Does Insurance Effect the Outcome in Patients With Acute Coronary Syndrome?: An Insight from the Most Recent National Inpatient Sample.

Several studies have shown disparities in outcome in the patients with Acute coronary syndrome (ACS) based on several factors. Treatment might differ based on insurance type. Therefore, we retrospectively analyzed National Inpatient Sample (NIS 2016) data to identify the impact of different types of insurances on mortality outcome in patients admitted with ACS. ICD-CM-10 codes were used to identify hospital discharges with a principal diagnosis of ACS. Observations were stratified based on insurance (Medicare, Medicaid, Private, and No insurance). Primary and secondary outcomes were in-hospital mortality, length of stay and total cost. Any potential confounders were adjusted using multivariate logistic regression. STATA/IC 15.1 Stata Corp LLC was used for analysis. A total of 8,01,195 hospitalizations with the primary diagnosis of ACS were identified, of which 59.2% had Medicare, 9.72% had Medicaid, 26.8% had Private insurance, and 4.3% had no insurance. Higher odds of mortality were seen in the patients with Medicare, Medicaid, and Noninsured group. Adjusted Odds ratio for mortality in Medicare was 1.01 (confidence interval [CI]: 0.94-1.1; P = 0.65), in Medicaid was 1.16 (CI: 1.03-1.30; P = 0.01) and in uninsured group was 1.46 (CI: 1.26-1.69; P ≤ 0.01). However, the patients with private insurance adjusted odds ratio for mortality were 0.77 (CI: 0.70-0.84; P ≤ 0.01) compared to the patients with other insurance groups. Above results show that the disparity exists in the outcome of patients admitted with ACS based on their insurance types, particularly for Medicaid patients. We need further studies to understand the root cause of this disparity.

Outcomes of Clostridioides difficile in Patients with Vitamin D Deficiency: A Propensity-Matched National Inpatient Sample Analysis.

OBJECTIVES: We aimed to determine in-hospital outcomes, length of hospital stay, and resource utilization in a contemporary cohort of Clostridioides difficile infection (CDI) and vitamin D deficiency (VDD). METHODS: The National Inpatient Sample database for 2016 and 2017 was used for data analysis using International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) codes to identify the patients with the principal diagnosis of CDI and VDD. We assessed the all-cause in-hospital mortality, morbidity, length of hospital stay (LOS), and total costs between propensity-matched groups of CDI without VDD versus CDI with VDD. RESULTS: We identified 202,234 patients with CDI, 4515 of whom were patients with VDD and 197,719 of whom were without VDD. After propensity matching, there was no difference in the in-hospital mortality between the two groups (odds ratio [OR] 1.5, 95% confidence interval [CI] 0.58-4.3; P = 0.90). CDI with VDD has a higher odds of sepsis (OR 1.6, 95% CI 1.3-1.9; P = 0.0), and peritonitis (OR 1.6, 95% CI 1.4-3.8; P = 0.01). Mean LOS (5.9 ± 1.8 vs 5.4 ± 2, P < 0.01) and mean total charges ($11,500 vs $9971, P < 0.04) were higher in CDI with VDD. The factors affecting the LOS were acute coronary syndrome (P = 0.04), mechanical ventilation (P = 0.03), obesity (P = 0.004), acute kidney injury (P = 0.04), and sepsis (P = 0.05). CONCLUSIONS: In this large cohort in a propensity-matched analysis, VDD does not increase the in-hospital mortality in CDI. VDD increases the odds of complications with a higher LOS and resource utilization. These findings may be clinically relevant to guide clinicians to routinely monitor vitamin D status and supplement in patients at risk of CDI.

Incidence, Predictors, Causes, and Cost of 30-Day Hospital Readmission in Chronic Obstructive Pulmonary Disease Patients Undergoing Bronchoscopy.

