Clinical features and risk factors of adverse clinical outcomes in central pulmonary embolism using machine learning analysis.

BACKGROUND: In prior studies, central pulmonary embolism (PE) was associated with high clot burden and was considered an independent predictor for thrombolysis. Further information about predictors of adverse outcomes in these patients is needed for better risk stratification. The objective is to describe independent predictors of adverse clinical outcomes in patients with central PE. METHODS: Large retrospective, observational, and single-center study of hospitalized patients with central PE. Data were gathered on demographics, comorbidities, clinical features on admission, imaging, treatments, and outcomes. Multivariable standard and Least Absolute Shrinkage and Selection Operator (LASSO) machine learning logistic regressions and sensitivity analyses were used to analyze factors associated with a composite of adverse clinical outcomes, including vasopressor use, mechanical ventilation, and inpatient mortality. RESULTS: A total of 654 patients had central PE. The mean age was 63.1 years, 59% were women, and 82% were African American. The composite adverse outcome was observed in 18% (n = 115) of patients. Serum creatinine elevation (odds ratio [OR] = 1.37, 95% CI = 1.20-1.57; p = 0.0001), white blood cell (WBC) count elevation (OR = 1.10, 95% CI = 1.05-1.15; p < 0.001), higher simplified pulmonary embolism severity index (sPESI) score (OR = 1.47, 95% CI = 1.18-1.84; p = 0.001), serum troponin elevation (OR = 1.26, 95% CI 1.02-1.56; p = 0.03), and respiratory rate increase (OR = 1.03, 95% CI = 1.0-1.05; p = 0.02) were independent predictors of adverse clinical outcomes. CONCLUSION: Among patients with central PE, higher sPESI score, WBC count elevation, serum creatinine elevation, serum troponin elevation, and respiratory rate increase were independent predictors of adverse clinical outcomes. Right ventricular dysfunction on imaging and saddle PE location did not predict adverse outcomes.

Impact of achieving euthyroidism on pulmonary artery systolic pressures in hyperthyroidism-associated pulmonary hypertension - a systematic review.

In this systematic review, we seek to clarify the impact of treatment of hyperthyroidism on pulmonary hypertension in patients with both these conditions. We included 39 of 709 articles retrieved, that studied patients with hyperthyroidism and pulmonary hypertension (PH). From these, those with a documented pre-treatment Pulmonary Artery Systolic Pressure (PASP) > 35 mmHg and complete follow up were analyzed, yielding 3 case series and 22 case reports with a total of 81 cases. A significant improvement in PASP was noted with achieving euthyroidism in the 3 case series. The case reports showed a significant reduction in mean PASP from 60.5 ± 13.2 mmHg to 37.5 ± 10.1 mmHg (p < 0.001) in patients with Grave's disease with achieving euthyroidism. No deaths were reported during the follow up period. Achievement of a euthyroid state in patients with hyperthyroidism is associated with statistically significant reductions in PASP.

Demographic and clinical profile of patients suffering prolonged severe hypoxia in COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) may result in rapid onset of hypoxemic respiratory failure. This study aimed to characterize the factors and outcomes associated with prolonged hypoxia in patients with COVID-19. Prolonged severe hypoxia (PSH) was defined as hypoxia requiring ≥6 L/min of oxygen by nasal cannula or equivalent for more than 10 days. RESEARCH DESIGN AND METHODS: This study was designed as a single-center retrospective analysis. Multivariable logistic regression was utilized to assess factors associated with PSH. RESULTS: The sample included 554 patients with 117 (21%) having PSH. Median length of stay of patients with PSH was significantly longer (median IQR: 18 days vs 6 days, p < 0.0001). Patients with PSH had significantly higher rates of venous thromboembolism (p < 0.0001) and major bleeding (p < 0.004). The presence of cirrhosis (OR 3.32, 95% CI [1.02 to 10.83]) and hypertension (OR 1.99, 95% CI [1.12 to 3.53]) were independently associated with PSH, while outpatient use of anti-platelet agents had an inverse association (OR 0.57, 95% CI [0.36 to 0.91]). CONCLUSION: PSH is associated with increased length of stay, morbidity, and mortality. Hypertension and liver cirrhosis were significantly associated with higher odds of PSH, while use of anti-platelet therapy had a protective effect.

