Prevalence, Length of Stay, and Hospitalization of Acute Kidney Injury in Patients With and Without Sjogren's Syndrome.

BACKGROUND: Literature on the outcome of acute kidney injury (AKI) in Sjogren's syndrome (SJS) is quite scanty. Acute kidney injury has emerged as a significant cause of morbidity and mortality in patients with autoimmune diseases such as systemic lupus erythematosus. OBJECTIVE: To examine the outcome of AKI with and without SJS. To achieve this, we examined the prevalence, mortality, outcomes, length of stay (LOS), and hospital charges in patients with AKI with SJS compared with patients without SJS from a National Inpatient Sample (NIS) database in the period 2010 to 2013. DESIGN: A retrospective cohort study using NIS. SETTING: United States. SAMPLE: Cohort of 97 055 weighted patient discharges with AKI from the NIS. MEASUREMENTS: Not applicable. METHODS: Data were retrieved from the NIS for adult patients admitted with a principal diagnosis of AKI between 2010 and 2013, using the respective International Classification of Diseases, Ninth Revision (ICD-9) codes. The study population divided into 2 groups, with and without Sjogren's disease. Multivariate and linear regression analysis conducted to adjust for covariates. We omitted patients with systemic sclerosis and rheumatoid arthritis from the analysis to avoid any discrepancy as they were not meant to be a primary outcome in our study. RESULTS: The study population represented 97 055 weighted patient discharges with AKI. Analysis revealed AKI patients with Sjogren's compared with patients without Sjogren's had statistically significant lower hyperkalemia rates (adjusted odds ratio: 0.65, confidence interval: 0.46-0.92; P = .017. There was no statistically significant difference in mortality, LOS, hospital charges, and other outcomes. LIMITATIONS: Study is not up to date as data are from ICD-9 which are testing data from 2010 to 2013, and data were obtained through SJS codes, which have their limitations. Also, limitations included lack of data on metabolic acidosis, hypokalemia, and not including all causes of AKI. CONCLUSIONS: At present, our study is unique as it has examined prevalence, mortality, and outcomes of Sjogren's in patients with AKI. Patients with Sjogren's had significantly lower hyperkalemia during the hospitalization. Further research is needed to identify the underlying protective mechanisms associated with Sjogren's that resulted in lower hyperkalemia. TRIAL REGISTRATION: Not applicable.

CONTEXTE: La documentation portant sur les issues de l'insuffisance rénale aiguë (IRA) en présence du syndrome de Sjorden (SSJ) est assez peu abondante. L'IRA apparaît comme une cause importante de morbidité et de mortalité chez les patients atteints de maladies auto-immunes telles que le lupus érythémateux systémique. OBJECTIFS: Examiner les issues de l'IRA avec ou sans SSJ. Pour ce faire, nous avons consulté la période entre 2010 et 2013 de la base de données National Inpatient Sample (NIS) pour comparer la prévalence, la mortalité, les issues, la durée des hospitalisations, et les frais d'hospitalisation chez des patients atteints d'IRA avec ou sans SSJ. TYPE D'ÉTUDE: Une étude de cohorte rétrospective utilisant la NIS. CADRE: États-Unis. ÉCHANTILLON: Les congés pondérés de 97 055 patients atteints d'IRA tirés de la NIS. MESURES: Sans objet. MÉTHODOLOGIE: Les codes diagnostic CIM-9 ont servi à l'extraction des données de la NIS pour les adultes admis avec un diagnostic primaire d'IRA entre 2010 et 2013. La population étudiée a été divisée en deux groupes: avec ou sans syndrome de Sjorden. Des analyses par régression linéaire et multivariée ont été conduites pour corriger les covariables. Pour éviter les disparités, les patients atteints de sclérose systémique et de polyarthrite rhumatoïde ont été exclus de l'analyse puisque ces affections ne devaient pas constituer un résultat principal de l'étude. RÉSULTATS: La population étudiée était constituée de 97 055 patients atteints d'IRA et ayant obtenu leur congé de l'hôpital. L'analyse a révélé que les patients atteints d'IRA et du SSJ présentaient des taux d'hyperkaliémie statistiquement plus faibles (rapport de cotes [RC] corrigé: 0,65; IC à 95 %: 0,46-0,92; p =0,017) que les patients sans SSJ. Aucune différence significative n'a été observée entre les deux groupes en ce qui concerne la mortalité, la durée du séjour, les frais d'hospitalisation et les autres résultats. LIMITES: L'étude n'est pas à jour puisque les données sont tirées des codes CIM-9, soit sur des données de 2010 à 2013 obtenues par l'entremise des codes du SSJ, lesquels ont leurs propres limites. L'étude est également limitée par le manque de données sur l'acidose métabolique, l'hypokaliémie et par le fait qu'elle n'inclut pas toutes les causes d'IRA. CONCLUSION: À ce jour, notre étude est la seule qui ait examiné la prévalence, la mortalité et les issues du syndrome de Sjorgren chez les patients atteints d'IRA. Les patients atteints du syndrome de Sjogren ont présenté moins d'hyperkaliémie pendant leur hospitalisation. Des études supplémentaires sont nécessaires pour identifier les mécanismes sous-jacents, associés au syndrome de Sjogren, ayant entraîné moins d'hyperkaliémie. ENREGISTREMENT DE L'ESSAI: Sans objet.

