Outpatient Biopsy Research Articles

Dehydration Secondary to Acute Olmesartan Associated Enteropathy with Concomitant Lymphocytic Colitis

Introduction: Olmesartan is an angiotensin II receptor blocker recently described to cause a spruelike enteropathy. Duodenal biopsies are identical to those of Celiac disease (CD), however the patient will be negative for transglutaminase. Unlike Olmesartan associated enteropathy (OAE), CD has been associated with lymphocytic colitis (LC). LC can cause significant diarrhea, although it typically does not cause dehydration. Case Report: 84-year-old Caucasian female with a past medical history of dementia and hypertension was hospitalized for diarrhea. She was noted to have an acute kidney injury (AKI) with a creatinine of 1.79 mg/dL. Her C. diff screen was positive and the patient was treated with oral vancomycin. Her AKI resolved with rehydration and she was discharged home. At home she began to have 20 liquid bowel movements daily and was taken to another local hospital. Repeat C. diff screening was negative; however, she was again treated with oral Vancomycin. She was discharged home despite still having diarrhea. Outpatient esophagogastroduodenoscopy and colonoscopy were performed for follow up evaluation. Further, she was noted to have been recently started on Olmesartan which was discontinued prior to endoscopic evaluation. Endoscopy revealed negative gross evaluation of the duodenum and biopsy revealed blunted villous architecture with increased intraepithelial lymphocytes and focal neutrophilic infiltrates. Colonic biopsies revealed lymphocytic colitis. Shortly after, the patient had altered mental status and hypotension and was sent to the emergency department. Initial vital signs were significant for temperature of 91.7 °F and a blood pressure of 72/57 mm Hg. Physical exam was unremarkable besides altered mentation. Initial bloodwork revealed an AKI with a creatinine of 7.74 mg/dL. She continued to have profound diarrhea and outpatient biopsy results were not immediately available. Repeat C. diff screening, stool cultures, Shiga toxins, and ova and parasites were checked and found to be negative. Computer tomography of the abdomen showed diverticulosis. With the duodenal biopsy results transglutaminase IgA and IgG were checked and were negative. The AKI resolved with rehydration and the diarrhea improved with budesonide. Discussion: Celiac sprue enteritis is associated with LC, OAE has not been described to be associated with it. Clinicians should suspect a concomitant process in patients with LC presenting with dehydration.

Improving the safety and tolerability of local anaesthetic outpatient transperineal prostate biopsies: A pilot study of the CAMbridge PROstate Biopsy (CAMPROBE) method.

Objectives:The aim of this study was to pilot the use of a bespoke device (CAMPROBE, the CAMbridge PROstate Biopsy) to enable routine outpatient free-hand local anaesthetic (LA) transperineal prostate biopsies.Materials and methods:The CAMPROBE prototype was designed and built in our institution. Men on active surveillance due prostate resampling were invited to have a CAMPROBE biopsy as an alternative to repeat transrectal ultrasound-guided prostate biopsies (TRUSBx) as part of an approved trial (NCT02375035). Biopsies were performed using LA infiltration only, without sedation or additional analgesia. Patient-reported outcomes were recorded at day 0 and 7 using validated questionnaires and visual analogue scales (VAS). Complications were recorded prospectively.Results:Thirty men underwent biopsies with a median of 11 cores taken per procedure (interquartile range 10–12). There were no infections, sepsis or retention episodes. Haematuria and haematospermia occurred in 67% and 62% of patients, which are similar to rates reported for TRUSBx. Mean VAS for pain (0–10 scale) was less than 3 for every part of the procedure. All 30 men described the procedure as tolerable under LA. In total, 26/30 (86.7%) men expressed a preference for a CAMPROBE procedure over TRUSBx and a further 3 (10.0%) would have either.Conclusions:In this small pilot study, the CAMPROBE device and method appears to be a safe, simple and well-tolerated out-patient transperineal replacement for TRUSBx. A major new National Institute for Health Research grant will allow its further development from a prototype to a single use, low-cost disposable device ready for multi-centre testing.Level of evidence:1b: individual cohort study.