Introduction Chronic obstructive pulmonary disease (COPD) has a significant disease burden and is among the leading causes of hospital readmissions, adding a significant burden on healthcare resources. The association between 30-day readmission in a COPD patient undergoing bronchoscopy and a wide range of modifiable potential risk factors, after adjusting for sociodemographic and clinical factors, has been assessed, and comparison has been made with COPD patients not undergoing bronchoscopy. Methods We conducted a comprehensive analysis of the 2016 Nationwide Readmission Database (NRD) of 30-day all-cause readmission among COPD patients undergoing bronchoscopy. A Cox's proportional hazards model was used to obtain independent relative risks of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy. Our primary outcome was the 30-day all-cause readmission rate in both groups. Other secondary outcomes of interest were the 10 most common reasons for readmission, resource utilization, independent predictors of readmission, and relative proportion of comorbidities between the index admission (IA) and the readmission in both groups. Results The overall rate of readmission following bronchoscopy in COPD patients as compared to patients not undergoing bronchoscopy was 17.32% and 15.87%, respectively. The final multivariate model in the bronchoscopy group showed that the variables found to be an independent predictor of readmission were: pulmonary hypertension (hazard ratio [HR] 2.35; 95% confidence interval [CI] 1.26-4.25; P < .01), adrenal insufficiency (HR 4.47; 95% CI 1.44-13.85; P = .01) and discharge to rehab status. Independent predictor variables of admission in Group B were gender (women < men; HR 0.91; 95% CI 0.88-0.93; P < .01), and type of insurance (Medicaid > Medicare > private insurance). For all patients undergoing bronchoscopy, the mean length of stay (LOS) for IA was 11.91 ± 20.21 days, and LOS for readmission was 5.87 ± 5.48 days. The mean total cost of IA for patients undergoing bronchoscopy was much higher than that of readmission ($26,916 vs. $12,374, respectively). The entire LOS for readmission was 1,265 days, with a total cost of $2.66 million. For patients not undergoing bronchoscopy during the IA, mean LOS for IA was 4.26 ± 4.27 days, and mean LOS for readmission was 5.39 ± 5.51 days, which was longer than the IA in Group B but still shorter than LOS for readmission in Group A (patients undergoing bronchoscopy). The mean total cost of readmission was higher than the IA ($8,137 for IA vs. $10,893 for readmission). The total LOS in this group of patients was 313,287 days, with the total cost of readmission at $628 million. Conclusions Patients undergoing bronchoscopy have a slightly higher rate of 30-day readmissions as compared to patients not undergoing bronchoscopy, and the LOS is also slightly higher in this group during subsequent readmissions as compared to readmission in patients not undergoing bronchoscopy in IA. The readmission rate in COPD patients is impacted by a variety of social, personal, and medical factors. Patients with multiple medical comorbidities have a higher risk of readmission. In our understanding, bronchoscopy in a patient with acute exacerbation of COPD should be reserved for selected patients, and the rationale should be clarified, as it affects the overall LOS and healthcare expenditure.

Trends in Hospitalization and Inpatient Outcomes of Behçet's Disease: A Nationwide Inpatient Sample Study.

Objective After an extensive review of the literature, we discovered that no study had addressed trends in hospitalization for people with Behçet's disease (BD). Hence, in this study, we explore multiple variables in patients with BD in the US for the year 2016. Methods We analyzed the data relating to hospitalized patients for the year 2016 using the National Inpatient Sample (NIS) database with a listed discharge diagnosis of BD based on the International Classification of Diseases, 10th Revision (ICD-10) diagnosis code M35.2. The mean age in years, alive discharges, lumbar puncture procedures, type of hospital, the Charlson Comorbidity Index (CCI), comorbidities, mean length of stay (LOS) and factors affecting it, and total cost and charges for the admissions were analyzed. A p-value of <.05 was considered statistically significant. Results A total of 2,605 discharges with the diagnoses of BD were identified among 35.7 million overall discharges in 2016. Among patients hospitalized with underlying BD, the majority were white and female. The mean hospital LOS was 5.57 ± 0.37 days, which is higher than in the general population and statistically significant (5.57 days vs 4.62 days; p: 0.009). Mean LOS in patients undergoing lumbar puncture was 8.54 ± 2.91 days. Patients with BD had lower medical comorbidity burden (16.9% with a CCI of ≥3) vs the general population (24.67% with a CCI of ≥3) (p: 0.00). Medical comorbidities with a statistically significant difference in their prevalence in the two groups were renal disease, dementia, peptic ulcer disease, heart failure, rheumatologic disorders, malignancy, and dyslipidemia. Conclusion Increased awareness about this rare condition in an inpatient setting will help in the early identification of the disease and associated complications. This will help caregivers to provide quality care in a timely manner, thereby decreasing the morbidity, mortality, LOS, and hospital costs associated with BD.

