Current Admission Research Articles

P1733 Late onset of arrhytmogenic cardiomyopathy, unmasked by myocarditis - when multimodality imaging solves the puzzle

Abstract Introduction Arrhythmogenic cardiomyopathy (AC) is a genetic disease, associated with arrhythmic sudden death in young people. Since inflammation might be also present, differential diagnosis with myocarditis is necessary. We present a challenging case, initially diagnosed with ventricular tachycardia (VT) and acute myocardial infarction (AMI), in which multimodality imaging changed the initial diagnosis. Clinical case. A 68-year old woman with dyslipidaemia and hypertension was admitted with chest pain, negative T waves in anterior leads, epsilon wave in V1, V2 (Fig. A, B), negative troponin I (TpI), and elevated NT-proBNP (342 ng/ml). One month before, she was hospitalized for a monomorphic VT with left bundle branch block (LBBB) pattern, with hemodynamic instability, cardioverted electrically to sinus rhythm. Increased TpI suggested an AMI. She recalls an episode of flu with high fever (39°C) before admission. At current admission, transthoracic echo (TTE) revealed LVEF 52%, severe lateral wall hypokinesia, severe RV dysfunction with fractional area change 23%, and TAPSE 15 mm. Coronary angiography excluded significant lesions. Speckle tracking echo(STE) revealed patchy areas of decreased LV myocardial deformation (Fig. C), and decreased basal deformation in RV free wall(Fig. D). Cardiac magnetic resonance (CMR) revealed LVEF 59%, lateral and septal wall hypokinesia, late gadolinium enhancement (LGE) in mid-ventricular lateral wall and interventricular septum (Fig. F), with correspondent increased extracellular volume (ECV) >30%, increased native T1 time, increased T2 mapping, and small pericardial effusion (7 mm); RV was dilated (diastolic volume 107 ml/m2 and systolic volume 69 ml/m2), with severely decreased RV ejection fraction (RVEF) of 35%, hypokinesia of free wall, dyssynchronous contractions, and microaneurysms (Fig. E, F). Diagnosis was concluded for AC with delayed onset, revealed by an acute myocarditis. Betablocker, ACEI, and implantable cardioverter defibrillator (ICD) in secondary prevention were decided. Relatives were screened for the presence of AC. Patient`s daughter presented 8000 isolated monomorphic ventricular ectopic heart beats with LV origin, no echo signs, but incipient signs of AC on CMR (increased ECV on T1 mapping in 7 LV myocardial segments, without LGE). Discussion We presented a rare case of late arrhythmic onset of AC in a patient, in which the first aetiology of VT was considered to be ischaemic. VT with LBBB morphology can be caused by myocarditis, AMI, or AC. Similarly, epsilon wave with negative T waves in precordial leads may have multiple aetiologies. In our case, multimodality imaging approach excluded AMI and suggested an inflammatory cause for VT. CMR allowed the identification of morphologic condition AC and the trigger condition of myocarditis. Conclusions Our case highlights the importance of a multimodality imaging approach in diagnosing AC and myocarditis, for a correct and complete management. Abstract P1733 Figure.

Predictive Validity of Saudi Admission Criteria for Freshmen Students’ English Performance: Experience of King Saud Bin Abdulaziz University for Health Sciences

This study examines the relationship and correlation between initial admission criteria and English performance of first year students at King Saud bin Abdulaziz University for Health Sciences. The performance of 1,595 English language students was compared to the initial academic admission criteria to determine if a correlation exists between academic achievement pre and post admission. Admission criteria include high school grades, General Aptitude Test score (GAT), and Scholastic Achievement Admission Test scores (SAAT). Deep statistical analyses, including independent t tests and multiple linear regression reveal a correlation between pre and post admission performance. For this student population, GAT score was more predictive of English performance than SAAT scores, while the high school grade had no significant relationship to performance on the course. Furthermore, GAT had a higher predictive weight of 7% when compared individually with other admission criteria. However, in a combined model, all of the admission tests cumulatively predicted 17.3% of English performance. Such power is relatively low and requires additional variables to accurately predict a student’s final English score. This study provides unique analyses of performance within the Saudi higher education system and provides insight for those teaching or studying English as a second language. This study is therefore relevant for educators in universities using English for the instruction of non-English, native students and raises questions as to the value of current admission criteria.

