcinoma, acinar predominant were used. Patients were divided based on chemotherapy status. Summary and univariate analysis was performed. Multivariable proportional hazard regression analyses were used to obtain hazard ratios (HR). Results: A total of 6685 patients, with a mean (±SD) age of 66.1 ± 11.0 years, were included; 4148 (62%) were females. Most patients were Caucasian (84%). Chemotherapy was administered in 1141 patients (17%); multiagent chemotherapy: n = 1034 (91%). AIC was the most common subtype (n = 6302, 94%) followed by MEC (n = 304, 4.6%) and ACC (n = 73, 1.1%). Patients who received chemotherapy were younger (64.0 ± 9.0 vs 66.5 ± 11.3; p < 0.001), otherwise, there was no significant difference in baseline demographics. Unadjusted 5-year survival for stage I PSGC was significantly lower in the chemotherapy arm (60.5% vs 72%, p < 0.001). Chemotherapy did not improve survival in resected stage II or III PSGC. Overall survival was inferior with chemotherapy on multivariable analysis (adjusted HR: 1.32, 95%CI (1.13-1.55), p = 0.0006). Older age, male gender, positive margins, higher clinical stage, comorbidities, rural population and pneumonectomy were associated with lower overall survival (Table). Conclusions: Contrary to previous studies AIC is the most common tumor type among PSGC. Adjuvant chemotherapy is associated with worse survival in resected PSGC and current guidelines for administering adjuvant chemotherapy in resected lung cancer is inadequate for this population. [Table: see text]

Sulphur doses and application times on yield and oil quality of canola grown in calcareous soil

Pakistan has been constantly deficient in its oil seed production and it is very difficult to meet the edible oil requirement of its ever-increasing population. A field experiment was conducted at the Agronomy Research Farm, The University of Agriculture Peshawar, Northern Pakistan during winter (2013–14). Five sulphur levels (15, 30, 45, 60 and 75 kg·ha-1) and times of application (at seedling, bolting and flowering stages) were used for the canola variety Abasin-95. The experiment was laid out in a randomized complete block design replicated four times on a 5 m × 3.2 m plot size. The results showed that the sulphur-applied plots gave the highest seed yield, biological yield, glucosinolate, erucic acid, oil content, protein content, oleic acid and linoleic acid compared to the control plots. Sulphur applied at the rate of 60 kg·ha-1 and applied at the bolting stage increased seed yield, biological yield, oil content, and protein content.

124 Ovarian follicular development and steroid secretion during oestrous cycle of Lohi sheep

Pakistan has 30.9 million heads of sheep; however, little information is available on their reproductive aspects. The objective of this study was to document ovarian physiology and endocrinology of Lohi ewes during the oestrous cycle. Nine Lohi ewes, synchronized by administering single prostaglandin F2α (PGF2a; Cyclomate, Star Laboratories), were monitored for ovarian follicular dynamics using transrectal ultrasonography (7.5MHz, HS-1500, Honda) for two consecutive oestrous cycles during the breeding season (September to November 2018). Changes in plasma progesterone and oestradiol-17β concentrations of ewes (n=9) were also determined during the oestrous cycle using radioimmunoassay. The interovulatory interval of Lohi ewes averaged 17.0±0.1 days, and the duration of follicular and luteal phases was 4.6±0.2 and 11.3±0.2 days, respectively. Follicles emerged in either 3- or 4-wave patterns, but the frequency of the 3-wave pattern was higher than that of the 4-wave (87 vs. 13%, respectively; P=0.05). Following ovulation (Day 0), follicles (=3mm) in 3-wave cycles (n=14) emerged on Days 0.7, 5.2, and 10.5, whereas in 4-wave cycles (n=2) follicles emerged on Days 0.1, 4, 8.5, and 11.5. The maximum diameter of preovulatory follicles and corpora lutea (CL) were 5.4±0.3 and 10.4±0.3mm, respectively. Regardless of the wave pattern, single ovulation occurred in each cycle. The CL was first detectable on Day 4±0.1, it reached maximum diameter on Day 9±0.1, and luteolysis began on Day 12.2±0.2 of the cycle. The peak plasma oestradiol-17β concentration (42.5±2.6 pgmL−1) was observed 48h before ovulation and correlated with the diameter of the preovulatory follicle during the follicular phase (r=0.84; P&lt;0.05). The peak plasma progesterone concentration (11.8±1.7ngmL−1) was observed on Day 9±0.1 and coincided with the diameter of CL throughout the oestrous cycle (r=0.93; P&lt;0.05). In conclusion, the majority of oestrous cycles in Lohi ewes had a 3-wave pattern and were mono-ovulatory in nature.

