Small Bowel Obstruction Due to Metastatic Urachal Adenocarcinoma: A Rare Presentation.

Urachal adenocarcinoma is a rare but highly malignant epithelial cancer that accounts for <1% of all bladder malignancies and commonly presents with hematuria. We report a case of metastatic urachal adenocarcinoma presenting as bowel obstruction. A 54-year-old male patient with a history of alcohol abuse presented to the emergency with acute-onset, diffuse, cramping abdominal pain, worst in the epigastrium and lasting one day. Abdominal examination revealed moderate guarding and generalized tenderness with hypoactive bowel sounds. Imaging confirmed an evolving small bowel obstruction and a urachal remnant with a superimposed mass lesion. The patient underwent an exploratory laparotomy and a high-grade small bowel obstruction due to the mass was identified. An intraoperative frozen section identified adenocarcinoma. A biopsy of the urachal mass confirmed urachal adenocarcinoma. The final diagnosis was moderately differentiated urachal adenocarcinoma. The tumor was deemed unresectable due to the involvement of multiple loops of the small bowel and the mesentery of the small and large bowels. Systemic chemotherapy with 5-fluorouracil (5-FU), leucovorin, and oxaliplatin (modified FOLFOX-6) was initiated. Our patient did not report any prior urinary symptoms or recurrent abdominal pain, which are the common symptoms that urachal adenocarcinoma presents with. Bowel obstruction is a rare presentation of urachal adenocarcinoma since the spread of the disease to the viscera occurs much later in the course. This case report highlights a rare presentation of an even rarer malignancy.

Cardiac sarcoidosis and ventricular arrhythmias. A rare association of a rare disease. A retrospective cohort study from the National Inpatient Sample and current evidence for management.

BACKGROUND: Sarcoidosis is an increasingly recognized multi-systemic condition. Cardiac sarcoidosis is associated with ventricular arrhythmias and higher mortality rates. Little epidemiological data is available regarding the disease and associated ventricular arrhythmias. METHODS: Data from the National Inpatient Sample (NIS) database 2012-2014, were reviewed. Dis-charges associated with sarcoidosis were identified as the target population using relevant ICD-9-CM codes. Primary outcome was a diagnosis of ventricular tachycardia (VT) in the sarcoidosis population. Secondary outcomes include rate of ventricular fibrillation (VF) and cardiac arrest. Subgroup analyses were performed to examine the association of VT with multiple potential confounding clinical variables. RESULTS: Of 18,013,878 health encounters, 46,289 (0.26%) subjects had a diagnosis of sarcoidosis. VT and VF were more prevalent among patients with sarcoidosis compared to those without a diagnosis of sarcoidosis (2.29% vs. 1.22%; p < 0.001 and 0.25% vs. 0.21%; p < 0.001, respectively). Sarcoidosis was also associated with a higher prevalence of cardiac arrest (0.72% vs. 0.6%; p < 0.001). In unadjusted analyses, all examined comorbidities were significantly more common in those with sar-coidosis, including diabetes mellitus (31.6% vs. 21.25%; p < 0.001), hypertension (65.2% vs. 51.74%; p < 0.001), chronic kidney disease (21.09% vs. 14.02%; p < 0.001), heart failure (24.87% vs. 15%; p < 0.001) and acute coronary syndrome (4.32% vs. 3.35%; p < 0.001). CONCLUSIONS: The present study showed that sarcoidosis was associated with increased rates of ven-tricular tachyarrhythmia, which can affect the overall disease morbidity and mortality.

Palliative Care in Myocardial Infarction: Patient Characteristics and Trends of Service Utilization in a National Inpatient Sample.