GATE: Graph-Attention Augmented Temporal Neural Network for Medication Recommendation

Medication recommendation based on Electronic Health Records (EHRs) is an important research direction, which aims to make prescription recommendations according to EHRs of patients. Most existing methods either only make recommendation through EHRs of the current admission while ignoring the patient's historical records, or fail to fully consider the correlations among the clinical events from every single admission. These methods have shown their limitations in dealing with the complex structural correlations and temporal dependencies of clinical events in EHRs, which results in the defect of recommendation quality as well as the lack of temporal prediction ability. For that, a novel graph-attention augmented temporal neural network is proposed to model both the structural and temporal information simultaneously. For each admission record, a co-occurrence graph is constructed to establish the correlations among clinical events, and then a graph-attention augmented mechanism is used to learn the structural correlations on the graphs to obtain better representation of this admission. Then a temporal updating module based on the gated recurrent units is further proposed to learn the temporal dependencies between multiple admissions of each patient. Furthermore, our proposed model is also constrained by the co-occurrence graph, which can capture the internal correlations of clinical events and provide better modeling capability when the training data is sparse. Experiments illustrate that our model is superior to the state-of-the-art methods on a real-world dataset MIMIC-III in all effectiveness measures.

Do elderly trauma patients receive the required treatment? Epidemiology and outcome of geriatric trauma patients treated at different levels of trauma care.

In an ageing society, geriatric trauma displays an increasing challenge in trauma care. Due to comorbidities and reduced physiologic reserves, these patients might benefit from an immediate specialised care. The current study aims to clarify the prevalence and outcome of geriatric trauma depending on the level of the primary trauma centre. Data sets of 124,641 patients entered in the TR-DGU between 2009 and 2016 were included. Geriatric trauma was defined above 65years and ISS ≥ 9. Analysing the prevalence, the age structure of all trauma cases registered in 2014 was compared to demographic data of the German Federal Statistical Office. Differences in injury pattern, in-hospital care and outcome between the primary levels of care were analysed. In comparison to their share of population, geriatric patients are highly overrepresented in the TR-DGU. Despite minor injury mechanisms, severe head injuries are common. A tendency to under-triage can be observed, as level II and III trauma centres receive a higher percentage of older patients. Nevertheless, there is no effect on the mortality. 10% of these patients require an early transfer to a higher levelled trauma centres mainly due to severe head and spine injuries. Surprisingly, pre-clinical available signs such as GCS or blood pressure were not altered in these patients. Patients above the age of 65years represent a second group with high risk for traumatic injuries besides younger adults. Despite low-energy trauma mechanisms, these patients are prone to suffer from severe injuries, which require specialised care. Current admission practice appears adequate, as pre-clinical available symptoms did not correlate with injuries that demanded an early inter-hospital transfer. Specialised geriatric triage scores might further improve admission practice.

A Study on the Recognition of College Admission System

본 연구는 입학자원 확보에 어려움을 겪고 있는 전문대학 입학제도의 문제점을 확인하고 입시 환경 변화에 효과적으로 대응할 수 있도록 전문대학의 입학제도를 개선하기 위한 연구이다. 연구의 목적을 달성하기 위해 전국 전문대학 입학관계자 및 교원, 고교교사를 대상으로 설문조사를 진행하였고, 대학별 입학관계자 및 교수 205명의 응답 자료를 분석하였다. 또 입학관련 업무 경력이 있는 대학 관계자 5명과 고교교사 5명을 권역을 고려하여 선정하여 심층면담을 진행하였다. 이를 통해 현재 전문대학 입학제도의 문제점과 일반대학 및 기타 고등교육기관과의 차별화된 전문대학 입학제도 마련의 필요성을 확인하였다. 구체적으로 전문대학 입학자원 확보를 위해 필요한 노력 및 미래사회를 대비한 전문대학 입학제도 개선방안을 위한 구체적인 모집시기의 변화, 모집대상의 구분, 모집방법은 어떻게 바뀌어야 하는지에 대한 연구결과를 제시하였다. 본 연구를 통해 전문대학 입학제도뿐만 아니라 교육과 취업의 선순환 구조가 효과적으로 작동하여, 지역사회와 산업계, 전문대학이 함께 상생할 수 있는 의미 있는 방안을 제안하였다.This research aims to suggest specific plans to improve the Korean College Admission System, which has been plagued with problems related to securing reduced student related enrollment resources, by identifying issues within the college admission system and policy responses from government. To achieve this aim, we conducted a survey of a group of admission officials, professors, and high school teachers and analyzed the data. In total, 108 admission officials and 205 professors on 75 colleges (55.1%) responded. We also considered regional colleges and high schools by interviewing five officials related to college admissions and five high school teachers. We recognized issues within the current college admission system and the necessity of preparing specific differentiated admission plans not just for university or other higher education institute but also for colleges. Furthermore, for securing reduced college enrollment resources, we suggested through our research results how a shift in the application periods, a classification of application targets, and a method of application could be changed. Through this research, we seek effective solutions to overcome the college admission crisis and create a virtuous circle of education and employment that make a mutual growth of the community, the industry and the colleges.