141 Effect of combined treatment of melatonin and equine chorionic gonadotrophin on fresh semen quality of Beetal bucks during the non-breeding season

In the subtropics, bucks show seasonal breeding patterns, and their semen quality decreases during the non-breeding season. Therefore, breeders tend to improve bucks’ semen quality before the breeding season for higher conception rates. In the current study, we hypothesised that simultaneous administration of equine chorionic gonadotrophin (ECG) and melatonin would improve fresh semen quality in bucks before the breeding season. Nine Beetal bucks were randomly assigned (n=3 per treatment) to three treatments: control, melatonin, and melatonin + ECG. Melatonin implants (18 mg; BTC Lab) were placed subcutaneously at the base of the ear. Bucks in the melatonin + ECG treatment were administered ECG (400 IU; Syncro-Part, Ceva Santé Animale) intramuscularly on every fourth day until the end of the experiment. Control bucks were administered normal saline (400 IU; Otuska Pakistan) intramuscularly on every fourth day. Semen was collected twice per week using an artificial vagina (42°C) and immediately evaluated for volume, color, pH, and contaminants. Sperm concentration, motility and kinematics (curvilinear velocity, straight-line velocity, average path velocity, and amplitude of lateral head displacement), viability, DNA, and acrosomal and mitochondrial integrity were monitored using a computer-assisted semen analyzer (AndroVision, Minitube). Weekly concentrations of plasma testosterone and melatonin of all bucks were analysed using radioimmunoassay (Immunotech, Beckman Coulter Ltd.) and enzyme-linked immunosorbent assay (450nm), respectively. Comparisons within and between treatments were made using generalised linear models (repeated-measures analysis of variance). Weekly single-point variance between the treatments was determined (analysis of variance) at P ≤ 0.05 (SPSS ver. 20.0; IBM Corp.). Semen quality (volume, pH, total motility (%), and concentration) improved after Week 4 in the melatonin + ECG treatment compared with the control and melatonin treatments (P&lt;0.05). Similarly, progressive motility (%), viability, DNA, acrosomal and mitochondrial integrity, and sperm kinematics (curvilinear velocity, straight-line velocity, average path velocity, and amplitude of lateral head displacement) improved (P&lt;0.05) after Week 4 in the melatonin + ECG treatment. Similarly, non-viability and ratio of abnormal spermatozoa decreased by Week 3 in the melatonin + ECG treatment (P&lt;0.05) compared with the control and melatonin treatments. Likewise, plasma testosterone concentration (ngmL−1) of bucks was higher (P&lt;0.05) at Week 3 in the melatonin + ECG treatment (4.2±0.2) than in the melatonin (0.8±0.1) and control (1.2±0.1) treatments. Within the melatonin + ECG treatment, plasma testosterone concentration was higher (P&lt;0.05) at Week 5 (4.9±0.2) and Week 9 (4.5±0.1) than at Week 3 (4.2±0.2). Plasma melatonin concentration (pgmL−1) increased (P&lt;0.05) from Week 5 onward in the melatonin + eCG (12.5±0.1) and melatonin (10.2±0.1) treatments compared with the control (2.65±0.1). In conclusion, the simultaneous administration of melatonin and ECG improved fresh semen quality in Beetal bucks.

Computer-Based versus Paper-Based Insulin Infusion Algorithms in Diabetic Ketoacidosis

BACKGROUND

Paper-based and computer-based insulin infusion algorithms facilitate appropriate glycemic therapy. The data comparing these algorithms in the management of diabetic ketoacidosis in the intensive care unit (ICU) setting are limited. We aimed to determine the differences in time to diabetic ketoacidosis resolution and incidence of hypoglycemia between computer and paper-based insulin infusion.

