OBJECTIVES Atrial fibrillation (AF) has been suggested as a cause for pulmonary embolism (PE). We aimed to explore the prevalence and clinical impact of AF in patients with PE. METHODS Using the 2012-2014 National (Nationwide) Inpatient Sample database, we identified "adult patients with PE" as the principal discharge diagnosis. The identified admissions were stratified into two cohorts based on the presence or absence of AF. We used multivariable regression models to evaluate in-hospital mortality, length of stay, nonhome discharge, and in-hospital complications. RESULTS The prevalence of AF among the 201,360 patients with PE was 11.62%. Patients with AF were more likely to have massive PE (odds ratio 1.59, 95% confidence interval 1.4-1.81, P < 0.001), with higher mortality (adjusted odds ratio 1.48, 95% confidence interval 1.27-1.71, P < 0.001) and a greater risk of mechanical ventilation, cardiac arrest, and nonhome discharges. The length of hospital stay in patients with PE and comorbid AF was significantly longer than those without (6.24 ± 0.10 vs 4.79 ± 0.03 days). CONCLUSIONS AF is associated with a higher rate of massive PE, higher in-hospital mortality, a longer length of hospital stay, and a higher incidence of in-hospital complications and nonhome discharge.

Background: Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) is an effective treatment of acute ischemic stroke (AIS). The safety of intravenous rtPA in patients with thrombocytopenia is unclear. This study sought to evaluate the impact of thrombocytopenia on in-hospital outcomes in patients with AIS who received intravenous thrombolysis. Methods: This was a retrospective study using the 2012-2014 National Inpatient Sample (20% stratified sample of US hospitals). The study identified adult patients admitted with AIS who received intravenous rtPA during hospitalization. The identified admissions were stratified into 2 cohorts based on the presence or absence of thrombocytopenia. Multilevel, multivariate regression analysis and propensity matching were performed to evaluate in-hospital mortality, length of stay, and in-hospital complications. Results: Of 101,527 patients admitted for AIS and received intravenous rtPA from 2012 to 2014, 3,520 (3.47%) had thrombocytopenia. In-hospital mortality was 10.8 vs. 6.9% in patients with and without thrombocytopenia in original data, p < 0.001. In-hospital length of stay was significantly higher in the thrombocytopenia group (5.9 vs. 8.2 days, p < 0.001). The differences were significant in both the multivariate regression model and the propensity score matching model. Patients with thrombocytopenia also had a statistically higher incidence of intracranial hemorrhage, postprocedural bleeding, blood transfusion, tracheotomy, and mechanical ventilation. Conclusion: Thrombocytopenia is associated with higher in-hospital mortality, longer length of stay, a higher incidence of intracranial hemorrhage, postprocedural bleeding, and mechanical ventilation in stroke patients who received intravenous rtPA. (C) 2019 S. Karger AG, Basel

Streptococcus thoraltensis, Genus Streptococcus sensu stricto, is a rare species of streptococci that has been very rarely reported to cause infection in humans. It is isolated from the sows and is found in the intestinal tract of pigs. We describe here a case of S. thoraltensis bacteremia in a postpartum patient with pneumonia.

BACKGROUND:Diabetic ketoacidosis entails a huge health burden among patients with diabetes. Atrial fibrillation (AF) is the most common type of heart arrhythmia. This study aimed to evaluate the impact of AF on clinical outcomes in patients with diabetic ketoacidosis.METHODS:Using the 2012-2014 National Inpatient Sample database, we identified adult patients hospitalized with diabetic ketoacidosis as the principal discharge diagnosis. The identified admissions were stratified into 2 cohorts based on the AF presence. We used multivariable regression models and propensity score matching models to evaluate in-hospital mortality, length of stay, comorbidities, and in-hospital complications.RESULTS:The study included 478,890 adult patients who were admitted for diabetic ketoacidosis in the year 2012-2014. A total of 467,780 (97.68%) had no AF and 11,125 (2.32%) had AF. In both multivariable regression models and propensity score matching models, compared with nonatrial fibrillation group, the AF group had higher in-hospital mortality rates (2.36 [1.69-3.32], P < 0.001) and longer length of stay (5.5 versus 3.3 days, P < 0.001). AF was also associated with a significantly higher incidence of complications including septic shock, pulmonary failure, mechanical ventilation, neurological failure, cerebral edema, acute kidney injury, acute hematologic failure, and cardiac arrest.CONCLUSIONS:Among patients who were hospitalized for diabetic ketoacidosis, comorbid AF led to increasing in-hospital mortality rates and longer length of stay. A potential explanation was that AF increased the risk of in-hospital complications including respiratory failure with a more frequent requirement for mechanical ventilation, cardiac arrest, and metabolic encephalopathy.

