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Inability to Match into a fellowship is usually not a reflection of some failure on the part of the resident, but rather a problem of supply and demand. Understanding how to advise residents to maximize their success in an environment with limited spots and limited fellowship faculty resources to perform holistic review remains one of the primary objectives of most residency mentors. Residents can alter the odds in their favor by engaging with local faculty and in national society mentorship programs, performing ‘enough’ research, building their ‘brand,’ and concentrating on high quality personal statements.

Purpose to investigate the Thyroid Imaging Reporting and Data System (TIRADS) as a new classification system for solitary thyroid nodules by high resolution Ultrasonography in correlation with histopathological study. Materials and Methods Thirty patients with clinically suspected thyroid nodules referred to Radiology department at Ain shams University hospitals after fulfilling inclusion and exclusion criteria. All thyroid nodules are examined by ultrasound and charactrized according to internal components, margins, echogenicity, shape and evidence of echogenic foci the classified according to the American college of radiology (ACR) TIRADS guidline, then compared with histopathological examination by Fine needle aspiration cytology (FNAC) . Results Many ultrasound features were predeictors of malignancy hypoechoic echopattern, taller than wider shape, punctate echogenic foci, and lobulated and irregular margins with (p Conclusion Our results suggest that ACR TIRADS classification is reliable in predicting thyroid malignancy. It could lead to a significant decrease of the number of unnecessary FNAC.

Major bleeding remains one of the most frequent complications seen in transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate outcomes, trends, and predictors of major bleeding in patients undergoing TAVI.We utilized the National Inpatient Sample (NIS) data from the year 2011 to 2018. Baseline characteristics were compared using a Pearsonχ2 test for categorical variables and Mann-Whitney U-Test for continuous variables. A multivariable logistic regression model was used to evaluate predictors of major bleeding. Propensity Matching was done for adjusted analysis to compare outcomes in TAVI with and without major bleeding.A total of 215,938 weighted hospitalizations for TAVI were included in the analysis. Of the patient undergoing the procedure, 20,102 (9.3%) had major bleeding and 195,836 (90.7%) patients did not have in-hospital bleeding events. Patients in the major bleeding cohort were older and had greater female gender representation. At baseline patients with thrombocytopenia (Odds Ratio [OR], 1.47[confidence interval (CI), 1.36-1.59]), colon cancer (OR, 1.70[CI, 1.27-2.28]), coagulopathy (OR, 1.17[CI, 1.08-1.27]), liver disease (OR, 1.31[CI, 1.21-1.41]), chronic obstructive pulmonary disease (OR, 1.29[CI, 1.25-1.33]), congestive heart failure (OR, 1.12[CI, 1.08-1.16]), and end-stage renal disease (ESRD) (OR, 1.47[CI, 1.38-1.57]) had higher adjusted rates of major bleeding. The percentage of adjusted in-hospital mortality (14.4% vs. 4.2%, P 0.01) was significantly higher in the major bleeding group Patients with major bleeding had higher median cost of stay ($235,274 vs. $177,920) and length of stay (7 vs 3 days).In conclusion, we report that mortality is higher in patients with major bleeding and that baseline comorbidities like ESRD, liver disease, coagulopathy and colonic malignancy are important predictors of this adverse event.

Introduction: Myocardial infarction (MI) remains a leading cause of mortality. Palliative care (PC) has recently expanded in scope to include noncancer-related conditions. There is little data available regarding the use of PC in critical MI patients. Methods: We used discharge data from the National Inpatient Sample for the years 2012 to 2014. We examined discharges with a primary diagnosis of MI. We measured the rate of PC referral, trend in utilization during the study period and possible predictors of PC utilization. Results: Among 1 667 520 discharges of those patients ≥18 years of age and with a primary diagnosis of MI, use of PC was seen in 2.5% of all patients and in 24% of patients who died. In a multivariable logistic regression, we found the presence of cancer, cardiogenic shock, dementia, stroke, hemiplegia, the use of circulatory support, and mechanical ventilation were associated with higher likelihood of PC referral. Palliative care referral increased during the study period, odds ratio of 1.18 per year (95% confidence interval: 1.14-1.21; P value Conclusion: Several comorbidities were associated with the use of PC, most notably the use of mechanical ventilation and the presence of metastatic cancer. There was a trend of increasing use of PC during the study period.

