Tracheostomy trends in preterm infants with bronchopulmonary dysplasia in the United States: 2008-2017.

OBJECTIVE: To determine the trends in tracheostomy placement and resource use in preterm infants less than or equal to 30 weeks gestational age (GA) with bronchopulmonary dysplasia (BPD) in the United States from 2008 to 2017. STUDY DESIGN: This was a retrospective, serial cross-sectional study using data from the NIS. Inclusion criteria were: GA less than or equal to 30 weeks, hospitalization at less than or equal to 28 days of age, assignment of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) or ICD10-CM codes for BPD and tracheostomy. Trends in tracheostomy and resource utilization were assessed using Jonckheere-Terpstra test. p-value < .05 was considered significant. RESULTS: Overall, 987 out of 68,953 (1.4%) hospitalizations with BPD had tracheostomy. Characteristics of the study population: 60.8% were male, 68.4% less than or equal to 26 weeks GA, 43.8% White, 60.5% with Medicaid or self-pay, 65.2% in the Midwest and South census regions of the United States, and 45.7% had gastrostomy tube placement. Tracheostomy placement (expressed as per 100,000 live births) decreased from 2.7 in 2008 to 1.9 in 2011. Thereafter, it increased from 1.9 in 2011 to 3.5 in 2017 (p < .001). GA less than or equal to 24 weeks was significantly associated with increased odds of tracheostomy placement. Median length of stay increased significantly from 170 to 231 days while median inflation adjusted hospital cost increased significantly from $323,091 in 2008-2009 to $687,141 between 2008-2009 and 2016-2017. CONCLUSION: Although tracheostomy placement among preterm hospitalizations with BPD was rare, the frequency of its placement and its associated resource utilization significantly increased during the study period. Future studies should probe the reasons and factors behind these trends.

Surgery and Resource Utilization Trends for Pediatric Intussusception From 2005 Through 2014.

BACKGROUND: Air or barium enema reduction is becoming increasingly common and safer for pediatric intussusception. However, little is known about trends of pediatric intussusception requiring surgical intervention in the United States.  Methods: National Inpatient Sample database was analyzed from 2005-2014 to identify pediatric (≤18 years) intussusceptions along with procedures such as enema and/or surgical intervention. Trends in the rates of surgical intervention were examined according to encounter-level (age, gender, race, comorbidities) and hospital-level (hospital census region, teaching status) characteristics. Outcomes of pediatric intussusception requiring surgical intervention were analyzed in terms of length of stay and cost of hospitalization. Factors associated with surgical intervention were also analyzed. P value of < 0.05 was considered significant.  Results: Out of 21,835 intussusception hospitalizations requiring enema or surgical intervention, 14,415 (66%) had surgical intervention; 90% of which (12,978) had no preceding enema. Surgical intervention rates among intussusception hospitalizations varied by age (highest < 1 year), gender (male > females) and race (Hispanics > Whites and Blacks). During the study period, overall surgical intervention rate remained stable (2.2 to 1.7, P=0.07) although it declined in those under 1 year of age. Children with severe disease, gastrointestinal comorbidities over the age of 4 years had increased odds of surgical intervention, whereas hospitalization in large and urban teaching hospitals had decreased odds of surgical intervention. Length of stay and hospital cost remained stable from 2005-2014. CONCLUSION: The rates of surgical intervention and resource utilization for pediatric intussusception remained stable from 2005-2014, however they declined significantly in infants. The proportion of intussusception hospitalization requiring surgery remains high and further studies are needed to explore the possible factors.

Temporal Trends of Intracranial Hemorrhage Among Immune Thrombocytopenia Hospitalizations in the United States.

BACKGROUND:  Intracranial hemorrhage (ICH) is a rare but severe complication in patients with immune thrombocytopenia (ITP). We aimed to examine the incidence and outcomes of ICH among ITP hospitalizations and factors associated with it. Additionally, we studied resource utilization for these hospitalizations. METHODS:  Using National (Nationwide) Inpatient Sample, International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM/ICD-10-CM) codes, we studied ITP hospitalizations with occurrence of ICH between 2007 and 2016. RESULT:  Out of 348,906 weighted ITP hospitalizations, ICH occurred in 3,408 encounters (incidence 1.1 ± 0.04%). The incidence remained stable over time (2007-2008: 1.01%, 2015-2016: 1.20%; P = 0.3). People with age ≥25 years, especially those aged ≥65 years (odds ratio [OR] 3.69, 95% confidence interval [CI] 2.34-5.84), or those with gastrointestinal bleed (OR 1.60, 95% CI 1.18-2.16) were significantly more likely to develop ICH. Female gender (OR 0.81, 95% CI 0.68-0.97) had lower odds for developing ICH. Overall mortality in ITP hospitalizations with ICH was 26.7%. Length of stay (LOS) was longer (4.8 vs. 2.6 days) and costs of hospitalization (COH) were higher ($20,081 vs. $8,355) in ICH hospitalizations compared to non-ICH ITP hospitalizations. Increasing age and comorbidities such as gastrointestinal bleed, hematuria, and other bleeding were also associated with longer LOS and higher COH. CONCLUSION: Although rare, ICH in ITP was associated with a high mortality and increased resource utilization. Clinicians should be cognizant of factors associated with risk of ICH in ITP, and future studies should reassess the ICH trends to study the impact of novel therapeutic options such as thrombopoietin receptor agonists.