3:27 PM Abstract No. 114 Nationwide trends in pediatric percutaneous kidney and liver biopsies: is there a value proposition for interventional radiologists who can safely perform these procedures as outpatients?

To investigate trends, costs, relative safety, and potential savings of inpatient versus outpatient percutaneous kidney and liver biopsies in the pediatric population. Data on admission type and cost (using billed charges as a cost-surrogate) from all percutaneous kidney and liver biopsies performed from 2008-2015 was collected using the Pediatric Health Information System (PHIS), a comparative database of patient encounters from 44 US Children’s Hospitals. Regression analysis was performed to evaluate the annual trend in the biopsy patients admitted as inpatients vs outpatients. Costs were compared using the Tukey-Kramer Method (significance: p < 0.05). To assess safety of outpatient biopsies performed by interventional radiology (IR), data was collected on all percutaneous kidney and liver biopsies performed at a single, large tertiary care children’s hospital (“Hospital A”) from 2014-2017, using complications requiring escalation in care (SIR Classifications B-F) as a surrogate for safety. 7,835 kidney and 9,984 liver biopsies were performed by all specialties at all PHIS hospitals. Regression analysis showed a significant annual decline in percentage of kidney (-0.6%, p = 0.008) and liver (-3.0%, p = 0.01) biopsies. Notably, > 15% and >10% of kidney and liver biopsies were still performed as inpatients as of 2015, respectively. Costs were significantly (p < 0.0001) higher for inpatient biopsies (mean: $65,872 + $201,572 for kidney, mean: $173,331+ $505,177 for liver) vs outpatients (mean: $13,410 + $7,385 kidney, mean: $10,338+ $7,273 liver). 223 kidney biopsies and 441 liver biopsies were performed on outpatients from 2014-17 by IR at Hospital A. Percutaneous kidney biopsy complication rate = 1.3% (1 SIR class C, 2 SIR class D). Percutaneous liver biopsy complication rate = 0.2% (1 SIR Class C). A substantial percentage of pediatric patients are still admitted as inpatients for postprocedure monitoring following percutaneous kidney and liver biopsies. Our study shows that these procedures can be done safely by IRs as outpatients, offering substantial potential cost savings for healthcare systems.

Antithrombotic Therapy: Evaluation of the Safety of Performing Core Needle Biopsy of the Breast Without Suspending Medication .

Patients are increasingly presenting for outpatient breast biopsy while taking medically necessary antithrombotic therapy. Cessation of this medication prior to biopsy increases patients' risk of vascular complications. . This article evaluates the safety of performing core needle biopsies of the breast in patients without suspending prescription antithrombotic therapy. . In this retrospective chart review study, patients continued prescription antithrombotic therapy prior to and including the day of biopsy. Follow-up telephone assessment, relying on patient self-report, was completed on the same or next business day. The chart review included report of bleeding as a postprocedure complication. . None of the 42 women who completed core needle biopsy of the breast while on antithrombotic therapy reported postdischarge bleeding, and 2 reported hematoma, supporting the safety of continuing antithrombotic therapy in patients who undergo core needle biopsy of the breast.

Penile leiomyosarcoma

Introduction. Leiomyosarcoma of the penis (LSP) is an extremely rare form of penile tumor. LSP can be divided into two subtypes: deep and superficial. The goal of this manuscript is to present very rear case of LSP. Case outline. On exam, the patient presented with a slowly ?growing penile bump?, for which an initial diagnosis of non-inflamed penile atheroma was given. Further diagnostic workup was omitted. Outpatient excisional biopsy was performed, and the tumor was sent for pathohistological examina-tion (PHE), which revealed LSP. The patient has not received any further treatment. The most recent follow up was 2.5 years after surgery, and the patient continues to do well without any complications. Conclusion. LSP is an extremely rare disease which can be cured if it is diagnosed in its early stage. PHE is necessary for diagnosis of LSP.