In-hospital outcomes of angiography versus intravascular ultrasound-guided percutaneous coronary intervention in ST-elevation myocardial infarction patients.

BACKGROUND: We compared the in-hospital complications, outcomes, cost, and length of stay (LOS) between angiography-guided percutaneous coronary intervention (PCI) and intravascular ultrasound (IVUS)-guided PCI in patients with ST-elevation myocardial infarction (STEMI) in the USA. METHODS: A nationwide inpatient database was queried to identify patients >18 years with STEMI who underwent angiography-guided and IVUS-guided PCI from January 2016 to December 2016. We compared the in-hospital mortality, complications, cost, and LOS between the two groups. RESULTS: We identified 100,485 patients who underwent angiography-guided PCI and 5,460 patients who underwent IVUS-guided PCI. In-hospital mortality was not statistically different (odds ratio [OR] 0.76, 95% CI 0.46 - 1.22, P = 0.24). Patients who underwent PCI with IVUS were more likely to have coronary artery dissection (OR 4.26, 95% CI 2.34 - 7.7, p = <0.01), and both groups had a similar incidence of acute kidney injury requiring hemodialysis. The mean LOS was similar, but the mean total cost was higher in the group that underwent PCI under IVUS guidance. CONCLUSIONS: The in-hospital mortality, hemodialysis, and the use of support devices did not reach a statistical difference between the two groups. However, we observed higher rates of coronary dissection with the use of IVUS in STEMI management.

Pneumococcal Meningitis Complicated by Spinal Cord Dysfunction and Acute Polyradiculopathy.

Background: Meningitis caused by Streptococcus pneumoniae is associated with devastating clinical outcomes. A considerable number of patients will develop long-term neurologic complications. Hearing loss, diffuse brain edema, and hydrocephalus are frequently encountered. Acute spinal cord dysfunction and polyradiculopathy can develop in some patients. Case Report: A 63-year-old female was admitted to our hospital with sudden-onset bilateral lower extremity weakness. On admission, the patient had evidence of spinal cord dysfunction given the abnormal motor and sensory physical examination findings and the absent sensation with a sensory level at dermatome T4 on neurologic examination. Computed tomography myelography did not show evidence of spinal cord compression or transverse myelitis. Cerebrospinal fluid examination was positive for pneumococcal meningitis. The patient was treated with antibiotics and steroids. Nerve conduction studies demonstrated the absence of response, suggesting damage to the peripheral nerves and polyradiculopathy. The patient was treated with plasmapheresis for possible Guillain-Barré syndrome; however, she did not improve despite appropriate antibiotics, steroids, and plasmapheresis. She developed persistent quadriparesis, sensory impairments in upper and lower extremities, and bowel and bladder sphincter dysfunction. Conclusion: Our case demonstrates the development of spinal cord dysfunction (supported by the sudden onset of paraplegia and the presence of a sensory level) and polyradiculopathy (flaccid paralysis, ascending weakness, and absence of response in neurophysiologic studies suggesting severe damage to the peripheral nerves). The appearance of either complication is unusual, and the simultaneous occurrence of both complications is even more uncommon.

