Bronx-Lebanon Hospital Center

Emphysematous gastritis (EG) is a rare and life-threatening condition characterized by gas-forming microorganisms causing gas to accumulate within the stomach wall. It has a high mortality rate and is associated with risk factors like gastroenteritis, alcohol use disorder, diabetes mellitus, renal failure, recent abdominal surgery, long-term corticosteroid use, and ingestion of corrosive agents. Diagnosis is challenging due to its rarity and nonspecific symptoms, including severe abdominal pain, coffee-ground emesis, fever, and signs of systemic infection. We present two cases of patients with signs and symptoms of EG, where prompt diagnosis and treatment were achieved, avoiding further complications. Surgical intervention was avoided due to the successful response to conservative treatment. These cases highlight the importance of early detection and intervention in improving patient outcomes and preventing complications associated with EG.

Introduction: Hypertensive disorders of pregnancy (HDP) are increasing in prevalence in the USA and affect maternal morbidity and mortality. Hypothesis: Echocardiographic strain abnormalities may be more prevalent in patients with HDP in active labor, which may unmask subclinical left ventricular dysfunction. Methods: A total of 59 healthy term parturients (≥37 wks gestational age) in active labor (≥6cm cervical dilation) underwent echocardiography to assess cardiac function during peak physiologic stress. Speckle tracking strain analysis was performed using apical 4-, 3- and 2-chamber views during uterine contraction and relaxation with a S5-1 Philips Sparq probe and analyzed with Qlab 9 strain analysis software (Philips, Andover, MA, USA). Abnormal strain cutoff was >-20%. Mean ± SD summarized continuous variables; absolute and relative frequencies for categorical. Welch T-test and Chi-square were used for group comparisons. Results: HDP was present in 21 subjects and absent in 39. Mean age, parity, and prevalence of diabetes did not differ significantly between the two groups. The HDP group had a higher mean BMI (Table 1). The non-HDP group had strain abnormalities in two segments during uterine relaxation, absent during contraction. The HDP group had abnormalities in 5 segments during uterine relaxation, 4 of which were persistently abnormal during uterine contraction (Fig 1). Conclusions: Abnormal strain values were detected at a higher rate in HDP group than in non-HDP group in active labor. Future research is needed to determine if subclinical strain abnormalities in those with HDP during active labor are predictive of developing future cardiovascular disease.

Pre-workout supplement use has increased in recent years. Multiple side effects and off-labeled substances have been reported. We report a case of a 35-year-old patient who recently started a pre-workout and was found to have sinus tachycardia, elevated troponin, and subclinical hyperthyroidism. The echocardiogram showed normal ejection fraction and no wall motion abnormality. Beta-blockade therapy with propranolol was offered, but she refused, and her symptoms and troponin levels improved after proper hydration within 36 hours. A cautious and accurate assessment of young, fitness-enthusiastic patients experiencing unusual chest pain is essential to identify a reversible cardiac injury and possible off-label substances in over-the-counter supplements.

Introduction: Acute myocardial infarction (AMI) is a leading cause of death in the US. More than 800,000 adults experience an AMI each year, and up to 20% of the patients are rehospitalized within 30 days. Predicting 30-day readmission accurately could help clinicians identify high-risk patients and tailor treatment accordingly. Hypothesis: The neural network will generate the best performing model for predicting 30-day readmissions following an AMI. Methods: The cohort included adults hospitalized with incident AMI (6,506) at Dartmouth Hitchcock Medical Center between 2011-2016. Patients who died before discharge (236) were excluded, leaving 6,270 patients. Our outcome was 30-day hospital readmissions. Candidate features were selected using an Extra Tree Classifier. Selected features included demographics and clinical characteristics. Multiple imputation using K-Nearest Neighbors was performed. Five machine learning models were implemented: logistic regression, LASSO, neural network, random forest, and XGBoost. Models were evaluated on a hold-out test-set, using AUROC. Results: Among the cohort, about 36% were female, the majority were white and non-Hispanic, and the 30-day readmission rate was 6.2%. Neural network was the best performing model with an AUROC of 0.80 (95% CI: 0.75, 0.84). However, the XGBoost and random forest models performed similarly with AUROCs of 0.80 (95% CI: 0.76, 0.85) and 0.79 (95% CI: 0.75, 0.84), respectively. The logistic regression and LASSO models performed poorly, with AUROCs below 0.5, respectively. Important predictor variables were major depression, race, and antidepressant at discharge. Conclusions: Neural network, random forest, and XGBoost models predicted 30-day readmission following an AMI with good performance. Across these models, depression was an important feature for predicting 30-day readmissions. Results reinforce the importance of mental health among patients hospitalized for AMI.