Predicting Carbapenem-Resistant Enterobacteriaceae Carriage at the Time of Admission Using a Statewide Hospital Discharge Database.

BackgroundTimely identification of patients likely to harbor carbapenem-resistant Enterobacteriaceae (CRE) can help health care facilities provide effective infection control and treatment. We evaluated whether a model utilizing prior health care information from a state hospital discharge database could predict a patient’s probability of CRE colonization at the time of hospital admission.MethodsWe performed a case–control study using the Illinois hospital discharge database. From a 2014–2015 patient cohort, we defined cases as index adult patient hospital encounters with a positive CRE culture collected within the first 3 days of hospitalization, as reported to the Illinois XDRO registry; controls were all patient admissions from the same hospital and month. We split the data into training (~60%) and validation (~40%) sets and developed a logistic regression model to estimate coefficients for predictors of interest.ResultsWe identified 486 index cases and 340 005 controls. Independent risk factors for CRE at the time of admission were age, number of short-term acute care hospital (STACH) hospitalizations in the prior 365 days, mean STACH length of stay, number of long-term acute care hospital (LTACH) hospitalizations in the prior 365 days, mean LTACH length of stay, current admission to LTACH, and prior hospital admission with an infection diagnosis code. When applying the model to the validation data set, the area under the receiver operating characteristic curve was 0.84.ConclusionsA prediction model utilizing prior health care exposure information could discriminate patients who were likely to harbor CRE at the time of hospital admission.

2348 A Rare Case of Biktarvy-Induced HBV Flare

INTRODUCTION: Exacerbation of chronic hepatitis B virus (HBV) is defined as an acute rise in alanine aminotransferase (ALT) more than five times the upper limit of normal. Flare-ups of chronic HBV and human immunodeficiency virus (HIV) coinfection receiving antiretroviral therapy is seldom due to discontinuation or initiation of emtricitabine treatment. Here, we present a rare case of reinitiation of Biktarvy causing HBV flare. CASE DESCRIPTION/METHODS: A 53-year-old male presented to the emergency department from infectious disease clinic for worsening transaminitis, nausea and right upper quadrant (RUQ) pain for two days. Patient did not report any alcohol, supplement or acetaminophen use. Past medical history is significant for HIV and chronic HBV. He had been non-adherent to Biktarvy (bictegravir, emtricitabine, tenofovir alafenamide) for months and was restarted on the medication three weeks prior to presentation. His vitals were within normal limits. Physical examination revealed RUQ tenderness. Complete blood count showed platelet count of 137K. Coagulation study, basic metabolic panel, lipase were within normal limits. HBV Viral load: 7,126,237, HIV Viral load: undetectable, aspartate aminotransferase (AST): 599, ALT: >680. Hepatitis panel showed immunity to Hepatitis A, Hepatitis C: negative, HBV surface antigen: positive, HBV core IgM: positive and no seroconversion of Hep Be antigen to antibody. All viral serologies, HIV, HBV status and transaminases listed in Tables 1 and 2 from former and current admission. Autoimmune and hereditary conditions work up done during current admission were negative (Table 3). RUQ ultrasound was unremarkable. Patient was seen in clinic two weeks later and reported adherence with Biktarvy. Liver enzymes continued to trend down and his symptoms of nausea and RUQ pain subsided. DISCUSSION: Emtricitabine is one of the components of HIV regimen of Biktarvy. Treatment flares due to emtricitabine arise only in 5-10% of patients and are usually asymptomatic. Our patient had symptomatic hepatotoxicity after restarting Biktarvy over the span of three weeks. Hepatotoxicity could be due to the variations of viral replication activating immune responses. Even though the flare ups of chronic HBV can be due to initiation of emtricitabine, it is recommended to continue the agent and monitor for down trending pattern of aminotransferases which was depicted in our case.

