Sandeep Patri

Demographic parameters related to 30-day readmission of patients with pulmonary embolism: Analysis of 650,819 hospitalizations

BACKGROUND Pulmonary embolism (PE) is a serious medical condition associated with major morbidity, mortality and economic burden. Preventable hospital readmissions are a major economic challenge for the healthcare organizations and identifying patient subsets at risk of readmission will help report the issue. This retrospective study was performed to determine demographic parameters and major diagnosis linked with 30day readmission after a PE. METHODS Nationwide Inpatient Sample (NIS) data was used to extract data of patients discharged after PE during index admission for years 2009-2013. Patients were identified by Diagnosis Related Group (DRG) number 175 and 176 which represents PE with major complications and comorbidities (MCC) and PE without MCC. Demographic parameters associated with high readmission rate were identified along with causes related to readmissions. RESULTS We identified a total of 650,819 hospitalizations with PE as the index stay DRG of which 13.44% were readmitted within 30 days after hospitalizations. Patients with age >65years (14.05%), female (13.87%), Medicaid insurances (20.49%), low median income for zip code (15.1%) and metropolitan areas (13.71%) were associated with higher 30day readmission rates. The most common identified cause of readmission in PE with MCC from 2009 to 2010 was heart failure (4.25%) and from 2011 to 2013 was severe sepsis (4.8%) while for PE without MCC from 2009 to 2013 was PE without MCC itself (10.24%). CONCLUSIONS Interventions need to be directed against these set of patients and the identified causes of readmissions to reduce the rehospitalisations from PE.

Right Lung Agenesis with Tracheal Stenosis due to Complete Tracheal Rings and Postpneumonectomy Like Syndrome Treated with Tissue Expander Placement

Congenital lung agenesis is an extremely rare condition with an estimated prevalence of 34 in 1,000,000 live births. It is often associated with other congenital malformations of the skeletal, cardiovascular, urogenital, and gastrointestinal systems. We discuss the case of a 5-month-old who presented with increasing stridor over 1 month. Imaging revealed right lung agenesis, complete dextromalposition of heart, and compression of distal trachea. An intrathoracic saline tissue expander was placed which marked improved distal tracheal stenosis. In patients who are symptomatic it becomes imperative to perform surgeries to increase survival as was the case in this patient.

Association between hypothyroidism and Takotsubo Cardiomyopathy: Analysis of Nationwide Inpatient Sample Database.

BACKGROUND Takotsubo Cardiomyopathy (TC), also called transient left ventricular (LV) ballooning syndrome, resembles myocardial infarction and is characterized by LV dysfunction in the absence of coronary artery disease. Hypothesis described for TC has been an intense social stressor, pheochromocytoma, thyrotoxicosis among others. We performed this study to analyze the association of hypothyroidism with TC. METHODS We queried the Nationwide Inpatient Sample which represents 20% of all the United States hospital data for our study. We identified TC and hypothyroidism through their respective ICD9. Codes for years 2006-2012. SAS 9.4 was used to perform a chi-square analysis to find any statistical significance and p < 0.05 used to determine statistical significance. Significant differences were identified using odds ratio (OR) estimates. RESULTS A total of 19,713 cases with TC were identified of which 17,340 (87.96%) were females and 2,373 (12.04%) were males. 3,272 patients with TC had diagnosis of hypothyroidism. There is statistically significant evidence of an association between TC and hypothyroidism (OR 2.21 (95% CI: 2.11- 2.31); p<0.0001). There is evidence of increased statistical significance of females having TC 5.24 (95% CI: 4.96-5.53; (p<0.0001)) compared to males, with an increased statistically significance of females with hypothyroidism having TC, OR 6.65 (95% CI: 5.57-7.93; p< 0.001) compared to males. CONCLUSION There is an increased association of hypothyroidism, especially hypothyroidism for females with TC.

Hiding in plain sight: a case of chronic disseminated histoplasmosis with central nervous system involvement.

A 64-year-old man presented with gradual onset of confusion, ataxia and 25-pound weight loss over 3 months. MRI of the brain revealed two enhancing cerebellar lesions suspicious for metastases. Positron emission tomography-CT showed enhancement of cervical and axillary lymph nodes. Left axillary lymph node biopsy showed no evidence of malignancy but instead showed fungal organisms morphologically consistent with Histoplasma spp. Disseminated histoplasmosis with central nervous system involvement was suspected. Further history revealed that the patient had been having subjective fever for the past several months. He has had mild pancytopenia for about 2 years, which had not been further evaluated. Additionally, he had an oesophagogastroduodenoscopy 3 months prior to admission, which had shown granulomatous gastritis. Subsequently, the diagnosis of disseminated histoplasmosis was confirmed by serological testing and bone marrow biopsy. The patient was started on liposomal amphotericin B. Unfortunately, the patient had a catastrophic stroke and was transitioned to comfort care measures.

Granulicatella elegans endocarditis: a diagnostic and therapeutic challenge

A 63-year-old man with a history of non-ischaemic cardiomyopathy presented with acute worsening of heart failure and septic shock. Echocardiogram revealed a large aortic valve vegetation with new onset severe aortic incompetence. Blood cultures grew Granulicatella elegans, for which antimicrobial sensitivities could not be carried out in our lab. Despite antibiotic therapy and aggressive care, the patients clinical condition worsened and he died. G. elegans, previously grouped under nutrient variant streptococci (NVS), is an extremely rare cause for bacterial infective endocarditis (IE). Unlike with the Viridans group, IE caused by NVS has a very poor outcome and higher mortality rate. The difficulty in isolation of the bacteria in culture, inability to reliably measure antibiotic susceptibility in vitro, frequent treatment failure and complications such as multivalvular involvement, make this an extremely challenging infection to treat. Early detection of the organism, appropriate antibiotics and early surgical management when indicated, are key to management.

Retinopathy of prematurity screening leading to cardiopulmonary arrest: fatal complication of a benign procedure.

A 6-week-old female infant born at 31 weeks of gestation was brought to the ophthalmology office for retinopathy of prematurity (ROP) screening. One drop of phenylephrine (2.5%) and tropicamide (1%) ophthalmic solution was instilled in each eye for ROP evaluation. She was breast fed about 5 min after receiving the medication. She was covered in a blanket and soon her mother could not feel her suckling. Cardiopulmonary resuscitation was initiated with return of spontaneous circulation in 1–2 min. She was admitted to the paediatric intensive care unit and monitored overnight. After an uncomplicated hospital course, she was discharged the following day. It was determined that the eye drops had induced cardiopulmonary arrest (CPA) as apnoea and bradycardia of prematurity resolve by 36 weeks and CPA occurred within minutes of the medication administration. Identification of CPA, prompt intervention and awareness of the offending agent is of prime importance in management of such complications.