The Case of the XPloding Liver: Cholestatic Drug-Induced Liver Injury Secondary to N.O.Xplode®

INTRO: We present a case of drug-induced liver injury (DILI) associated with N.O.Xplode®, a commonly used creatine blend pre-workout supplement. Due to the lack of stringent regulation of herbal and dietary supplements (HDS), it is important to consider DILI when treating patients with unexplained liver injury. To our knowledge, this is only the second case that can definitively be attributed to this particular supplement. CASE REPORT: A 42-year-old male with no history presented with three weeks of abdominal pain, diarrhea, weight loss, nausea, vomiting, pruritis, and jaundice. An outpatient workup found elevated liver function tests (LFTs), as well as diffuse enlargement of his liver. He was referred to our institution for further workup. On initial evaluation, he endorsed crampy upper quadrant pain worse after eating, as well as constant diarrhea and a 13-pound weight loss. Over the past week, he noticed pale, chalky stools and dark urine but no hematochezia or melena. He denied recent antibiotics, sick contacts, or travels. He admitted to rare use of Tylenol but denied any alcohol or illicit drug use. He worked out 5 days a week and used a weight-building supplement called N.O.Xplode® before each workout. He was on no other medications and had no family history of liver disease. Physical exam found scleral icterus, jaundice, and mild RUQ tenderness on palpation without hepatomegaly or shifting dullness. Laboratory data are detailed in Table 1. Workup for causes of chronic liver disease, including imaging, were negative. After clinical improvement, patient was discharged and an outpatient liver biopsy was performed. Findings were concerning for drug induced injury with no evidence of balloon degeneration, steatosis, plasma cells, fibrosis, or necrosis. The patient discontinued the supplement and was started on ursodeoxycholic acid with resolution of his symptoms.Table: Table. Laboratory dataDISCUSSION: DILI is a leading cause of acute liver failure in the US, with HDS as an increasingly common cause, accounting for more than 7% of cases. Patients on HDS have a more protracted course of liver injury. It took 5 months for our patient's hepatic function to normalize. Risk factors of idiopathic DILI are not clear. Recent data has shown that almost half of U.S. adults use some sort of dietary supplement. Therefore, it may be useful to initiate a population-based study to investigate the causes and incidence in the US, which may help in future regulation of such products.

Single dose quinolone prophylaxis for out-patient transrectal prostate biopsy: The first experience in Taiwan

ObjectiveWe retrospective reviewed the cases of transrectal prostate biopsy (TRUSPBX) at out-patient department for the relation between febrile urinary tract rate and regimen of antibiotic prophylaxis. Materials and methodsCases of TRUSPBX at out-patient department since January 2005–December 2013 were reviewed. Relevant data before biopsy was collected. ResultsTotally 689 patients with a mean age of 66 years were included for analysis. Among them, 584 cases had single dose of levofloxacin 500 mg as prophylaxis (group 1) and 105 cases had multiple doses/types of prophylactic antibiotics (group 2) were enrolled. The mean age, number of biopsy core, PSA level, total prostate volume, and cancer rate were comparable between groups. Postoperative fever occurred in 4 (0.68%) patients of group 1 and none of group 2 (p = 0.9). ConclusionSingle dose quinolone prophylaxis for out-patient transrectal prostate biopsy may be applicable in Taiwan.

Outpatient Liver Biopsy in Children: Safety, Feasibility, and Economic Impact.

Liver biopsy is a valuable tool. Even though outpatient liver biopsies are routinely performed in adults, there are no clear recommendations on its safety and feasibility in children. We reviewed the records of children who underwent a percutaneous liver biopsy at our institution between January 2005 and June 2015. A total of 626 biopsies were performed on 497 patients (250 boys, median age 6 [0.2-19.3] years). Abnormal liver function tests for investigation 288 (46%) was the most common indication. Thirty (4.8%) biopsies had complications, most common being subcapsular hematoma 14 of 30 (46.7%). Complications were identified within 8 hours of the biopsy in all patients. Approach, needle size, or number of passes did not affect the complication rate. Bleeding-related complications were not related to the international normalized ratio. Performing liver biopsies on an outpatient basis would have saved 60 beds/AU$ 80,000/year. The present study suggests that if an observation period of 8 hours is instituted, outpatient liver biopsies can be performed safely in children.