Risk factors associated with intubation and readmissions in patients with angioedema: A single-center experience al. / Ann Allergy Asthma Immunol 127 (2021) xxx-xxx"?>.

BACKGROUND: Given the heterogeneity of etiologies, pathophysiology, and presentation of angioedema, variations in clinical outcomes, such as intubation and hospital readmissions, need further clarification. OBJECTIVE: To determine the factors associated with intubation and hospital readmissions in patients with angioedema. METHODS: Retrospective study of patients evaluated with a diagnosis of angioedema in a 6-year period. Demographic and clinical data, such as medication use, family history, comorbidities, and symptoms, were recorded. Multivariable logistic regression was used to analyze factors associated with intubation, whereas Cox regression was used to analyze readmissions. RESULTS: Of 636 patients, the most common cause of angioedema was that induced by angiotensin-converting enzyme inhibitor (ACEI) at 58%. The overall mortality was 0.5%. After adjusting for sex, race, comorbidities, and type of angioedema, smoking (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.10-2.93; P = .02), calcium channel blocker therapy (OR, 1.91; 95% CI, 1.18-3.10; P = .009), histaminergic symptoms (OR, 3.21; 95% CI, 1.93-5.33; P < .001), and age (OR, 1.02; 95% CI, 1.00-1.04; P = .02) were independently associated with increased odds of intubation. Involvement of either the pharynx, larynx, or tongue was associated with higher odds of intubation (OR, 20.96; 95% CI, 10.63-41.33; P < .001). A total of 10% of the patients had a readmission for angioedema within 90 days, and 75% occurred within 30 days. After multivariable Cox regression analysis, only chronic obstructive pulmonary disease and asthma (OR, 2.13; 95% CI, 1.12-4.07; P = .02) and ACEI-related angioedema (OR, 2.93; 95% CI, 1.33-6.47; P = .008) were significantly associated with readmissions. CONCLUSION: Smoking, calcium channel blocker use, histaminergic symptoms, age, and upper airway involvement were markedly associated with intubation. The presence of chronic obstructive pulmonary disease, asthma and ACEI-related angioedema were independently associated with increased odds of readmission.

Factors associated with hospital readmissions among patients with COVID-19: A single-center experience.

Identify factors associated with readmission after an index hospital admission for coronavirus disease 2019 (COVID-19) infection in a single center serving an underserved and predominantly minority population. This retrospective descriptive study included 275 patients who tested COVID-19 positive via reverse transcriptase-polymerase chain reaction assay at our institution and who survived the index hospitalization. The main outcomes were 1- and 6-month readmission rates after an index hospitalization for COVID-19. The mortality rate among the readmitted patients was also determined. Factors independently associated with readmission were investigated using multivariable logistic regression. A final sample of 275 patients was included. The mean age was 64.69 ± 14.64 (SD), 133 (48%) were female and 194 (70%) were African American. Their chronic medical conditions included hypertension 203 (74%) and diabetes mellitus 121 (44%). After the hospitalization, 1-month readmission rate was 7.6%, while 6-month readmission rate was 24%. Nine percent of patients who were readmitted subsequently died. Coronary artery disease (CAD) was significantly associated with 6-month readmission odds ratio (OR), 2.15 (95% confidence interval [CI]: 1.04-4.44; p = 0.039) after adjustment for age, gender, ethnicity, and comorbidities. Readmissions were due to cardiac, respiratory, and musculoskeletal symptoms. Hispanic ethnicity was associated with increased readmission OR, 3.16 (95% CI: 1.01-9.88; p = 0.048). No significant difference was found between inflammatory markers or clinical outcomes during the index hospitalization among patients who were readmitted compared to those who were not. A significant number of patients hospitalized for COVID-19 may be readmitted. The presence of CAD is independently associated with high rates of 6-month readmission.

A 65-Year-Old Woman With Dyspnea After Atrial Fibrillation Ablation.

CASE PRESENTATION: A 65-year-old woman with a history of chronic persistent atrial fibrillation, tobacco use, and COPD was admitted to the hospital 2 months after catheter ablation for persistent atrial fibrillation and dyspnea. Her dyspnea was present at rest and worsened by exertion with limitation to ambulating less than two blocks. She also endorsed a 1-month history of cough with minimally productive whitish sputum with frequent nocturnal exacerbations and orthopnea. She denied any fevers, chest pain, or hemoptysis.