Cerebellar ataxia a unique initial presentation of Legionnaires' disease.

We present a case of Legionnaires' disease complicated by cerebellar ataxia. A 60-year-old man was diagnosed with Legionnaires' disease by urine antigen after presenting to the hospital with a main problem of headache and gait instability. He also had a productive cough, as well as nausea, vomiting and diarrhoea. Initial physical examination revealed a positive Romberg test, positive pronator drift, severely unsteady gait and bilateral upper extremity resting tremors with the remainder of cranial nerves and neurological examination being unremarkable. The patient had a prolonged hospital course requiring endotracheal intubation and mechanical ventilation. He received 14 days of levofloxacin with resolution of the pneumonia. On repeat assessment prior to discharge, the patient's neurological symptoms improved; however, he still had mild residual gait instability, dysdiadokinesia and difficulty with fine motor tasks such as writing. Romberg test remained positive.

The Impact of Hospital Teaching Status on Colonoscopy Perforation Risk: A National Inpatient Sample Study.

BACKGROUND: Colonoscopy has been widely used as a diagnostic tool for many conditions, including inflammatory bowel disease and colorectal cancer. Colonoscopy complications include perforation, hemorrhage, abdominal pain, as well as anesthesia risk. Although rare, perforation is the most dangerous complication that occurs in the immediate post-colonoscopy period with an estimated risk of less than 0.1%. Studies on colonoscopy perforation risk between teaching hospitals and non-teaching hospitals are scarce. METHODS: The National Inpatient Sample database was queried for patients who underwent inpatient colonoscopy between January 2010 and December 2014 in teaching versus non-teaching facilities in order to study their perforation rates. Our study population included 257,006 patients. Univariate regression was performed, and the positive results were analyzed using a multivariate regression module. RESULTS: Teaching hospitals had a higher risk of perforation (odds ratio 1.23, confidence interval 1.07 - 1.42, P = 0.004). Perforation rates were higher in females, patients with inflammatory bowel disease and dilatation of strictures. Polypectomy did not yield any statistical difference between the study groups. Other factors such as African-American ethnicity appeared to have a lower risk. CONCLUSION: Perforation rates are higher in teaching hospitals. More studies are needed to examine the difference and how to mitigate the risks.

Delayed Diagnosis of Buried Bumper Syndrome When Only the Jejunostomy Extension is Used in a Percutaneous Endoscopic Gastrostomy-jejunostomy Levodopa-carbidopa Intestinal Gel Delivery System.

Direct intrajejunal levodopa-carbidopa intestinal gel (LCIG) administered through a percutaneous endoscopic gastrostomy (PEG) with a jejunal extension tube (PEG-J) is an FDA-approved modality for treatment of patients with advanced Parkinson's disease (PD). Buried bumper syndrome (BBS) is a rare complication associated with PEG tubes inserted for drug administration or enteral feeding. The syndrome is diagnosed endoscopically revealing burial of the internal bumper in the gastric wall, causing numerous serious complications. When only the J extension of a PEG-J is used to deliver medications, and the G tube is not utilized, a delay in the diagnosis of BBS can occur. This is likely as the small caliber J extension tube remains patent and functional. We present the case of an elderly patient with advanced PD on LCIG therapy, who presented with a dislodged J-tube from a PEG-J system. Endoscopy revealed BBS that had likely developed prior to dislodgment of J-extension and despite a conservative approach, the internal bumper needed to be surgically extracted to prevent further complications.

Characteristics of 30-day readmission in spontaneous pneumothorax in the United States: a nationwide retrospective study.