METHODS

Single-institution retrospective review of patients admitted to the ICU with diabetic ketoacidosis between 4/1/2015 and 7/20/2018. Our institution introduced computer-based insulin infusion (Glucommander) to the intensive care unit on 3/28/2016. Patients were grouped into either paper-based group (preintervention) or a computer-based group (postintervention). Summary and univariate analyses were performed.

RESULTS

A total of 620 patients (paper-based=247; computer-based=373) with a median (IQR) age of 40 (26-56) years were included; 46% were male. Patients in the computer-based group were significantly older (p=0.003); otherwise, there were no significant differences in gender, race, body mass index and HbA1c. The mean (±SD) time to diabetic ketoacidosis resolution in the computer-based group was significantly lower than the paper-based group (p=0.02). The number of patients in the paper-based group who developed severe hypoglycemia (<50 mg/dl) was significantly higher {8% vs 1%; p<0.0001}.

CONCLUSION

Our analyses demonstrate statistically significant decreases in time to DKA resolution and hypoglycemic events in DKA patients who were managed using a computer-based insulin infusion algorithm providing a more effective and safer option when compared to paper-based insulin infusion.

P2668Causes and predictors of 30 and 90 days readmission after cardiac arrest: insights from the nationwide readmission database

Background

Cardiac arrest (CA) is a lethal condition with high public health burden and grave long-term implications. We aimed to evaluate the rate and predictors of readmission after CA

Methods

We used the Nationwide Readmission Database 2014 to determine patient with index admission CA by using relevant ICD-9 codes. We excluded patients <18 years and admissions in October, November, and December to allow 90 days readmission follow up. We evaluated rates and causes of 30 and 90 days readmission. We investigated disposition options for CA survivors and rates of readmissions. Multivariable analysis was done for relevant variables to demonstrated predictors of readmission.

Results

A total cohort of 71,780 patients suffered CA and survived to hospital discharge. Mean age was 63.9±15 years and 61.3% were males. Mean length of stay was 14.2±18.3 days, primary payer was Medicare 58%, 42.2% were discharged home, 33% to skilled nursing/intermediate care facility, 18.5% to home with home health services, 5% to short term hospital, and 0.8% left against medical advice (AMA). All-cause 30 and 90 days readmission rates were 18% and 28.9%, respectively. According to each disposition group 30/90 days readmission rates were; home 13.6/23%, facility 22/35.7%, home health 21/31.9%, short term hospital 16.8/24.1%, and 33.7/42.4% left AMA. The most common causes of readmission at 30 and 90 days were congestive heart failure and infection (11% each). CA on readmission was 1.5% at 30 and 90 days. The most common predictors of readmission were CHF odds ratio (OR) 1.3, (95% CI: 1.3–1.4; P<0.001), renal failure OR 1.7, (95% CI: 1.7–1.8; P<0.001), chronic lung disease OR 1.3, (95% CI: 1.2–1.; P<0.001), and depression OR 1.1 (95% CI: 1.1–1.2; P<0.001).

Conclusion

Readmissions are common at 30 and 90 days in CA survivors and are associated with high cost. CHF and infection are the most common causes of 30 and 90-day readmission, while renal failure is the strongest predictor of readmission after adjusting for unbalanced covariates. Discharge to home was the most common disposition, and had the lowest rate for readmission. Leaving AMA had the highest rate of readmission.

Comparison of a clinical-laboratory algorithm, 4t and heparin-induced thrombocytopenia expert probability scores in the diagnosis of heparin-induced thrombocytopenia in the critical care setting

BACKGROUND

Several scoring systems are utilized to calculate the pre-test probability of heparin-induced thrombocytopenia (HIT). We hypothesize that a clinical-laboratory algorithm combining the 4Ts score with the optical density (OD) of anti-PF4-heparin antibody is more accurate than either the 4Ts or HIT expert probability (HEP) scores in the critical care setting.

METHODS

A single-institution retrospective review of adult patients admitted to the intensive care unit (ICU) that were evaluated for HIT was conducted. Two reviewers independently rated the proposed algorithm, 4Ts and HEP score. Summary, univariate and area under receiver operator characteristic analyses were performed.