Patterns of Vitamin D Deficiency in a Community Outpatient Psychiatric Practice: a Real-World Evaluation of Treatment Gaps.

Vitamin D is traditionally recognized for its role in bone mineralization but recent observations suggest additional pertinent functions in neuronal biology. The present study examines the rate and pattern of Vitamin D deficiency in the outpatient mental health clinic of a community teaching hospital as well as the vitamin D supplementation practices of outpatient psychiatrists. Participants include 148 consecutive psychiatric outpatients. Individuals with conditions that alter the metabolism of vitamin D were excluded from the study as are those who may be taking medications that influence Vitamin D metabolism. Statistical analysis was performed using the SPSS 25th edition, statistical significance set at p < 0.05. The majority of patients in the study were between 41 and 65 years old (n = 91, 61.5%), African American (n = 120, 81.1%) and female (n = 80, 54.1%). The median level is 23.7 ng/ml. As defined by the Endocrine Society's Clinical Practice Guidelines, 68.2% of the population had insufficient and deficient Vitamin D levels (32.4% and 35.8% respectively), 62.4% of whom were not prescribed any Vitamin D supplementation and of this untreated group, 84% were African Americans. No clinical or demographic characteristics showed any statistical difference in both the "treated" and "not treated groups". Logistic regression did not reveal any significant predictors for Vitamin D deficiency. Vitamin D deficiency remains a significant issue among patients with psychiatric disorders. Our findings show gaps in Vitamin D deficiency treatment and recommend that future studies examine physician prescription practices in light of the racial disparity in Vitamin D deficiency treatment oberved in this study.

Outcomes of Direct-Acting Antiviral Treatment of Psychiatric Patients with Comorbid Hepatitis C Virus Infection.

BACKGROUND: The highest burden of hepatitis C virus (HCV) infection is seen in patients with psychiatric disorders who have been excluded from traditional treatments with Interferon due to treatment-emergent neuropsychiatric adverse effects. The goal of this study is to determine the tolerability, treatment retention, and efficacy of direct-acting antivirals with psychiatric disorders and comorbid substance use disorders in real-life settings. METHODS: This is a retrospective cohort observational study of HCV patients treated with direct-acting antivirals between January 2016 and December 2018. Patients were stratified and sub-stratified based on their psychiatric diagnosis and substance use. The primary assessment was the sustained virologic response at 12 weeks post-treatment (SVR12). RESULTS: Among the 291 patients analyzed, patients with psychiatric diagnosis and non-psychiatric patients made up 51.2% (n = 149) and 48.8% (n = 142) respectively. Majority of the patients included in the study were African-Americans (68.7%, n = 200). Overall, 95.3% (142/149) and 94.4% (134/142) of psychiatric and non-psychiatric patients, respectively, achieved SVR12 and treatment response was similar between the groups (p = 0.72). Among psychiatric patients, only the prior treatment status was identified as a predictor of treatment response (OR 0.153, 95% CI 0.03-0.79; p = 0.05). No statistical difference was observed among the patients with SVR12 based on their primary psychiatric diagnoses or by comorbid substance abuse. CONCLUSION: The results of our study show that direct-acting antiviral treatments are well tolerated in psychiatric patients, and an overwhelming majority of patients achieved SVR12. Our study highlights the need to integrate HCV screening with treatment linkage in psychiatry and primary care practice.

A Case of Hydroxocobalamin-Induced False Blood Leak Alarm on Dialysis Machine.

Hemodialysis machines are equipped with a blood leak detector/alarm to prevent loss of blood following rupture of semipermeable membrane; the blood leak alarms could also be triggered by sensor malfunction or presence of air bubbles in the system. Hydroxocobalamin is a Food and Drug Administration-approved rapid-acting antidote to cyanide poisoning that converts cyanide to nontoxic cyanocobalamin. Side effects are reddish discoloration of skin and body fluids, urticarial rash, and rarely anaphylaxis. In this article, a case of false blood leak alarm following treatment of cyanide poisoning with hydroxocobalamin is reported, wherein the blood leak detector in dialysis machines prevented the patient from undergoing hemodialysis by repeatedly activating blood leak alarms. Continuous renal replacement therapy was used to overcome this problem. As the use of hydroxocobalamin increases, health care professionals should be educated about its potential to interfere with hemodialysis.

