PERT era, race-based healthcare disparities in a large urban safety net hospital.

Pulmonary embolism (PE) is the third leading cause of cardiovascular death in the United States. Black Americans have higher incidence, greater clot severity, and worse outcomes than White Americans. This disparity is not fully understood, especially in the context of the advent of PE response teams (PERT), which aim to standardize PE-related care. This retrospective single-center cohort study compared 294 Black and 131 White patients from our institution's PERT database. Primary objectives included severity and in-hospital management. Secondary outcomes included length of stay, 30-day readmission, 30-day mortality, and outpatient follow-up. Clot  (p = 0.42), acute treatment (p = 0.28), 30-day mortality (p = 0.77), 30-day readmission (p = 0.50), and outpatient follow-up (p = 0.98) were similar between races. Black patients had a lower mean household income ($35,383, SD 20,596) than White patients ($63,396, SD 32,987) (p < 0.0001). More Black patients (78.8%) had exclusively government insurance (Medicare/Medicaid) compared to White patients (61.8%) (p = 0.006). Interestingly, government insurance patients had less follow-up (58.3%) than private insurance patients (79.7%) (p = 0.001). Notably, patients with follow-up had fewer 30-day readmissions. Specifically, 12.2% of patients with follow-up were readmitted compared to 22.2% of patients without follow-up (p = 0.008). There were no significant differences in PE severity, in-hospital treatment, mortality, or readmissions between Black and White patients. However, patients with government insurance had less follow-up and more readmissions, indicating a socioeconomic disparity. Access barriers such as health literacy, treatment cost, and transportation may contribute to this inequity. Improving access to follow-up care may reduce the disparity in PE outcomes.

A rare case of Rosai-Dorfman disease presenting as a pulmonary artery mass in a 33-year-old female with hypoxia.

Rosai-Dorfman disease (RDD) is a rare form of non-Langerhans histiocytosis. It is often idiopathic in etiology, but has been associated with viral, autoimmune, and malignant disease. Adequate diagnosis of RDD requires a combination of clinical symptoms, radiography, and histology. Most commonly, patients with RDD present with cervical lymphadenopathy. We describe a case of a young female who was initially thought to have a pulmonary embolism at the time of a COVID-19 infection but was noted to have a rare occurrence of RDD presenting as a pulmonary artery mass upon further evaluation of radiology and histology. Though RDD is frequently benign, extranodal involvement can progress to end organ damage and must be recognized appropriately.

Nasopharyngolaryngoscopy as a Triage Tool for Airway Compromise in Angioedema: A Retrospective Cohort Study.

Background Airway compromise and respiratory failure are feared complications of angioedema leading to intensive care unit (ICU) admission. However, few of these patients decompensate. There is a paucity of tools that predict airway compromise in patients with angioedema, and it is unclear if automatic triage to the ICU is warranted. We analyzed patients admitted to our tertiary center ICU with angioedema for "airway watch" to find a way to triage those at greatest risk of respiratory decompensation. Methods We performed a retrospective review of patients with angioedema admitted to our ICU between 2017 and 2020. Data collected included demographics, comorbidities, nasopharyngolaryngoscopy (NPL) findings, need for intubation, and length of stay. Descriptive analysis and subsequent ANOVA or T-test statistical analysis was performed to determine the relationships between individual variables and outcomes. Categorical variables were compared using Pearson's Chi-squared test or Fisher's exact test where applicable. Continuous variables were compared using a Mann-Whitney U test. Results Of 134 patients admitted to our ICU, 63 (47%) required intubation, primarily in the emergency department (92.1%). Of those who required intubation, 61.9% had abnormal NPL findings in contrast to 25.35% of patients who did not require intubation (p<0.0001). Normal NPL findings had a negative predictive value for requiring intubation of 86.5%. Abnormal NPL findings had a positive predictive value for requiring intubation of 68.4%. Conclusion While airway compromise is a serious complication of angioedema, there is scant evidence to support triage to the ICU for those not intubated immediately. The majority of patients with angioedema who required intubation had abnormal NPL findings, and the majority of those with normal NPL findings did not require intubation. This suggests that NPL findings in patients with angioedema can help with triage to the ICU.

Assessment of Bronchiectasis in HIV Patients among an Urban Population.

