Haemorrhagic Mycobacterium avium complex pericarditis presenting with cardiac tamponade in an immunocompetent woman.

A young woman in her mid-40s was referred by her primary care physician for fever, worsening shortness of breath, pleuritic chest pain and tachycardia. CT angiogram of the chest revealed a large pericardial effusion. Echocardiogram confirmed tamponade physiology despite her being haemodynamically stable. She had an emergency pericardiocentesis which revealed evidence of a haemorrhagic pericardial effusion. However, the patient was still symptomatic after treatment and had to undergo video-assisted thoracoscopic surgery with a pericardial window and chest tube. Postoperatively, her fevers resolved. Pan-culture was initially negative, and all antibiotics were discontinued. Acid-fast bacilli cultures later grew Mycobacterium avium complex. She continued to have chest discomfort postoperatively, but follow-up CT of the chest 3 months postoperatively showed continued resolution of her pericardial effusion. The patient's symptoms improved, and she has had no recurrence of effusion without the need for anti-tuberculosis drugs.

Sinking Skin Flap Syndrome After Decompressive Hemicraniectomy in a Patient With Calvarial Multiple Myeloma Who Underwent a Lumbar Puncture: A Case Report.

Sinking skin flap syndrome (SSFS) or "syndrome of the trephined" is a rare complication that can occur after decompressive craniectomy. Disabling neurologic deficits, as well as the impairment of overall mental status with the development of a concave deformity and relaxation of the skin flap, are frequently observed. This usually develops several weeks to months after craniectomy. The pathophysiology of the syndrome includes cerebrospinal fluid (CSF) hypovolemia and the development of an atmospheric pressure gradient that can be worsened by CSF diversion, dehydration, and change in position such as can be seen with a lumbar puncture. We present a case of a 40-four-year-old male with calvarial multiple myeloma three months after craniectomy who developed SSFS two days after lumbar puncture was performed to investigate possible leptomeningeal spread. It is imperative to recognize the syndrome early and proceed with urgent management with measures that initially increase intracranial pressure such as IV hydration and Trendelenburg positioning. In certain cases, proceeding with surgical management, such as epidural patch or cranioplasty, can be life-saving.

Risk, Outcomes, and Trends of Clostridium Difficile Infection in Multiple Myeloma Patients from a Nationwide Analysis.

BACKGROUND: Patients hospitalized with hematologic malignancy are particularly vulnerable to infection. We sought to determine the risk of Clostridium difficile infection (CDI) in hospitalization with multiple myeloma (MM), as well as its outcomes and trends, using a nationally representative database. METHODS: The Nationwide Inpatient Sample (NIS) from January 2010 to September 2015 was used for this study. We identified all patients aged 18 years or older with a diagnosis of MM using the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes. We identified trends in the annual rates of CDI in MM using negative binomial regressions with robust error variance. We conducted multivariate logistic regression to determine the incidence and the associated risk factors of CDI in MM and compared the outcomes between those with and without CDI using the propensity score method inverse probability weighting to adjust for baseline covariates. RESULTS: In our cohort study of 114,249 MM patients, 45.96% were females and 54.04% were males. CDI was present in 3.1% of the MM patients. The number of CDI cases increased over the study period with an average rate of 3.27% per year. The mortality rate decreased over the same period with an average rate of 10% decrease per year. Hematopoietic stem cell transplantation (HSCT), neutropenia, inflammatory disease, atrial fibrillation (AF), and chronic kidney disease (CKD) were significant associated risk factors of CDI in MM patients. After adjusting for covariates, patients with CDI had a prolonged hospital stay, inpatient mortality, and significantly increased odds of acute kidney injury (AKI) and AKI requiring hemodialysis, along with higher healthcare resources utilization with significantly higher hospital costs. CONCLUSION: MM patients with CDI have significantly increased odds of inpatient mortality, AKI, and AKI requiring hemodialysis. They also have increased healthcare resource utilization compared with those without CDI. Despite the increased rate of the CDI over the years, the mortality rate is going down.

