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Research on longitudinal trends in readmission rates after diabetic ketoacidosis (DKA) is lacking. This retrospective study was aimed at identifying trends in readmissions after hospitalization for DKA, as well as trends in outcomes after readmission, over time among adults with type 1 diabetes in the United States. Findings indicate that the DKA readmission rate increased from 53 to 73 events per 100,000 between 2010 to 2018, and low-income and uninsured patients had higher odds of readmission. There was no significant change in mortality after readmission over time. Improved access to care and affordable management options may play a crucial role in preventing readmissions.

Longitudinal data on the trends in systemic lupus erythematous (SLE) readmissions are limited. We aimed to study trends in 30-day readmissions of patients admitted for SLE flares and all SLE hospitalizations in the USA from 2010 to 2018.Data were obtained from the nationwide readmission database (NRD). We performed a retrospective 9-year longitudinal trend analysis using the 2010-2018 NRD databases. We searched for index hospitalizations of adult patients diagnosed with SLE using the International Classification of Diseases (ICD) codes. Elective and traumatic readmissions were excluded from the study. Multivariable logistic and linear regression analyses were used to calculate the adjusted p value trend for categorical and continuous outcomes, respectively.The 30-day readmissions following index admissions of all SLE patients and for SLE flares decreased from 15.6% in 2010 to 13.3% in 2018 (adjusted p trend 0.0001), and 20.3% in 2010 to 17.6% in 2018 (adjusted p trend = 0.009) respectively. Following SLE-flare admissions, hospital length of stay (LOS) decreased from 6.7 to 6 days (adjusted p trend = 0.045), while the proportion with a Charlson comorbidity index (CCI) score ≥ 3 increased from 42.2 to 54.4% (adjusted p trend 0.0001) during the study period. SLE and its organ involvement, sepsis, and infections were common reasons for 30-day readmissions.About 1 in 5 SLE-flare admissions resulted in a 30-day readmission. The 30-day readmissions following index hospitalization for SLE flares and all SLE hospitalizations have decreased in the last decade. Although the readmission LOS was reduced, the CCI score increased over time. Key Points • The 30-day readmissions following index hospitalization for SLE flares and all SLE hospitalizations have reduced in the last decade although the CCI score increased over time. • SLE, its organ involvement, and infections are common reasons for readmission. • Infection control strategies, optimal management of SLE and its complications, and emphasis on an ideal transition of care are essential in reducing SLE readmissions.

The Agency for Healthcare Research and Quality (AHRQ) developed patient safety indicators (PSIs) to help hospitals identify potentially preventable complications after surgeries and procedures.1 Despite their use by federal programs to assess quality of care, there is no consensus on their accuracy as a marker of quality.2 This article examines how a midsize community hospital used PSI-90 scores to develop targeted interventions that resulted in improved patient safety and quality ratings.

We aim to assess the influence of obesity on gastroparesis (GP) hospitalizations in the United States (US).The National Inpatient Sample was analyzed from 2007-2017 to identify all adult hospitalizations with a primary discharge diagnosis of GP. They were subdivided based on the presence or absence of obesity (body mass index30). Hospitalization characteristics, procedural differences, all-cause inpatient mortality, mean length of stay (LOS), and mean total hospital charge (THC) were identified and compared.From 2007-2017, there were 140 293 obese GP hospitalizations accounting for 13.75% of all GP hospitalizations in the US. Obese GP hospitalizations were predominantly female (76.11% vs 64.36%,In the US, compared to non-obese, a higher proportion of obese GP hospitalizations were female and Blacks. Obese GP hospitalizations also had higher THC, LOS, and rates of upper endoscopy.

The study involved hospitalizations with a diagnosis of hypertriglyceridemia-induced acute pancreatitis (HTGAP). This cohort was grouped into plasmapheresis and nonplasmapheresis groups using ICD-10 codes (6A550Z3 and 6A551Z3). Information was obtained on inpatient mortality, length of stay, total hospital charges, as well as the occurrence of comorbid systemic immune response syndrome, sepsis, septic shock, acute respiratory failure, acute respiratory distress syndrome, kidney failure, hypocalcemia, and need for transfusion of blood products. The study identified independent predictors of plasmapheresis. The plasmapheresis group had a higher proportion of patients with diabetes mellitus and obesity. Inpatient mortality was higher in the plasmapheresis group (0.86% vs 0.57%), and plasmapheresis was also associated with longer length of stay and higher total hospital charges. Overall, plasmapheresis was associated with higher proportions of inpatient complications. Patients with HTGAP had higher odds of undergoing plasmapheresis if they were in an urban location (adjusted odds ratio [aOR] 6.14, 95% confidence Interval [CI] 1.86–20.28, P = 0.003), larger hospital (aOR 3.37, 95% CI 2.14–5.29, P

Background/Aims: Proinflammatory cytokines released from adipocytes can influence the development, progression, and treatment of inflammatory bowel disease (IBD), and may be associated with worse clinical outcomes. Methods: For 2016–2018, we analyzed data from the Nationwide Inpatient Sample to identify adult (≥18 years) hospitalizations with a primary discharge diagnosis of IBD. The study sample was divided based on the presence or absence of obesity. The primary outcomes included inpatient mortality, while the secondary outcomes consisted of system-based complications and disease implications on the United States healthcare system.Results: We identified 282,005 hospitalizations of IBD from 2016 to 2018. Of these hospitalizations, 26,465 (9.4%) had a secondary diagnosis of obesity while 255,540 (90.6%) served as controls. IBD hospitalizations with obesity had a higher mean age (47.9 years vs. 45.2 years, PPPPP

Chronic kidney disease (CKD) and end-stage renal disease are considered independent risk factors for developing atrial fibrillation (AF). Percutaneous occlusion of left atrial appendage (LAAC) using WATCHMAN device is a widely accepted alternative to anticoagulation therapy to prevent ischemic stroke in AF in patients who are not candidates for anticoagulation. There is limited data regarding the utilization and periprocedural safety of this intervention in patients with CKD/ESRD.We retrospectively reviewed all hospitalizations from 2016 to 2017 with (ICD-10) procedure diagnosis code of LAA closure using WATCHMAN procedure with and without a secondary diagnosis of CKD/ESRD in acute-care hospitals across the United States using the national inpatient sample. Demographic variables (gender, race, income, hospital characteristics, medical comorbidities) were collected and compared. The primary outcomes were inpatient mortality, hospital length, and cost of stay.There were over 71 million discharges included in the combined 2016 and 2017 NIS database. Sixteen thousand five hundred five hospitalizations were for adult patients with a procedure code for LAA closure via watchman procedure. Of 16,505 patients, 3245 (19.66%) had CKD and ESRD. There was no statistically significant difference in mortality, length, and cost of stay in patients with and without CKD/ESRD. There were no statistically significant differences in periprocedural cerebrovascular accidents in both groups.Patients with and without ESRD/CKD who undergo LAA occlusion with Watchman have similar procedure related, in-hospital mortality, and complications.