Bronchiectasis is characterized by permanent destruction of the airways that presents with productive cough, as well as bronchial wall thickening and luminal dilatation on computed tomographic (CT) scan of the chest; it is associated with high mortality. Accumulating data suggests higher rates of bronchiectasis among the HIV-positive population. This case series involves 14 patients with bronchiectasis and HIV followed at two major urban institutions from 1999 to 2018. Demographics, clinical presentation, microbiology, radiographic imaging, and outcomes were collected and compiled. Mean age was 42 years (range 12-77 years). 36% had a CD4 count greater than 500 cells/mm3, 28% had a CD4 count between 200 and 500 cells/mm3, and 36% had AIDS. 43% were treated for Pneumocystis jiroveci pneumonia (PJP) and 50% for Mycobacterium avium complex (MAC) infection. 21% had COPD, 7% had asthma, and 7% had a history of pulmonary aspergillosis. Two patients were followed up by pulmonary services after diagnosis of bronchiectasis on CT. The timeline of the follow-up in these cases was within months and after three years respectively. It is posited that the prevalence of bronchiectasis in HIV patients may be underestimated. Improving recognition and management of bronchiectasis could help diminish rehospitalization rates.

Assessment of interstitial lung disease among black rheumatoid arthritis patients.

BACKGROUND: Conflicting reports exist regarding the racial and the gender distribution of rheumatoid arthritis-related interstitial lung disease (RA-ILD). In a major population study of predominately Whites, RA-ILD was reported mainly among smoker middle-aged men. However, recent data suggest that the disease is that of elderly women. Our study aimed to assess the prevalence and identify the gender differences and clinical characteristics of RA-ILD in a predominantly Black population. METHODS: Cross-sectional analysis of data obtained from the records of 1142 patients with RA diagnosis by ICD codes of which 503 cases met the inclusion criteria for the study. Eighty-six patients had chronic respiratory symptoms of cough and dyspnea and were further assessed by our multidisciplinary group of investigators. Thirty-two subjects with an established diagnosis of rheumatoid arthritis met the diagnostic criteria for interstitial lung disease. RESULTS: Of the 32 patients with RA-ILD, mean age was 62.6 ± 2.2 (± SEM), 93.7% were females, and 89% Blacks with a BMI = 29.2 (Kg/m2). Usual interstitial pneumonia (UIP) was found in 24/32 (75%) of the cases. Seventy-two percent of the RA-ILD patient had seropositive RA. Smoking history was reported in 31.3% of the cohort, gastroesophageal reflux disease (GERD) in 32.3%, and cardiovascular disease (CVD) risk factors in 65.6%. CONCLUSION: Our study indicates RA-ILD among Blacks is predominantly a disease of elderly females with higher rates of GERD and CVD risk factors. Further studies are needed to identify the pathogenetic differences accounting for the gender distribution of RA-ILD among Black and White populations.Key Points• First study to assess ILD among predominantly Black RA patients.• The prevalence of RA-associated ILD was 6.36%, affecting mostly women in their sixth decade with seropositive disease.• COPD was the most common airway disease among non-RA-ILD Black population.• GERD was found in approximately one-third of patients with RA-associated ILD versus one-fifth of those RA patients without any lung disease.

Assessment of Cardiovascular Disease Risk and Therapeutic Patterns among Urban Black Rheumatoid Arthritis Patients.

Rheumatoid arthritis (RA) patients have nearly twice the risk of cardiovascular disease (CVD) compared to the general population. We aimed to assess, in a predominantly Black population, the prevalence of traditional and RA-specific CVD risk factors and therapeutic patterns. Utilizing ICD codes, we identified 503 RA patients ≥18 years old who were seen from 2010 to 2017. Of them, 88.5% were Black, 87.9% were women and 29.4% were smokers. CVD risk factors (obesity, diabetes, hypertension, dyslipidemia) were higher than in previously reported White RA cohorts. Eighty-seven percent of the patients had at least one traditional CVD risk factor, 37% had three or more traditional CVD risk factors and 58% had RA-specific risk factors (seropositive RA, >10 years of disease, joint erosions, elevated inflammatory markers, extra-articular disease, body mass index (BMI) < 20). CV outcomes (coronary artery disease/myocardial infarction, heart failure, atrial fibrillation and stroke) were comparable to published reports. Higher steroid use, which increases CVD risk, and lesser utilization of biologics (decrease CV risk) were also observed. Our Black RA cohort had higher rates of traditional CVD risk factors, in addition to chronic inflammation from aggressive RA, which places our patients at a higher risk for CVD outcomes, calling for revised risk stratification strategies and effective interventions to address comorbidities in this vulnerable population.