Predictors of Escalation to Intensive Care Unit Level of Care Among Admissions for Alcohol Withdrawal.

According to the 2019 National Survey on Drug Use and Health, 14.5 million people ages 12 and older had alcohol abuse disorder. Alcohol withdrawal syndrome (AWS) can be defined as a collection of physical symptoms experienced due to abrupt cessation of alcohol after long-term dependence. In instances where regular inpatient management fails to control AWS symptoms, patients are shifted to intensive care units (ICUs) for closer monitoring and prevention of life-threatening complications like withdrawal seizures and delirium tremens (DTs), labeled as severe alcohol withdrawal syndrome (SAWS). Although this represents a significant healthcare burden, minimal studies have been conducted to determine objective predictors. In this study, we aim to determine the effect of patient demographics, socio-economic status, biochemical parameters, and clinical factors on the need for escalation to ICU level of care among admissions for AWS. Our study showed that factors such as a history of DTs or alcohol-related seizures, the initial protocol of management, degree of reported alcohol usage, activation of rapid response teams, mean corpuscular value, alcohol level on admission, highest Clinical Institute Withdrawal Assessment Alcohol Revised (CIWA-Ar) scored during the hospital stay, and the total amount of sedatives used were significantly associated with escalation to ICU level of care. Clinicians must use these objective parameters to identify high-risk patients and intervene early. We encourage further studies to establish a scoring algorithm incorporating biochemical parameters to tailor management algorithms that might better suit high-risk patients.

Pericardial Tamponade and Berger's Disease: An Unusual Association.

Cardiac tamponade is considered a medical emergency because a patient can deteriorate easily and die of cardiac arrest if the fluid is not drained immediately. The most common etiologies are the same as pericarditis as fluid accumulates due to pericardial inflammation, including infection, malignancy, trauma, iatrogenic, autoimmune, post-myocardial infarction, radiation, and renal failure. Although the treatment is pericardiocentesis or pericardial window, finding the etiology responsible for the development of pericardial effusion is important. Here, we describe the case of a 40-year-old female who presented to the emergency department with a chief complaint of severe epigastric pain of a two-day duration that was associated with multiple episodes of nausea, vomiting, dysphagia, and severe shortness of breath (New York Heart Association III). The patient was eventually diagnosed with cardiac tamponade as a cause of her dyspnea, as a two-dimensional cardiac echocardiogram detected a large pericardial effusion (>2 cm) with echocardiographic indications for cardiac tamponade with severe pulmonary hypertension. The patient underwent a therapeutic pericardial window with drainage of 250 mL of pericardial fluid. Ultrasound of the abdomen focusing on the kidneys showed an atrophic and echogenic right kidney with a bidirectional flow in the hepatic veins, suggestive of right heart failure. Subsequently, she underwent a kidney biopsy that showed diffuse mesangial proliferative glomerulonephritis with segmental sclerosing features consistent with IgA nephropathy, associated with tubular atrophy, interstitial fibrosis, interstitial inflammation, and moderate arteriosclerosis. The patient was diagnosed with stage V chronic kidney disease secondary to IgA nephropathy. IgA nephropathy is usually common in Caucasian or Asian males in their teens and late 30s, with hematuria as a usual presentation. This case is unique as cardiac tamponade with renal failure is rarely the presenting symptom of IgA nephropathy.

Drug-Induced Liver Injury Secondary to Turmeric Use.