Characteristics and Outcomes of Patients With Cardiogenic Shock Utilizing Hemodialysis for Acute Kidney Injury.

In the setting of cardiogenic shock (CS), impaired biventricular function can cause acute decrease in renal function via reduced renal perfusion and increased renal venous pressure. We sought to analyze the characteristics and outcomes of patients hospitalized with CS who utilized renal replacement therapy (hemodialysis) for acute kidney injury (AKI-HD). We utilized data from the National Inpatient Sample to calculate national rates of in-hospital mortality, use of temporary mechanical support, vascular injury requiring surgery, length of stay (LOS) and hospitalization cost from 2010 to September 2015. We compared the in-hospital outcomes between CS with AKI-HD and a propensity score-matched group without AKI-HD. We identified 6,076 hospitalizations (weighted n = 24,272) with CS and AKI-HD and 76,878 (weighted n = 378,553) with CS not AKI-HD. Among these cases 48.1% (n = 39,403, weighted n = 193,746) had ST elevation myocardial infarction as the cause of CS. Patients with CS and AKI-HD had higher comorbidity burden and they were also more likely to receive mechanical circulatory support device (absolute standardized difference >10% for all comparisons) compared with CS patients without AKI-HD. After matching 4,457 cases for patient-level and hospital-level characteristics, CS with AKI-HD was associated with significantly higher in-hospital mortality (75.74% vs 51.58%, p <0.001), use of temporary mechanical support (24.0% vs 19.3%, p <0.001), LOS (21.4 vs14.4 days, p <0.001) and cost ($80,406 vs $52,833, p <0.0001). AKI-HD occurred in approximately 6% of patients with CS in years 2010 to 2015 and was associated with significantly increased in-hospital morbidity and mortality, LOS, and cost.

Regional disparity in outcomes among patients hospitalized for Takotsubo cardiomyopathy in the United States✰.

INTRODUCTION: Takotsubo cardiomyopathy (TTCM), an entity first described in Japan over two decades ago following myocardial stunning cases without evidence of coronary stenosis, has emerged as a unique entity with global recognition. We sought to investigate the extent and magnitude of regional variations in its outcomes. METHOD: We used the National Inpatient Sample (NIS) of the Agency for Healthcare Research and Quality (2010-2014). Risk-adjusted rates of outcomes across the US geographical regions were calculated by fitting a Poisson regression model with a robust error variance under generalized estimating equations. Discrete numeric variables with over-dispersed count distributions -length of stay and continuous variables with a right skewed spread- cost of hospitalization were modeled using a generalized linear regression with a negative binomial function and gamma function respectively. RESULT: We found significant regional variations in-patient mortality. While there was significantly higher risk of in-hospital death in the West (5.28 [4.34-6.44]) vs 4.40 [3.57-5.43] vs 4.10 [3.38-498] vs 4.78 [3.96-5.77]), there was a different pattern of variation in the length of days with longer hospital stay in the Northeast. Likewise, the risk-adjusted rate of non-routine home discharges was highest for Northeast. The West had the highest cost of hospitalization (West: $40,217 vs. South: $28,465) CONCLUSION: Significant geographic variation exists in the cost of hospitalization and in-hospital mortality of TTCM across the US. Understanding this variation requires a detailed understanding of the processes of care and identification of effective strategies to eliminate these disparities.

Predictors, Burden, and the Impact of Arrhythmia on Patients Admitted for Acute Myocarditis.

A significant proportion of patients with acute myocarditis experience sudden cardiac death presumably due to cardiac arrhythmia. In this study, we explore the burden, the predictors of arrhythmia in acute myocarditis and the association between arrhythmias and adverse in-hospital outcomes. After evaluating the frequency of various tachyarrhythmias and bradyarrhythmia in myocarditis population, we built a logistic model to determine the independent predictors of arrhythmias in myocarditis and a 1:1 propensity-matched analysis to examine the impact of arrhythmias. Overall, cardiac arrhythmias were identified in 33.71% of the hospitalized myocarditis cases. Ventricular tachycardia and atrial fibrillation were most common arrhythmias. There were increased odds of in-hospital mortality, cardiogenic shock, use of mechanical circulatory support, pacemaker implantation, and nonroutine hospital discharges in the arrhythmia cohorts. Length of stay and cost of hospitalization were also significantly higher. A significant proportion of patients with myocarditis have cardiac arrhythmias. As the occurrence of arrhythmias in myocarditis is associated with worse outcomes, it may be important to risk stratify patient to identify those who will benefit from early intervention.

