Sijan Basnet

Ischemic Stroke and Impact of Thyroid Profile at Presentation: A Systematic Review and Meta-analysis of Observational Studies

BACKGROUND Stroke is the fifth leading cause of mortality in the United States and a leading cause of disability. A complex relationship between thyroid hormone levels and severity of, and outcome after, stroke has been described. AIM Our objective is to identify the association between baseline thyroid function profile and outcome after acute ischemic stroke. METHODS Studies looking at the association between thyroid function and functional stroke outcomes were identified from available electronic databases from inception to December 16, 2016. Study-specific risk ratios were extracted and combined with a random effects model meta-analysis. RESULTS In the analysis of 12 studies with 5218 patients, we found that subclinical hypothyroidism was associated with better modified Rankin scale scores at 1 and 3 months (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.13-5.91, P = .03 and OR 2.28, 95% CI 1.13-3.91, P = .003, respectively) compared with the euthyroid cases. Likewise, patients with higher initial thyrotropin-releasing hormone (TSH) and fT3 or T3 levels had favorable outcomes at discharge (mean differences of TSH .12 [95% CI .03-.22, P = .009] and of fT3 .36 (CI .20-.53, P < .0001]) and at 3 months (mean differences of TSH .25 [95% CI .03-.47, P = .03] and of T3 8.60 [CI 4.58-12.61, P < .0001]). CONCLUSIONS Elevated initial TSH (clinical or subclinical hypothyroidism) may correspond to better functional outcomes, whereas low initial T3/fT3 might correlate with worse outcomes in acute ischemic stroke among clinically euthyroid patients. This complex relation merits further well-designed investigations. Whether correcting thyroid profile with hormone supplementation or antagonism may lead to improved outcomes will require large, prospective, interventional studies.

Hypercalcemia associated with cosmetic injections: a systematic review

INTRODUCTION Cosmetic injections with silicone and polymethylmethacrylate are not FDA approved for augmentation of body parts such as breast, buttock or legs, but they have been widely used for decades. Cosmetic injections can cause foreign body granulomas and occasionally severe and life-threatening hypercalcemia. We aimed to systematically analyze the published literature on cosmetic injection-associated hypercalcemia. METHODS We searched relevant articles on hypercalcemia associated with various cosmetic injections and extracted relevant data on demographics, cosmetic injections used, severity of hypercalcemia, management and outcomes. RESULTS We identified 23 eligible patients from 20 articles. Mean age was 49.83 ± 14.70 years with a female preponderance (78.26% including transgender females). Silicone was most commonly used, followed by polymethylmethacrylate and paraffin oil (43.48, 30.43, and 8.70% respectively). The buttock was the most common site followed by the breast (69.57% and 39.13% respectively). Hypercalcemia developed at mean duration of 7.96 ± 7.19 years from the initial procedure. Mean ionized calcium at presentation was 2.19 ± 0.61 mmol/L and mean corrected calcium at presentation was 3.43 ± 0.31 mmol/L. 1,25-Dihydroxyvitamin D (1,25(OH)2D or calcitriol) was elevated while 25-hydroxyvitamin D (25(OH)D) and PTH were low in majority of cases. Hypercalcemia was managed conservatively with hydration, corticosteroids and bisphosphonates in majority of cases. Surgery was attempted in 2 cases but was unsuccessful. Renal failure was the most common complication (82.35% cases) and 2 patients died. CONCLUSION Hypercalcemia from cosmetic injections can be severe and life threatening and can present years after the initial procedure. Cosmetic injection-associated granuloma should be considered a cause of hypercalcemia, especially in middle-aged females presenting with non-PTH-mediated, non-malignant hypercalcemia, which is often associated with elevated calcitriol; however, it should be noted that calcitriol level may be normal as well.

Mycobacterium mucogenicum Hand Infection in an Intravenous Drug Abuser

Mycobacterium mucogenicum is a rapidly growing mycobacterium found ubiquitously in water sources. It has been reported to cause widespread infections with infection entry from wound or central venous catheters especially in immunocompromised patients. Diagnosis is made from blood cultures which may take at least a week. Management includes removal of the source or drainage of wound infections and combination antimicrobial therapy.

Comparison of Outcomes after Hospitalization among Heart Failure Patients with and without History of Heart Transplantation

INTRODUCTION Heart transplantation is an effective treatment option for end-stage heart failure patients. The effect of heart failure admission post heart transplantation has not been explored in the past. METHODS We used the National Inpatient Sample to compare the outcome of hospitalization in heart failure patients after heart transplantation with heart failure patients without heart transplantation. We used diagnosis codes for heart failure and history of heart transplantation from International Classification of Disease-9 and Clinical Classification Software-Diagnoses codes. RESULTS We used multivariable logistic regression for this purpose, which showed no difference in outcome in terms of mortality, length of stay, and cost. CONCLUSION Our study showed similar outcomes in hospitalized heart failure patients regardless of the history of heart transplantation. This is an important statistic for outcome in a patient undergoing heart transplantation.

Prevalence of chronic obstructive pulmonary disease (COPD) among rheumatoid arthritis: results from national inpatient database

ABSTRACT Rheumatoid arthritis (RA) is being increasingly recognized as an important contributor to chronic obstructive pulmonary disease (COPD). Although smoking is a major risk factor, other factors may play a role. We used National Inpatient Sample (NIS) from 2013 to explore this relationship. We used propensity matching with a 1:3 nearest-neighbor-matching algorithm to match 1 RA hospitalization to 3 age- and-sex-matched comparators. In the age- and-sex-matched population, RA had a higher odds of COPD (OR 1.20, 95% CI: 1.17–1.22, p < 0.0001). RA is associated with increased COPD prevalence, independent of smoking. COPD might fall within the spectrum of RA complications, likely due to autoimmune and inflammatory mechanisms.