Objective: Our study aimed to determine the national estimates of the 30-day all-cause readmission rate among patients with spontaneous pneumothorax and to investigate the burden of these readmissions in terms of mortality, length of stay and hospitalization costs in the USA. Methods: We utilized the Nationwide Readmission Database for 2013-2014 and identified adults with a primary diagnosis of spontaneous pneumothorax. We analyzed and reported patient- and hospital-level variables of the study cohort. Our primary outcome was 30-day readmission rate, including the reasons for readmission. Our secondary outcomes included all-cause mortality, resources utilization and predictors of readmissions. Results: We identified 47,108 index admissions with spontaneous pneumothorax. The 30-day readmission rate was 13.6%. The most common reason for admission was recurrent pneumothorax. In index admissions, the in-hospital mortality rate was 3.1%; whereas, in readmissions, the mortality was higher (4.6%, p < 0.001). Both age group 45-64 (HR: 1.31, 95% CI: [1.15-1.49], p < 0.001) and history of cancer (HR: 1.34, 95% CI: [1.17-1.53], p < 0.001) were found to predict the risk of 30-day readmission. Conclusion: The 30-day readmission rate in patients with spontaneous pneumothorax was 13.6%, and a recurrent event was the most likely cause. The 30-day readmissions were associated with higher mortality and hospitalization charges. Middle age and history of cancer increase likelihood of 30-day readmission.

Clozapine-Induced Cardiotoxicity Presenting as Sepsis: A Case Report and Literature Review.

Clozapine is an atypical antipsychotic agent indicated in the treatment of medication-resistant schizophrenia. It is often reserved as a last line of treatment owing to the potential for serious and potentially life-threatening side effects, the most serious being agranulocytosis requiring close hematological monitoring and possible discontinuation of the medication from further use in the patient even when the agranulocytosis resolves. Other complications of clozapine include sedation, weight gain, elevated triglyceride levels, postural hypotension, and tachycardia. However, the potentially serious complication of myocarditis, though rare (with an incidence of 3%), may lead to cardiomyopathy as described in our present case. We present a 21-year-old patient who was started on clozapine for management of schizophrenia. He developed fever and tachycardia and was admitted to the medical unit on intravenous antibiotics for management of sepsis as he met the criteria for systemic inflammatory response syndrome. His labs revealed an elevated troponin and trending eosinophilia, which, in the context of clozapine use, raises the suspicion of clozapine cardiotoxicity. Echocardiogram showed reduced systolic function (45%). Clozapine was immediately discontinued, and his repeat echocardiogram showed normalization of his systolic function. In view of the increased prevalence of psychiatric illnesses, internists should be aware of rare but potentially life-threatening side effects.

Valproic acid induced acute liver injury resulting in hepatic encephalopathy- a case report and literature review.

Valproic acid (VPA) is a commonly used agent in the management of seizures and psychiatric disorders. Hyperammonemia is a common complication of VPA with 27.8% of patients having elevated levels - that is unrelated to hepatotoxicity and normal transaminases. Common side effects include obesity, insulin resistance, metabolic disorder and severe forms of hepatotoxicity. Other rare and idiosyncratic reactions have been reported, one of which is presented in our case. A 27-year old patient presented with hyperammonemia and encephalopathy as a consequence of idiosyncratic VPA reaction causing drug-induced liver injury (DILI) with severely elevated transaminases. DILI is commonly overlooked when investigating encephalopathy in the setting of VPA. Physicians should consider DILI in the context of hyperammonemia and transaminitis.

A Rare Case of Acute Pancreatitis Due to Very Severe Hypertriglyceridemia (>10 000 mg/dL) Successfully Resolved With Insulin Therapy Alone: A Case Report and Literature Review.

A 48-year-old male presented to the psychiatric emergency room for dysmorphic mood. He was admitted to medical service for the management of hyponatremia, which was discovered in his initial laboratory workup. After the first day of admission, he developed abdominal pain and fever, and subsequent laboratory work revealed a triglyceride level of 10 612 mg/dL (reference range = 0-194 mg/dL). Computed tomography scan of the abdomen and pelvis revealed a hypodense lesion in the pancreas surrounded by a moderate amount of peripancreatic fluid suggestive of hemorrhagic pancreatitis. Based on the laboratory findings and imaging, we diagnosed acute pancreatitis (AP) secondary to hypertriglyceridemia. The patient was initiated on intravenous fluids and insulin to help decrease the triglyceride level with the plan to initiate apheresis. However, the patient improved on insulin therapy alone, which negated the need for apheresis, and the patient was discharged with fenofibrate with no further complications. While elevated triglycerides are a well-known cause of AP, we sought to assess various treatment options in management, especially considering a severely elevated triglyceride level of >10 000 mg/dL. Along with supportive care in AP, there are additional options in hypertriglyceridemia AP, including heparin, insulin, apheresis, antioxidants, and fibrates. Currently, there are no clear guidelines favoring one therapeutic option over the other.