2465 A-DRESS-ing the Big Picture: Liver Injury as Evidence of DRESS Syndrome

INTRODUCTION: Drug reaction with eosinophilia and systemic symptoms syndrome is a rare and potentially life-threatening form of drug hypersensitivity which can be difficult to diagnose due to its long latency period and nonspecific symptoms. We present a case of a woman diagnosed with DRESS after a gastroenterology consult for elevated LFTs. CASE DESCRIPTION/METHODS: A 60-year-old female with a complex past medical history including polysubstance abuse presented to the hospital with fever, diffuse body rash, shortness of breath and altered mental state. Four weeks prior to her admission, the patient was hospitalized for alcohol withdrawal. An EEG at that time showed status epilepticus and she was placed on phenytoin and levetiracetam, then discharged. On the current admission, the patient was afebrile, tachycardic, tachypneic, hypotensive. The patient was on a ventilator, diffusely tender to palpation of her abdomen, and had a diffuse brawny rash. Her labs showed an elevated leukocyte count of 27.7 K/mm3 with 30% eosinophils and elevated ALP of 206 IU/L. CXR showed left basilar consolidation, consistent of pneumonia. She was started on antibiotics, but was suspected to have an adverse drug reaction. Few days later her LFTs worsened. ALP went up to 1315 IU/L, AST 294 U/L, ALT 260 U/L, but bilirubin was normal. Further workup to rule out other causes of liver injury, including an acute hepatitis panel, ANA, AMA, and ASMA were all negative. RUQ ultrasound and CT scan of the abdomen were unrevealing. ALP levels continued to increase to 1673 IU/L and WBC peaked at 60 K/mm3 with 50% eosinophilia. DRESS was suspected secondary to anticonvulsants started from prior hospitalizations. Phenytoin and levetiracetam were discontinued and changed to zonisamide. She was closely monitored in the hospital for several weeks. Her pulmonary function, leukocytosis, eosinophilia, and LFTs improved and she was discharged to a nursing facility where she fully recovered. DISCUSSION: DRESS syndrome is a severe form of drug hypersensitivity that involves the skin and often other visceral organs. Although our patient had many typical findings of DRESS, including fever, rash, abnormal LFTs, leukocytosis, and eosinophilia, diagnosis was challenging due to the patient's multiple comorbidities and prior hospital admissions initially overlooked. As treatment hinges on cessation of the culprit agent, it is essential to get a complete history and evaluate the patient as a whole to avoid missing this potentially life-threatening condition.

1345 Pancreatic Pseudocyst Leading to Gastric Outlet Obstruction: A Hard Diagnosis to Swallow

INTRODUCTION: Recurrent pancreatitis with pseudocyst can present with gastric outlet obstruction. Endoscopic evaluation should be utilized in certain contexts, especially to exclude more sinister causes of this presentation. CASE DESCRIPTION/METHODS: A 43-year-old woman with a history of alcohol use disorder presented with a gastric outlet obstruction. This was felt secondary to a pancreatic pseudocyst given multiple episodes of recurrent pancreatitis, the last being 1 week prior to her current admission. On presentation, physical exam was significant for ascites and epigastric tenderness. Labs were notable for AST 214 U/L, ALT 99 U/L, alkaline phosphatase 147 U/L, lipase of 203 U/L, and negatives serum alcohol. Notably, Ca 19-9 was elevated to 154 IU/mL during admission 2 weeks prior. Computed tomography chest and abdomen revealed bilateral pleural effusions, pseudocyst, and abdominal ascites. A thoracentesis and paracentesis were performed with cytology for both peritoneal fluid and pleural fluid confirming metastatic adenocarcinoma. Given her refractory symptoms, an esophagogastroduodenoscopy (EGD) was performed which showed an obstructing tumor at the gastric outlet with biopsies revealing poorly differentiated gastric adenocarcinoma. A gastric stent was placed; however, she had continued nausea and vomiting. Repeat EGD showed gastric stent failure and subsequent endoscopic gastrojejunostomy with Axios stent was placed. The patient's functional status declined rapidly as a result of her advanced malignancy and on hospital day 8 she suffered a cardiac arrest, passing shortly after being transitioned to comfort cares. DISCUSSION: The patient's prior history of alcohol use disorder, recurrent pancreatitis, and imaging consistent with pancreatic pseudocyst made this case prone to numerous cognitive errors initially obscuring the etiology of her gastric outlet obstruction and pancreatitis. By reframing the presentation, we were able to question pancreatic pseudocyst as the sole source of the gastric outlet obstruction. Traditionally, Ca 19-9 is associated with pancreatic adenocarcinoma. It also can be elevated in the setting of other gastric malignancies and acute pancreatitis. In pancreatitis, absolute value and trends of Ca 19-9 can help differentiate between pancreatitis and malignancy. The diagnostic uncertainty around this patient's presentation with recurrent pancreatitis, pseudocyst, and gastric outlet obstruction required endoscopic evaluation to ultimately diagnose metastatic gastric adenocarcinoma.