Introduction: Clinical decision-making around AF-related stroke risk management is complicated by the widely available and safe direct acting oral anticoagulants (AC) and uncertain long term risks of left atrial appendage occlusion (LAAO) in patients who are older and more female than clinical trial participants. Hypothesis: Among matched sex-stratified Medicare beneficiaries with AF, there is no difference in risk of mortality, stroke, and bleeding associated with LAAO versus AC alone. Methods: Medicare beneficiaries with AF and CHA2DS2VASc of 2 (males) or 3 (females) (2015-2019) were divided into those who underwent LAAO or received AC only. LAAO and AC patients were propensity score matched 1:1 within sex subgroups based on available characteristics. A Cox proportional hazards model was used to model the survival time from the LAAO implant date to evaluate the comparative risks of mortality, stroke/thromboembolism, and any bleeding events based on ICD-10 codes. Results: Matching sex-stratified AC and LAAO patients was successful (SMD < 10% on all variables). Average follow-up was 1 year. Among females (n=4,085; mean 76 years, CHA2DS2VASc 5.1), LAAO was associated with reduced risk of mortality and stroke/thromboembolism (HR 0.51 95% CI 0.45-0.58; HR 0.66 95% CI 0.56-0.77, p<0.0001) compared with AC; similar findings were observed among males (n=5,378; mean 75.3 years, CHA 2 DS 2 VASc 4.1) regarding mortality and stroke/ thromboembolism (HR 0.54 95% CI 0.49-0.60; HR 0.65 95% CI 0.55-0.76, p<0.0001). Comparative bleeding risk varied over time with LAAO associated with greater risk early then lesser risk (females HR 1.03 95% CI 0.92-1.16; males HR 1.05 95% CI 0.95-1.17). (Figure) Conclusion: Within sex subgroups during an average of 1 year follow up, LAAO was associated with a reduced risk of mortality and stroke/thromboembolism when compared with AC alone among Medicare beneficiaries with AF. There was no difference in the risk of bleeding between LAAO and AC groups.

Abstract Background In general, rates of in-hospital cardiac arrest are reportedly 9 to 10 arrests per 1000 admissions, with survival rates of approximately 20–25%. Data regarding clinical characteristics and outcomes in patients with COVID-19 who received in-hospital CPR (cardiopulmonary resuscitation) are limited. This information can help guide end-of-life care conversations between families and health care workers based on real-world experience. Purpose To observe the outcomes (survival to discharged alive from the hospital) in critically sick COVID-19 patients who experienced in-hospital cardiac arrest. Methods This is a multi-centre institutional review board (IRB) approved retrospective study. The RT-PCR confirmed adult COVID-19 patients consecutively admitted from March 1st to April 30, 2020, were included. Data were extracted manually using the hospital's electronic medical record. The final date of follow-up to monitor clinical outcomes was January 2021. Results A total of 721 patients were admitted to the hospital. Of these, only 64 (8.87%) patients had “no CPR” orders.Cardiac arrest occurred in 141 (19.5%) patients. The mean duration of beginning of resuscitation was less than a minute and the mean duration of CPR was 19 minutes. The median age was 65 years; 62.4% were male. The most common co-morbidities were hypertension (66%) and diabetes mellitus (56%). The initial rhythm was non-shockable in 93.7% of patients [asystole in 48.4% and Pulseless Electrical Activity (PEA) in 45.3% of patients]. Only six (4.2%) patients had pulseless ventricular tachycardia and three (2.1%) patients had ventricular fibrillation. A total of eight patients (5.6%) survived and were discharged from the hospital; six (4.25%) had non-shockable and two (0.82%) had shockable initial rhythms. The median age of those who survived was 60 years (Figure 1). Conclusions Our study showed that critically sick patients with COVID-19 have a high rate of cardiac arrest and poor outcomes in those who received CPR. A non-shockable initial rhythm indicates that non-cardiac reasons might be playing a major role. These include acute respiratory insufficiency, severe sepsis, or multiorgan failure. These data should inform end-of-life care discussions between providers and patients' families. Funding Acknowledgement Type of funding sources: None.

Introduction: Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare entity, mostly associated with autoimmune conditions such as SLE. It is benign, focal, self-limited, and despite abundant literature, its pathogenesis remains unknown. We report a unique case of KFD in a patient with coexisting Crohn’s disease. Case description/methods: A 23-year-old female with no medical history was evaluated for Iron deficiency anemia and anorexia. She underwent a colonoscopy which revealed normal colonic mucosa, however, an ulcerated and congested terminal ileum was seen. Biopsies were significant for acute cryptitis and granuloma. Serology was positive for anti–Saccharomyces cerevisiae antibody and fecal calprotectin was elevated. She was initially started on oral corticosteroids and later transitioned to azathioprine and Adalimumab, with a good response. 7 months later, she was planned for a repeat colonoscopy to check for endoscopic healing, however, at her pre-procedure COVID testing, she was noted to have rubbery painless LAD of the right neck. The procedure was postponed and she was immediately asked to discontinue her medications. She was referred to an oncologist. A CT chest was unremarkable and an excisional biopsy of the largest of the lymph node revealed necrotizing lymphadenitis, favoring KFD. Infectious workup was negative. Over the next 2 months, her LAD spontaneously resolved without the need for medications. A repeat colonoscopy was aborted due to poor prep. A follow-up MRE revealed long segment mid and distal Crohn's ileitis, and fecal calprotectin remained elevated. She was started on oral budesonide with plans to restart biological therapy after repeating a colonoscopy. Discussion: KFD may rarely involve the terminal ileum, potentially masquerading as Crohn’s disease. Our patient, however, had histological findings pathognomic for Crohn’s and her ileitis did not resolve with the resolution of LAD. Lymphoma remains a feared adverse outcome of both immunomodulators and Anti-TNF medications, thus necessitating their cessation upon signs of LAD. However negative EBV testing, an unrevealing chest CT, and a benign histological diagnosis of KFD may allow our patient to safely resume these medications to treat her Crohn's.Figure 1.: Excisional Lymph node biopsy specimen demonstrating necrotizing histiocytic lymphadenitis. No infectious organisms were identified (Negative PAS, Warthin-Starry stain, Tuberculosis, HSV 1/2 and EBV immunohistochemistry).