Man vs. man-made marijuana: A case of drug-induced posterior reversible encephalopathy syndrome (PRES) due to K2, a ynthetic cannabinoid (SCB).

Synthetic Cannabinoids (SCB) are engineered chemical compounds that share a similar chemical structure with the active ingredient of marijuana, delta-9-tetrahydrocanabinol. Although the FDA has not approved the use of SCB without a prescription from a licensed health-care provider, the cost effectiveness and availability of SCB has made it a popular choice among recreational drug users. Manufacture of SCB as a street drug is not regulated. These SCB are highly potent chemicals that cause various severe toxicities. In this case report, we describe an adult who suffered from PRES after consuming K2, a synthetic cannabinoid.

Heart Failure Drug Class Effects on 30-Day Readmission Rates in Patients with Heart Failure with Preserved Ejection Fraction: A Retrospective Single Center Study.

Background: The pharmacologic management of heart failure with preserved ejection fraction (HFpEF) involves far fewer options with demonstrated additional benefit. Therefore, we examined the effect of combination of multiple classes of HF medication in the 30-day hospital readmission in patients with HFpEF. Methods: All adult patients discharged with a diagnosis of HFpEF and a left ventricular ejection fraction (LVEF) of ≥ 50% reported during the admission or within the previous six months from our institution were retrospectively studied for a 30-day hospital readmission risk. Individual as well as combination drug therapy at the time of hospital discharge were evaluated using Pearson chi2 test and multivariate logistic regression. Results: The overall 30-day readmission rate in this HFpEF cohort of 445 discharges was 29%. Therapy with loop diuretics (p = 0.011), loop diuretics and angiotensin receptor blocker (p = 0.043) and loop diuretics and beta blockers (p = 0.049) were associated with a lower risk of 30-day hospital readmission. Multivariate logistic regression revealed only loop diuretics to be associated with a lower risk of hospital readmission in patients with HFpEF (OR 0.59; 95% CI, 0.39-0.90; p = 0.013). Conclusions: Our study revealed that loop diuretics at discharge decreases early readmission in patients with HFpEF. Further, our study highlights the implication of a lack of guidelines and treatment challenges in HFpEF patients and emphasizes the importance of a conservative approach in preventing early readmission in patients with HFpEF.

Heart Failure with Preserved Ejection Fraction and 30-Day Readmission.

OBJECTIVE: Several studies identify heart failure (HF) as a potential risk for hospital readmission; however, studies on predictability of heart failure readmission is limited. The objective of this work was to investigate whether a specific type of heart failure (HFpEF or HFrEF) has a higher association to the rate of 30-day hospital readmission and compare their predictability with the two risk scores: HOSPITAL score and LACE index. DESIGN: Retrospective study from single academic center. METHODS: Sample size included adult patients from an academic hospital in a two-year period (2015 - 2017). Exclusion criteria included death, transfer to another hospital, and unadvised leave from hospital. Baseline characteristics, diagnosis-related group, and ICD diagnosis codes were obtained. Variables affecting HOSPITAL score and LACE index and types of heart failure present were also extracted. Qualitative variables were compared using Pearson chi2 or Fisher's exact test (reported as frequency) and quantitative variables using non-parametric Mann-Whitney U test (reported as mean ± standard deviation). Variables from univariate analysis with P values of 0.05 or less were further analyzed using multivariate logistic regression. Odds ratio was used to measure potential risk. RESULTS: The sample size of adult patients in the study period was 1,916. All eligible cohort of patients who were readmitted were analyzed. Cumulative score indicators of HOSPITAL Score, LACE index (including the Charlson Comorbidity Index) predicted 30-day readmissions with P values of <0.001. The P value of HFpEF was found to be significant in the readmitted group (P < 0.001) compared to HFrEF (P = 0.141). Multivariate logistic regression further demonstrated the association of HFpEF with higher risk of readmission with odds ratio of 1.77 (95% CI: 1.25 - 2.50) and P value of 0.001. CONCLUSIONS: Our data from an academic tertiary care center supports HFpEF as an independent risk factor for readmission. Multidisciplinary management of HFpEF may be an important target for interventions to reduce hospital readmissions.

Late Atrial Thrombus Formation After Percutaneous Patent Foramen Ovale Closure.

Late thrombus formation is a rare complication associated with patent foramen ovale (PFO) closure devices. We report the case of an incidental discovery of large thrombi in both atria 9 months after percutaneous PFO occlusion that required cardiac surgery for thrombi removal. (Level of Difficulty: Beginner.).

A Rare Case of Isolated and Idiopathic Spontaneous Renal Artery Dissection in a Female Patient on Multiple Medications.

Constituting less than 25% of all renal artery dissections (RAD), isolated spontaneous renal artery dissection (SRAD) is a rare diagnosis that can cause subsequent renal infarction with impairment. The majority of SRAD cases are idiopathic. Management ranges from conservative, medical to endovascular, and surgical repair. We report a case of a young female on multiple medications who presented with SRAD. She presented with acute abdominal pain and was found to have isolated spontaneous renal artery dissection. The etiology of this patient's isolated SRAD could possibly be pinned down to her multiple stimulant medications used after the major known causes were ruled out.

Trimethoprim-sulfamethoxazole Induced Pancytopenia: A Common Occurrence but A Rare Diagnosis.

Trimethoprim-sulfamethoxazole (TMP-SMX) is a bacteriostatic antimicrobial medication used for the treatment of a variety of infections and has many reported skin and hematologic side effects. Due to the easy availability and cost effectiveness, TMP-SMX is one of the medications commonly used for treatment of skin and soft tissue in patients with methicillin-resistant Staphylococcus aureus (MRSA) infection. One of the rare hematologic manifestations of TMP-SMX is pancytopenia, which is a reduction in all cell lines. In this case report, we are documenting a case of pancytopenia due to severe drug reaction to TMP-SMX in a 70-year-old female after two weeks of medication use. Upon initial stabilization she underwent a thorough workup and was subsequently diagnosed with severe drug-induced pancytopenia. Detailed history, early diagnosis, prompt discontinuation of the offending medication along with supportive care remain the mainstay of treatment in the management of TMP-SMX induced pancytopenia.