Daptomycin associated eosinophilic pneumonia: case report and differential diagnoses

ABSTRACT Daptomycin is a bactericidal antibiotic approved for treatment of gram-positive skin and soft tissue infections. We present a case of an 89-year-old man who presented with fever, shortness of breath and nonproductive cough on week 4 of starting daptomycin for infective endocarditis. Computerized tomography scan showed bilateral interstitial infiltrates predominantly affecting the lower lobes. He also had peripheral eosinophilia of 6%. He was diagnosed with eosinophilic pneumonia secondary to daptomycin use. His symptoms improved with discontinuation of daptomycin and initiation of corticosteroids. Clinical correlation of pneumonia-like presentation with recent use of daptomycin should make physicians rule out this rare adverse effect for early institution of correct treatment.

Multifactorial aetiology for non-uremic calciphylaxis: a case report

ABSTRACT Calciphylaxis is commonly associated with end-stage renal disease patients on haemodialysis. We present a rare case of calciphylaxis in a non-uremic patient. The diagnosis was made clinically and confirmed with skin biopsy showing calcification of the dermal and subcutaneous tissues in the von Kossa stain. We believe that the combination of uncontrolled diabetes mellitus, a non-functioning paraganglioma and vitamin D deficiency in a susceptible female patient was responsible for causing calciphylaxis in our patient. An index of suspicion should be maintained by clinicians for calciphylaxis even in patients without uremia.

Predictors and outcome of invasive mechanical ventilation in hospitalized patients with sepsis: data from National Inpatient Sample

ABSTRACT Background: Sepsis is a significant cause of mechanical ventilation in hospitalized patients. Objective: The aim of our study was to recognize the demographic and clinical characteristics associated with an increased need for invasive mechanical ventilation in hospitalized sepsis patients. Methods: We used National Inpatient Sample database from the years 2009–2011 to identify sepsis patients requiring invasive mechanical ventilation. We compared demographic and clinical characteristics of sepsis patients requiring and not requiring ventilator support and conducted univariate and multivariate analyses to determine odds ratio (OR) of association. Results: A total of 4,827,769 sepsis patients were identified among which 21.38% required invasive ventilation. Multivariate logistic regression [OR (95% CI), p<0.001] determined the following to be associated with increased odds of ventilator use: morbid obesity [1.37 (1.31–1.42)] and age group 35-64 years [1.18 (1.14–1.22)] compared to 18–34 years, whereas females [0.90 (0.88–0.91)] and age >85 years [0.49 (0.47–0.52)] had reduced odds of invasive ventilation. Hyperkalemia [1.12 (1.09–1.16)] and hypernatremia [2.26 (2.16–2.36)] were associated with increased odds while hypokalemia [0.94 (0.91–0.97)] had reduced odds of invasive ventilation. Septic patients requiring IMV had higher length of stay by 9.72 ± 0.17 days, hospitalization cost by US

1458: PREDICTORS OF MECHANICAL VENTILATION IN HOSPITALIZED PATIENTS WITH SEPSIS

43010.31 ± 988.24 and in-hospital mortality (41.33% vs 8.91%). Conclusion: Sepsis is a major cause of intensive care unit admission and initiation of invasive ventilation. Baseline demographic and clinical features affect the need for invasive ventilation. A clear understanding of these risk factors is integral for an appropriate and timely management.

Pulmonary Mucormycosis in Chronic Lymphocytic Leukemia and Neutropenia

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Sepsis is a major cause of increased ventilation requirement in hospitalized patients. Recognition of clinical presentations associated with an increased need to initiate invasive ventilation is integral for timely intervention. The aim of our study was to recognize the demographic and clinical characteristics associated with an increased need for invasive ventilation in hospitalized sepsis patients. Methods: We used National Inpatient Sample (NIS) database from the years 2009–2011 to identify adult patients (≥18 years) with sepsis requiring invasive ventilation. We compared demographic and clinical characteristics of sepsis patients requiring and not requiring ventilator and conducted univariate and multivariate analyses to determine odds ratio of association Results: A total of 3,467,149 sepsis patients were identified among which 18.97% required invasive ventilation. Multivariate logistic regression determined the following independent predictors of ventilator use: Charlson comorbidity index (OR 1.11, 95% CI 1.09–1.13, p < 0.0001); acute respiratory distress syndrome (2.08, 95% CI 1.88–2.29, p < 0.0001), acute kidney injury (OR 2.23, 95% CI 2.17–2.29, p < 0.0001), acidosis(OR 2.96, 95% CI 2.86–3.06, p < 0.0001), hyperkalemia (OR: 1.17, 95% CI 1.13–1.20, P < 0.000 1), hypernatremia (OR 2.03, 95% CI 1.93– 2.13, p < 0.0001), volume overload (OR 1.75, 95% CI 1.63–1.90, p < 0.0001) and age groups of 35–64 (OR 1.28, 95% CI 1.22–1.33, p < 0.0001) and 65–84 years (OR 1.06, 95% CI 1.01–1.33, p < 0.013) in comparison to 18–34 years. Conversely, decreased odds of continuous invasive ventilation was noted among females (OR 0.92, 95% CI 0.91–0.94, p < 0.0001), age > 85 years (OR 0.57, 95% CI 0.54–0.61, p < 0.0001) and volume depleted status (OR 0.54, 95% CI 0.54–0.56, p < 0.0001). Conclusions: Sepsis is a major cause of intensive care unit admission and initiation of invasive ventilation. Baseline demographic and clinical features, as well as the other complications that arise during the course of hospitalization, affect the need for invasive ventilation. A clear understanding of these risk factors will aid appropriate management.