RESULTS

A total of 88 patients with a mean (SD) age of 62 (15) years were included. The sensitivity, positive predictive value and negative predictive value were superior in our clinical-laboratory algorithm compared to the 4Ts score ≥ 4 and the HEP score ≥ 2. The algorithm's specificity was non-inferior to the 4Ts score and HEP score. There was no significant difference between our clinical-laboratory algorithm and the 4Ts score or the HEP score in predicting HIT.

CONCLUSION

Our study confirms that the combination of clinical and laboratory criteria is crucial in the presumable diagnosis of HIT. This is the first study that validates different HIT scores in an isolated ICU population.

An Unusual Case of Diffuse Alveolar Hemorrhage as a Clinical Manifestation of Atypical Hemolytic Uremic Syndrome: A Case Report

Hemolytic uremic syndrome (HUS) is a constellation of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury. HUS is subcategorized into primary or secondary HUS. Primary HUS is synonymous with atypical HUS (aHUS) and is attributed to genetic complement deficiency. Diffuse alveolar hemorrhage (DAH) is a serious condition complicating multiple systemic conditions. aHUS presenting as DAH is exceedingly rare. In this case, we present a 75-year-old male patient who presented with generalized weakness, malaise, and hemoptysis. He was found to have hemolytic anemia and thrombocytopenia, with elevated creatinine. Bronchoscopy confirmed DAH. He was started on plasmapheresis with a suboptimal response. aHUS was suspected and the patient was started on eculizumab with subsequent laboratory and clinical improvement. HUS and aHUS can present as DAH. It is very important to recognize both conditions as both are life threatening with high morbidity and mortality.

Angiotensin converting enzyme inhibitors use and development of lung cancer: A systematic review and meta-analysis

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Background: Angiotensin-converting enzyme inhibitors (ACEIs) are commonly prescribed medications for hypertension and heart failure. Generally, ACEIs are well-tolerated medications with reasonable safety profile making them a favorable choice by many clinicians. However, several studies with conflicting results have signaled an association between ACEIs use and the development of lung cancer. We sought to systematically review the literature and perform the first meta-analysis to study the risk of lung cancer among ACEI users. Methods: We performed a literature review by searching multiple databases. A random effect meta-analysis approach was used to pool the data and relative risk was used to calculate the overall effect estimate. Results: A total of 423 articles were identified but only 6 observational studies were included with a total of 872,220 patients (634,672. ACEIs users). The relative risk of lung cancer development among ACEIs users was 1.02 (CI 0.89-1.16) compared to non-ACEIs users. Conclusions: Current systematic review and meta-analysis show no significant association between ACEIs use and the development of lung cancer. The result of our meta-analysis provides further assurance to the health care providers regarding ACEIs use.

Enhanced readability of discharge summaries decreases provider telephone calls and patient readmissions in the posthospital setting

INTRODUCTION

Hospital discharge instructions provide critical information necessary for patients to manage their own care; however, often they are written at a substantially higher readability level than recommended (ie, 6th-grade level) by the American Medical Association and the National Institutes of Health. We hypothesize that improving the reading level of discharge instructions will decrease the number of patient telephone calls and readmissions in the posthospital setting.

METHODS

We conducted a prospective observational study. Patient discharge instructions were edited and incorporated to enhance the readability level in August 2015. Return telephone call and readmissions of patients admitted before the intervention from August 1, 2014, to January 31, 2015, were compared with the prospective cohort studied from September 1, 2015, to September 30, 2016.

RESULTS

A total of 1,072 patients were included (preintervention: n = 493, postintervention: n = 579). Patient demographics, injury characteristics, and education level were similar among both groups. The median discharge instruction readability level in the postintervention group was significantly lower (10.0, 95% CI 10.0-10.2 vs 8.6, 95% CI 8.8-8.9; P < .0001). The proportion of patients calling after hospital discharge was significantly reduced after the intervention (21.9% vs 9.0%; P < .0001). Monthly hospital readmissions were decreased by 50% for every 100 patients discharged after the intervention (1.9% vs 0.9%; P = .002). The proportion of patients calling and readmissions for poor pain control significantly decreased after the intervention (7.1% vs 2.59%; P = .0005 and 2.8% vs 1.0%; P = .029, respectively).