Metachronous Granular Cell Tumor of the Descending Colon.

Granular cell tumors (GCTs) are uncommon tumors. They are believed to be neuronal in origin and are usually found in the head and/or neck area of the body. They have also been reported in various locations of the gastrointestinal (GI) system, usually discovered during routine screening colonoscopy. We report a case of GCT in a 58-year-old asymptomatic African American female as a metachronous tumor of a well-differentiated adenocarcinoma of the sigmoid colon, which was an incidental finding in screening colonoscopy. To our knowledge, this is the first case with GCT identified as a metachronous tumor following an adenocarcinoma of the colon.

Sofosbuvir based regimens in the treatment of chronic hepatitis C genotype 1 infection in African-American patients: a community-based retrospective cohort study.

BACKGROUND: Direct-acting antiviral (DAA) drugs have been highly effective in the treatment of chronic hepatitis C (HCV) infection. Limited data exist comparing the safety, tolerability, and efficacy of DAAs in African-American (AA) patients with chronic hepatitis C genotype 1 (HCV GT-1) in the community practice setting. We aim to evaluate treatment response of DAAs in these patients. PATIENTS AND METHODS: All the HCV GT-1 patients treated with DAAs between January 2014 and January 2018 in a community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with a sustained virologic response at 12 weeks post-treatment (SVR12), and adverse reactions were assessed. RESULTS: Two-hundred seventy-eight patients of AA descent were included in the study. One-hundred sixty-two patients were treated with ledipasvir/sofosbuvir (SOF)±ribavirin, 38 were treated with simeprevir/SOF±ribavirin, and 38 patients were treated with SOF/velpatasvir. Overall, SVR at 12 weeks was achieved in 94.6% in patients who received one of the three DAA regimens (93.8% in ledipasvir/SOF group, 92.1% in simeprevir/SOF group, and 97.4% in SOF/velpatasvir group). Previous treatment experience, HCV RNA levels and HIV status had no statistical significance on overall SVR achievement (P=0.905, 0.680, and 0.425, respectively). Compensated cirrhosis in each of the treatment groups did not influence overall SVR of 12. The most common adverse effect was fatigue (27%). None of the patients discontinued the treatment because of adverse events. CONCLUSION: In the real-world setting, DAAs are safe, effective, and well tolerated in African-American patients with chronic HCV GT-1 infection with a high overall SVR rate of 94.6%. Treatment rates did not differ on the basis of previous treatment and compensated cirrhosis status.

Sofosbuvir Based Regimens in the Treatment of Chronic Hepatitis C with Compensated Liver Cirrhosis in Community Care Setting.

BACKGROUND: Direct-acting antiviral (DAA) drugs have been highly effective in the treatment of chronic hepatitis C (CHC) infection. We aim to evaluate the treatment response of Sofosbuvir based DAA in CHC patients with compensated liver cirrhosis as limited data exists in the real-world community setting. METHODS: All the CHC patients with compensated liver cirrhosis treated with Sofosbuvir based DAAs between January 2014 and December 2017 in a community clinic setting were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy with the sustained virologic response at 12 weeks posttreatment (SVR12), and adverse reactions were assessed. RESULTS: One hundred and twelve patients with CHC infection and concurrent compensated cirrhosis were included in the study. Black patients represented the majority of the study population (64%). Eighty-seven patients were treated with Ledipasvir/Sofosbuvir (LDV/SOF) ±Ribavirin and 25 patients were treated with Sofosbuvir/Velpatasvir (SOF/VEL). Overall, SVR 12 after treatment was achieved in 90% in patients who received one of the two DAA regimens (89.7% in LDV/SOF group and 92% in SOF/VEL group). SVR 12 did not vary based on age, sex, body mass index, baseline HCV viral load, HCV/HIV coinfection, type of genotype, and prior treatment status. Apart from a low platelet count, there were no other factors associated with a statistical difference in SVR 12(p=0.002) between the two regimens. Fatigue (35%) was the most common adverse effect and no patients discontinued treatment due to adverse effects. CONCLUSION: In the community care setting, Sofosbuvir based DAAs are safe, effective with high overall SVR, and well tolerated in patients with CHC patients with compensated liver cirrhosis.