294 Emergency Department Patients Who Smoke Have Higher Admission Rates Than Non-Smokers

Smoking is a known risk factor for poor health outcomes. We hypothesized smoking would result in an increased admission rate from the emergency department (ED). Our goal was to determine the magnitude of the difference in admission rates from the ED for smokers versus nonsmokers. Design retrospective cohort. Setting: Suburban community teaching hospital with annual visits of 90,000. Population: Consecutive ED patients from 40 to 70 years of age for the period 6-1-18 to 4-9-19. While the adverse effects from cigarette use and the age at which adverse health outcomes first appear varies, we a priori chose to examine the age group > 40 years of age. We also excluded patients greater than 70 years because other comorbidities may play a larger role. Trauma patients were also excluded as their smoking status is unlikely to influence the admission decision. Protocol: We obtained the current smoking and admission status from the electronic medical record. We calculated the admission rates for smokers and non-smokers and the relative change along with the 95% confidence interval (CI). Of the 28,894 patients who met our exclusion criteria, 18% were smokers. The average age of smokers and nonsmokers was 56 years. Females comprised 50% of the total patients. The percent of smokers in females and males was 15% and 22% respectively. The admission rate for smokers and nonsmokers was 61% and 45% respectively a relative increase of 37% (95% CI: 34% to 41%, p < 0.0001). We found a marked increase in admission rates in smokers compared to nonsmokers. To our knowledge this is the first report of an association between smoking and admission rates of ED patients who smoke. Modifiable lifestyle choices such as smoking should be addressed when counseling ED patients who smoke.

3198 An Unusual Case of Severe Hypertriglyceridemia in an Alcohol Naïve Patient

INTRODUCTION: Hypertriglyceridemia (HT) is a metabolic disorder due to an altered synthesis of lipoproteins. Although HT is often asymptomatic, acute cases can result in pancreatitis and chronic elevations of HT can lead to the development of atherosclerotic disease. HT is most commonly caused by obesity, diabetes mellitus and excess alcohol intake. Alcohol-induced HT is due to increased very-low-density lipoprotein secretion and impaired lipolysis. Previous research has shown an association of severe HT with chronic alcohol use. Here, we present an unusual case of new onset severe HT in a patient who recently began drinking alcohol. CASE DESCRIPTION/METHODS: A 42 year old female with a history of anxiety presented to the hospital with a primary complaint of suicidal ideation. Patient was subsequently admitted to psychiatric inpatient ward and medical team was consulted after labs revealed triglyceride level of 3930. Patient was questioned about recent travel, recent drug use, and recent medication use and patient's answers were noted to be unremarkable for any concerning history in relation to her HT. She does admit to moderate alcohol use for the first time as an adult during the last week and her alcohol level on admission was slightly elevated at 45. Patient's vitals were reviewed and noted to be within normal limits and patient's laboratory values were also noted to be within normal limits including her CBC, CMP, urine drug screen and chest x-ray. Additionally, triglyceride levels obtained on prior visits have ranged from the 40's to the 120's with the most recent level one year prior to current admission being 47. CT abdomen and pelvis showed no signs of acute intra abdominal pathology. At time of exam, patient was resting comfortably in bed and her only complaint was anxiety. Patient's triglyceride level returned to normal during hospital stay after treatment with insulin and gemfibrozil. DISCUSSION: One of the most common causes of HT in the United States is alcohol abuse. More specifically, previous research has shown severe HT developing as a consequence of chronic alcohol use. This case highlights severe HT in a patient who is alcohol naïve and had previous normal triglyceride values. Additionally, her moderate consumption of alcohol during the previous week would not explain such high values of triglycerides. More research is needed to clearly identify the risk of severe HT in a patient who has limited history in drinking alcohol.

3032 Acute Presentation of Undiagnosed Pancreatic Cancer With Fatal Prognosis

INTRODUCTION: Most common presentation of pancreatic cancer are abdominal pain, weight loss and jaundice. However, these symptoms manifest mostly with advance disease and are non-specific making the early diagnosis difficult. Consequences of missing diagnosis can be fatal leading to metastatic disease and decease life expectancy. We came across similar case with obstructive jaundice and had pancreatic mass with life span of 2 months after diagnosis. CASE DESCRIPTION/METHODS: 69 years old male was admitted for a mechanical fall. His past medical history included CAD, chronic pancreatitis, and diabetes mellitus. He reported 6 days history of pale stools and dark urine which resolved 2 days prior to presentation but had some associated chronic abdominal pain with 50 lb unexplained weight loss over past 6 months. On examination, he was found to have scleral icterus and jaundiced skin. On blood work, he was noted to have AST 242, ALT 477, ALP 508, and bilirubin 13.0 and direct bilirubin of 10.4. All values were normal one month prior to current admission. Abdominal ultrasound showed dilated CBD to 15 mm, intrahepatic ducts and a distended gallbladder without stones. He underwent MRCP and was found to have dilated CBD with 13 mm diameter, intrahepatic biliary ducts, and distended gall bladder with abrupt cut off of the distal CBD. There is also dilatation of pancreatic duct measuring up to 11 mm with a cut off of the proximal pancreatic duct by a large amorphous mass. ERCP was done, but wire passage in CBD was restricted by possible tumor which lead to limitations like lack of biopsy and stent placement. PET CT showed fullness in pancreatic head with increased FDG uptake. He underwent cholecysto-gastrostomy for internal biliary decompression and was noted to have distended gallbladder, and fibrotic pancreas with no pancreatic mass. Bilirubin dropped the surgery. Patient refused invasive procedures afterwards for tissue diagnosis of cancer. He died 2 months after surgery. DISCUSSION: Pancreatic cancer is fourth leading cause of cancer related deaths in United States. Incidence increases after the age of 45 with more male to female ratio 1.3:1. USPSTF found no evidence of improved mortality with screening in asymptomatic patients. Surgical resection is only curative with less role among patients with late presentation emphasizing the importance of early diagnosis. Physician should have high suspicion among patients with risk factors to avoid deadly complications.