Objective: Diabetic retinopathy (DR) is one of the most common microvascular complications of type 2 diabetes (T2D). The reported prevalence of DR from different populations in the last decade was 13 - 38.1%. A report from our center 17 years ago showed that DR prevalence was 43.6%. With the all accumulated evidence showing that diabetes control decreases DR risk and the introduction of new drugs that helped better T2D control, we aimed to assess the current prevalence and predictors of DR among patients with T2D attending out-patient department at our tertiary care center. Methods: We conducted a cross-sectional study involving 638 patients. We collected information about their baseline characteristics, confirmed DR with its severity and maculopathy diagnosis, age at T2D diagnosis, duration of T2D, and averages of HbA1C, blood pressure (BP), cholesterol, and vitamin D levels over the previous year. A statistical analysis was performed using the software SPSS 23.0. A multivariate logistic regression analysis examined the independent predictors of DR development. Results: The mean age of the patients was 55.8 ± 10.3 years, and 42.8% were males. The mean BMI was 32.4 ± 12.4 kg/m2 with 58% had obesity. The mean duration of T2D was 11.5 ± 7.7 years, and the mean age at T2D diagnosis was 44.0 ± 9.98 years. The mean HbA1C was 8.3 ± 1.6 % with 77% had average HbA1C above 7% and 51.3% had average HbA1c above 8%. The mean systolic and diastolic BP were 136.37 ± 15.01 mmHg and 74.12 ± 8.078 mmHg, respectively. DR was diagnosed in 223 cases (35%). Of the 638 patients, 24.5% had non-proliferative DR, 9.2% had proliferative DR, and 4.2% had maculopathy. There was no significant difference in DR prevalence between males (36%) and females (34.1%) (P = 0.59). Predictors of DR development were age above 40 years, duration of T2D more than 10 years, early age of T2D diagnosis, average HbA1C more than 8%, and hypertension. Discussion: T2D is a major health challenge to our community with its very high prevalence. The prevalence of DR in T2D patients attending our institution was significant (more than one-third, 35%) in comparison to reports from other centers. However, we showed an improvement in DR development in our patients from 43.6% to 35%, probably due to better T2D and BP control. Similar to previous reports, T2D patients with older age, long T2D duration, younger age at T2D diagnosis, uncontrolled diabetes, and uncontrolled BP were more likely to develop DR. Conclusion: Physicians treating T2D patients should ensure regular retina screening especially for those with risk factors for DR. Also, they should fix the modifiable risk factors of DR; diabetes and BP control. References: (1) Alaboud et al. Saudi Med J 2016; Vol. 37 (12): 1408–1411.doi: 10.15537/smj.2016.12.17062. (2) Lim MC et al. Ann Acad Med Singapore. 2008 Sep;37(9):753–9. (3) Hammes H-P et al. PLoS ONE 10(7): e0132492. doi:10.1371/journal. pone.0132492

Obstructive Sleep Apnea (OSA) increases the risk of diastolic dysfunction and heart failure. The impact of OSA on hospitalization for heart failure with preserved ejection fraction (HFpEF) is not well elucidated. We used data from the National Inpatient Sample for the years 2012 to 2014. We identified discharges (age ≥18 years) associated with OSA and HFpEF using the International Classification of Diseases, Ninth Revision, Clinical Modification codes (327.23 and 428.3x), respectively. Propensity score analysis, adjusting for age, gender, race, and comorbidities, compared the rates of admission for HFpEF in patients with OSA to those without OSA. Out of 12,608,637 discharges included, there were 147,463 patients with HFpEF, and 653,762 or 5.2% of all discharges had OSA. The prevalence of OSA in patients with HFpEF was 16.8%. Patients with OSA were older, more likely to be men, more likely to have diabetes, hypertension, history of coronary artery disease, chronic kidney disease, obesity, atrial fibrillation, African-American race, and smoking status. In patients with OSA, HFpEF occurred in 3.8% versus 1.0%, with adjusted odds ratio: 2.2 (95% confidence interval 2.16 to 2.23), p0.001. Subgroup analysis showed similar results in men and women. After propensity score matching, OSA was associated with increased risk of admission with HFpEF, relative risk = 2.2 (95% confidence interval 2.12 to 2.21). In conclusion, OSA was associated with increased risk of hospitalization for HFpEF.

