Jj Lieber

Nephrotic syndrome after treatment of Crohn's disease with mesalamine: Case report and literature review

Inflammatory bowel disease and its various treatments may affect the kidney in several ways. Recently, case reports have been published documenting the development of nephrotic syndrome after the treatment for inflammatory bowel disease with 5-aminosalicylic acid derivatives. We report a 50-year-old patient who was diagnosed with Crohns disease and was treated with mesalamine. The patient subsequently developed nephrotic syndrome and a renal biopsy showed minimal change disease. He was treated with losartan and rosuvastatin and showed improvement in his renal function and serum cholesterol level. This is the first reported case in Crohns disease although there have been six previous case reports of nephrotic syndrome following salicylic acid derivatives for ulcerative colitis.

Morbidity and Mortality of Congestive Heart Failure in Trauma Patients

Background: Cardiovascular morbidity and mortality in heart failure (HF) patients comprise a major health and economic burden, especially when readmission rate and length of stay (LOS) are considered. With increasing average life expectancy, HF prevalence continues to rise. Diseases such as diabetes mellitus, hypertension and ischemic heart disease continue to be the leading causes of HF. Current data suggest that HF is the most common cause for hospital admission in patients older than 65 years. Objective: In this study, we sought out to compare the 30‐day readmission rate in trauma patients who have a preexisting history of HF to those who do not have a history of HF. Additionally, we emphasized the effect of different cardiac variables in the HF group such as the pathophysiology of HF (HF with preserved ejection fraction [HFpEF] versus HF with reduced ejection fraction [HFrEF]) and the etiology of HFrEF (ischemic versus nonischemic). Methods: A retrospective chart analysis of 8,137 patients who were admitted to our hospital between 2005 and 2013 secondary to trauma with an Injury Severity Score <30. Data were extracted using International Classification of Diseases, Ninth Revision codes. Neurotrauma patients were excluded. Results: Of 8,137 trauma patients, 334 had preexisting HF, of which 169 had HFpEF while 165 had HFrEF). Of the 165 HFrEF cases, 121 were ischemic in etiology versus 44 nonischemic. Of 334 HF patients, 81 patients (24%) were readmitted within 30 days versus 1,068 (14%) of the non‐HF patients (95% CI: 1.52‐2.25, relative risk: 1.85, P < 0.0001). Of the 81 readmitted HF patients, 64 had HFpEF while 35 had HFrEF. There was no statistical significance observed in any of the endpoints in the HFpEF versus HFrEF groups. Mortality, 30‐day readmission and LOS were all significantly higher in the ischemic versus nonischemic HFrEF group. Conclusions: In our trauma population, HF patients had a significantly higher 30‐day readmission rate when compared to non‐HF patients. The pathophysiology of HF (HFpEF versus HFrEF) did not seem to play a role. However, after subgroup analysis of the HFrEF group based on etiology, all endpoints including mortality, readmission and LOS were significantly higher in the ischemic HFrEF subgroup rendering this entity higher importance when treating trauma patients with preexisting HF.

Pseudo-Pelger–Huët anomaly and granulocytic dysplasia associated with human granulocytic anaplasmosis

Pseudo-Pelger–Huët anomaly (PHA) refers to mono- or bi-lobed granulocytes, reportedly observed in patients with severe infections and inflammation or hematological malignancies including myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). Dysplastic changes in granulocytes are typical manifestations in MDS and granulocytic leukemias. Here, we report the unique case of a patient found to have human granulocytic anaplasmosis (HGA), a tick-borne disease caused by Anaplasma phagocytophilum, a Gram-negative coccobacillus. This patient showed striking hematological manifestations including a large number of pseudo-PHA, a severe degree of left shift, and dysplastic granulocytes. These hematological presentations on the peripheral smear all resolved with doxycycline treatment, implying that the changes were most likely reactive manifestations secondary to HGA, rather than underlying hematological malignancies such as MDS or AML.