A Successful Percutaneous Endoscopic Gastrostomy Tube Feeding over Two Decades with No Complication: A Rare Case Report.

Percutaneous endoscopic gastrostomy (PEG) feeding is a common and widely performed procedure appropriate for long-term enteral nutrition in patients with multiple indications. We present the case of a 59-year-old woman with a PEG tube placed owing to complication following thyroid surgery approximately 20 years ago, representing the most extended duration of PEG tube feeding without any significant complication for chronic mechanical dysphagia. This case highlights the importance of PEG feeding, where this route can be used indefinitely in an appropriate clinical setting without complications. Interestingly, self-replacement of PEG tube was performed by the patient herself whenever she noticed clogging up of tube while self-feeding.

National Trends and Hospitalizations Related to Pancreatic Cancer in Acute Pancreatitis Patients: A Nationwide Inpatient Sample Study.

Background Pancreatic cancer (PC) is one of the common cancers in the United States (U.S.) and is associated with high mortality and morbidity. In spite of the modest improvement in survival, cancer care costs including PC continue to rise and inpatient costs contribute a significant chunk to cancer care, which is often ignored. Acute pancreatitis (AP) is a rare manifestation of PC. This study aims to determine the national trends and associated health care utilization of PC patients hospitalized with AP in the U.S. Methods We used National Inpatient Sample (NIS) to extract data for patients hospitalized with a primary diagnosis of PC in AP in 2016 using International Classification of Diseases, 10th revision, and Clinical Modification (ICD-10-CM) codes. The analysis included disease etiologies, age, race, sex, hospital region, hospital size, institution type, mortality, length of hospital stay (LOS), and commonly associated comorbidities were correlated. Results There were 250 patients with a discharge diagnosis of PC in patients admitted with AP. Most of the patients were whites (76.6%) with the mean age of 39.42 ± 2.51 years, had Medicare (63.26%) as primary insurance, were from Southern region (46%) and had higher Charlson comorbidity index (CCI) (76.00% with CCI > = 3). The mean hospital charges were $48,462.13, and mean LOS was 5.24 days. The LOS was significantly impacted by race, hospital region, endoscopic retrograde cholangiopancreatography (ERCP), and comorbidities such as dementia, smoking, and seizure. Out of the 250 patients admitted with PC, 245 patients (98%) were discharged alive. Conclusions Our study shows a downward trend in LOS, hospital charges, and in-hospital mortality as compared to other studies despite PC and AP presenting together versus PC with or without other etiologies.

Ecstasy induced acute systolic heart failure and Non-Ischemic Cardiomyopathy in a young female: a rare case report and literature review.

Ecstasy or 3,4-methylenedioxymethamphetamine (MDMA) is an illicit recreational drug. Effects include euphoria, increased sensory awareness, and central stimulation. Although various arrhythmias, as well as dilated cardiomyopathy, have been previously noted to occur with chronic use, cardiac toxicities are seldom reported in an acute setting. Herein, we present a 28-year-old female patient with no prior medical condition that presented to the Emergency Department with chest pain following intake of MDMA. Electrocardiographic findings, as well as laboratories, were suggestive of possible Acute Non-ST elevation myocardial infarction. Upon admission, cardiac catheterization revealed patent coronary arteries. Stark regional wall motion abnormalities were observed along with reduced ejection fraction. Acute systolic heart failure was treated with standard medical management. Subsequent reassessment of ventricular function with Echocardiography revealed marked improvement. This article describes a case of MDMA induced heart failure, including details of evaluation, management, and monitoring of patient progress. It brings further attention to potential acute harmful effects of MDMA on cardiac function and viability.

Gastric diffuse large B-cell lymphoma with bilateral adrenal metastasis.