The literature on the mortality and 30-day readmissions for acute heart failure and for acute myocardial infarction among renal-transplant recipients is limited.To study the in-hospital mortality, cardiovascular complications, and 30-day readmissions among renal transplant recipients (RTRs).Data from the national readmissions database sample, which constitutes 49.1% of all hospitals in the United States and represents more than 95% of the stratified national population, was analyzed for the years 2012-2018 using billing codes.A total of 588,668 hospitalizations in renal transplant recipients (mean age 57.7 ± 14.2 years; 44.5% female) were recorded in the study years. A total of 15,788 (2.7%) patients had a diagnosis of acute heart failure; 11,320 (71.7%) had acute heart failure with preserved ejection fraction and 4468 (28.3%) had acute heart failure with reduced ejection fraction; 17,256 (3%) patients had myocardial infarction, 3496 (20%) had ST-Elevation myocardial infarction while 13,969 (80%) had non-ST-elevation myocardial infarction. Overall, 11,675 (2%) renal-transplant patients died, of whom 757 (6.5%) had acute heart failure, 330 (2.8%) had acute reduced and 427 (3.7%) had acute preserved ejection fraction failure. Among 1652 (14.1%) patient deaths with myocardial infarction, 465 (4%) were ST-elevation- and 1187 (10.1%) were non-ST-Elevation-related. The absolute yearly mortality rate due to acute heart failure increased over the years 2012-2018 (p-trend 0.0002, 0.001, 0.002, 0.05, respectively), while the mortality rate due to myocardial infarction with ST-elevation decreased (p-trend 0.002).Cardiovascular complications are significantly associated with hospitalizations among RTRs. The absolute yearly mortality, and rate of heart failure (with reduced or preserved ejection fraction) increased over the study years, suggesting that more research is needed to improve the management of these patients.

Hypertriglyceridemia (HTG) is a well-established cause of acute pancreatitis often leading to significant morbidity, mortality, and healthcare burden. This study aimed to describe the rate, reasons, and predictors of HTG-induced acute pancreatitis (HTG-AP) in the USA.This retrospective study analyzed the Nationwide Readmissions Database (NRD) for 2018 to determine all adults (≥ 18 years) readmitted within 30 days of an index hospitalization of HTG-AP. Hospitalization characteristics and adverse outcomes for 30-day readmissions were highlighted and compared with index admissions of HTG-AP. Furthermore, independent predictors for 30-day readmissions of HTG-AP were also identified. P values ≤ 0.05 were considered statistically significant.In 2018, the rate of 30-day readmission of HTG-AP was noted to be 13.5%. At the time of readmission, AP (45.2%) was identified as the most common principal diagnosis, followed by chronic pancreatitis (6.3%) and unspecified sepsis (4.8%). Compared to index admissions, 30-day readmissions of HTG-AP had a higher proportion of patients with Charlson Comorbidity Index (CCI) scores ≥ 3 (48.5% vs. 33.8%, P0.001). Furthermore, we noted higher rates of inpatient mortality (1.7% vs. 0.7%, odds ratio (OR): 2.55, 95% confidence interval (CI): 1.83 - 3.57, P0.001), mean length of stay (LOS) (5.6 vs. 4.1 days, OR: 1.5, 95% CI: 1.2 - 1.7, P0.001), and mean total healthcare charge (THC) ($56,799 vs. $36,078, OR: 18,702, 95% CI: 15,136 - 22,267, P0.001) for 30-day readmissions of HTG-AP compared to index admissions. Independent predictors for 30-day all-cause readmissions of HTG-AP included hypertension, protein energy malnutrition (PEM), CCI scores ≥ 3, chronic kidney disease and discharge against medical advice.AP was the principal diagnosis on presentation in only 45.2% patients for 30-day readmissions of HTG-AP. Compared to index admissions, 30-day readmissions of HTG-AP had a higher comorbidity burden, inpatient mortality, mean LOS and mean THC.

Radiotherapy (RT) is a treatment modality that uses high-energy rays or radioactive agents to generate ionizing radiation against rapidly dividing cells. The main objective of using radiation in cancer therapy is to impair or halt the division of the tumor cells. Over the past few decades, advancements in technology, the introduction of newer methods of RT, and a better understanding of the pathophysiology of cancers have enabled physicians to deliver doses of radiation that match the exact dimensions of the tumor for greater efficacy, with minimal exposure of the surrounding tissues. However, RT has numerous complications, the most common being radiation proctitis (RP). It is characterized by damage to the rectal epithelium by secondary ionizing radiation. Based on the onset of signs and symptoms, post-radiotherapy RP can be classified as acute or chronic, each with varying levels of severity and complication rates. The treatment options available for RP are limited, with most of the data on treatment available from case reports or small studies. Here, we describe the types of RT used in modern-day medicine and radiation-mediated tissue injury. We have primarily focused on the classification, epidemiology, pathogenesis, clinical features, treatment strategies, complications, and prognosis of RP.

