Walid Ibrahim

Percutaneous coronary intervention or coronary artery bypass grafting for unprotected left main coronary artery disease

Recent trials comparing PCI with CABG for unprotected left main disease yielded discrepant evidence.

Antiplatelet Therapy and Spontaneous Retroperitoneal Hematoma: A Case Report and Literature Review

Patient: Male, 66 Final Diagnosis: Spontaneous retroperitoneal hematoma seconday dual antiplatelet therapy Symptoms: Anemia • knee joint pain Medication: — Clinical Procedure: None Specialty: Cardiology Objective: Rare disease Background: Dual antiplatelet therapy has proven efficacy in primary and secondary prevention of coronary artery disease with a relatively good safety profile. Review of the literature revealed 8 cases of spontaneous retroperitoneal hematoma secondary to antiplatelet treatment. Case Report: We report the case of a 66-year-old male with a flare of acute gout secondary to uncontrolled chronic myeloid leukemia. The patient was started on dual antiplatelet treatment following a drug-eluted stent placement for symptomatic coronary artery disease. He suffered from an unexplained acute drop of five grams of hemoglobin from 10.4 to 5.8 g/dL and symptomatic anemia. The initial labs excluded occult GI bleeding, hemolysis, and bone marrow suppression. However, an abdominal CT scan showed an approximately 7.2×4.7×6.7 cm spontaneous retroperitoneal hematoma involving the left iliacus muscle. The patient was successfully treated conservatively by discontinuing antiplatelet therapy and supportive measures. Conclusions: A spontaneous retroperitoneal hematoma often presents without localizing signs and symptoms and therefore should be considered in any case of unexplained blood loss in patients on antiplatelet therapy. CT without contrast is the modality of choice to diagnose retroperitoneal hematoma.

Effect of Hospital Ownership on Outcomes of Heart Failure Hospitalization

This study aimed to evaluate the impact of hospital ownership on heart failure (HF) hospitalization outcomes in the United States using data from the National Inpatient Sample of the Agency for Healthcare Research and Quality. Hospital ownership was classified into three, namely, nonfederal government, not-for-profit, and for-profit hospitals. Participants were adults hospitalized with a primary diagnosis of HF (2013 to 2014). End points included inpatient mortality, length-of-stay, cost and charge of hospitalization, and disposition at discharge. Of the estimated 1.9 million HF hospitalizations in the United States between 2013 and 2014, 73% were in not-for-profit hospitals, 15% were in for-profit hospitals, and 12% were in nonfederal government hospitals. Overall, mortality rate was 3%, mean length of stay was 5.3 days, median cost of hospitalization was USD 7,248, and median charge was USD 25,229, and among those who survived to hospital discharge, 51% had routine home discharge. There was no significant difference in inpatient mortality between hospital ownership among male patients, but there was a significant difference for female patients. Compared with government hospitals, mortality in female patients was lower in not-for-profit (odds ratio: 0.85 [95% confidence interval: 0.77 to 0.94]) and for-profit hospitals (odds ratio: 0.77 [0.68 to 0.87]). In addition, mean length of stay was highest in not-for-profit hospitals (5.4 days) and lowest in for-profit hospitals (5 days). Although cost of hospitalization was highest in not-for-profit hospitals (USD 7462) and lowest in for-profit hospitals (USD 6,290), total charge billed was highest in for-profit hospitals (USD 35,576) and lowest in government hospitals (USD 19,652). The average charge-to-cost ratio was 3:1 for government hospitals, 3.5:1 for not-for-profit hospitals, and 5.9:1 for for-profit hospitals. In conclusion, there exist significant disparities in HF hospitalization outcomes between hospital ownerships. Outcomes were generally better in for-profit hospitals than other tiers of hospital and, notably, there was a significant difference in inpatient mortality for female patients (but not for male patients).

Disseminated Tuberculosis among Adult Patients Admitted to Hamad GeneralHospital, Qatar: A Five Year Hospital Based Study

Objectives: To describe the demographic, clinical features, diagnostic and procedure results, organ involvement and outcomes in patients with disseminated tuberculosis (TB). Patients and methods: This retrospective observational study was conducted at Hamad general hospital in Qatar. It involved all patients 15 years of age or older who were admitted to Hamad general hospital with disseminated TB from January 1, 2006 to December 31, 2010. Results: We enrolled 100 patients. There were 74 (74%) males and the mean age (±SD) of patients was 31.3±12.2. The most common presenting symptom was fever (95%). Fifteen (15%) patients had other underlying medical conditions; the most common being diabetes mellitus 7 (7%), while two patients had human immunodeficiency virus (HIV) infection. The tuberculin skin test was positive in 42 (42%) patients. Sputum and gastric lavage examination were performed in 84 (84%) and 9 (9%) patients respectively while bronchoscopy was performed on 32 (32%) cases. Most patients 94 (94%) completed their treatment in Qatar whereas (3%) left the country before completion. The in-hospital mortality rate was 3% (3 patients). Systemic corticosteroids were prescribed for 36 (36%) cases and 15 patients had complications, the most being tuberculoma 9/23 (39.1%). Drug toxicity was noted in 17 (17%) patients, including hepatitis, optic neuritis and hyperurecemia. Only presence of underlying medical conditions was found to be an independent predictor of mortality. Conclusions: Disseminated TB has a non-specific clinical picture, gives rise to high morbidity