BACKGROUND: Delirium is associated with worse outcomes in critically ill patients. In the subset of patients with myocardial infarction (MI), the impact on clinical outcomes of delirium is not as well elucidated. HYPOTHESIS: Delirium is associated with increased mortality in patients hospitalized for MI. METHODS: The study used data from the National Inpatient Sample 2012 to 2014, Healthcare Cost and Utilization Project. We included discharges associated with the primary diagnosis of MI using the relevant International Classification of Diseases, Ninth Revision, Clinical Modification codes. The outcome was inpatient mortality between the delirium group and propensity score–matched controls without delirium. RESULTS: The study included 1 330 020 weighted discharges with MI as the principal diagnosis. Within this cohort, 18 685 discharges (1.4%) had delirium. Delirium was associated with older age, lower rates of percutaneous coronary intervention, and increased comorbid conditions. The delirium group had higher mortality (10.5% vs 2.6%, P

Background: Primary adrenal insufficiency is known to be induced by certain medications, including anesthetics, antimycotic and antiparasitic medications. However, it is rarely being reported that caused by antitumor immune checkpoint inhibitors PD-1. Clinical Case: A 82-year-old female with a significant history of lung adenocarcinoma status post of recent Pembrolizumab therapy. She presented with multiple complaints, including increasing confusion, mainly memory loss, generalized aches, and pains who was found to have recurrent hyponatremia with a sodium level of 122, treated with water restriction and sodium tablets. Initial screening labs were suggestive of adrenal insufficiency: level of ACTH was within the normal range (11 pg/dL, normal range 7.2–63 pg/dL), level of cortisol was low (1.6 ng/dL, normal range 3–23 pg/dL). MRI brain without contrast ruled out metastatic disease. An ACTH-stimulating test was performed, with the results revealing an inadequate cortisol response at 0, 30, and 60 minutes(1.4 ug/gl, 8.5 ug/dl, 11.9 ug/dl, normal range 18–20 ug/gl). Therefore, a diagnosis of primary adrenal insufficiency was made. The patient was prescribed a daily oral dose of 5 mg of hydrocortisone. Her symptoms improved after a few days, and her hydrocortisone gradually increased to 15 mg daily, and her energy and memory were back to baseline after six months. Conclusion: This is a rare case of primary adrenal insufficiency caused by Pembrolizumab using for non-small lung cancer treatment. With the growing use of Pembrolizumab, it is necessary to be aware of possible adrenal insufficiency that could be associated with receiving pembrolizumab therapy amid any clinical suspicion. Reference: Chang, L.S., et al., Endocrine Toxicity of Cancer Immunotherapy Targeting Immune Checkpoints. Endocr, Rev, 2019. 40(1): p. 17–65

Loperamide is an over-the-counter antidiarrheal agent that is considered by many patients to be safe, but has been used as a drug of abuse due to its opioid properties. However, cardiotoxicity has been reported, prompting the FDA to release a warning regarding the arrhythmogenic potential of loperamide. We present a case of a 38-year-old female presenting with cardiac arrest thought to be secondary to abuse of the loperamide that she was using to alleviate the heroin withdrawal symptoms. Cardiac ischemia and other drug toxicities were ruled out. Loperamide induces QTc prolongation and cardiac dysrhythmias. She had recurrent ventricular arrhythmias with multiple cardiac arrests. The persistence of the cardiotoxicity for a longer duration than previously reported in the literature is unique in this clinical presentation. We also highlight the potential mechanisms for loperamide cardiotoxicity and its challenging management. Abbreviations: ACLS: Advanced cardiac life support; GI: Gastrointestinal