Background Clostridiodes difficile is a leading cause of healthcare-associated diarrhea. In this study, we aimed to identify the rates and predictors for 30-day readmissions of Clostridiodes difficile Enterocolitis (CDE) in the United States. Methods We conducted a retrospective study of the Nationwide Readmissions Database to identify adult hospitalizations with a principal diagnosis of CDE for 2018. Individuals

Hyperthyroidism is associated with an elevated risk of cardiovascular events and worse hospital outcomes. The Nationwide Readmissions Database (NRD) 2018 was used to determine the characteristics of 30-day readmission in patients with hyperthyroidism. The 30-day all-cause readmission rate for hyperthyroidism was 10.3%. About 21.7% had hyperthyroidism as the principal diagnosis on readmission. Readmissions were associated with an increased odds of inpatient mortality (odds ratio, 7.04; 95% confidence interval [CI], 3.97 to 12.49), length of stay (5.2 days vs. 4.0 days; 95% CI, 0.7 to 1.8), total hospital charges, and cost of hospitalizations. Independent predictors of 30-day all-cause readmissions included Charlson Comorbidity Index ≥3 (adjusted hazard ratio [aHR], 1.76; 95% CI, 1.15 to 2.71), discharge against medical advice (aHR, 2.30; 95% CI, 1.50 to 3.53), protein-energy malnutrition (aHR, 1.54; 95% CI, 1.15 to 2.07), and atrial fibrillation (aHR, 1.41; 95% CI, 1.11 to 1.79). Aggressive but appropriate monitoring is warranted in patients with hyperthyroidism to prevent readmissions.

BACKGROUND Alcoholic liver cirrhosis (ALC) is a chronic liver disease with varying disease severity. Readmissions of ALC are associated with poor outcomes. AIM To identify and assess trends of readmissions for ALC over an eight-year period. METHODS This retrospective interrupted trend study analysed 30-d readmissions of ALC in the United States from 2010 to 2018 using the National Readmissions Database. Hospitalization for ALC was the reason for index admission obtained using the International Classification of Diseases codes (571.2 and K70.3X). Biodemographic characteristics and hospitalization trends were highlighted over time. A multivariate regression analysis model was used to calculate the trend for risk-adjusted odds of 30-d all-cause ALC readmissions, ALC specific readmission rate, ALC readmission proportion, inpatient mortality, mean length of stay (LOS) and mean total hospital cost (THC) following adjustments for age, gender, grouped Charlson Comorbidity Index, insurance, mean household income, and hospital characteristics. RESULTS There was a trend towards increasing total 30-d readmissions of ALC from 7660 in 2010 to 15085 in 2018 (P < 0.001). Patients readmitted for ALC were noted to have an increasing comorbidity burden over time. We noted a rise in the risk-adjusted 30-d all-cause readmission of ALC from 24.9% in 2010 to 29.9% in 2018 (P < 0.001). ALC-specific readmission rate increased from 6.3% in 2010 to 8.4% in 2018 (P < 0.001) while ALC readmission proportion increased from 31.4% in 2010 to 36.3% in 2018 (P < 0.001). Inpatient mortality for 30-d readmissions of ALC declined from 10.5% in 2010 to 8.2% in 2018 (P = 0.0079). However, there was a trend towards increasing LOS from 5.6 d in 2010 to 6.3 d in 2018 (P < 0.001) and increasing THC from 13790 dollars in 2010 to 17150 dollars in 2018 (P < 0.001). The total days of hospital stay attributable to 30-d readmissions of ALC increased by 119.2% while the total attributable hospital costs increased by 149% by the end of 2018. CONCLUSION There was an increase in the 30-d readmission rate and comorbidity burden for ALC; however, inpatient mortality declined. Additionally, there was a trend towards increasing LOS and THC for these readmissions.

Vasovagal syncope (VVS) (or neurocardiogenic syncope) is a common clinical condition that is challenging to both physicians and patients alike. Severe episodes of recurrent syncope can result in physical injury as well as psychological distress. This article provides a brief overview of current management strategies and a detailed overview of therapeutic modalities such as closed loop stimulation (CLS) and cardioneuroablation (CNA).

We report on three patients with prior pulmonary vein isolation who presented with atrial tachycardia/atrial flutter. During electrophysiology study, the whole tachycardia cycle length was mapped to the left atrium. Multiple ablation attempts failed to terminate the tachycardia and, subsequently, right atrial mapping revealed a focal early site of origin near the superior vena cava–right atrial junction in two patients and outside the coronary sinus ostium in one patient. In this report, we discuss the probable mechanism of these tachycardias.

The objective of this study was to characterize epidemiological trends, outcomes in hospitalized patients, and the disease burden of hospitalizations for diabetic ketoacidosis (DKA) in patients with type 1 diabetes mellitus (T1DM). This was a retrospective interrupted trends study involving hospitalizations for DKA in patients with T1DM in the US from 2008 to 2018 using data from the Nationwide Inpatient Sample. The total number of hospitalizations during each calendar year was obtained, and trends in inpatient mortality rate, mean length of hospital stay (LOS), and mean total hospital cost (THC) were calculated. Between 2008 and 2018, there was a trend toward increasing hospitalizations for T1DM with DKA (P-trend 1. There was no statistically significant change in adjusted inpatient mortality in patients with T1DM admitted for DKA over the study period despite an apparent trend of a decreasing crude mortality rate (P-trend = 0.063). There was a statistically significant decrease in both LOS and THC over the study period. In conclusion, there was a significant decrease in both LOS and THC, potentially reflecting improvements in the management of DKA in patients with T1DM.