Comparison of Hospital Outcomes of Transcatheter AorticValve Implantation With Versus Without Hypothyroidism

Comparative outcomes of transcatheter aortic valve implantation (TAVI) in patients with and without hypothyroidism were not previously reported. This study aimed to appraise the clinical outcomes and impact of hypothyroidism on patients who underwent TAVI. Patients with hypothyroidism who underwent TAVI from 2011 to 2014 were identified in the National Inpatient Sample database using the International Classification of Diseases, ninth Revision, Clinical Modification. The primary outcome was the effect of hypothyroidism on inpatient mortality. Secondary outcomes were the impact of hypothyroidism on post-TAVI complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding. The hypothyroid patients who underwent TAVI had no significant increase in the risk of in-hospital mortality (odds ratio 0.78; 95% confidence interval 0.51 to 1.21, p = 0.282), or most postprocedural complications. However, hypothyroid patients were more likely to develop hemorrhage requiring transfusion (odds ratio 1.36, 95% confidence interval 1.05 to 1.76, p = 0.043). In conclusion, TAVI is a feasible and relatively safe alternative with reasonable in-hospital outcomes in patients with hypothyroidism and severe symptomatic aortic stenosis. However, hypothyroid patients are more likely to require a blood transfusion after TAVI. Additional randomized trials are needed to evaluate TAVR outcomes in hypothyroid patients.

IMPACT OF HOSPITAL OWNERSHIP ON IN-PATIENT MORTALITY AND COST OF HOSPITALIZATION IN PATIENTS ADMITTED FOR HEART FAILURE: INSIGHT FROM THE NATIONAL INPATIENT SAMPLE (NIS)

Background: We sought to investigate the impact of hospital ownership on hospitalization outcomes in heart failure (HF) patients. Methods: Using the National Inpatient Sample for HF hospitalizations in the U.S (2011-2013), we evaluated the impact of hospital ownership on clinical outcomes (i.e.

Metastatic adenocarcinoma of the lung presenting as deep vein thrombosis: an evidence of anchoring bias

Background: Non-small cell lung cancer is the most common type of lung cancer and it is often diagnosed at the advanced stages of this disease. Although skeletal metastasis is a common manifestation of lung cancer, distal appendicular skeletal metastasis, especially distal to the knee and elbow joints, is relatively rare. Case representation: We described a 51-year-old female patient who had been admitted with a classical presentation and diagnosis of lower-extremity deep vein thrombosis that cannot be cured using conventional treatment. Further workup revealed a mass arising from the head of the fibula compressing the adjacent vasculature that was found to be metastatic pulmonary adenocarcinoma. Conclusion: Identifying such uncommon presentations may be delayed or missed due to cognitive errors including anchoring bias. Knowledge and insight of such errors may possibly reduce their incidence and their consequent preventable patient injury.

‘All that glitters is not gold’: when hyperammonaemia is not from hepatic aetiology

Hyperammonaemia is often caused by decompensated liver disease. However, non-hepatic causes can sometimes result in hyperammonaemia, severe enough to cause symptoms. We report a case of a 65-year-old man with a history of hypertension and bilateral peripelvic renal cyst who presented with acute confusion. Laboratory investigations revealed hyperammonaemia and normal liver function test. The abdominal ultrasound did not reveal any finding of liver disease or portal-systemic shunting but demonstrated bilateral peripelvic cysts with no hydronephrosis. Hyperammonaemia was attributed to urinary tract infection with a urea-splitting Escherichia coli bacterium. Antibiotic therapy and lactulose were administered. His neurological status rapidly normalised over the next 48 hours, concomitantly with a decrease in ammonia level. Clinician awareness of non-hepatic causes of hyperammonaemic encephalopathy like urinary tract infection can contribute to early diagnosis and timely initiation of appropriate and potentially life-saving treatment including antimicrobial therapy, alleviating urinary obstruction, if present, and lactulose.

Fibrin sheath-associated endovascular infection of the heart: the Trojan horse of indwelling central venous catheters.

Chronic indwelling central venous catheters can result in formation of fibrin sheaths increasing risk of occlusion, thrombosis and infection. Endovascular infection of right-sided heart structures induced by such sheaths is very rare. A 48-year-old woman with end-stage renal disease initially treated for diabetic ketoacidosis developed persistent Staphylococcus epidermidis bacteraemia without an identifiable source. Although transthoracic echocardiography was unremarkable, transoesophageal echocardiography revealed a fibrin sheath and vegetations in superior vena cava–right atrium junction, which was the site of the tip of a central catheter that had been removed 2 months prior, consistent with fibrin sheath-associated endovascular infection. The bacteraemia cleared and clinical improvement was seen with prolonged intravenous vancomycin. In patients with unexplained bacteraemia and history of a central catheter, rare causes of endovascular infections of right-sided heart structures like fibrin sheaths should be considered. These can persist months after catheter removal. Transoesophageal echocardiogram should be used for earlier detection.