Case 273.

HistoryA 55-year-old man with a history of chronic pancreatitis secondary to chronic alcohol abuse presented to the hospital with acute abdominal pain, generalized weakness, weight loss, and pyrexia. A clinical examination revealed he was tender to touch in the upper abdomen. Laboratory tests revealed a serum alkaline phosphatase level of 370 U/L (6.1 µkat/L) (normal range, 30-130 U/L [0.5-2.2 µkat/L]), a lipase level of 172 U/L (2.9 µkat/L) (normal range, 0-60 U/L [0-1.0 µkat/L]), a C-reactive protein level of 159 mg/L (1514 nmol/L) (normal value, <8.0 mg/L [76.2 nmol/L]), and a white cell count of 7 × 109/L (normal range, [4-11] × 109/L). During the present admission, the patient underwent urgent CT for his acute symptoms. His relevant medical history included a hospital admission 2 months earlier for abdominal discomfort. Given his history of chronic pancreatitis, baseline abdominal MRI was performed to determine the cause of his symptoms and to assess the pancreas (Figs 1-3).Figure 1a:(a, b) Images from axial fat-suppressed T2-weighted MRI (repetition time msec/echo time msec, 1000/87; section thickness, 6 mm) of the upper abdomen obtained 2 months prior to admission. (c, d) Images from axial fat-suppressed T1-weighted MRI (3.69/1.62; section thickness, 4 mm) of the upper abdomen acquired 60 seconds after intravenous administration of gadopentetate dimeglumine (0.1 mL per kilogram of body weight; Magnevist; Bayer Healthcare, East Mississauga, Ontario) during the current admission.Figure 1b:(a, b) Images from axial fat-suppressed T2-weighted MRI (repetition time msec/echo time msec, 1000/87; section thickness, 6 mm) of the upper abdomen obtained 2 months prior to admission. (c, d) Images from axial fat-suppressed T1-weighted MRI (3.69/1.62; section thickness, 4 mm) of the upper abdomen acquired 60 seconds after intravenous administration of gadopentetate dimeglumine (0.1 mL per kilogram of body weight; Magnevist; Bayer Healthcare, East Mississauga, Ontario) during the current admission.Figure 1c:(a, b) Images from axial fat-suppressed T2-weighted MRI (repetition time msec/echo time msec, 1000/87; section thickness, 6 mm) of the upper abdomen obtained 2 months prior to admission. (c, d) Images from axial fat-suppressed T1-weighted MRI (3.69/1.62; section thickness, 4 mm) of the upper abdomen acquired 60 seconds after intravenous administration of gadopentetate dimeglumine (0.1 mL per kilogram of body weight; Magnevist; Bayer Healthcare, East Mississauga, Ontario) during the current admission.Figure 1d:(a, b) Images from axial fat-suppressed T2-weighted MRI (repetition time msec/echo time msec, 1000/87; section thickness, 6 mm) of the upper abdomen obtained 2 months prior to admission. (c, d) Images from axial fat-suppressed T1-weighted MRI (3.69/1.62; section thickness, 4 mm) of the upper abdomen acquired 60 seconds after intravenous administration of gadopentetate dimeglumine (0.1 mL per kilogram of body weight; Magnevist; Bayer Healthcare, East Mississauga, Ontario) during the current admission.Figure 2:Coronal T2-weighted MRI (repetition time msec/echo time msec, 1000/89; section thickness, 4 mm) of the upper abdomen obtained 2 months prior to admission.Figure 3:Coronal CT image of the abdomen acquired 60 seconds after administration of intravenous contrast material (100 mL of iohexol, Omnipaque 350; GE Healthcare, Princeton, NJ). This CT examination was performed during the current admission.