The goal of this study was to examine healthcare burden, hospitalizations, mortality, and healthcare cost utilization from hyperthyroidism to further our understanding of the effect of changes in thyroid disease management over the past decade. This was a retrospective longitudinal trends study involving hospitalizations for hyperthyroidism in the US from 2008 to 2018. We trended crude hospitalization rate, estimated incidence of hospitalizations, trends in inpatient mortality rate, mean length of hospital stay, and mean total hospital cost of patients with hyperthyroidism. The number of hyperthyroid hospitalizations decreased from 12,689 in 2008 to 9110 in 2018 (28.2%) (P trend

Background This study was designed to determine the epidemiological trends and adverse outcomes of hepatopulmonary syndrome (HPS). Methods This retrospective interrupted trend study analyzed data from the Nationwide Inpatient Sample (NIS) for the years 2012, 2014, 2016 and 2018 to identify adult (≥ 18 years) hospitalizations with a diagnosis of HPS. We highlighted epidemiological trends for HPS. Inpatient mortality, mean length of stay (LOS) and mean total hospital charge (THC) were estimated using multivariate regression trend analysis. Results We observed an increase in the total number of HPS hospitalizations from 1,565 in 2012 to 2,495 in 2018, with mean age ranging from 55.8 to 58.1 years. There was a trend towards increasing hospitalizations (P-trend < 0.001) with increasing mean age (P-trend = 0.003) for HPS. Whites made up most of the study population. The inpatient mortality for HPS ranged from 12.4% to 12.6%, but there was no statistically significant trend for mortality (P-trend = 0.534) between 2012 and 2018. Additionally, there was no change in both mean LOS (P-trend = 0.545) and mean THC (P-trend = 0.534) for HPS for these years. Conclusions Hospitalizations and mean age for HPS were on the rise. Inpatient mortality ranged from 12.4% to 12.6%; however, a statistically significant trend for mortality was absent.

BACKGROUND Pacemaker implantation in the U.S. is rising due to an aging population. The aim of this analysis was to identify risk factors associated with increased mortality and complications in hospitalized patients requiring pacemaker implantation. METHODS We performed a retrospective analysis using the National Inpatient Sample database, identifying hospitalized patients who underwent pacemaker implantation using International Classification of Disease, Tenth Revision, Clinical Modification codes. Independent predictors of inpatient mortality were identified using multivariate logistic regression analysis. RESULTS There were 242,980 hospitalizations with pacemaker implantation during 2016 and 2017. The most frequently encountered indications for hospitalizations involving pacemaker insertion included sick sinus syndrome (SSS) (27.60%), complete atrioventricular (AV) block (21.57%), and second-degree AV block (7.83%). Chronic liver disease was associated with the highest adjusted odds of inpatient mortality (aOR = 5.76, 95% CI: 4.46 to 7.44, p

Postural orthostatic tachycardia syndrome (POTS) is a clinical syndrome causing patients to experience light-headedness, palpitations, tremors, and breathlessness upon assuming an upright posture. Despite the absence of available long-term, multicenter, randomized controlled trial data, this literature review aims to concisely present the nonpharmacological and pharmacological interventions that have been used in the treatment of POTS reported to date by cross-sectional studies, cohort studies, and retrospective studies. We attempt to classify treatments as first-, second-, and third-line therapies based on our own experience and available data.

Hyperkalemia is a recognized and potentially life-threatening complication of heart transplantation. In the complex biosystem created by transplantation, recipients are susceptible to multiple mechanisms for hyperkalemia which are discussed in detail in this manuscript. Hyperkalemia in heart transplantation could occur pre-transplant, during the transplant period, or post-transplant. Pre-transplant causes of hyperkalemia include hypothermia, donor heart preservation solutions, conventional cardioplegia, normokalemic cardioplegia, continuous warm reperfusion technique, and ex-vivo heart perfusion. Intra-transplant causes of hyperkalemia include anesthetic medications used during the procedure, heparinization, blood transfusions, and a low output state. Finally, post-transplant causes of hyperkalemia include hemostasis and drug-induced hyperkalemia. Hyperkalemia has been studied in kidney and liver transplant recipients, but there is limited data on the incidence, causes, management, and prevention in heart transplant recipients. Hyperkalemia is associated with an increased risk of hospital mortality and readmission in these patients. This review describes the current literature pertaining to the causes, pathophysiology, and treatment of hyperkalemia in patients undergoing heart transplantation and focuses primarily on post-heart transplantation.

Background: With increasing utilization of cannabis in the United States (US), clinicians may encounter more cases of Gastroparesis (GP) in coming years.Objective: The primary outcome was inpatient...

GOALS We aimed to assess outcomes of patients with liver cirrhosis who underwent therapeutic or diagnostic endoscopic retrograde cholangiopancreatography (ERCP) to determine whether these patients had different outcomes relative to patients without cirrhosis. BACKGROUND ERCP is an important procedure for treatment of biliary and pancreatic disease. However, ERCP is relatively technically difficult to perform when compared with procedures such as esophagogastroduodenoscopy or colonoscopy. Little is known about how ERCP use affects patients with liver cirrhosis. STUDY Using patient records from the National Inpatient Sample (NIS) database, we identified adult patients who underwent ERCP between 2009 and 2014 using International Classification of Disease, Ninth Revision coding and stratified data into 2 groups: patients with liver cirrhosis and those without liver cirrhosis. We compared baseline characteristics and multiple outcomes between groups and compared outcomes of diagnostic versus therapeutic ERCP in patients with cirrhosis. A multivariate regression model was used to estimate the association of cirrhosis with ERCP outcomes. RESULTS A total of 1,038,258 hospitalizations of patients who underwent ERCP between 2009 and 2014 were identified, of which 31,294 had cirrhosis and 994,681 did not have cirrhosis. Of the patients with cirrhosis, 21,835 (69.8%) received therapeutic ERCP and 9459 (30.2%) received diagnostic ERCP. Patients with cirrhosis had more ERCP-associated hemorrhages (2.5% vs. 1.2%; P

OBJECTIVE The aim of this study was to describe rates and characteristics of non-elective 30-day readmission among patients hospitalized for adrenal insufficiency and to assess predictors of readmission. DESIGN We analysed the 2018 National Readmission Database. Adrenal insufficiency hospitalizations were identified using the International Classification of Diseases, Tenth Revisions, Clinical Modification diagnosis codes for principal diagnostic codes of primary adrenal insufficiency, Addisonian crisis, drug-induced adrenocortical insufficiency, and other and unspecified adrenocortical insufficiency. PATIENTS During the study period, 7738 index hospitalizations were identified as patients with AI who met the inclusion criteria. Of these, 7691 were discharged alive. MEASUREMENTS We utilized chi-squared tests to compare baseline characteristics between readmissions and index hospitalizations. Multivariate Cox regression was used to identify independent predictors of readmission. RESULTS The 30-day all-cause readmission rate for AI was 17.3%. About 1 in 5 readmissions was for AI. Other reasons for readmission included sepsis (10.8%), unspecified pneumonia (3.1%) and acute renal failure unspecified (1.6%). Readmission was associated with significantly higher odds of inpatient mortality. Independent predictors of 30-day all-cause readmissions included index hospitalizations with the Charlson Comorbidity Index (CCI) ≥3 (adjusted hazards ratio (aHR): 2.53, 95% CI: 1.85-3.46, p

