Improving the diagnostic yield of echocardiography in acute ischemic stroke: A quality improvement project in a community hospital in Maryland, USA.

Background: Echocardiography is routinely ordered in acute ischemic stroke workup. No standardized or structured criteria is used to select or exclude echocardiography in such settings. Moreover, the diagnostic yield of echocardiography in stroke is low in our medical center. This article presents newly proposed selection criteria for echocardiography in ischemic stroke workup. Methods: A quality improvement project was implemented in a 385-bed community hospital in Maryland, USA. A computerized decision support tool consisting of new criteria for selecting echocardiography in ischemic stroke workup was created. 639 patients hospitalized with ischemic stroke were followed-up over 12 months after intervention, and 686 matched-controls with ischemic stroke were retrospectively analyzed from the 12 months prior to intervention. Cost-effectiveness and diagnostic yield of echocardiography in ischemic stroke were measured before and after intervention. Results: Following intervention, the diagnostic yield of echocardiography in ischemic stroke workup significantly increased by 51% (from 3.8% to 7.8%, odds ratio (OR) 2.1, P= 0.01). The number of echocardiography studies needed to detect and treat one patient with a cardiac source of embolism was reduced from 50 to 25 studies. The overall use of echocardiography in stroke workup significantly decreased (OR 0.4, p < 0.001). Patients with lacunar infarcts or atrial fibrillation had significant reduction in echocardiography (OR 0.2, p < 0.001 and OR 0.4, p < 0.001, respectively). Conclusion: The new criteria for echocardiography selection in hospitalized patients with ischemic stroke significantly improved the cost-effectiveness and the diagnostic yield of echocardiography and reduced unnecessary echocardiography in lacunar infarcts or atrial fibrillation.

Association of proton pump inhibitor use and significant hyponatremia-a US population-based case-control study.

Hyponatremia is the most common electrolyte abnormality encountered in clinical practice. Several medications are associated with hyponatremia. Proton pump inhibitors were reported to cause hyponatremia in one large Swedish population-based study and small observational studies or case reports. This article presents the results of a single-center retrospective case-control study based on a US patient population that examined the association between the use of proton pump inhibitors and significant hyponatremia. Cases were 792 hospitalized patients with hyponatremia, extracted from 473,000 patient encounters over 6 years, and matched controls were 774 hospitalized patients with normal serum sodium levels whose risk factors for hyponatremia were comparable to those of the study cases. The results showed that use of proton pump inhibitors for at least 30 days prior to hospital admission was significantly higher in patients with hyponatremia than in patients who had normal serum sodium levels (32.7% vs 23.3%, respectively, odds ratio 1.6, P < 0.001). Also, proton pump inhibitor use was nonsignificantly higher among patients with recurrent hyponatremia in subsequent hospitalizations compared with patients who did not have recurrence of hyponatremia (35.5% vs 30.4%, respectively, odds ratio 1.3, P = 0.13). To our knowledge, no prior US population-based study addressing such an association has been published.

Thinking Beyond Acute Kidney Injury.

Acute kidney injury (AKI) can be a significant clue to solving a puzzling patient presentation. Postrenal AKI should be suspected if imaging shows any degree of hydronephrosis and can be caused by a variety of conditions. Diagnosis of urinary obstruction without significant dilatation of the pelvic-ureteral system requires a higher degree of suspicion, and hence, its identification can become late. In patients without prior cancer screening, the etiology of obstructive uropathy must be broadened to include primary or metastatic malignancy. Clinicians should look beyond the AKI to properly evaluate the etiology of the patient's presentation and symptoms. In this report, we present the case of a middle-aged female with no known past medical history who presented with AKI secondary to malignant retroperitoneal fibrosis as the first manifestation of metastatic breast cancer. Her AKI was associated with acute onset anuria and was found to have nondilated postrenal AKI with no significant abnormalities on renal imaging. Early onset anuria in the setting of AKI, which persists despite fluid resuscitation, can suggest complete urinary tract obstruction even with reassuring results of initial renal images, and in the patient with no history of cancer screening, malignancy should be suspected as a primary cause of obstructive uropathy.

Successful use of montelukast in eosinophilic gastroenteritis: a case report and a literature review.

BACKGROUND: Eosinophilic gastrointestinal disorders, also known as eosinophilic gastroenteritis, are rare inflammatory conditions characterized by eosinophilic infiltration of different parts of the gastrointestinal tract, along with peripheral eosinophilia in most cases. Other known causes for gut eosinophilic infiltration must be excluded to confirm the diagnosis of eosinophilic gastroenteritis. Symptoms of the disorder depend on the affected gastrointestinal tract segment and depth of involvement. Treatment includes systemic glucocorticoids and/or dietary therapy with an empiric elimination diet. Second line therapies include the leukotriene receptor antagonist montelukast, and other anti-allergy drugs such as mast cell stabilizers (including cromolyn and the H1-antihistamine ketotifen), suplatast tosilate which is a selective Th-2 cytokines (IL-4 and IL-5) inhibitor, and the monoclonal anti-IgE antibody omalizumab. We report a case of eosinophilic gastroenteritis who was successfully treated and achieved remission with montelukast as an initial monotherapy. Upon extensive literature review, this represents the second reported adult case of eosinophilic gastroenteritis who responds to montelukast alone as a first line therapy. CASE PRESENTATION: A 49-year-old female presented with recurrent abdominal pain, vomiting, diarrhea and unexplained eosinophilia. She was diagnosed with eosinophilic gastroenteritis and was successfully treated with montelukast monotherapy. After 7 days of therapy, the patient responded well and had complete resolution of her gastrointestinal symptoms and peripheral eosinophilia. Patient remained in remission on follow-up after 12 months. We reviewed the literature for leukotriene antagonist use in the treatment of eosinophilic gastroenteritis and included the cases treated with the leukotriene antagonist montelukast as an initial therapy or as a second line therapy for refractory disease. CONCLUSION: Montelukast may be an effective treatment for eosinophilic gastroenteritis, either alone or in combination with systemic steroids or ketotifen. Our patient is the second reported adult case of eosinophilic gastroenteritis who responded to montelukast alone as a first line therapy. Further studies and clinical trials are required to confirm efficacy compared to standard therapy.

Thoracic Point-of-Care Ultrasound: A SARS-CoV-2 Data Repository for Future Artificial Intelligence and Machine Learning.

Current experience suggests that artificial intelligence (AI) and machine learning (ML) may be useful in the management of hospitalized patients, including those with COVID-19. In light of the challenges faced with diagnostic and prognostic indicators in SARS-CoV-2 infection, our center has developed an international clinical protocol to collect standardized thoracic point of care ultrasound data in these patients for later AI/ML modeling. We surmise that in the future AI/ML may assist in the management of SARS-CoV-2 patients potentially leading to improved outcomes, and to that end, a corpus of curated ultrasound images and linked patient clinical metadata is an invaluable research resource.

Acute Ischemic Colitis due to Oral Phenylephrine.

Oral phenylephrine is a commonly used over-the-counter nasal decongestant drug. It is usually taken for symptomatic relief (in combination drug products) for upper respiratory tract infections, allergic rhinitis, or sinusitis. Adverse cardiovascular effects of intravenous phenylephrine, including organ ischemia, are well known; however, oral phenylephrine is rarely associated with significant adverse effects. We describe the first case of acute ischemic colitis in a young patient due to over-the-counter oral phenylephrine, which was taken as a nasal decongestant. We reviewed the literature of colonic ischemia related to the use of systemic nasal decongestants phenylephrine and pseudoephedrine.