INTRODUCTION: Myocardial infarction (MI) remains a leading cause of mortality. Palliative care (PC) has recently expanded in scope to include noncancer-related conditions. There is little data available regarding the use of PC in critical MI patients. METHODS: We used discharge data from the National Inpatient Sample for the years 2012 to 2014. We examined discharges with a primary diagnosis of MI. We measured the rate of PC referral, trend in utilization during the study period and possible predictors of PC utilization. RESULTS: Among 1 667 520 discharges of those patients ≥18 years of age and with a primary diagnosis of MI, use of PC was seen in 2.5% of all patients and in 24% of patients who died. In a multivariable logistic regression, we found the presence of cancer, cardiogenic shock, dementia, stroke, hemiplegia, the use of circulatory support, and mechanical ventilation were associated with higher likelihood of PC referral. Palliative care referral increased during the study period, odds ratio of 1.18 per year (95% confidence interval: 1.14-1.21; P value <.001). Palliative care was not associated with prolonged length of stay. CONCLUSION: Several comorbidities were associated with the use of PC, most notably the use of mechanical ventilation and the presence of metastatic cancer. There was a trend of increasing use of PC during the study period.

Relationship of Atrial Fibrillation to Outcomes in Patients Hospitalized for Chronic Obstructive Pulmonary Disease Exacerbation.

INTRODUCTION: Chronic Obstructive Pulmonary Disease (COPD) is a major cause of hospitalization and is associated with an increased incidence of atrial fibrillation (AF). The impact of AF on in-hospital outcomes, including mortality, in patients hospitalized for COPD exacerbation is not well elucidated. METHODS: We used the National Inpatient Sample database to examine discharges with the primary diagnosis of COPD exacerbation and compared mortality, length of stay and costs in patients with AF compared to those without AF. The study adjusted the outcomes for known cardiovascular risk factors and confounders using logistic regression and propensity score matching analysis. RESULTS: Among 1,377,795 discharges with COPD exacerbation, 16.6% had AF. Patients with AF were older and had more comorbidities. Mortality was higher (2.4%) in the AF group than in the no AF group (1%), p <0.001. After adjustment to age, sex and confounders, AF remained an independent predictor for mortality, OR:1.44 (95% CI 133 - 1.56, p <0.001), prolonged length of stay, OR:1.63 (95% CI 1.57 - 1.69, p <0.001) and increased cost, OR: 1.45 (95% CI: 1.40 - 1.49, p <0.001). CONCLUSIONS: among patients with COPD exacerbation, AF was associated with increased mortality and higher resource utilization.

Impact and Outcomes of Patients with Congestive Heart Failure Complicating Non-ST-Segment Elevation Myocardial Infarction,Results from a Nationally-Representative United States Cohort.

INTRODUCTION: Congestive heart failure (CHF) is seen in up to 13-25% of patients with NSTEMI. Recent data describing the impact of congestive heart failure (CHF) on in-hospital outcomes in patients with non-ST-segment elevation myocardial infarction (NSTEMI) in the United States is limited. We sought to examine the in-hospital outcomes, and management of CHF in patients admitted to the hospital with NSTEMI. METHODS: National Inpatient Sample (NIS) database (2010-2014) was analyzed to identify patients with NSTEMI using ICD-9-CM codes. The primary outcome was in-hospital mortality. Propensity score-matching analysis compared mortality in CHF patients to matched controls without CHF. RESULTS: Of 247,624 patients with NSTEMI, 84,115 (34%) had CHF. Patients with CHF were less likely to receive percutaneous coronary intervention (PCI) [20.48% vs. 40.9%, P < 0.001] or coronary artery bypass grafting (CABG) [8.2% vs 9.6%, P < 0.001] during hospitalization. Also, they had longer lengths of stay and higher risk for in-hospital adverse outcomes. CHF was the strongest predictor of in-hospital death. The increased mortality risk was persistent after propensity matching (RR 1.27; 95% CI 1.22 to 1.33). CONCLUSION: CHF among patients with NSTEMI is associated with increased risk for in-hospital mortality and adverse outcomes.