INTRODUCTION: Chronic Obstructive Pulmonary Disease (COPD) is a major cause of hospitalization and is associated with an increased incidence of atrial fibrillation (AF). The impact of AF on in-hospital outcomes, including mortality, in patients hospitalized for COPD exacerbation is not well elucidated. METHODS: We used the National Inpatient Sample database to examine discharges with the primary diagnosis of COPD exacerbation and compared mortality, length of stay and costs in patients with AF compared to those without AF. The study adjusted the outcomes for known cardiovascular risk factors and confounders using logistic regression and propensity score matching analysis. RESULTS: Among 1,377,795 discharges with COPD exacerbation, 16.6% had AF. Patients with AF were older and had more comorbidities. Mortality was higher (2.4%) in the AF group than in the no AF group (1%), p

Episcleritis is the inflammation of the thin, loose, highly vascular connective tissue layer that lies between the conjunctiva and sclera. Incidence is less than 1/1000. It is more common in women and those between 40 and 50 years of age. Most cases are idiopathic. It is classified into simple and nodular. Most attacks resolve within 1–3 months. The nodular type tends to be more recurrent and painful. It presents with acute onset of redness, lacrimation, and photophobia. The diagnosis of is essentially clinical, and eye pain or tenderness should raise the concern for scleritis. Ophthalmological referral is recommended to rule out scleritis. Bloodwork to diagnose associated systemic rheumatological disease may be helpful. Cold compresses and artificial tears provide symptomatic relief. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids are used for persistent symptoms. Rarely, systemic steroids may be necessary. Immunosuppressive treatment to control an underlying autoimmune disorder is the last resort for resistant cases.

Cardiogenic shock (CS) carries high mortality and morbidity. The use of mechanical circulatory support (MCS) is one parameter of the increased resource utilization to address this morbid condition. Sex-based differences in the use of MCS in CS are not well elucidated We used data from the National

BACKGROUND: Obstructive sleep apnea (OSA) is a known independent risk factor for a multiple cardiovascular morbidities and mortality. The association of OSA and ventricular arrhythmias is less well understood. The aim of this analysis is to study the relationship between OSA and ventricular tachyarrhythmias. HYPOTHESIS: OSA is associated with increased ventricular arrhythmias. METHODS: Data from the national inpatient sample (NIS) 2012 to 2014, were reviewed. Discharges associated with OSA were identified as the target population using the relevant ICD‐9‐CM codes. The primary outcome was a diagnosis of ventricular tachycardia (VT) in the OSA population. Secondary outcomes include the rate of ventricular fibrillation (VF) and cardiac arrest. Multivariable analyses were performed to examine the association of VT with multiple potential confounding clinical variables. RESULTS: Of 18 013 878 health encounters, 943 978 subjects (5.24%) had a diagnosis of OSA. VT and VF were more prevalent among patients with OSA compared to those without a diagnosis of OSA (2.24% vs 1.16%; P < 0.001 and 0.3% vs 0.2%; P < 0.001, respectively). Odds ratio for cardiac arrest in OSA group was not statistically significant (1, 95% confidence interval 0.97‐1.02, P < 0.76). In unadjusted analyses, all examined comorbidities were significantly more common in those with OSA, including diabetes mellitus, hypertension, chronic kidney disease, acute coronary syndrome, and heart failure. CONCLUSION: OSA is associated with increased rates of ventricular tachyarrhythmia.

Immune thrombocytopenic purpura (ITP) is a bleeding disorder characterized by isolated thrombocytopenia (platelet count

INTRODUCTION Congestive heart failure (CHF) is seen in up to 13-25% of patients with NSTEMI. Recent data describing the impact of congestive heart failure (CHF) on in-hospital outcomes in patients with non-ST-segment elevation myocardial infarction (NSTEMI) in the United States is limited. We sought to examine the in-hospital outcomes, and management of CHF in patients admitted to the hospital with NSTEMI. METHODS National Inpatient Sample (NIS) database (2010-2014) was analyzed to identify patients with NSTEMI using ICD-9-CM codes. The primary outcome was in-hospital mortality. Propensity score-matching analysis compared mortality in CHF patients to matched controls without CHF. RESULTS Of 247,624 patients with NSTEMI, 84,115 (34%) had CHF. Patients with CHF were less likely to receive percutaneous coronary intervention (PCI) [20.48% vs. 40.9%, P