Spontaneous spinal epidural hematoma is a rare predominantly idiopathic entity which can prompt acute neurologic symptoms and if not managed in time can lead to devastating outcomes. High index of suspicion is required for early diagnosis on MRI for a prompt management of patients showing sudden neurologic deficits. Our patient was 42-year-old female who presented with sudden onset of numbness followed by weakness in both lower limbs and urinary retention without any comorbidity or any medication. MRI whole spine done within 14 hours of symptom onset showed ventral epidural hematoma without any vascular malformation. Immediate decompressive laminectomy with evacuation of hematoma improved power in both lower limbs with regaining bowel and bladder function. The key here is timely surgical decompression of the hematoma for a favorable neurosurgical outcome. Although there is a recent development towards non–surgical treatment, it needs to be well established yet and require such approach on case-to-case basis.

Histoplasmosis is the fungal infection caused by Histoplasma capsulatum fungus. It is commonly found in a few endemic areas in the United States, where there is a large number of birds or bats and can spread through their droppings. Disseminated histoplasmosis is a severe manifestation of the fungal infection which is commonly seen in individuals with underlying immunosuppression. Our case is an unusual case of disseminated histoplasmosis in a 60-year-old, immunocompetent male patient with a history of significant alcohol abuse, which led to end stage liver failure. While the patient showed some signs of improvement initially upon beginning the treatment, he ultimately continued to deteriorate despite treatment due to an overwhelming histoplasmosis infection. This case demonstrates the importance of keeping a high index of suspicion even amongst immunocompetent patients with no obvious exposure to risk factors. It also shows that timely diagnosis with a high index of suspicion is required with an integrated treatment approach.

Amyloidosis is a systemic illness that affects multiple organ systems, including the cardiovascular, renal, gastrointestinal, and pulmonary systems. Common manifestations include restrictive cardiomyopathy, arrhythmias, nephrotic syndrome, and gastrointestinal hemorrhage. It is unknown whether coexisting atrial fibrillation (AF) worsens the disease burden and outcomes in patients with systemic amyloidosis. In this study, those with a diagnosis of amyloidosis with and without coexisting AF were identified by querying the Healthcare Cost and Utilization Project-specifically, the National Inpatient Sample for the year 2016-based on International Classification of Diseases, 10th Revision, Clinical Modification codes. During 2016, a total of 2,997 patients were admitted with a diagnosis of amyloidosis, including 918 with concurrent AF. Greater rates of mortality (7.4% vs. 5.6%); heart block (6.8% vs. 2.8%); cardiogenic shock (5% vs. 1.6%); placement of an implantable cardioverter-defibrillator, cardiac resynchronization therapy device, or permanent pacemaker (14.5% vs. 4.5%); renal failure (29% vs. 21%); heart failure (66% vs. 30%); and bleeding complications (5.7% vs. 2.8%) were observed in patients with a diagnosis of amyloidosis and coexisting AF when compared with in patients without AF. Interestingly, patients with amyloidosis without comorbid AF had greater odds of associated stroke relative to those with concurrent AF (7.9% vs. 3.4%).

Coronary injury presenting as ST segment elevation (STE) during ablation procedures for different arrhythmias is a rare and most feared complication. There have been multiple reports on STE during various ablation procedures in the recent past. Herein, we review various mechanisms, presentations, and management of STE observed during various ablations, including atrial fibrillation ablation cavotricuspid isthmus and ablation, supraventricular tachycardia ablations, coronary sinus ablation, and ventricular arrhythmia ablations., In this review, we have performed a literature search and attempt to provide the readership with a comprehensive overview of ST segment elevation during ablations and its mechanism and guidance for physicians on what to do when faced with such situations.

Clostridium difficile is a gram-positive anaerobic spore forming bacillus that can cause infection in a setting of antibiotic use. Pneumonia is a major cause of morbidity and mortality in an inpatient setting and is frequently associated with significant antibiotic administration. This study aims to compare the outcomes of C. difficile infection (CDI) with and without pneumonia to determine the impact of pneumonia in hospitalized patients with CDI. This population-based retrospective observational propensity matched analysis study uses data from the National Inpatient Sample database for the years 2016 and 2017. The primary outcomes were in-hospital mortality, total hospital charges, and mean length of stay. Secondary outcomes were the rates of sepsis, septic shock, non-ST elevation myocardial infarction (NSTEMI), acute renal failure, deep vein thrombosis, and pulmonary embolism. In-hospital mortality was noted to be higher in patients with pneumonia than those without (6.5% vs 1.2%, adjusted OR (aOR) 3.85; 95% CI 2.90 to 5.11, p

Context Diabetic ketoacidosis (DKA) is a serious endocrine emergency, associated with morbidity and mortality. Readmissions play a significant but sometimes preventable role in healthcare cost burden on the US. Objective This study aimed to describe rates and characteristics of nonelective 30-day readmission among adult patients with diabetes mellitus type 1 (T1DM) hospitalized for DKA and also identify predictors of readmission. Methods The study analyzed the 2018 Nationwide Readmission Database. DKA hospitalizations in patients with T1DM were classified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We utilized chi-squared tests to compare baseline characteristics between readmissions and index hospitalizations. Multivariable Cox regression was employed to identify independent predictors of readmission. Following this, we developed a 30-day readmission risk scoring system based on independent predictors. Results The 30-day all-cause readmission rate for DKA was 19.4%. A majority of patients (64.8%) had DKA as the principal diagnosis on readmission. Readmitted patients had a significantly higher mean age (35.3 vs 34.9 years, P = .018) and a higher proportion of females (52.8 vs 49.6%, P Conclusion The readmission rate for DKA in T1DM patients is high, and most patients have DKA as the principal diagnosis on readmission. A CCI equal to or greater than 3, hypertension, female sex, and being discharged AMA were significant predictors of readmission.