Is obstructive sleep apnea associated with ventricular tachycardia? A retrospective study from the National Inpatient Sample and a literature review on the pathogenesis of Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is a known independent risk factor for a multiple cardiovascular morbidities and mortality. The association of OSA and ventricular arrhythmias is less well understood. The aim of this analysis is to study the relationship between OSA and ventricular tachyarrhythmias. HYPOTHESIS: OSA is associated with increased ventricular arrhythmias. METHODS: Data from the national inpatient sample (NIS) 2012 to 2014, were reviewed. Discharges associated with OSA were identified as the target population using the relevant ICD-9-CM codes. The primary outcome was a diagnosis of ventricular tachycardia (VT) in the OSA population. Secondary outcomes include the rate of ventricular fibrillation (VF) and cardiac arrest. Multivariable analyses were performed to examine the association of VT with multiple potential confounding clinical variables. RESULTS: Of 18 013 878 health encounters, 943 978 subjects (5.24%) had a diagnosis of OSA. VT and VF were more prevalent among patients with OSA compared to those without a diagnosis of OSA (2.24% vs 1.16%; P < 0.001 and 0.3% vs 0.2%; P < 0.001, respectively). Odds ratio for cardiac arrest in OSA group was not statistically significant (1, 95% confidence interval 0.97-1.02, P < 0.76). In unadjusted analyses, all examined comorbidities were significantly more common in those with OSA, including diabetes mellitus, hypertension, chronic kidney disease, acute coronary syndrome, and heart failure. CONCLUSION: OSA is associated with increased rates of ventricular tachyarrhythmia.

Relation of Obstructive Sleep Apnea to Risk of Hospitalization in Patients With Heart Failure and Preserved Ejection Fraction from the National Inpatient Sample.

Obstructive Sleep Apnea (OSA) increases the risk of diastolic dysfunction and heart failure. The impact of OSA on hospitalization for heart failure with preserved ejection fraction (HFpEF) is not well elucidated. We used data from the National Inpatient Sample for the years 2012 to 2014. We identified discharges (age ≥18 years) associated with OSA and HFpEF using the International Classification of Diseases, Ninth Revision, Clinical Modification codes (327.23 and 428.3x), respectively. Propensity score analysis, adjusting for age, gender, race, and comorbidities, compared the rates of admission for HFpEF in patients with OSA to those without OSA. Out of 12,608,637 discharges included, there were 147,463 patients with HFpEF, and 653,762 or 5.2% of all discharges had OSA. The prevalence of OSA in patients with HFpEF was 16.8%. Patients with OSA were older, more likely to be men, more likely to have diabetes, hypertension, history of coronary artery disease, chronic kidney disease, obesity, atrial fibrillation, African-American race, and smoking status. In patients with OSA, HFpEF occurred in 3.8% versus 1.0%, with adjusted odds ratio: 2.2 (95% confidence interval 2.16 to 2.23), p <0.001. Subgroup analysis showed similar results in men and women. After propensity score matching, OSA was associated with increased risk of admission with HFpEF, relative risk = 2.2 (95% confidence interval 2.12 to 2.21). In conclusion, OSA was associated with increased risk of hospitalization for HFpEF.

Impact of delirium on patients hospitalized for myocardial infarction: A propensity score analysis of the National Inpatient Sample.

BACKGROUND: Delirium is associated with worse outcomes in critically ill patients. In the subset of patients with myocardial infarction (MI), the impact on clinical outcomes of delirium is not as well elucidated. HYPOTHESIS: Delirium is associated with increased mortality in patients hospitalized for MI. METHODS: The study used data from the National Inpatient Sample 2012 to 2014, Healthcare Cost and Utilization Project. We included discharges associated with the primary diagnosis of MI using the relevant International Classification of Diseases, Ninth Revision, Clinical Modification codes. The outcome was inpatient mortality between the delirium group and propensity score-matched controls without delirium. RESULTS: The study included 1 330 020 weighted discharges with MI as the principal diagnosis. Within this cohort, 18 685 discharges (1.4%) had delirium. Delirium was associated with older age, lower rates of percutaneous coronary intervention, and increased comorbid conditions. The delirium group had higher mortality (10.5% vs 2.6%, P < 0.001). Propensity score-matching analysis showed increased mortality in the delirium group (10.5% vs 7.6%, relative risk: 1.39 [95% confidence interval: 1.2-1.6, P < 0.001) using nearest neighbor 1:1 matching. CONCLUSIONS: In individuals with MI, delirium was associated with increased inpatient mortality.