Squamous Cell Carcinoma of Left Buccal Alveolar Ridge.

Squamous cell carcinoma (SCC) of the oral cavity accounts for 4% of malignancies in men and 2% of malignancies in women, and is responsible for 3% of all cancer deaths. Cancers of the gingiva often escape early detection and lead to a delay in intervention, since their signs and symptoms resemble common dental and periodontal infections. Here we present a case of a 55-year-old female patient who presented to our clinic with a left lower gingival mass for two weeks. Based on the clinical presentation, and possible differential diagnosis, this case highlights the importance of timely intervention and management.

Migratory Polyarthritis in the Setting of Chlamydial Infection.

Reactive arthritis is defined as a sterile inflammation involving the synovial membrane, tendons and/or fascia, elicited by an infection, usually originating from gastrointestinal or genitourinary tracts. Reactive arthritis can also be triggered by a sexually transmitted disease, referred to as sexually acquired reactive arthritis. The most common identifiable cause of non-gonococcal urethritis is Chlamydia trachomatis. Herein, we present a case of a 30-year-old healthy male patient, who developed migratory oligoarthritis in the setting of elevated inflammatory markers, highlighting the importance of obtaining an appropriate history and ordering pertinent laboratory tests, along with literature review on reactive arthritis.

Selective Type 2 Respiratory Failure Followed by Ocular Myasthenia Gravis Diagnosed by Ice Pack Test: A Case Report.

Myasthenia gravis is an autoimmune neuromuscular disorder that can present with skeletal muscle involvement, ocular muscles involvement and can progress to respiratory muscle paralysis. Here, we present a unique case of type 2 respiratory failure due to myasthenia gravis with the delayed ocular presentation. A 46-year-old female patient presented to the outpatient clinic with complaints of dyspnea. On further evaluation, she was found to be hypercapnic on arterial blood gas analysis with no muscular weakness in any of the limbs. The patient further progressed to ocular symptoms. With the use of an ice pack test, a bedside test for improvement of ptosis, the patient was diagnosed with myasthenic ptosis preventing further progression of type 2 respiratory failure and intubation. With this case report, we emphasize the critical role of such simple bedside test in timely diagnosis and management of myasthenia gravis while awaiting the final results.

Risk of Congenital Heart Disease in Newborns with Prenatal Exposure to Anti-depressant Medications.

Introduction It is uncertain whether the use of selective serotonin-reuptake inhibitors (SSRI) and other anti-depressants during pregnancy is associated with an increased risk of congenital heart disease (CHD) in newborn. There have been various studies showing a number of adverse outcomes, including gestational hypertension, reduced birth weight, altered neonatal pain responses and persistent pulmonary hypertension of the newborn with exposure to anti-depressant medications. There have been very few longitudinal studies showing CHD association with the use of anti-depressant medications. Our objective is to examine the risk for congenital heart disease of the newborn associated with prenatal exposure to antidepressant medication. Methods We reviewed charts of mothers who were referred for a fetal echocardiogram between January 1st, 2009 and December 31st, 2014. We identified mothers who were exposed to antidepressant medications prenatally. Fetal echocardiograms for these patients were reviewed by two fetal cardiologists and each was blinded to the others' findings. Results A total of 40 patients were identified with prenatal exposure to SSRI. Seven (18%) out of these 40 were found to have a form of CHD. Two fetuses whose mothers were exposed to fluoxetine during pregnancy had large posteriorly malaligned ventricular septal defect, sub-aortic stenosis and critical coarctation identified on fetal echocardiogram. Exposure to citalopram during pregnancy was found to be associated with a moderate size secundum atrial septal defect on one patient and a moderate size mid muscular ventricular septal defect seen on fetal echocardiogram in another patient. Exposure to venlafaxine during pregnancy showed two small muscular ventricular septal defects on fetal echocardiogram on one patient and ductal constriction with increased ductal velocity on another patient. One of the women on escitalopram had a fetus with a large membranous ventricular septal defect (VSD), secundum atrial septal defect (ASD) and left superior vena cava. None of the women on a combination of drugs had CHD. Conclusion There is a risk of congenital heart disease in patients who are prenatally exposed to anti-depressant medications as evident by the specific echocardiographic abnormalities noted in the study.

Hypertriglyceridemia with Acute Pancreatitis in Pediatric Diabetic Ketoacidosis: A Case Report.

A 16-year-old female with new-onset diabetic ketoacidosis (DKA) developed acute pancreatitis and hypertriglyceridemia within 24 hours after admission. Her insulin regimen was continued after resolution of DKA, and her pancreatitis with hypertriglyceridemia showed resolution. We are presenting a case of pediatric DKA with hypertriglyceridemia and pancreatitis treated with extended insulin.