This study aimed to describe the trends, inpatient outcomes, and disease burden of hospitalizations for ulcerative colitis (UC) and Crohn’s disease (CD). Our study included data on hospitalizations with a principal discharge diagnosis of CD and UC gathered from the Nationwide Inpatient Sample for the years 2008, 2010, 2012, 2014, 2016, and 2018. Individuals ≤18 years and elective hospitalizations were excluded. From 2008 to 2018, we noted a rising trend for UC hospitalizations (P trend < 0.001). However, there was no statistically significant trend for CD hospitalizations (P trend = 0.249). The overall inpatient mortality for UC downtrended from 1.09% in 2008 to 0.42% in 2014 (P trend < 0.001). Additionally, inpatient mortality for CD also downtrended with a decrease from 0.28% in 2008 to 0.17% in 2016 (P trend = 0.002). Odds of inpatient mortality from 2008 to 2018 were significantly higher for UC than for CD. In conclusion, both CD and UC saw a significant decline in mortality over the study period, but UC hospitalizations had a higher odds of inpatient mortality for all study years.

We aimed to identify prevalence and association of comorbid chronic kidney disease (CKD), acute kidney injury (AKI) and utilization prevalence of continuous renal replacement therapy (CRRT) in COVID-19-hospitalized patients as a function of severity status. With the ongoing struggle across the globe to combat COVID-19 disease, published literature has described the role of kidney disease in COVID-19 patients based on single/multicenter experiences across the globe. We extracted data from observational studies describing comorbid CKD, AKI and CRRT and outcomes and severity of COVID-19-hospitalized patients from December 1, 2019–August 20, 2020 following PRISMA guidelines. Severity of COVID-19 includes intensive care unit admission, oxygen saturation

This study compares the odds of being admitted for inflammatory bowel disease (IBD) in patients with psoriasis compared with those without psoriasis alone. We also compared hospital outcomes of patients admitted primarily for IBD with and without a secondary diagnosis of psoriasis. Data were abstracted from the National Inpatient Sample (NIS) 2016 and 2017 database to search for hospitalizations of interest using International Classification of Diseases, 10th Revision codes. Multivariate logistic regression model was used to calculate the adjusted OR (AOR) of IBD being the principal diagnosis for hospitalizations with and without a secondary diagnosis of psoriasis. Multivariate logistic and linear regression analyses were used accordingly to compare outcomes of hospitalizations for IBD with and without secondary diagnosis of psoriasis. There were over 71 million discharges included in the combined 2016 and 2017 NIS database. Hospitalizations with a secondary diagnosis of psoriasis have an AOR of 2.66 (95% CI 2.40 to 2.96, p

Background Gastric antral vascular ectasia (GAVE) syndrome is a rare but significant cause of acute or chronic gastrointestinal (GI) bleeding, particularly in the elderly. The primary objective of this study was to determine the biodemographic characteristics, adverse outcomes, and the impact of GAVE hospitalizations on the US healthcare system. Methods This retrospective database cross-sectional study used the National Inpatient Sample (NIS) from 2001 to 2011 to identify all adult hospitalizations with a primary discharge diagnosis of GAVE, with and without hemorrhage, using the International Classification of Diseases, Ninth Revision (ICD-9) codes. Individuals less than 17 years of age were excluded from the study. The outcomes included biodemographic characteristics, comorbidity measures, and inpatient mortality and the burden of the disease on the US healthcare system in terms of healthcare cost and utilization. Results We noted an increase in the total hospitalizations for GAVE from 25,423 in 2001 to 44,787 in 2011. Furthermore, GAVE hospitalizations with hemorrhage rose from 19,168 in 2001 to 27,679 in 2011 while GAVE hospitalization without hemorrhage increased from 6,255 in 2001 to 17,108 in 2011. We also noted a female predominance, the proportional trend of which did not show significant difference from 2001 to 2011. For GAVE hospitalizations, the inpatient mortality decreased from 2.20% in 2001 to 1.73% in 2011. However, the cost of hospitalization increased from $11,590 in 2001 to $12,930 in 2011. After adjusting for possible confounders, we observed that the presence of hemorrhage in GAVE hospitalizations was associated with an increased risk of mortality (odds ratio (OR): 1.27; 95% confidence interval (CI): 1.1 - 1.46; P = 0.001). Conclusions For the study period, the total number of GAVE hospitalizations increased with an increase noted in the proportion of GAVE hospitalizations without bleeding, reflecting an improvement in diagnostic and therapeutic techniques. Although inpatient mortality for GAVE slightly decreased, we noted a significant increase in the cost of care likely secondary to increased use of advanced and expensive interventions.

Background There is a paucity of contemporary national estimates for Clostridium difficile infection (CDI) hospitalizations by age group, sex, and region in the US population. Also, there is lack of contemporary national statistics on CDI hospitalizations with comorbidities. Methods We analyzed the 2017 National Inpatient Sample (NIS) to determine the population-based rates of CDI hospitalizations, characteristics of hospitalizations with CDI, and the rates of comorbidities associated with CDI hospitalizations. Results There were 329,460 CDI-related hospitalizations in 2017 (almost 1% of all hospitalizations). The average age for patients admitted with CDI as a principal or secondary diagnosis was 64.7 years (almost 20 years older when compared with all other hospitalizations). Patients 85 years and older had the highest rate of CDI hospitalizations (716 per 100,000 hospitalizations), and patients less than 18 years of age had the lowest rate (12 per 100,000 hospitalizations). There was a progressive increase in the CDI hospitalization rates with each successive age group. The hospitalization rates were higher in females (114 per 100,000 hospitalizations) than males (88 per 100,000 hospitalizations). The CDI hospitalization rate was highest in the Northeast (109 per 100,000 hospitalizations) and lowest in the West (84 per 100,000 hospitalizations). Fluid and electrolyte disturbance (63.3%) and renal failure (33.4%) were the two most common comorbidities associated with CDI hospitalizations. When CDI is a secondary diagnosis, major loss of function, extreme likelihood of dying, septicemia, and septic shock were more common in comparison to CDI as a principal diagnosis. Conclusions CDI hospitalization rates were highest in the elderly over 85 years old and declined with successive decreases in age. Women had higher CDI hospitalization rates than men, and fluid and electrolyte disturbances and renal failure were the most common comorbid conditions. The presence of CDI as a comorbid condition at the time of hospitalization for other principal diagnoses or development of CDI during a hospitalization for other principal diagnoses significantly increases the risk of in-hospital morbidity and mortality.