Turmeric is a herbal medication and spice which has been used for thousands of years in traditional Eastern medicine for its flavour, colour, and purported anti-inflammatory, antioxidant, antineoplastic and antimicrobial properties. It has recently garnered interest and popularity worldwide for these reasons. While turmeric supplements are generally safe, some reports of toxicity are emerging. Compounds like piperine are added to turmeric to enhance its bioavailability, potentially contributing to its toxicity. Here, we describe a 55-year-old woman with progressive jaundice and elevated bilirubin and liver enzymes but no evidence of acute liver failure. She was treated with N-acetyl cysteine (NAC) for 24 hours and liver function tests (LFTs) were closely monitored. As a downtrend in LFTs was noted and the patient remained asymptomatic, she was discharged with close outpatient follow-up. LFTs eventually normalized 2 months after the initial presentation. Clinicians must keep this differential in mind when evaluating acute liver injury. With our case report, we question the utility of NAC in non-acetaminophen-related liver injury and encourage further studies. LEARNING POINTS: Eliciting information on recent drug or supplement use should be part of comprehensive history-taking to evaluate acute liver injury.Turmeric supplements which may contain piperine to enhance bioavailability are a potential source of acute liver injury.The role of N-acetyl cysteine in managing non-acetaminophen-related liver injury is unclear and further studies are required.

Impact of Obesity on In-Hospital Morbidity and Mortality Among Patients Admitted for Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD).

Background Obesity has been considered to be a risk factor for increased morbidity and mortality among patients with cardiopulmonary diseases. The burden of chronic obstructive pulmonary disease (COPD) and obesity is very high in the United States. We aimed to use the National Inpatient Sample (NIS) to evaluate the impact of obesity on the outcomes of patients hospitalized with COPD exacerbation. Materials & Methods This is a retrospective cohort study from the NIS database involving adult patients hospitalized for COPD exacerbation in the year 2019 obtained using the international classification of diseases, 10th revision coding system (ICD-10). Obese and morbidly obese subgroups were identified. Statistical analyses were done using the Stata software, and regression analysis was performed to calculate odds ratios. Adjusted odds ratios (aOR) were calculated after adjusting for potential confounders. Results Among patients hospitalized for COPD exacerbations, mortality rates were lower among obese and morbidly obese patients; aOR 0.72 [0.65, 0.80] and aOR 0.88 [0.77-0.99], respectively. Obese and morbidly obese were more likely to require non-invasive ventilation aOR 1.63 [1.55, 1.7] and aOR 1.93 [1.85-2.05], respectively, and were more likely to require mechanical ventilation aOR 1.25 [1.19, 1.31], and aOR 1.53 [1.44-1.62], respectively. The tracheostomy rate was 1.17%, 0.83%, and 0.38% among patients with morbid obesity, obesity, and nonobese patients, respectively. Obese (aOR 1.11 [1.07-1.14]) and morbidly obese patients (aOR 1.21 [1.16-1.26]) had higher odds of being discharged on home oxygen and to a skilled nursing facility (SNF), aOR 1.32[1.27-1.38] and aOR 1.37 [1.3-1.43], respectively. Average hospital charges and length of hospitalization were significantly higher for morbidly obese and obese patients as compared to non-obese patients (p < 0.01). Conclusions Among admissions for COPD exacerbation, the rates of non-invasive ventilation, mechanical ventilation, tracheostomy, discharge with supplemental oxygen, length of hospitalization, hospitalization charges, and discharge to an SNF were higher among obese patients representing a higher morbidity and healthcare utilization in this group. This, however, did not translate into increased mortality among obese patients admitted with COPD exacerbations, and further randomized controlled trials are required to confirm our findings.

Intestinal Perforation: A Rare Complication of Treatment With Bevacizumab.

Bevacizumab, a monoclonal immunoglobulin-G1 antibody directed against vascular endothelial growth factor (VEGF), inhibits angiogenesis. Gastrointestinal perforation is a serious and often fatal adverse event related to bevacizumab use. Bevacizumab is indicated in the treatment of colorectal malignancies, certain subtypes of non-small cell lung carcinoma, metastatic renal cell carcinomas, and cervical cancers. It is also indicated in the treatment of recurrent glioblastoma (GBM) in adult patients as the sole treatment agent or in combination with other antineoplastic medications. We present a case of a patient on bevacizumab currently with glioblastoma multiforme and seizures, who was previously treated with radiation treatment and temozolomide. The patient presented to the emergency room with abdominal pain, seizures and was diagnosed to have an intestinal perforation.