Cognitive Bias in the COVID-19 Pandemic.

Cognitive bias plays a significant role in medical errors. In the pandemic of corona virus disease-19 (COVID-19), recognizing and creating strategies to minimize these biases is crucial to optimize medical care for our patients. In this article we present a case of a 68-year-old male with decreased appetite, subjective fears, dry cough, and confusion. The report illustrates the concept of cognitive bias during a pandemic and discusses strategies to ameliorate them.

Tracheobronchopathia osteochondroplastica: rare but not to be forgotten.

We report a case of a 59-year-old male with a one-month history of pleuritic chest pain who was diagnosed with tracheobronchopathia osteochondroplastica (TO). TO is a rare benign condition characterized by protruding submucosal nodules into the tracheobronchial lumen. The disease is generally asymptomatic, with rare cases of progressive nodularity, cough, dyspnoea, and haemoptysis. Diagnosis can be made via bronchoscopic visualization of bony and cartilaginous nodules on tracheal walls. Although generally benign, the rarity of this condition makes diagnosis difficult even for trained pulmonologists and frequently predisposes patients to unnecessary invasive diagnostic testing and improper management of symptoms and contributing co-morbid conditions. We present this case to increase physician and patient awareness about this disease to help improve diagnostic strategy and knowledge of disease manifestations and potential complications.

The Right to Write: Who 'Owns' the Case Report?

In this Letter to the Editor, Agrawal et al. debate the conflicts that can arise regarding the authorship of case reports. Like all other medical journals, EJCRIM has zero tolerance for the willful undisclosed re-submission of papers that have already been published elsewhere. However, this may occasionally happen by accident, especially in large healthcare institutions in which multiple teams of physicians may care for a patient throughout their illness. EJCRIM endorses and recommends to all potential authors the very sensible suggestions made by Agrawal et al. to avoid such an error occurring. EJCRIM would also encourage authors to consider the following: The first author should ensure that no one else involved in the case has reported it or plans to report it. This is especially important for physicians working in large healthcare centres, and/or for case reports of patients who have been under investigation or treatment for prolonged periods.On rare occasions EJCRIM will consider a case that has already been published, provided that this is fully and explicitly disclosed, and there is a clear reason why re-publication is justified. An example might be where new information has come to light that significantly changes the conclusions of the original report. As in all reports published by EJCRIM the decision to publish will depend on the educational value, or learning points, of the case.

Breaking your heart-A review on CPR-related injuries.

Cardiopulmonary resuscitation (CPR) has been shown to increase survival after cardiac arrest, but is associated with the risk of acquired injuries to the patient. While traumatic chest wall injuries are most common, other injuries include upper airway, pulmonary and intra-abdominal injuries. This review discusses the risk factors and prevalence of CPR-related injuries.

IVC filters-Trends in placement and indications, a study of 2 populations.

Inferior vena cava filter (IVCF) placement appears to be expanding over time despite absence of clear directing evidence.Two populations were studied. The first population included patients who received an IVCF between January 2005 and August 2013 at our community hospital center. Demographic information, indications for placement, and retrieval rate was recorded among other variables. The second population comprised of patients receiving an IVCF from 2005 to 2012 according to the Nationwide Inpatient Sample (NIS) using ICD-9CM coding. Patients were divided into 2 groups based on the year of admission for comparison, that is, first group from 2005 to 2008 and the second from 2009 to 2012. In addition, we analyzed annual trends in filter placement, acute venothromboembolic events (VTE) and several underlying comorbidities within this population.At our center, 802 IVCFs were placed (55.2% retrievable); 34% for absolute, 61% for relative, and 5% for prophylactic indications. Major bleeding (27.5%), minor self-limited bleeding (13.7%), and fall history (11.2%) were the commonest indications. Periprocedural complication rate was 0.7%, and filter retrieval rate was 7%. The NIS population (811,487 filters) saw a decline in IVCF placement after year 2009, following an initial uptrend (Ptrend < 0.01). IVCF use among patients with neither acute VTE nor bleeding among prior VTE saw a 3-fold absolute reduction from 2005 to 2012 (33,075-11,655; Ptrend < 0.01). Patients from 2009 to 2012 were more likely to be male and had higher rates of acute VTE, thrombolytic use, cancer, bleeding, hypotension, acute cardiorespiratory failure, shock, prior falls, blood product transfusion, hospital mortality including higher Charlson comorbidity scores. The patients were younger, had shorter length of stay, and were less likely to be associated with strokes including hemorrhagic or require ventilator support. Prior falls (adjusted odds ratio-aOR 2.8), thrombolytic use (aOR 1.76), and shock (aOR 1.45) were most predictive of IVCF placement between 2009 and 2012 on regression analysis.Recent trends suggest that a higher proportion of patients receive temporary IVCF, for predominantly relative indications. Nationally, the number of filters being placed is decreasing, especially among those who did not experience acute VTE or bleeding events. Prior falls, thrombolytic therapy, and shock were most predictive of IVCF placement in latter half of the study period.