Hemolytic uremic syndrome (HUS) is the triad of nonimmune (Coombs negative) hemolytic anemia, low platelet count, and renal impairment. HUS has been associated with a variety of gastrointestinal malignancies and chemotherapeutic agents. We present a patient with pancreatic cancer treated with gemcitabine for palliation who developed gemcitabine-induced HUS (GiHUS) which responded to some extent to blood and platelet transfusions. With the increase in the use of gemcitabine therapy for pancreatic and other malignancies, it is essential to accurately and timely diagnose GiHUS to avoid the life-threatening complications.

The vast majority of sudden cardiac arrests occur in patients with structural heart disease and in approximately 10% of the cases, it can occur in those with structurally normal hearts. Brugada syndrome is an autosomal dominant sodium channelopathy that has been implicated in sudden deaths. Given their low prevalence, our knowledge about Brugada syndrome is still evolving. Apart from schizophrenia, there have been no reports of associated medical conditions. We recently encountered a patient with vascular Ehlers-Danlos syndrome who was also found to have Brugada syndrome. Both these conditions share some common clinical presentations including a propensity for sudden death.

AIM To evaluate the safety and efficacy of ledipasvir/sofosbuvir on hepatitis C eradication in patients with hepatitis C virus (HCV)/human immunodeficiency virus (HIV) co-infection in an urban HIV clinic. METHODS A retrospective cohort study of 40 subjects co-infected with HIV-1 and HCV treated with the fixed-dose combination of ledipasvir and sofosbuvir for 12 wk from 2014 to 2016. All patients included were receiving anti-retroviral therapy (ART) with HIV RNA values of 100 copies/mL or fewer regardless of baseline HCV RNA level. The primary end point was a sustained virologic response of HCV at 12 wk (SVR12) after the end of therapy. RESULTS Of the 40 patients enrolled, 55% were black, 22.5% had been previously treated for HCV, and 25% had cirrhosis. The patients were on a wide range of ART. Overall, 39 patients (97.5%) had a SVR 12 after the end of therapy, including rates of 97.1% in patients with HCV genotype 1a and 100% in those with HCV genotype 1b. One patient with HCV genotype 3a was included and achieved SVR12. Rates of SVR12 were similar regardless of previous treatment or the presence of compensated cirrhosis. Only 1 patient experienced relapse at week 12 following treatment and deep sequencing didn't reveal any resistance associated mutation in the NS5A or NS5B region. Interestingly, 7 (17.5%) patients who were adherent to ART experienced HIV viral breakthrough which resolved after continuing the same ART regimen. Two (5%) patients experienced HIV-1 virologic rebound due to noncompliance with HIV therapy, which resolved after resuming the same ART regimen. No severe adverse events were observed and no patient discontinued treatment because of adverse events. The most common adverse events included headache (12.5%), fatigue (10%), and diarrhea (2.5%). CONCLUSION This retrospective study demonstrated the high rates of SVR12 of ledipasvir/sofosbuvir on HCV eradication in patients co-infected with HCV and HIV, regardless of HCV baseline levels, HCV treatment history or cirrhosis condition. The oral combination of ledipasvir/sofosbuvir represents a safe and well tolerated HCV treatment option that does not require modification for many of the common HIV ART. Occasional HIV virologic rebound occurred but later resolved without the need to change ART.

Key Clinical Message We describe an extremely rare case of migraine‐associated monocular diplopia developed in a 23‐year‐old man after sudden cessation of smoking. The physical examination and brain MRI scan were unremarkable. The symptoms resolved after starting nicotine patch. We reviewed the literature and discussed the diagnosis and possible mechanism of this phenomenon.