Endovascular management of life threatening bleeding from a radiation induced internal iliac artery branch pseudoaneurysm

BackgroundAmong radiation induced arterial complications, stenoses and occlusions are commonly reported. Radiation induced pseudoaneurysms (PSA) and their management outcomes are rarely reported.Case presentationA 48 year old male underwent low anterior resection surgery for a clinically staged T2N0M0 rectal adenocarcinoma and adjuvant chemoradiation for the findings of lymphovascular invasion and focally positive distal margin 2 years prior to current admission. The patient now presented with syncope and anemia. The patient was hypotensive after an episode of hematochezia during the hospital stay. An urgent sigmoidoscopy revealed bleeding from friable necrotic rectal mucosa with focal pulsations along the left posterolateral aspect of the rectal wall. An emergent pelvic angiogram revealed active extravasation from a 3 mm PSA from the anterior division of left internal iliac artery. After coil embolization of the affected vascular branch on either side of the neck of PSA, there was no opacification of PSA or extravasation. The patient remained asymptomatic for 3 years.ConclusionsRadiation induced PSA must be considered in the absence of trauma. Endovascular coil-embolization of radiation induced PSAs from small caliber vessels can be an effective treatment.

Prevalence and Risk Factors of Hypoxemia after Coronary Artery Bypass Grafting: The Time to Change Our Conceptions

Background: Acute hypoxemia is the main characteristic of acute respiratory distress syndrome (ARDS), which is one of the most critical complications of coronary artery bypass grafting (CABG). Given the dearth of data on acute hypoxemia, we sought to determine its prevalence and risk factors among post-CABG patients. Methods: This cross-sectional study was conducted on on-pump CABG patients in Tehran Heart Center in 2 consecutive months in 2012. The effects of arterial blood gas variables, age, gender, the duration of the pump and cross-clamping, the ejection fraction, the creatinine level, and the body mass index on the prevalence of hypoxemia at the cutoff points of ARDS and acute lung injury were assessed. Results: Out of a total of 232 patients who remained in the study, 174 (75.0%) cases were male. The mean age was 60.60±9.42 years, and the mean body mass index was 27.15±3.93 kg/m2. None of the patients expired during the current admission. Theratioof partial pressure arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) 1 hour after admission to the intensive care unit (ICU), before extubation, and at 4 hours after extubation was less than 300 mmHg in 66.6%, 72.2%, and 86.6% of the patients and less than 200 mmHg in 20.8% 17.7%, and 30.2% of the patients, respectively. Among the different variables, only a heavier weight was associated with a PaO2/FiO2 ratio of less than 300 mmHg at 1 hour after ICU admission and at 4 hours after extubation (P=0.001). A rise in the cross-clamp time showed a significant association with the risk of a PaO2/FiO2 ratio of less than 200 mmHg at 4 hours after extubation (P=0.014). Conclusion: This study shows that hypoxemia following CABG is very common in the first 48 postoperative hours, although it is a benign and transient event. The high prevalence may affect the accuracy of the ARDS criteria and their positive or negative predictive value.

Over-admission and over-treatment of patients with cellulitis: a 5-year audit against international guidelines.

Application of evidence-based guidelines in the management of cellulitis is poorly studied in Ireland and it is observed that current admission and prescription practices in this country vary widely from internationally accepted standards of care. We aimed to examine the management of cellulitis with regard to hospital admission and initial antibiotic therapy. A retrospective audit of patients admitted with cellulitis from 2013 to 2017 in an Irish district general hospital. Exclusion criteria included specialist regions of the body and surgical site infections. Appropriateness of admission and management was compared against international guidelines (Clinical Research Efficiency Support Team (CREST) and Infectious Disease Society of America (IDSA)). Five hundred twenty emergency admissions with cellulitis were analysed. Thirty-five percent (n = 182) were deemed inappropriate admissions compared with CREST and IDSA guidelines, with an estimated cost of €152,203 per annum. Ninety-six percent (n = 501) of patients with cellulitis were treated with a combination of flucloxacillin and benzylpenicillin, despite level 1 evidence showing combination therapy to provide no benefit over appropriate monotherapy. There is a significant discrepancy between current clinical practice and international guidelines for the management of cellulitis in Ireland; local guidelines are not in keeping with newer evidence and there is a lack of national guidelines for this common condition. Closer adherence to international guidelines would significantly reduce costs by reducing unnecessary admissions and initial monotherapy would improve antibiotic stewardship. This study shows a clear need for local institutions to re-examine antibiotic guidelines to ensure the HSE provides effective evidence-based treatment in the correct setting.

An interactive nomogram to predict healthcare-associated infections in ICU patients: A multicenter study in GuiZhou Province, China.