Quel est l’intérêt de l’échographie 3D et fusion d’image IRM pour la détection du cancer de la prostate ?

The strategic therapy for prostate cancer depends on histo-pronostics data, which could be upgraded by obtaining targeted biopsies (TB) with MRI (magnetic resonance imagery) fusion 3D ultrasound. To compare diagnostic yield of image fusion guided prostate biopsy using image fusion of multi-parametric MRI (mpMRI) with 3D-TRUS. Between January 2010 and April 2013, 179 consecutive patients underwent outpatient TRUS biopsy using the real-time 3D TRUS tracking system (Urostation™). These patients underwent MRI-TRUS fusion targeted biopsies (TB) with 3D volume data of the MRI elastically fused with 3D TRUS at the time of biopsy. A hundred and seventy-three patients had TBs with fusion. Mean biopsy core per patient were 11.1 (6-14) for SB and 2.4 (1-6) for TB. SBs were positive in 11% compared to 56% for TB (P<0.001). TB outperformed systematic biopsy(SB) in overall any cancer detection rate, detection of clinically significant cancer (58% vs. 36%), cancer core length (6.8mm vs. 2.8mm), and cancer rate per core (P<0.001). In multivariable logistic regression, with TB we have more chance to find a clinically significant cancer (OR:3.72 [2-6.95]). When both TRUS and MRI are positive, there is 2.73 more chance to find a clinically significant cancer. MR/TRUS elastic fusion-guided biopsies outperform systematic random biopsies in diagnosing clinically significant cancer. Ability of interpretation of real-time TRUS is essential to perform the higher level of MR/US fusion and should be use for active surveillance. 4.

Limited Post-observation Period in Pediatric Outpatient Ultrasound-Guided Liver Biopsies.

We retrospectively studied whether a limited 2 h post-biopsy observation period after a percutaneous outpatient ultrasound-guided liver biopsy is a sufficient monitoring period for children. This study is an IRB-approved retrospective cohort review of consecutive outpatient percutaneous ultrasound-guided liver biopsies from June 01, 2014, to June 30, 2016. A total of 198 biopsies in 192 patients (85 females and 113 males) underwent an outpatient ultrasound-guided liver biopsy between June 01, 2014, and June 30, 2016 (age range 3weeks-18years, mean 11.6years). Outpatient biopsies were performed with a limited patient observation time [median (IQR) observation 2.25 (0.83) h]. Adequate histopathology was obtained in 99% (197/198) of cases. Only one case was determined by a pathologist as not sufficient to render a diagnosis. 84% (166/198) of the biopsies were performed with a 16G needle, and 16% (32/198) were performed with an 18G needle. Overall, seven complications were detected (3.5% of all biopsies, 7/198) in seven patients. All complications detected were minor, 1.5% (3/198) were categorized as SIR A and 2% (4/198) as SIR B. The most common complication included pain after biopsy (4/198), followed by rash at the biopsy site (3/198). No major complications were detected in our sample. In a consecutive cohort of children, the use of a limited 2 h observation period after an ultrasound-guided percutaneous biopsy was a sufficient monitoring period for complications. Additionally, we did not observe a high proportion of patients returning for follow-up medical care after discharge due to complications.