ID: 1: STATINS DECREASE MORTALITY RATE AND LENGTH OF HOSPITALIZATION IN HEART FAILURE PATIENTS

Introduction Many theories and clinical trials have attempted to address the effect of low-density lipoprotein (LDL) lowering in chronic congestive heart failure (CHF). Several studies have demonstrated that higher lipid and lipoprotein levels, including total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides, are associated with significantly improved outcomes in HF of both ischemic and nonischemic etiologies. Hypothesis In light of the association between high cholesterol levels and improved survival in HF, statin or other lipid-lowering therapy in HF remains controversial. In this study we evaluated the outcome of statins use in HF patients. Method We performed a retrospective chart analysis of 1,616 patients who were admitted to the hospital from 2005 to 2012 due to decompensated HF. 781 patients had HFrEF and 780 patients had HFpEF. The medications of all patients with HFrEF and HFpEF were reviewed. Each of HFrEF and HFpEF patients were divided into two groups: Statin-treated and non-Statin treated. The 30-day readmission rate, mortality rate and LOS were subsequently determined. Results Of the 1616 patients with decompensated HF, 776 patients had heart failure with preserved ejection fraction [HFpEF] and 780 patients had HFrEF. After the medications for each group were standardized, the 30-day readmission rate and mortality rate in the HFpEF versus HFrEF groups who received statin therapy did not differ (p=0.9 and 0.3, respectively). The HFpEF patients who received statin therapy had a lower mortality rate comparing to the non-statin therapy group (OR: 0.2, 95% CI: 0.1–0.5, p<0.001). Furthermore, LOS was significantly lower in the HFpEF statin therapy group 5.4 days versus 6.8 days in the HFpEF non-statin group (p<0.001). 30-day readmission rate did not differ between the two groups (p=0.9). The HFrEF patients who received statin therapy had a lower mortality rate comparing to HFrEF patients who did not receive statin therapy (OR: 0.3, 95% CI: 0.1–0.6, p<0.001). Additionally, LOS was significantly lower in the HFrEF statin therapy group 5.4 days versus 7 days in the HFrEF non-statin therapy group (p=0.04). 30-day readmission rate did not differ between the two groups (p=0.9). Conclusion Our study showed that statin therapy was associated with both a lower mortality rate and LOS among both HFpEF and HFrEF patients. However, the benefit of statin use on 30-day readmission rate did not differ between the two groups of HF patients.

ID: 14: DIGITALIS INCREASES THE 30-DAY READMISSION RATE IN PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION

Introduction Digitalis has been used for over 200 years to treat patients with heart failure (HF). Evidence from clinical trials supports the use of digitalis in patients with HF due to left ventricular (LV) systolic dysfunction, particularly in patients with more advanced symptoms. However, there is no evidence that digitalis improves survival. Hypothesis We evaluated the role of digitalis use in the 30-day readmission rate, mortality rate and length of stay (LOS) in patients with heart failure and reduced ejection fraction (HFrEF). Methods We performed a retrospective chart analysis of 1,616 patients who were admitted to the hospital from 2005 to 2012 due to decompensated HF. 781 patients had HFrEF. The medications of all 781 patients with HFrEF were reviewed. The HFrEF patients were divided into two groups: digitalis-treated and non-digitalis treated. The 30-day readmission rate, mortality rate and LOS were subsequently determined. Results Of the 781 patients with HFrEF, 196 (25%) did receive digitalis treatment versus 584 (75%) did not receive Digitalis treatment. After the other medications in each group were standardized, the digitalis-treatment HFrEF group had a higher 30-day readmission rate compared to the non-digitalis treatment HFrEF group (OR: 1.5, 95% CI: 1.1–2.2, p=0.04). The morality rate and LOS between the digitalis-treatment and non-digitalis treatment groups did not differ (p=0.7 and 0.4, respectively). Conclusion Our study confirmed that digitalis use in HFrEF does not improve the survival rate and length of stay. However, our study showed that digitalis use can increase the 30-day readmission rate.