Lethargy and vision loss: successful management of rhinocerebral mucormycosis.

Rhinocerebral mucormycosis (RCM) is an angioinvasive fungal infection most often caused by Rhizopus oryzae It is usually associated with an underlying risk factor and is associated with a poor prognosis. There are no consensus guidelines on the optimal management of this aggressive disease; most management decisions are based on case reports and expert opinion. We report a successfully managed case of RCM in an insulin-dependent diabetic, initially presenting with a change in mental status, rapidly progressing to complete right eye blindness and ophthalmoplegia and complicated by multiple cerebral infarctions and abscesses. We describe the diagnostic approach and various therapeutic interventions undertaken to successfully manage our patient.

Incidental findings on computed tomography angiography in patients evaluated for pulmonary embolism.

RATIONALE: To investigate how often computed tomography (CT) pulmonary angiography contributes to establishing a diagnosis in patients presenting to the emergency department and how it performs compared to chest radiograph. OBJECTIVES: The objective of this study was to measure the ability to identify a diagnosis and to investigate the prevalence and significance of incidental findings in patients evaluated with computed tomography pulmonary angiography in the emergency department. METHODS: All adult patients evaluated with CT angiography over a 2-year period (January 1, 2011 to December 31, 2012) were included in the analysis. A total of 641 records were identified. Chest radiographs and CT angiography reports were reviewed to determine whether they could provide a diagnosis in patients without pulmonary embolism (PE). Studies negative for PE were stratified into three categories according to significance: type I prompted immediate action, type II required follow up, and type III had findings of limited significance. MEASUREMENTS AND MAIN RESULTS: CT angiography identified a diagnosis in 22.46% of the patient population and in 14.31% of patients without PE. In patients who had CT angiography with chest radiograph, diagnoses were provided in 14.01 and 9.86% of patients, respectively. When analysis was isolated to patients with low probability for PE, CT angiography provided a diagnosis in 20% and chest radiography in 10.23% of patients. The majority of missed cases represented infiltrates too small to be detected by radiography and were believed to represent lung infections by the interpreting radiologist. Among studies negative for PE, 15% were type I, 17.07% were type II, 48.1% were type III, and the rest were normal. CONCLUSIONS: CT angiography is superior to chest radiography at providing a diagnosis in patients investigated for PE, even when no PE is present. However, in patients at low risk for PE, the clinical benefit of the additional diagnoses is questionable.

CT pulmonary angiography utilization in the emergency department: diagnostic yield and adherence to current guidelines.

The aim is to investigate the patterns of computed tomography pulmonary angiography (CTPA) use and adherence to current guidelines. Medical records of patients investigated with CTPA for pulmonary embolism (PE) in a single academic hospital from January 2011 until December 2012 were reviewed. Wells scores were calculated retrospectively by researchers blinded to the results of the CTPA. "Avoidable imaging" was defined as imaging performed against current recommendations of the European Society of Cardiology or the PIOPED investigation group. A total of 646 patients underwent testing; 61 cases of PE were diagnosed (9.4%). Potentially avoidable imaging was performed in 49.5% and 71.5% of patients, depending on the criteria used; 11.5% of imaging studies were performed in low-risk patients with negative D-dimer assays. There is evidence of CTPA overuse and D-dimer underuse. Adherence to guidelines and appropriate use of D-dimer assay might reduce avoidable imaging and ionizing radiation exposure.