Preoperative clinical pathway of breast cancer patients: determinants of compliance with EUSOMA quality indicators

Background:The European Society of Breast Cancer Specialists (EUSOMA) has defined quality indicators for breast cancer (BC). The aim of this study was to describe the preoperative clinical pathway of breast cancer patients and evaluate the determinants of compliance with EUSOMA quality indicators in the Optisoins01 cohort.Methods:Optisoins01 is a prospective, multicentric study. Data from operable BC patients were collected, including results from before surgery to 1 year follow-up. Seven preoperative EUSOMA quality indicators were compared with the clinical pathways Optisoins01.Results:Six hundred and four patients were included. European Society of Breast Cancer Specialists targets were reached for indicator 1 (completeness of clinical and imaging diagnostic work-up), 3 (preoperative definitive diagnosis) and 5 (waiting time). For indicator 8 (multidisciplinary discussion), the minimum standard of 90% of the patients was reached only in general hospitals and comprehensive cancer centres. Having more than 1 medical examination within the centre was associated with an increased waiting time for surgery, whereas it was reduced by having an outpatient breast biopsy. The comprehensive cancer centre type was the only parameter associated with the other quality indicators.Conclusions:European Society of Breast Cancer Specialists quality indicators are a useful tool to evaluate care organisations. This study highlights the need for a standardised and coordinated preoperative clinical pathway.

PD43-08 COMPLICATION RATES FOR OUTPATIENT,TRANSRECTAL, IN-BORE MRI-GUIDED BIOPSY: SEVEN YEARS’ EXPERIENCE

You have accessJournal of UrologyProstate Cancer: Detection & Screening VI1 Apr 2017PD43-08 COMPLICATION RATES FOR OUTPATIENT,TRANSRECTAL, IN-BORE MRI-GUIDED BIOPSY: SEVEN YEARS’ EXPERIENCE John Feller, Bernadette Greenwood, and Stuart May John FellerJohn Feller More articles by this author , Bernadette GreenwoodBernadette Greenwood More articles by this author , and Stuart MayStuart May More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1913AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The morbidity and mortality associated with TRUS biopsy has been well documented over the past three decades. Acute urinary retention, rectal bleeding, hematuria and hematospermia, uncomplicated urinary tract infection and urosepsis have all been reported at rates between 2-4%. Mortality is rare at less than 0.4%. The purpose of this study is to assess the rates of morbidity with reduced number of cores, targeted to only the tumor suspicious region under MRI-guidance in an outpatient setting. METHODS From 2009 to 2016, 3000 men received mpMRI of the prostate. Of those men, 700 underwent in-bore, MRI-guided biopsy in an outpatient setting. All MR guided biopsies were performed using a 1.5 Tesla Philips Achieva XR system (Philips Healthcare, Best, The Netherlands) for both mpMRI image acquisition and in-bore MRI-guided biopsy. DynaCAD and DynaLOC (Invivo, Orlando, FL, USA) software were used for image analysis and biopsy planning. A fully-automatic, titanium biopsy gun was inserted using the DynaTRIM positioning hardware (Invivo, Orlando, FL, USA). Two thirds of the patients undergoing mpMRI were recommended to undergo MR guided biopsy. Of those, 700 underwent MR guided in-bore biopsy. One third of the patients did not undergo prostate biopsy as a result of a negative mpMRI, reducing the number of prostate biopsies in this population. RESULTS Of the 700 men who underwent MRI-guided biopsy, only 0.8% experienced complications. Targeting the lesion and reducing the number of cores acquired may reduce morbidity associated with random, systematic biopsy. The average number of tumor suspicious regions identified on mpMRI was1.8 and the average number of core biopsies taken with each MRI-GB was 3.5 cores as opposed to the 12-18 cores taken on average with systematic TRUS Bx. The MRI-GB procedure time on average did not exceed 30 min. CONCLUSIONS In the current cost-containment environment in healthcare, any reduction in hospital admissions is welcomed. Transrectally delivered, outpatient MRI-guided biopsy may be a means to that end. Limiting the number of cores acquired by targeting biopsy only to MR-visible tumor suspicious regions results in a 0.8% complication rate in our experience. The MRI-GB procedure can be performed quickly and safely in an outpatient setting with or without conscious sedation. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e820 Advertisement Copyright & Permissions© 2017MetricsAuthor Information John Feller More articles by this author Bernadette Greenwood More articles by this author Stuart May More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Abstract No. 209 - Safety and cost-effectiveness of outpatient renal biopsy in children

Abstract No. 209 - Safety and cost-effectiveness of outpatient renal biopsy in children

Olfactory Neuroepithelial Neural Progenitor Cells from Subjects with Bipolar I Disorder.