CONCLUSION

Enhanced readability of discharge instructions was associated with a decrease in the number of telephone calls and readmissions in the posthospital setting, enhancing health literacy and simultaneously reducing the burden on providers. Improved patient instructions written to an appropriate level may also allow for better pain control in the posthospital setting.

Prothrombin Complex Concentrate Reversal of Coagulopathy in Emergency General Surgery Patients

BACKGROUND

Coagulopathy can delay or complicate surgical diseases that require emergent surgical treatment. Prothrombin complex concentrates (PCC) provide concentrated coagulation factors which may reverse coagulopathy more quickly than plasma (FFP) alone. We aimed to determine the time to operative intervention in coagulopathic emergency general surgery patients receiving either PCC or FFP. We hypothesize that PCC administration more rapidly normalizes coagulopathy and that the time to operation is diminished compared to FFP alone.

METHODS

Single institution retrospective review was performed for coagulopathic EGS patients during 2/1/2008 to 8/1/2016. Patients were divided into three groups (1) PCC alone (2) FFP alone and (3) PCC and FFP. The primary outcome was the duration from clinical decision to operate to the time of incision. Summary and univariate analyses were performed.

RESULTS

Coagulopathic EGS patients (n = 183) received the following blood products: PCC (n = 20, 11%), FFP alone (n = 119, 65%) and PCC/FFP (n = 44, 24%). The mean (± SD) patient age was 71 ± 13 years; 60% were male. The median (IQR) Charlson comorbidity index was similar in all three groups (PCC = 5(4-6), FFP = 5(4-7), PCC/FFP = 5(4-6), p = 0.33). The mean (± SD) dose of PCC administered was similar in the PCC/FFP group and the PCC alone group (2539 ± 1454 units vs. 3232 ± 1684, p = .09). The mean (±SD) time to incision in the PCC alone group was significantly lower than the FFP alone group (6.0 ± 3.6 vs. 8.8 ± 5.0 h, p = 0.01). The mean time to incision in the PCC + FFP group was also significantly lower than the FFP alone group (7.1 ± 3.6 vs. 8.8 ± 5.0, p = 0.03). The incidence of thromboembolic complications was similar in all three groups.

CONCLUSIONS

PCC, alone or in combination with FFP, reduced INR and time to surgery effectively and safely in coagulopathic EGS patients without an apparent increased risk of thromboembolic events, when compared to FFP use alone.

LEVEL OF EVIDENCE

IV single institutional retrospective review.

Not the Typical Pneumonia: An Unusual Case of Rasburicase-induced Methomoglobinemia

We present a rare case of rasburicase-induced methemoglobinemia and hemolytic anemia in the setting of presumed glucose-6-phosphate dehydrogenase (G6PD) deficiency. A 78-year-old male with a known history of chronic lymphocytic leukemia presented to the clinic with fever of unknown origin. Laboratory results were significant for hyperuricemia. He was empirically started on levofloxacin and rasburicase. He then presented to the emergency department with shortness of breath and syncope. Physical examination was remarkable for a fever of 102.8 °F, conjunctival pallor, and scleral icterus. An infiltrate was observed on his computed tomography (CT) angiogram of the chest. Arterial blood gas on 50% fraction of inspired oxygen was significant for an arterial oxygen level of 222 millimeters mercury and oxyhemoglobin of 85.9%. Co-oximetry was then obtained and methemoglobin level was 13.4%. Laboratory results were noteworthy for a drop-in hemoglobin, indirect hyperbilirubinemia, low haptoglobin and elevated lactate dehydrogenase; depicting hemolytic anemia. The patient received two units of packed red blood cells, intravenous broad-spectrum antibiotics and he clinically improved.

Validation of AAST EGS Grade for Acute Pancreatitis

BACKGROUND

The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods.

METHODS

Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014-1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems.

RESULTS

There were 297 patients with a mean (±SD) age of 55 ± 17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay.

CONCLUSIONS

The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system.

LEVEL OF EVIDENCE

IV Study Type: Single institutional retrospective review.

Cardiac troponin-I as a predictor of mortality in patients with first episode acute atrial fibrillation

BACKGROUND

Recent-onset atrial fibrillation (AF) is a frequent cause for presentation to the emergency department. Recent studies proposed that the addition of biomarker information might improve the prediction of clinical outcomes by enabling identification of patients at high risk.