RATIONALE, AIMS, AND OBJECTIVES:The impact of teaching versus nonteaching services on outcomes and resource use in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is unknown. The aim of the study is to evaluate the impact of an internal medicine teaching service compared to a nonteaching service on outcomes and resource use in patients admitted with AECOPD in a community teaching hospital.METHODS:A retrospective cohort study of patients admitted for a primary diagnosis of chronic obstructive pulmonary disease exacerbation to Florida Hospital Orlando, a large community teaching hospital, between January 1, 2011, and December 31, 2014. Data were extracted from Premier administrative database. Risk adjusted length of stay (LOS), cost of hospitalization, 30-day readmissions, and mortality rate were measured. Risk adjustment for outcomes was based on Premier CareScience methodology.RESULTS:A total of 1419 patients were included, 306 in the teaching group and 1113 in the nonteaching group. Risk adjusted cost and LOS were significantly lower in the teaching group compared to the nonteaching group (observed/expected cost 0.66 vs 1.06, P < .001) and (observed/expected LOS 0.93 vs 1.69, P < .001), respectively. No significant difference was found between the 2 groups in risk adjusted mortality and readmissions (P = .48 and .89, respectively). Use of consults was significantly lower in the teaching groups with 73% vs 31% of the patient in the teaching group had no consults compared to the nonteaching group (P < .001). The teaching service was significantly associated with decreased use of consults after adjustment for other variables (odds ratio, 0.17, 95% CI, 0.15-0.23, P < .001).CONCLUSION:The teaching service had more favorable outcomes compared to nonteaching services in patients hospitalized for AECOPD. The physician practice model has a major impact on the cost, LOS, and use of consults in patients with AECOPD.

OBJECTIVE:Gastrointestinal bleeding (GIB) is a common cause of hospitalization in the older adult population. The aim of the study was to identify factors that are associated with the need for a therapeutic intervention in patients older than 65 years with nonvariceal GIB.METHODS:This is a retrospective cohort study of older adult patients admitted to a tertiary care center between 2009 and 2011 with nonvariceal GIB. The primary outcome was a composite endpoint of inpatient mortality or need for an endoscopic, surgical, or radiologic procedure to control the bleed or to treat the underlying source of the bleed.RESULTS:A total of 314 patients were included. In-hospital mortality was 1.3% (4 patients). An intervention to control the bleeding was performed in 15 patients (4.8%). Four patients (1.3%) needed a nonurgent intervention. Twenty-three patients (7.23%) had the primary combined outcome of in-hospital mortality or need for any therapeutic endoscopic, surgical, or radiologic intervention. Factors that were independently associated with the primary outcome were systolic blood pressure within the first 24 hours of <90 mm Hg (odds ratio 3.05, 95% confidence interval 1.08-8.59, P = 0.001), and initial hemoglobin of <7 g/dL (odds ratio 4.81, 95% confidence interval 1.56-14.74, P = 0.006).CONCLUSIONS:Nonvariceal GIB in older adult patients ceases spontaneously in most patients without an invasive intervention. Systolic blood pressure within the first 24 hours of <90 mm Hg and an initial hemoglobin level of <7 g/dL could be used to identify high-risk patients who may benefit from an urgent therapeutic intervention.