Background:Research into the pathophysiology of bipolar disorder (BD) is limited by the inability to examine brain cellular processes in subjects with the illness.Methods:Endoscopic biopsy was performed in subjects with bipolar I disorder to establish olfactory neural progenitor (ONP) cell lines. Olfactory function was assessed prebiopsy and postbiopsy using the University of Pennsylvania Smell Identification Test (UPSIT). Cells were characterized to determine their lineage.Results:There were no significant complications associated with the biopsy procedure, including olfaction. Outpatient olfactory neuroepithelial biopsy yielded ONP cells in three out of 13 biopsy attempts (23.1%). ONPs were positive for neuron-specific proteins (β-tubulin III, nestin, hexaribonucleotide binding protein-3, and peripherin) and glia-specific proteins (glial fibrillary acidic protein and myelin basic protein).Conclusions:ONP cells can be obtained safely from awake outpatients and are potentially useful for pathophysiological studies of bipolar illness and perhaps other neuropsychiatric conditions. Such cells allow for the investigation of potential pathological cellular processes without the confounding factors of genetic manipulation, which is required for induced pluripotent cells.

Surviving a Double Whammy.

Surviving a Double Whammy.

3:09 PMAbstract No. 417 - Pediatric outpatient ultrasound-guided liver biopsies: does decreasing post-biopsy observation period time impact complication rates?

3:09 PMAbstract No. 417 - Pediatric outpatient ultrasound-guided liver biopsies: does decreasing post-biopsy observation period time impact complication rates?

Deep procedural sedation by a sedationist team for outpatient pediatric renal biopsies.

To date, no study has analyzed the use of deep PS for pediatric renal biopsies by a dedicated sedation team in an outpatient setting. Retrospective analysis of renal biopsies performed at CHOA from 2009 to 2013. Patient demographics, procedure success, and sedation-related events were analyzed. Logistic regression techniques were applied to identify characteristics associated with procedure safety and success. A total of 174 biopsies from 136 patients, aged 2-21 yr, were reviewed. Of the 174 biopsies, 63 of 174 (36%) were from native, and 111 of 174 (64%) were from transplanted kidneys, respectively. No deaths, allograft losses, or unanticipated hospital admissions occurred. The most commonly utilized interventions during sedation were blow-by oxygen (29.9%) and CPAP (12.1%). Children receiving the combination of F + P had significantly higher biopsy success rates vs. other drug combinations (96.1% vs. 79%; p = 0.014). There was no difference in complication rates regardless of drug combination or biopsy type (transplanted vs. native). The combination of F + P yields a high procedural success rate for outpatient native and transplanted kidney biopsies. We identified a number of sedation-related events that can be easily managed by a well-trained sedationist team.

A 10-year review of outpatient skin biopsy results and skin cancer subtypes

The results of skin biopsies over a 10 year period were reviewed from the outpatient dermatology clinic at the Brody School of Medicine in Greenville, North Carolina. This research was conducted because there are very few studies that characterize this information over a long-term horizon. The biopsy rate per patient encounter, the clinical reason for the biopsy, the biopsy outcomes, the distribution of cutaneous malignancies per encounter, and the distribution of the subtypes of basal cell carcinoma, squamous cell carcinoma, and melanoma were analyzed. Biopsy logs from January 1, 2001 to December 31, 2010 were reviewed. Our investigation found that 20% of patient encounters resulted in a biopsy. Of these biopsies, 87.9% were performed to rule out malignancy and 12.1% were completed on patients suspected of having inflammatory skin conditions. The basal cell carcinomas diagnosed in Greenville, NC have more aggressive histologic subtypes compared to other studies, whereas the squamous cell carcinomas and melanomas were less aggressive.