Extranodal adrenal involvement in non-Hodgkin's lymphoma is very rare, estimated to be around less than 0.2%. Most common sites involved are stomach, intestine and testis. It is very rare for adrenal tumours to present as primary adrenal insufficiency, with an incidence of around 1.2% in patients diagnosed with adrenal masses. Diffuse large B cell lymphoma (DLBL) originating from the stomach and metastasizing to bilateral adrenal glands is an extremely uncommon occurrence with only three cases found on review of the literature. We present a case of a 62-year-old African-American man who presented with nausea, vomiting, abdominal pain and hypotension, later being diagnosed as DLBL of the gastric antrum metastasized to bilateral adrenal glands. Initial laboratory workup revealed including hormonal analysis and cosyntropin test revealed adrenal insufficiency. The patient later died during the hospitalisation after developing respiratory failure, severe hypotension refractory to vasopressors and severe metabolic acidosis.

Variation in body mass index in patients with chronic obstructive pulmonary disease.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is associated with systemic inflammation. Weight loss seen in patients with COPD is a consequence of this inflammation. We hypothesized that higher grades of COPD are associated with greater degree of weight loss. MATERIALS AND METHODS: In this cross-sectional study, we assessed the body mass index (BMI) of 34 patients with COPD proven by handheld spirometer. The difference in BMI among various grades of COPD was compared. RESULTS: BMI was found to be inversely related to the grades of COPD in our study (P = 0.001). No significant difference was seen among the patients with regards to age and duration of symptoms before presentation. CONCLUSION: Advanced COPD is associated with greater degree of weight loss.

Ventriculoperitoneal Shunt Migration Inside the Gastric Lumen: A Rare Case Report.

Ventriculoperitoneal (VP) shunt placement is one of the more common procedures in neurosurgery and has a variety of indications. However, shunt placement can be associated with multiple complications, one of which is proximal and distal shunt migration. There have been reported cases of migration of the distal end of a VP shunt from the intraperitoneal cavity into different organs resulting in a variety of complications. Most of the reported cases are the result of spontaneous migration. However, shunt catheter migration could be iatrogenic as well. We present a case of intragastric VP shunt migration in a patient following placement of a percutaneous endoscopic gastrostomy tube.

An association of Helicobacter pylori infection with endoscopic and histological findings in the Nepalese population.

BACKGROUND: Helicobacter pylori (H. pylori) is one of the most common human infections worldwide particularly in the developing countries. We aimed to study an association of H. Pylori infection with endoscopic and histological findings in the Nepalese population. MATERIALS AND METHODS: We conducted a study between Oct 2014 and Jan 2015 after meeting inclusion and exclusion criteria. Institutional Review Board approval was obtained from National Academy of Medical Sciences. Endoscopic findings and histopathological diagnosis were documented and data were analysed. RESULTS: A total of 113 patients who had complete endoscopy were enrolled. The prevalence of H. pylori infections recorded was 27 (23.9%) patients. There were 17 (62%) male and 10 (37%) female infected with H. pylori (P = 0.33). All biopsied specimens were sent to pathology lab for examination. The most common endoscopic findings was erythematous antral gastritis (40.7%) followed by erosive gastritis 34 (30.1%), pangastritis 10 (8.8%), duodenal ulcer 13 (11.5%), gastric ulcer 9 (8%), erosive fundal gastritis 2 (1.8%), reflux esophagitis 10 (37%) (P < 0.04). Histology revealed that 23 (85.2%) patients had chronic active gastritis (CAG); (P < 0.001). CONCLUSIONS: Our study revealed that H. pylori infection is strongly associated with chronic active gastritis (CAG) and Reflux esophagitis in Nepalese adults.

Early Detection of Colon Cancer Following Incidental Finding of Clostridium septicum Bacteremia.

Clostridium septicum is a Gram-positive, anaerobic, spore-forming bacillus found in the intestine. It is linked to colon cancer and immunosuppression. Infection with C septicum may vary in manifestation and is associated with more than 60% mortality rate. In this article, we present a case of incidental isolation of C septicum in a patient who presented with fever and later on colonoscopy was found to have colon carcinoma. Bacteremia may be the unexpected initial presentation of undiagnosed colon carcinoma.