Introduction: Obesity is associated with better outcomes in patients with myocardial infarction and sepsis among other conditions a phenomena being described as obesity paradox. The impact of obesity and morbid obesity in DKA is not well studied. Objective: To estimate the impact of obesity and morbid obesity on in-hospital mortality in patients hospitalized for diabetic ketoacidosis (DKA). Methods: Data from the National Inpatient Sample (NIS) for the years 2012 to 2014, Health Care Utilization Project were reviewed. Patients with a diagnosis of DKA were included using the relevant ICD 9 codes. The primary outcome measured was in-hospital mortality. The Odds Ratio (OR) adjusted for age, gender, Charlson index and sepsis was calculated for obesity and morbid obesity respectively. Results: A total of 4,468,339 individuals with a diagnosis of DM were reviewed in this retrospective study. 132,362 patients (2.96%), who had a diagnosis of DKA were included. In patients with DKA, obesity (BMI 30-40) was present in 7,635 (5.77%). Morbid obesity was present in 5,290 (4%). Mortality was 1.8% vs. 1.9%, p=0.65 in patients with obesity and (3.5% vs. 1.9%, p Conclusion: In patients with DKA, morbid obesity was associated with increased mortality. A BMI of (30-40) was not associated with increased mortality. No protective effect of obesity or morbid obesity (obesity paradox) was observed in our study. Disclosure A. Elsheikh: None. A. Abdullah: None. A. Wahab: None. G.E. Eigbire: None. A. Salama: None. K. Rajamani: None.

Sarcoidosis is a multisystem granulomatous disorder. Cardiac manifestations of sarcoidosis are infrequent but are associated with increased mortality rates. Little epidemiological data is available on the relationship between Cardiac Sarcoidosis (CS) and Complete Heart Block (CHB). Data from the

Tophi (plural of tophus, Latin for “stone”) are stone-like deposits of monosodium urate in the soft tissues, synovial tissues, or in bones near the joints. They are pathognomonic for gout, the most common inflammatory arthritis in the United States, with an estimated lifetime prevalence of 4%. It is usually the end result of loss of the balance between uric acid production and excretion. It can be found anywhere in the body especially in areas of friction or trauma. It is usually painless and rarely to present as the initial manifestation of gout. It is diagnosed mainly clinically. Imaging is mainly used to assess the complication like bony erosions. The American College of Rheumatology (ACR) guidelines currently indicate that urate-lowering therapy should be initiated in patients with the presence of tophi visible on examination or imaging (ACR Evidence A). First-line therapy for urate lowering remains the xanthine oxidase inhibitor allopurinol. The ACR currently recommends colchicine, 0.6 mg (or 0.5 mg) once or twice daily, or low dose NSAIDs should be continued to reduce gout flare incidence for six months after resolution of the tophus. Daily prednisone ≤10 mg has been endorsed as an acceptable second-line prophylactic agent. Abbreviations: ACR: American College of Rheumatology; NSAID: non-steroidal anti-inflammatory drug

Introduction Takotsubo syndrome (TTS) is a relatively novel clinical entity that is increasingly diagnosed. Several factors affect the outcome of patients suffering from TTS but little is known about the impact of acute kidney injury Objective To assess the impact of acute kidney injury (AKI) on mortality Methods Using the National Inpatient Sample (NIS) for the years 2012, 2013 and 2014, Health Care and Utilization Project (HCUP), we identified patients with a diagnosis of (TTS). We also identified patients with a concomitant diagnosis of AKI. Patients were divided into two groups; AKI group and non-AKI group. We compared the mortality rates among patients with vs. without AKI. Multivariate logistic regression was performed to adjust for age, gender and comorbidities included in the Charlson comorbidity index Results Among 17,163 admissions with a diagnosis of TTS, there were 3,018 (17.58%) with a concomitant diagnosis of AKI. Patients with AKI were younger compared to patients without AKI (mean age 68.4 vs. 66.9; p Conclusion Among patients hospitalized with TTS, AKI was associated with increased risk of inhospital mortality.

Obstructive Sleep Apnea (OSA) is known to increase the risk of diastolic dysfunction (DHF) and incidence of acute heart failure in men. The impact of OSA on hospitalization with acute diastolic heart failure is not well described We analyzed data from the National Inpatient Sample (NIS), Health