Hospitalization after transrectal biopsy of the prostate: A nationwide population-based inpatient versus outpatient comparison in Taiwan

Purpose: The complications and hospitalization after transrectal biopsy of the prostate are increasingly concerned by patients and urologists. It remained unclear whether the incidence of complication after prostate biopsy at an inpatient basis is less than at an outpatient basis. The aim of the study is to compare complication rate the following inpatient versus outpatient prostate biopsy in Taiwan by analyzing the database of Bureau of National Health Insurance. Materials and Methods: Both outpatient and inpatient information were retrieved from the database maintained in the Bureau of National Health Insurance inTaiwan. The claimeddatasets between1996and2008basedon systemic sampling of 1,000,000 registered subjects at 2005 were searched for patients with prostate biopsy by using series connection of benign prostatic hyperplasia or prostate cancer patients with the prostate biopsy procedure. The hospitalization rate and visiting rate of emergency room (ER) were recorded and compared between inpatient and outpatient bases. Results: A total of 1155 inpatient and 308 outpatient patients received transrectal prostate biopsy. The age distribution did not differ (p1⁄4 0.478, chi-square test). The number of hospitalization between the inpatient and outpatient patients are 16 (1.36%) and 10 (3.25%), respectively (p1⁄4 0.027, chi-square test). The number of ER re-visit between the inpatient and outpatient patients are 36(3.11%) and 11 (3.51 %), respectively (p1⁄4 0.688, chi-square test). The reasons for hospitalization and ER re-visit of inpatient and outpatient patients are bleeding (11[0.95%] versus 3[0.97%], p1⁄4 0.972), infection (35[3.03%] versus 16[5.19%], p1⁄4 0.066), and lower urinary tract symptoms (6 [0.52%] versus 2[0.65%], p 1⁄40.784). Conclusion: The overall hospitalization and ER revisit rate is less at an inpatient basis than at an outpatient basis. The main causes are infection. Further study about the cost-effectiveness and predisposing factors are worthy to explore.

Cardiac vignette: An interesting case of concurrent hypertrophic obstructive cardiomyopathy (HOCM) and takotsubo cardiomyopathy (TCM)

A 73-year-old female presented with a syncopal episode on a background of left ventricular outflow tract obstruction of undifferentiated aetiology. Patient reported that the event was sudden and was preceded by palpitations, dizziness and central non-radiating chest discomfort. Witnesses reported that she slumped to the ground, with spontaneous recovery of consciousness after 3 minutes. The patient was admitted for telemetry monitoring under Cardiology. During her stay, routine ECGs revealed new ST elevation in the anterior leads with significant elevation in cardiac enzymes. Patient subsequently underwent emergent cardiac catheterisation which revealed normal coronary arteries and apical ballooning on left ventriculography. (Image 1) Subsequent transthoracic echocardiography revealed akinesis of the apex and hypokinesis of the anterior wall. Left ventricular function was moderately impaired. There was asymmetric hypertrophy of the mid-septal wall with a septal-to-posterior wall thickness ratio of 1.5. Systolic anterior motion of the mitral valve was also appreciated with associated eccentric mitral regurgitation of moderate severity. (Image 2) There was flow acceleration in the LVOT with a resting gradient of 40mmHg and 110mmHg with Valsalva manoeuvre. (Image 3) A diagnosis of Takotsubo Cardiomyopathy with concurrent HOCM was made. Patient was commenced on an ACE inhibitor and Beta-blockade therapy. Patient was subsequently discharged, with plan for outpatient endomyocardial biopsy and genetic testing. This case brings forth an interesting phenomenon of dual myocardial pathologies, with potential for a pre-existing LVOT gradient providing substrate for development of the typical TCM contracture design in context of a sympathetic surge.