ID: 12: THE ROLE OF ALCOHOL ABUSE AND TOBACCO USE IN THE INCIDENCE OF EARLY ACUTE CORONAY SYNDROME

Background Tobacco abuse and alcohol dependence have been established as risk factors for atherosclerotic heart disease (ASHD). Their potential synergistic effect, however, have not been previously evaluated. Abstract ID: 12 Table 1 Alcohol abuse/ Dependence Alcoholic abuse (n=172) Alcoholic- Smoker (n=51) Alcoholic Non-Smoker (n=121) Mean age (years) 55.1 51.1 56.1 95% CI (52–58) (48–54.2) (54.6–57.6) Non-Alcohol abuse/Dependence Non-Alcoholic (n=7904) Non-Alcoholic Smoker (n=909) Non-alcoholic Non-smoker (n=6995) Mean age (years) 63.8 56.3 71.3 95% CI (63.6–63.9) (55–57.7) (71–71.6) p Value <0.001 0.02 <0.001 Objective/Purpose To investigate the synergistic role of alcohol abuse/dependence and tobacco use in the early incidence of ACS. Methods A retrospective chart analyses of 8076 patients diagnosed with ACS between 2000 to 2014, defined by ICD-9 codes for acute MI, alcohol abuse/dependence and tobacco use. Average age of ACS was calculated for the general population. Patients were then divided into 4 subgroups based on alcohol abuse/dependence and tobacco use status as follows: non-alcoholic non-smokers, non-alcoholic smokers, alcoholic non-smokers and alcoholic smokers. Results The mean age of our 8076 ACS patients population was ∼59.5 (95% CI 59.2–59.8). Patients with history of alcohol abuse/dependence appeared to develop ACS ∼8.7 years younger than their non-alcoholic counterparts. When tobacco use is incorporated as a risk factor, those with both alcohol abuse/dependence and tobacco use seemed to develop ACS ∼5 years earlier than those with history of either alone, and ∼20 years earlier when compared to those with neither alcohol abuse/dependence nor tobacco use. (table 1 summarizes mean age of ACS incidence in our study subgroups). Conclusions Alcohol abuse/dependence appears to be a risk factor for earlier ACS. In our population, the average age of ACS incidence in alcoholic patients was significantly earlier than non-alcoholic patients. Furthermore, alcoholic patients who also used tobacco developed ACS at an even younger age when compared to those who had history of either alcohol abuse/dependence or tobacco use alone, suggesting a possible synergistic effect of these two risk factors in developing early ACS. Healthcare intervention in this population through screening, counseling and education regarding alcohol abuse/dependence and smoking cession is warranted to reduce early ACS.