Incidence and outcomes of cardiac tamponade in patients undergoing cardiac resynchronization therapy.

INTRODUCTION: Cardiac tamponade is a severe complication of cardiac resynchronization therapy (CRT) implantations. We provide a contemporary large-scale study evaluating the incident trends, predictors and impact of cardiac tamponade in patients undergoing CRT. METHOD: Data were obtained from the Nationwide Inpatient Sample (NIS) of 2007 through 2014. Trends in the annual rates of tamponades in CRT implantation were assessed using negative binomial regressions. Hierarchical mixed-effects logistic regression models were built to determine the independent predictors of tamponade in CRT implantation and 1:1 propensity-matched analysis performed to examine the impact of tamponade on outcomes. RESULT: An estimated 310,704 CRT implantations were performed in the United States between 2007 and 2014, out of which 536 patients (0.17%) developed procedure-related cardiac tamponade. A significant increasing trend in the tamponade incidence was observed over the 8-year study period [1.65 per 10,000 CRT implantation in 2007 to 38.16 in 2014 (p < 0.001)]. After multivariable adjustment, female sex and coagulation disorder were found to be independently associated with higher odds of tamponade. Conversely, prior history of CABG procedure was associated with lower odds of tamponade. CRT complicated with tamponade had significantly increased in-hospital mortality, bleeding requiring transfusion, prolonged hospital stay and increased cost. CONCLUSION: We found an increasing trend in the incidence of post CRT tamponade among hospitalized patients between 2007 and 2014. Female gender and coagulation disorder were associated with the development of tamponade among recipients of CRT. Risk stratification of patients who are undergoing CRT is crucial to improving outcome in CRT implantation.

Hypersensitivity to molds in New York City in adults who have asthma.

Molds have been linked epidemiologically to asthma as a key aeroallergen in several studies. Other allergens such as cockroach have been linked to asthma in New York City (NYC). To our knowledge, however, the pattern of mold hypersensitivity has never been examined systematically in the NYC area. Thus, we sought to determine the association between mold hypersensitivity and asthma in a large group of ambulatory patients evaluated for allergic disease for the years 1993 through 2001 at a single medical center. Serological testing for mold-specific immunoglobulin E (IgE) as well as IgE specific for other aeroallergens was performed and the associations between allergen-specific IgE and the presence of asthma were examined using bivariate and multivariate analysis. Factor analysis showed that three distinct groupings of aeroallergen-specific IgE existed within the panel of allergens used. Group 1 consisted of cat dander and dust mites (Dermatophagoides farinae). Group 2 consisted of tree, grass, and ragweed pollen. Group 3 consisted of the Deuteromycetes molds, Alternaria tenuis, Aspergillus fumigatus, and Cladosporium herbarum. Patients with asthma had a highly significant increase in the incidence of hypersensitivity to cat/dust mites and to the molds. Multivariate analysis showed that the presence of hypersensitivity to either A. tenuis or C. herbarum had a significant independent association with asthma after adjustment for cat/dust mite hypersensitivity and after adjustment for other clinical factors. On the other hand, pollen hypersensitivity was not associated independently with asthma. Mold hypersensitivity was strongly correlated with hypersensitivity to cat or dust mites in patients who did not have asthma but not in patients who did have asthma. In the NYC area, recent pollen and spore counts show that mold spores are measurable in at least 75% of the year. Thus it is conceivable that mold hypersensitivity plays a contributing and independent role in initiating or perpetuating the allergic response in patients with asthma in the New York area.