AIM

We aimed to examine the role of cardiac troponin I as a predictor of clinical outcome in patients with first episode acute AF.

DESIGN

Patients, 18 years or older, presenting to our hospital with a primary diagnosis of first episode acute AF were included in this retrospective study.

METHODS

The association between elevated cTnI with mortality or the composite endpoint (mortality, stroke or heart failure) was examined in a univariate Cox regression model.

RESULTS

Of the 274 study patients, 111 had elevated cTnI levels (41%). Increased cTnI was associated with older age, history of myocardial infarction, higher creatinine levels and higher heart rate (All P < 0.01). Elevated cTn was associated with an adjusted hazard ratio of 1.86 [95% confidence interval (CI) 1.17-2.96; P = 0.009] for mortality and 1.89 (95% CI 1.27-2.84; P = 0.002) for the combined endpoint.

CONCLUSIONS

Elevated cardiac Troponin I is a significant predictor of mortality and a composite endpoint of mortality, stroke or heart failure in patients presenting with first episode acute AF.

Efficiency of antifreeze glycoproteins for cryopreservation of Nili-Ravi (Bubalus bubalis) buffalo bull sperm

Experiments were conducted to evaluate the effect of Antarctic fish antifreeze glycoproteins, (AFGP) size 1-5 (34-10.5 kDa) and 7-8 (3.2 and 2.4 kDa) in extender on buffalo bull sperm at cooling (4 °C) and at post thawing. Semen was collected from three Nili-Ravi buffalo bulls with artificial vagina for 3 weeks. Qualifying ejaculates from each buffalo bull were diluted (at 37 °C having 50×10(6) sperm/mL) in tris-citric acid extender containing AFGP at 0 (control), 0.1, 1 and 10 μg/mL. An aliquot of diluted semen was evaluated for sperm progressive motility and plasma membrane integrity, while the remaining fraction was cooled to 4 °C in 2 h. Further, an aliquot of cooled semen was evaluated for the previously described variables and the remaining fraction was cryopreserved (-196 °C). After 24 h of storage, straws were thawed at 37 °C for 30 s to assess post-thaw sperm quality. Inclusion of AFGP in the extender did not affect (P>0.05) sperm progressive motility and plasma membrane integrity of buffalo bull sperm at cooling stage (4 °C). However, at post thawing, improvement (P<0.05) in sperm progressive motility and plasma membrane integrity was recorded in extender containing AFGP 1-5 and AFGP 7-8 at 1 μg/mL compared to the control. Percentage of live sperm with an intact acrosome remained similar (P>0.05) in extenders containing different amounts of AFGP and control. In conclusion, supplementation of 1 μg/ml of AFGP in extender improved the motility and plasma membrane integrity of Nili-Ravi buffalo sperm after thawing.

Primary splenic hydatidosis

Primary extrahepatic hydatid cysts are rare, and primary splenic hydatid cysts even more so, constituting 2% to 3.5% of all hydatid cysts. We report here a case series of isolated splenic hydatid cysts. Case records of 382 adult patients of abdominal hydatid cysts were analyzed; eight of them (2%; aged 23 to 45 years, 5 women and 3 men) had primary splenic hydatid cysts. Seven patients presented with dull dragging pain in the left hypochondrium. Four patients had splenomegaly. Diagnosis was made at ultrasonography and/or contrast-enhanced computed tomography. Enzyme linked immunosorbent assay for hydatid antibodies tested positive in all patients. One patient presented with hemoperitoneum. All patients underwent splenectomy. Primary splenic hydatid cyst is rare but should be considered in patients with cystic lesions of the spleen.

Micu Quiz

The patient was admitted to Medical ICU because of severe shortness of breath and fever. The patient is known case of renal transplant using immunosuppressant medications. Deep endotracheal tube aspirate reported as, Gram's stain showed delicate, filamentous, branching gram positive rods. Acid-fast staining showed partially acid fast filamentous branching rods.