ObjectiveTo develop and validate an interactive nomogram to predict healthcare-associated infections (HCAIs) in the intensive care unit (ICU).MethodsA multicenter retrospective study was conducted to review 2017 data from six hospitals in Guizhou Province, China. A total of 1,782 ICU inpatients were divided into either a training set (n = 1,189) or a validation set (n = 593). The patients’ demographic characteristics, basic clinical features from the previous admission, and their need for bacterial culture during the current admission were extracted from electronic medical records of the hospitals to predict HCAI. Univariate and multivariable analyses were used to identify independent risk factors of HCAI in the training set. The multivariable model’s performance was evaluated in both the training set and the validation set, and an interactive nomogram was constructed according to multivariable regression model. Moreover, the interactive nomogram was used to predict the possibility of a patient developing an HCAI based on their prior admission data. Finally, the clinical usefulness of the interactive nomogram was estimated by decision analysis using the entire dataset.ResultsThe nomogram model included factor development (local economic development levels), length of stay (LOS; days of hospital stay), fever (days of persistent fever), diabetes (history of diabetes), cancer (history of cancer) and culture (the need for bacterial culture). The model showed good calibration and discrimination in the training set [area under the curve (AUC), 0.871; 95% confidence interval (CI), 0.848–0.894] and in the validation set (AUC, 0.862; 95% CI, 0.829–0.895). The decision curve demonstrated the clinical usefulness of our interactive nomogram.ConclusionsThe developed interactive nomogram is a simple and practical instrument for quantifying the individual risk of HCAI and promptly identifying high-risk patients.

Factors considered by patients in provider selection for elective specialty surgery: A questionnaire-based survey.

This study was designed to comprehensively evaluate the factors considered by patients in provider selection for elective specialty surgery. A total of 200 patients (mean age 44.4 (range, 18.0-70.0) years, 51.0% were males), who were admitted to a tertiary care center for an elective surgery, participated on a voluntary basis in this cross-sectional questionnaire survey. The questionnaire form elicited items on sociodemographic characteristics of patients, characteristics of operation, factors contributing to physician selection by patients (physician-related factors, healthcare service/access related factors) and patients' view on factors contributing to physician selection. Amongst the physician-related factors, attitude of physician (all items considered very important by majority of patients) was the factor most significantly contributed to physician selection as followed by reputation (recommendation of physician by former patients considered very important by 58.5%) or professional experience (presence of subspecialty certificate in surgery considered very important by 67.5%) and social media presence of the physician (comments and ratings of users about the physician considered very important by 26.5% of patients) of the physician. Patients considered hospital hygiene (75.5%) as the most significant healthcare service/access related factor in physician selection. Physician selection was considered to be of utmost importance in the treatment outcome by 95.5% of patients, while getting information about the physician before contacting her/him was considered important and actually performed for the current admission by 74% of patients. In conclusion, our findings revealed that communicative skills of the physician, presence of subspecialty certificate in surgery, recommendations by former patients and comments and ratings of users were the leading factors contributed to physician selection by patients; being related to attitude, professional experience, reputation and social media presence of the physician, respectively. Hospital hygiene was the most significant healthcare service/access related factor contributed to physician selection.

A prospective study of severity of complications associated with use of misoprostol and other abortion methods in South West Nigeria.

To assess the severity of complications following misoprostol used to induce abortion compared with other methods among women admitted for postabortion complications. A cross-sectional study of women who presented with complications of induced abortion at nine secondary and tertiary hospitals in South West Nigeria between April 1, 2013 and May 31, 2014. Face-to-face interviews were conducted and information on the current admission was extracted from patient records. Associations between abortion method used and severity of abortion complications were evaluated using χ2 and Fisher exact tests. Of 522 women included in the study, 177 reported an induced abortion: 41 women (23.2%) had used misoprostol at the first attempt to induce abortion, whereas 79 (44.6%) women had undergone surgical abortion. Occurrence of fever (P=0.06), bleeding (P=0.3), and lower abdominal pain (P=0.32) was not significantly different between the misoprostol and surgical abortion/other methods groups. Severe complications were rare with misoprostol, but more common among women in the surgical abortion/other methods group. Maternal mortality occurred only among women in the surgical abortion/other methods group. Use of misoprostol for induced abortion was associated with fewer complications and no maternal mortality compared with surgical abortion/other methods.

Simulated co-location of patients admitted to an inpatient internal medicine teaching unit: potential impacts on efficiency and physician-nurse collaboration

Effective communication between nurses and physician teams on the internal medicine unit is crucial for high quality, safe, and efficient patient care. In our hospital of interest, a large academic health sciences centre, the physical layout of the unit, current admission process, and the presence of three separate physician teams contribute to uneven workload and communication barriers. We address this by physically co-locating each physician teams’ patients so as to facilitate physician-nurse collaboration, and more evenly distribute workload across all three teams. Based upon one year of real-world data, we developed a simulation model of inpatient flow through the internal medicine unit and determined the impact of two proposed changes: co-locating each team’s patients, and new admission rules for how patients are assigned to those teams. Under the new arrangement, each physician team would interact with roughly half the number of nurses, and nurses in turn would have fewer individual team members with whom to communicate, thereby improving effective communication and increasing time for direct patient care for both physicians and nurses.