Although rare, cardiac myxomas are the most common primary cardiac tumor with an incidence of 0.5 per million per year. Previous case series have reported on the epidemiology, clinical characteristics, diagnostic technologies and therapeutic outcomes that were evident at the time of publication. Because of the evolution of cardiac diagnostic (particularly imaging) and therapeutic options, we theorized that cardiac myxomas would be found at an earlier stage and this would result in improved therapeutic outcomes. Accordingly, a new case series (Current Group) is being reported and compared to historical case series that were published after widespread availability of echocardiography (after 1985). The case series were further divided into those published before (group 3), after (group 1) or overlapping (group 2) the proliferation of chest and cardiac imaging technologies that occurred in the mid-1990s. All 28 patients with pathologically proven cardiac myxoma at Florida Hospital Orlando from April 2007 to August 2013 (the Current Group) were studied. For comparative review, PubMed was searched for case series of cardiac myxoma from January 1, 1985 to December 31, 2013, and studies that met inclusion criteria were divided into three groups: Group 1: cases collected exclusively after 1995 (10 articles); Group 3: cases exclusively before 1995 (31 articles); and Group 2: those not belonging to group 1 or 3 (23 articles). The gender (2:1 female predominance), age and myxoma location (85% left atrium) have not changed significantly over time. However, the tumor size has declined from 5.3 cm to 3.3 cm. Asymptomatic cases (found unexpectedly) have increased to 21% of the Current Group while fever, heart failure and embolism have declined over time. Echocardiography has become the dominant diagnostic technology, followed by CT. Catheter based diagnostic imaging has declined substantially. Surgical mortality and tumor recurrence have remained low but unchanged. In summary, cardiac myxoma has trended to smaller, more frequently asymptomatic tumors found mostly by echocardiography or CT, but this has not altered surgical mortality or recurrence.

Introduction: Multiple myeloma (MM) is a malignant neoplasm of plasma cells. Nonsecretory multiple myeloma (NSMM) is a rare variant that accounts for 1-5% of all cases of MM. It is characterized by absence of monoclonal immunoglobulins in serum and urine protein electrophoresis. Extramedullary involvement has been reported in up to 20% of the cases of MM. Gastrointestinal (GI) involvement in MM is extremely rare (0.9%) and GI hemorrhage is occasionally reported. To the best of our knowledge, this is the first reported case of NSMM presenting with GI bleeding and involving multiple distinct sites of GI tract.Figure 1Figure 2Figure 3Case: A 64-year-old male presented with two-week history of hematochezia and fatigue. He was diagnosed with true NSMM a year previously. He completed five cycles of Bortezomib, Cyclophosphamide, and Dexamethasone (VCD) with minimal response and was switched to Lenalidomide and Dexamethasone. He was hemodynamically stable. Laboratory data showed Hemoglobin of 5.5 g/dl, Platelets 26000/ul, Blood Urea Nitrogen 9 mg/dl and INR 1.1. Esophagogastroduodenoscopy and Colonoscopy revealed multiple punctate ulcerations of the stomach, a duodenal bulb nodule and diffuse colonic ulcerations. Histopathology of all the biopsied lesions showed extensive mucosal infiltration by atypical monoclonal plasma cells. Despite transfusions he continued to have intermittent bleeding. He was deemed a poor candidate for further chemotherapy and opted for hospice care. Discussion: NSMM is a rare entity of MM. Gastrointestinal spread is an unusual phenomenon in MM, but where it does occur, small intestine is the most commonly involved site, followed by stomach, colon and esophagus. Endoscopically, morphology of GI plasmacytomas ranges from discrete ulcers, infiltrative masses, and nodules to polypoid lesions. Diagnosis is made on histopathology with plasma cell infiltration. Treatment of GI plasmacytomas remains the same as for systemic MM. Chemoradiation therapy and hematopoietic stem cell transplantation are the mainstay of treatment, and surgery is typically reserved for complications. The prognosis of MM patients with GI involvement has been reported to be poor despite aggressive measures. Conclusion: Although GI plasmacytomas are uncommon, they must be considered in the differential diagnosis of patients with GI symptoms, especially those with a prior history of MM. Endoscopic evaluation and histopathological examination is crucial for early diagnosis and further intervention.