ID: 68: CORONARY ARTERY DISEASE AND ACUTE CORONARY SYNDROME IN PATIENTS ≤40 YEAR OLD

Background Coronary artery disease (CAD) in the younger adult population has been commonly under-represented in clinical practice and research studies given its early latent asymptomatic course, in addition to the underestimation of this populations CHD lifetime risk by commonly used CHD risk predictors such as Framinghams score. Objective To assess the risk factor profile for premature coronary artery disease CAD and ACS presentation in younger adults. Methods Retrospective chart analysis of 393 patients ≤40 years old admitted from 2005 to 2014 for chest pain and underwent coronary angiography. The implication of modifiable risk factors and non-modifiable risk factors were evaluated in those with obstructive CAD (LM stenosis of ≥50% or stenosis of ≥70% in a major epicardial vessel), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). Additionally we evaluated the impact of the same risk factors on ACS presentation (NSTEMI vs STEMI) and the extent of CAD (single-vessel/multi vessel). Results Of 9012 patients who underwent cardiac catheterization, 393 (4.3%) patients were ≤40 years old. Out of 393, 212 (54%) had CAD (153 obstructive versus 59 non-obstructive) while 185 (46%) had normal coronaries. Fifty two (25%) patients presented with STEMI while 140 (66%) patients presented with NSTEMI. Of 153 patients with obstructive CAD, 87 (57%) patients had single vessel disease vs 66 (43%) multiple vessel disease. When compared to patients with normal coronaries patients with CAD were more likely to be smokers (p<0.0001), dyslipidemia (p<0.0001), Diabetic (p<0.0001) cocaine users (p 0.4) have a family history of premature CHD (<0.0001) and be males (p<0.0001) (figure=1). Smokers were more likely to present with acute coronary syndrome; 5 times more likely to present with STEMI (p<0.0001) and 1.7 with NSTEMI (p 0.0003) compared to the control group. When compared head to head, smokers were 2.2 times more likely to present with STEMI compared to NSTEMI (p<0.001). Smoking also, alone and with another risk factor increased the risk of obstructive versus no obstructive CAD (p=0.04 and 0.015, respectively). No significant difference was noted in the single vessel vs multi vessel CAD subgroups. Coronary artery disease was highest in South Asian population (38.4%), followed by Hispanic (13.7%), African-American (10%) and Caucasian (9%). The main in risk factors in African–American was Hyperlipidemia +/− Diabetes (47.8%) while the main risk factors in Hispanic and white were smoking alone (24.14% and 47.4% respectively). In East Asia population, Smoking with hyperlipidemia was the main risk factors (44%). Conclusion In our population of young adults, smoking as a single risk factor was the most prevalent for earlier CAD. It was also associated with more STEMIs and obstructive CAD. Healthcare intervention in the general population through screening, counseling and education regarding smoking cessation is warranted to reduce premature coronary artery disease. Abstract ID: 68 Figure 1

ID: 3: MORBIDITY AND MORTALITY OF CONGESTIVE HEART FAILURE IN TRAUMA PATIENTS: A RETROSPECTIVE CHART ANALTSIS

Background Cardiovascular morbidity and mortality in heart failure (HF) patients comprise a major health and economic burden, especially when readmission rate and length of stay are considered. With increasing life expectancy, HF prevalence continues to increase. Diseases such as diabetes mellitus, hypertension and ischemic heart disease continue to be the leading causes of HF. Current data suggests that HF is the most common cause for hospital admission in patients older than 65 years. Objective In this study, we sought out to compare the morbidity, mortality, 30-day readmission rate and length of stay in trauma patients who have a pre-existing history of HF to those who do not have a history of HF. Additionally, we emphasize the effect of different cardiac variables in the HF group such as the pathophysiology of HF (HF with preserved ejection fraction [HFpEF] vs. HF with reduced ejection fraction [HFrEF]) and the etiology of HFrEF (ischemic vs. nonischemic). Methods A retrospective chart analysis of 8,137 patients who were admitted to our hospital between 2005–2013 secondary to trauma with an Injury Severity Score<30. Data was extracted using ICD-9 codes. Neurotrauma patients were excluded. Results Of 8,137 trauma patients, 334 had pre-existing HF, of which 169 had HFpEF while 165 had HFrEF). Of the 165 HFrEF cases, 121 were ischemic in etiology vs. 44 nonischemic. Of 334 patients, 81 patients (24%) were readmitted within 30 days vs. 1,068 (14%) of the non-HF patients (95% CI 1.52–2.25, RR: 1.85, p<0.0001). Of the 81 readmitted HF patients, 64 had HFpEF while 35 had HFrEF. There was no statistical significance observed in any of the endpoints in the HFpEF versus. HFrEF groups (figure 1 and table 1). Mortality, 30-day readmission and length of stay were all significantly higher in the ischemic vs. non-ischemic HFrEF group (figure 1 and table 2). Conclusions In our trauma population, HF patients had a significantly higher morbidity, mortality and 30-day readmission rate when compared to non-HF patients. The pathophysiology of HF (HFpEF vs. HFrEF) did not seem to play a role. However, after subgroup analysis of the HFrEF group based on etiology, all endpoints including mortality, readmission and length of stay were significantly higher in the ischemic HFrEF subgroup rendering this entity higher importance when treating trauma patients with pre-existing HF. Abstract ID: 3 Figure 1