BACKGROUND Gallstones and cholecystectomy have been proposed as risk factors for non-alcoholic fatty liver disease (NAFLD). The reason for this may be that both gallstones, as well as NAFLD share several risk factors with regards to their development. Currently, there is a lack of sufficient evidence showing an association between these clinical conditions. AIM To determine whether there is a meaningful association between gallstones and cholecystectomy with NAFLD. METHODS We queried the National Inpatient Sample database from the years 2016 and 2017 using International Classification of Diseases, 10th revision, Clinical Modification diagnosis codes to identify hospitalizations with a diagnosis of gallstone disease (GSD) (includes calculus of gallbladder without cholecystitis without obstruction and acquired absence of gallbladder) as well as NAFLD (includes simple fatty liver and non-alcoholic steatohepatitis). Odds ratios (ORs) measuring the association between GSD (includes gallstones and cholecystectomy) and NAFLD were calculated using logistic regression after adjusting for confounding variables. RESULTS Out of 14294784 hospitalizations in 2016-2017, 159259 were found to have NAFLD. The prevalence of NAFLD was 3.3% in patients with GSD and 1% in those without. NAFLD was prevalent in 64.3% of women with GSD as compared to 35.7% of men with GSD. After controlling for various confounders associated with NAFLD and GSD, multivariate-adjusted analysis showed that there was an association between NAFLD with gallstones [OR = 6.32; 95% confidence interval (CI): 6.15-6.48] as well as cholecystectomy (OR = 1.97; 95%CI: 1.93-2.01). The association between NAFLD and gallstones was stronger in men (OR = 6.67; 95%CI: 6.42-6.93) than women (OR = 6.05; 95%CI: 5.83-6.27). The association between NAFLD and cholecystectomy was stronger in women (OR = 2.01; 95%CI: 1.96-2.06) than men (OR = 1.85; 95%CI: 1.79-1.92). P value was less than 0.001 for all comparisons. CONCLUSION NAFLD is more prevalent in women with GSD than men. The association between NAFLD and cholecystectomy/gallstones indicates that they may be risk factors for NAFLD.

Immunotherapy is rapidly evolving secondary to the advent of newer immunotherapeutic agents and increasing approval of the current agents by the United States Food and Drug Administration to treat a wide spectrum of cancers. Immunotherapeutic agents have gained immense popularity due to their tumor-specific action. Immunotherapy is slowly transforming into a separate therapeutic entity, and the fifth pillar of management for cancers alongside surgery, radiotherapy, chemotherapy, and targeted therapy. However, like any therapeutic entity it has its own adverse effects. With the increasing use of immuno-therapeutic agents, it is vital for physicians to acquaint themselves with these adverse effects. The aim of this review is to investigate the common systemic adverse effects and toxicities associated with the use of different classes of immunotherapeutic agents. We provide an overview of potential adverse effects and toxicities associated with different classes of immunotherapeutic agents organized by organ systems, as well as an extensive discussion of the current recommendations for treatment and clinical trial data. As we continue to see increasing usage of these agents in clinical practice, it is vital for physicians to familiarize themselves with these effects.

A subgroup of postural orthostatic tachycardia syndrome (POTS) patients may also have features of neurocardiogenic syncope (NCS). Syncope and presyncope are predominant clinical features in this subgroup of patients. Asystole has been reported as the cause of some recurrent syncopal episodes following evaluation with an implantable loop recorder (ILR). We present our experience of pacing in a group of patients with POTS and NCS, which resulted in the complete elimination of syncope. We reviewed the charts of 500 patients at the University of Toledo Medical Center from 2003 to 2013 and identified 40 patients who were eligible for inclusion in this study. Patients were included in this study if they had clinical features of POTS and unusually frequent episodes of syncope. All study participants subsequently underwent ILR implantation. Forty patients, including 32 (80%) women, aged 33 ± 13 years were included in this study. All patients demonstrated prolonged asystole (> 6 seconds) or severe bradycardia (heart rate < 30 bpm) during their syncope. Ten patients demonstrated an asystole of more than 10 seconds and also had prolonged and convulsive syncope. All patients had abrupt syncope without any warning signs. All 40 patients underwent dual-chamber pacemaker implantation. Syncope was eliminated in all 40 patients following pacemaker implantation; however, they continued to experience orthostatic tachycardia. Our findings support that dual-chamber pacing may help to eliminate syncope in a subgroup of POTS patients with recurrent syncope and prolonged asystole on ILR.

Here, we discuss mapping of an atrioventricular reciprocating tachycardia (AVRT) using color-coding and a coherence module of the CARTO® mapping system (Biosense Webster, Diamond Bar, CA, USA). AVRT is a reentry tachycardia and, when the atrial exit site of the arrhythmia circuit was mapped in this case, it appeared to have a focal centrifugal activation pattern as depicted by coherent mapping.

Medical conditions requiring treatment with anticoagulation (AC) or antiplatelet therapy have a huge burden on the average patient, but such conditions can have catastrophic effects on the careers of young, rising athletes, in particular those involved in contact sports at a professional level. Contact sports are defined as sports in which body-to-body contact is expected as part of the game such as football, basketball, soccer and hockey. The rates of injuries in these sports are high increasing the likelihood of bleeding event on AC. The main etiologies requiring AC and antiplatelets in athletes are venous thromboembolism and coronary artery disease, respectively. To date, there are no clear medical guidelines on the management of such conditions in athletes. Herein we review the traditional approach to treating such conditions afflicting athletes as well as more recently modified approaches to answer the ultimate question: should anticoagulation or antiplatelet therapy in contact sports be career limiting?