Assessment of Knowledge, Attitudes, and Practices Regarding Chronic Hepatitis C Treatment and Its Challenges: A Survey of Internal Medicine Residents in a Community Hospital.

BACKGROUND: Despite recent advances in chronic hepatitis C (CHC) treatment, only a small proportion of patients are connected with care and receive treatment. Internal medicine (IM) residents spend nearly one-third of their training in primary care settings and play a crucial role in diagnosing and counseling patients as well as linking patients with care and following up. METHODS: IM residents in a community hospital completed an anonymous questionnaire regarding their knowledge, attitude, and practice associated with CHC treatment and its challenges. RESULTS: Descriptive analysis of the survey showed that there is a substantial gap in knowledge regarding the newer treatment of CHC between IM residents' perceptions of patient awareness and IM residents. CONCLUSION: Updated education regarding CHC that is geared towards medical residents and focused on new modalities of treatment can narrow the gap and lead to considerable increases in the rates of diagnosis and treatment and decreases in morbidity and mortality.

Hypereosinophilic Syndrome Complicated by Eosinophilic Myocarditis With Dramatic Response to Steroid.

Introduction. Eosinophilic myocarditis is an infiltrative disease that affects the myocardium leading to various presentations. It can be precipitated by medications, helminthiasis, or hypereosinophilic syndrome. Case. We present the case of a young, male patient who presented with palpitations and dyspnea and was found to have heart failure with reduced ejection fracture of 12%. His past medical history was significant for recent lung problem treated with steroids. Based on his history and laboratory findings, he was started on intravenous steroids for treatment of eosinophilic myocarditis. Within 3 days, his ejection fracture improved to 35%. Conclusion. Given the nonspecific clinical presentations, mimicking other diseases, high index of suspicion is warranted to diagnose eosinophilic myocarditis. This is crucial as early detection and treatment with steroids can lead to a dramatic response.

Real-World Clinical Efficacy and Tolerability of Direct-Acting Antivirals in Hepatitis C Monoinfection Compared to Hepatitis C/Human Immunodeficiency Virus Coinfection in a Community Care Setting

BACKGROUND/AIMS: Limited data exist comparing the safety and efficacy of direct-acting antivirals (DAAs) in hepatitis C virus (HCV) monoinfected and HCV/human immunodeficiency virus (HIV) coinfected patients in the real-world clinic practice setting. METHODS: All HCV monoinfected and HCV/HIV coinfected patients treated with DAAs between January 2014 and October 2017 in community clinic settings were retrospectively analyzed. Pretreatment baseline patient characteristics, treatment efficacy, factors affecting sustained virologic response at 12 weeks (SVR12) after treatment, and adverse reactions were compared between the groups. RESULTS: A total of 327 patients were included in the study, of which 253 were HCV monoinfected, and 74 were HCV/HIV coinfected. There was a statistically significant difference observed in SVR12 when comparing HCV monoinfection and HCV/HIV coinfection (94% and 84%, respectively, p=0.005). However, there were no significant factors identified as a predictor of a reduced response. The most common adverse effect was fatigue (27%). No significant drug interaction was observed between DAA and antiretroviral therapy. None of the patients discontinued the treatment due to adverse events. CONCLUSIONS: In a real-world setting, DAA regimens have lower SVR12 in HCV/HIV coinfection than in HCV monoinfection. Further studies involving a higher number of HCV/HIV coinfected patients are needed to identify real predictors of a reduced response.