Synthesis and antimicrobial activity of meso-substituted polymethine cyanine dyes

The condensation reaction of equivalent amounts of 2-cyanomethyl benzooxazole or its derivatives with variously substituted aromatic aldehydes gave 2-cyano-styryl benzooxazole or its derivatives. The subsequent reaction of the 2-cyano-styryl benzooxazoles with 2(4)-methyl substituted heterocyclic quaternary salts afforded meso-substituted styryl-2(4)-polymethine cyanines. The condensation reaction of 2-cyanomethyl benzooxazole or its derivatives with alpha-nitroso-beta-naphthol followed by reaction with 2(4)-methyl substituted heterocyclic quaternary salts gave meso-substituted aza-2(4)-polymethine cyanines. The reaction of 2-cyanomethyl benzooxazole or its derivatives with N-methyl heterocyclic quaternary salts followed by the reaction with 2-methylquinolinium methiodide afforded the corresponding meso-substituted trimethine cyanine dyes. Elemental analyses, visible absorption, IR, (1)H NMR spectroscopy, and mass spectra established the structures of these compounds. The relationship between the structure and properties of these dyes has been studied and the solvatochromic behavior of some selected cyanine dyes in organic solvents is discussed. Finally, the antimicrobial activity of selected novel dyes was investigated in vitro using a wide spectrum of microbial strains.

An empirical investigation of hospital profitability in the post-PPS era

In this study, we identify the empirical determinants of hospital profitability, as measured by return on assets, using a comprehensive sample of hospitals from all four U.S. regions over the post-PPS era. We augment previous empirical models of hospital profitability by considering the effects of additional economic and financial variables and the effects of conversion of ownership status. Our empirical findings suggest that the following factors are significant determinants of hospital profitability during the post-PPS era: geographic location, ownership status, teaching status, conversion of ownership status, adjusted number of employees, length of stay, competition, financial indebtedness, bed capacity, and occupancy rate. We also find that a nonlinear relationship characterizes the dependence of hospital profitability on bed capacity and occupancy rate.

Bilateral asymmetric dissociated vertical deviation masquerading as unilateral double elevator palsy. A report of four cases

PURPOSE

To illuminate this difficult clinical situation and assist and improve in its diagnosis and management. METHODS AND STUDY: Record Review. All 4 patients had a unilateral DEP and increased hyperdeviation upon tilting the head to the contralateral shoulder. Two patients had surgery to the eye with the presumed diagnosis of DEP, consisting of recession of the inferior rectus muscle in one patient and a Knapp procedure in the second patient. The other two patients had weakening surgery of the superior rectus muscle of the contralateral eye.

RESULTS

The marked limitation of elevation in the eye with pseudo- DEP was either restored to normal or very satisfactorily improved. Bilateral DVD appeared in all four patients immediately after surgery.

CONCLUSION

Bilateral asymmetric DVD can masquerade as unilateral DEP due to inhibitional palsy of the elevators. Meticulous diagnostic tests can reveal the DVDs.

Unilateral modified Harada-lto procedure for excyclotorsion secondary to unilateral superior oblique palsy

BACKGROUND

The Fells modification of the Harada-lto procedure is usually performed bilaterally for the correction of excyclotorsion secondary to acquired bilateral superior oblique paresis. Excyclotorsion is not usually a major complaint in true unilateral superior oblique paresis. Occasional cases, however, may find this symptom bothersome and it may interfere with fusion. The purpose of the present study is to determine the effect of the unilateral modified Harada-lto procedure on the correction of symptomatic excyclotorsion in unilateral superior oblique paresis.

METHOD

A retrospective case-note review of patients with unilateral superior oblique paresis undergoing unilateral modified Harada-lto procedures during the five-year period 1988-1993 was performed.

RESULTS

Six patients fulfilled the inclusion criteria. Superior oblique paresis was congenital in one case, secondary to trauma in two cases and idiopathic acquired in three cases. There were four males and two females aged from 25 to 63 years and all but one had previous surgery. The mean pre-operative excyclotorsion was approximately 10 degrees (range 8-14 degrees). Mean post-operative excyclotorsion was 3 degrees (range 2 degrees incyclotorsion -10 degrees excyclotorsion).

CONCLUSION

The unilateral modified Harada-lto procedure is an effective surgical treatment of excyclotorsion resulting from superior oblique paresis and may improve sensory and motor fusion.