In patients with infective endocarditis (IE), ST-elevation myocardial infarction (STEMI) is an uncommon phenomenon. Due to limited data, we intend to evaluate the clinical outcomes in hospitalized patients with STEMI with and without underlying IE. Mortality and morbidity are exponentially worse in STEMI with concomitant IE when compared with without IE. Patients with primary diagnosis of STEMI with and without IE were identified by querying the Healthcare Cost and Utilization Project database of the National Inpatient Sample for the years 2013 and 2014 based on International Classification of Diseases, Ninth Revision codes. During 2013 and 2014, a total of 117,386 patients were admitted with the principle diagnosis of STEMI, out of whom 305 had comorbid IE. There was a significantly increased in-hospital mortality (27.5% vs 10.8%), length of stay (LOS) (14 days vs 5 days), acute kidney injury (AKI; 44.9% vs 18.7%), stroke (23.6% vs 3%), aortic valve replacement (9.5% vs 0.3%), mitral valve replacement (0.2%-5.2%), sepsis (50% vs 6%) and acute respiratory failure (36.7% vs 16.7%) in patients with STEMI with IE when compared with patients with STEMI and without comorbid IE. STEMI without IE had a higher number of angiographies (58.7% vs 25.9%) and percutaneous coronary interventions (50.7% vs 14.4%) during the hospital course when compared with STEMI with IE. In conclusions, hospitalized patients with STEMI with a concurrent diagnosis of IE are at higher risk of in-hospital mortality, increased LOS, AKI, stroke, valve replacements, and acute respiratory failure.

Immunotherapy is an extremely important breakthrough and an exciting new modality of treatment for a wide spectrum of cancers. It is focused around developing agents to stimulate or suppress the immune system, in a specific manner, to fight off a wide spectrum of diseases, particularly cancers. Traditional therapies available for the treatment of cancers include surgical intervention, chemotherapy, radiation therapy or a combination of these, which tend to be very non-specific. However, immunotherapy shows a stark difference from conventional therapy, in fact, that it has a high level of specificity for the tumor-specific antigens. The recent success of cancer immunotherapies in clinical trials is slowly revolutionizing the landscape for cancer therapy. The US Food and Drug Administration has approved numerous agents, after clinical trials showed promising results, for the treatment of multiple cancers. The role of immunotherapy in gastrointestinal cancers has also been very promising, particularly in patients with advanced metastatic disease or malignancies refractory to initial treatment. In this review of literature, we detail and discuss the immunotherapy agents approved for the treatment of GI cancers and glance at the future of immunotherapy for patients with these cancers.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019, COVID-19) pandemic has placed a tremendous burden on healthcare systems globally. Therapeutics for treatment of the virus are extremely inconsistent due to the lack of time evaluating drug efficacy in clinical trials. Currently, there is a deficiency of published literature that comprehensively discusses all therapeutics being considered for the treatment of COVID-19. A review of the literature was performed for articles related to therapeutics and clinical trials in the context of the current COVID-19 pandemic. We used PubMed, Google Scholar, and Clinicaltrials.gov to search for articles relative to the topic of interest. We used the following keywords: “COVID-19”, “therapeutics”, “clinical trials”, “treatment”, “FDA”, “ICU”, “mortality”, and “management”. In addition, searches through the references of retrieved articles was also performed. In this paper, we have elaborated on the therapeutic strategies that have been hypothesized or trialed to-date, the mechanism of action of each therapeutic, the clinical trials finished or in-process that support the use of each therapeutic, and the adverse effects associated with each therapeutic. Currently, there is no treatment that has been proven to provide significant benefit in reducing morbidity and mortality. There are many clinical trials for numerous different therapeutic agents currently underway. By looking back and measuring successful strategies from previous pandemics in addition to carrying out ongoing research, we provide ourselves with the greatest opportunity to find treatments that are beneficial.

Amyloidosis, a heterogenous group of disorders, is characterized by the extracellular deposition of autologous, insoluble, fibrillar misfolded proteins. These extracellular proteins deposit in tissues aggregated in ß-pleated sheets arranged in an antiparallel fashion and cause distortion to the tissue architecture and function. In the current literature, about 60 heterogeneous amyloidogenic proteins have been identified, out of which 27 have been associated with human disease. Classified as a rare disease, amyloidosis is known to have a wide range of possible etiologies and clinical manifestations. The exact incidence and prevalence of the disease is currently unknown. In both systemic and localized amyloidosis, there is infiltration of the abnormal proteins in the layers of the gastrointestinal (GI) tract or the liver parenchyma. The gold standard test for establishing a diagnosis is tissue biopsy followed by Congo Red staining and apple-green birefringence of the Congo Red-stained deposits under polarized light. However, not all patients may have a positive tissue confirmation of the disease. In these cases additional workup and referral to a gastroenterologist may be warranted. Along with symptomatic management, the treatment for GI amyloidosis consists of observation or localized surgical excision in patients with localized disease, and treatment of the underlying pathology in cases of systemic amyloidosis. In this review of the literature, we describe the subtypes of amyloidosis, with a primary focus on the epidemiology, pathogenesis, clinical features, diagnosis and treatment strategies available for GI amyloidosis.

The ongoing outbreak of severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2, or coronavirus disease 2019 (COVID-19)] was declared a pandemic by the World Health Organization on March 11, 2020. Worldwide, more than 65 million people have been infected with this SARS-CoV-2 virus, and over 1.5 million people have died due to the viral illness. Although a tremendous amount of medical progress has been made since its inception, there continues to be ongoing research regarding the pathophysiology, treatments, and vaccines. While a vast majority of those infected develop only mild to moderate symptoms, about 5% of people have severe forms of infection resulting in respiratory failure, myocarditis, septic shock, or multi-organ failure. Despite maximal cardiopulmonary support and invasive mechanical ventilation, mortality remains high. Extracorporeal membrane oxygenation (ECMO) remains a valid treatment option when maximal conventional strategies fail. Utilization of ECMO in the pandemic is challenging from both resource allocation and ethical standpoints. This article reviews the rationale behind its use, current status of utilization, and future considerations for ECMO in critically ill COVID-19 patients.