Brodifacoum poisoning occurs as a result of ingestion of rodenticide compounds. It acts as a superwarfarin, inhibiting vitamin K epoxide reductase, in an irreversible fashion much like warfarin but with a much longer half-life. A 48-year-old female patient reported 4 days of mild dyspnea, dry cough, bilateral popliteal fossae pain and diffuse upper abdominal pain. She had no history of liver disease or alcohol or illicit substance abuse. Initial physical examination was remarkable only for mildly pale conjunctivae and mild abdominal tenderness and pain in the left popliteal fossa. A complete blood count and complete metabolic panel were normal. Prothrombin time (PT) was above 100 s, partial thromboplastin time (PTT) was above 200 s and international normalized ratio was reported as above 12.0. Urinalysis revealed hematuria. Venous Doppler ultrasound of lower extremities demonstrated left popliteal vein thrombosis. Computed tomography scan of the abdomen demonstrated transmural hematoma, and fecal occult blood test was positive. A full anticoagulant work-up showed critical reduction of vitamin K-dependent factors II, VII, IX and X. PT and PTT corrected with mixing studies proving factor deficiency as the cause of the coagulopathy. Lupus anticoagulant studies were negative. Superwarfarin toxicity was suspected and confirmed with an anticoagulant poison panel positive for brodifacoum. The patient was hospitalized and successfully treated with fresh frozen plasma, cryoprecipitate and vitamin K. In conclusion, paradoxical thrombosis and hemorrhage should raise the suspicion for superwarfarin toxicity in the appropriate clinical setting. Further studies are required to define the management of these patients.

Cardiologists may be the principal attending physician or the consultant to general internists or hospitalists in hospitalized patients with cardiovascular diseases. To find out which role may be best for quality and efficiency, a retrospective cohort study of 15, 113 patients in 11 cardiovascular diagnosis groups was carried out. Hospital cost, length of stay, mortality, and 30-day readmissions were compared among attending physicians who were hospitalists, general internists, or cardiologists. After adjustment for differences in demography and severity, cardiologists generally had substantially lower cost and length of stay compared with internists or hospitalists, especially when the diagnosis group included a cardiovascular procedure. Hospitalists and internists did not differ substantially in cost or length of stay. There were no statistically significant differences among the physician groups in mortality or 30-day readmissions. In conclusion, cardiologists may be the more efficient attending physician for selected cardiovascular diseases, especially when procedures are involved.

Methicillin-resistant Staphylococcus aureus (MRSA) cultures were obtained from 288 mother-infant pairs. A questionnaire given to mothers and medical record review assessed risk factors for colonization. Only 2.1% of mothers and 0.7% of infants carried MRSA. There were no identical MRSA mother-newborn pairs. MRSA colonization by expectant mothers is uncommon and transmission to newborns from vaginal delivery did not occur.

BACKGROUND:The model of inpatient medical management has evolved toward Hospitalists because of greater cost efficiency compared to traditional practice. The optimal model of inpatient care is not known.OBJECTIVE:To compare three models of inpatient Internal Medicine (traditional private practice Internists, private Hospitalist Internists, and Academic Internists with resident teams) for cost efficiency and quality at a community teaching hospital.DESIGN:Single-institution retrospective cohort study.MEASUREMENTS AND MAIN RESULTS:Measurements were hospital cost, length of stay (LOS), mortality, and 30-day readmission rate adjusted for severity, demographics, and case mix. Academic Internist teams had 30% lower cost and 40% lower LOS compared to traditional private Internists and 24% lower cost and 30% lower LOS compared to private Hospitalists. Hospital mortality was equivalent for all groups. Academic teams had 2.3-2.6% more 30-day readmissions than the other groups.CONCLUSIONS:Academic teams compare favorably to private Hospitalists and traditional Internists for hospital cost efficiency and quality.

The etiology of non-Hodgkin's lymphoma (NHL) is not well understood. To develop hypotheses on causes of this tumor, data from a population-based case-control interview study of 1,867 white men (622 cases and 1,245 controls) in Iowa and Minnesota conducted during 1980-1983 were examined. Subjects, or their next of kin, were interviewed to obtain information on agricultural exposures, work history, medical conditions, and family history. This analysis focuses on risks of NHL by occupation, by industry, and by selected exposures. Although many comparisons were made, few significant associations were observed. Small numbers and limitations in exposure assessment, however, would tend to reduce opportunities to detect associations. The strongest finding was with various occupations that work in metals and metal products. The analysis by exposure estimates also uncovered a significant association with metals, but risks did not increase with estimated intensity of exposure. Slightly elevated risks were also noted among persons employed as painters and construction workers, agricultural and forestry workers, printers and typesetters, funeral directors and embalmers, and dry cleaners. Although the overall risks for benzene and other solvents were small, they increased slightly with level of assigned exposure. Although some associations may be due to chance, several of these occupations and industries have been linked to lymphoma in other investigations and deserve further attention.