Harrisburg Hospital

We present a case of acute fatty liver of pregnancy (AFLP) with significant coagulopathy despite no bleeding symptoms, which was managed with spinal anesthesia without adverse events. This phenomenon may not be attributable to coincidence alone. Upon reviewing the literature, standard coagulation tests fail to account for the simultaneous reduction in pro- and anticoagulant factors, leading to a misleading impression of coagulopathy and often overestimating the risk of bleeding. Thus, it is advised that coagulopathy tests associated with liver disease should not be used solely to dictate anesthesia decisions; a thorough history obtained from the patient, family, or medical records may be more informative than abnormal coagulation tests.

A 52-year-old woman presented to the emergency department with 3 days of abdominal pain. The pain began 1 day after undergoing a screening colonoscopy. On examination, her vital signs were normal and she had significant tenderness to the lower abdomen. Laboratory work revealed a white count of 22 K/µL and a normal lactate (0.8 mmol/L). An upright chest and abdominal x-ray were normal. Computed tomography (CT) of the abdomen with intravenous (IV) contrast was then performed. Intestinal perforation is a potentially life-threatening complication that may arise from diverse etiologies, including instrumentation.1-4 The initial step in workup of suspected intestinal perforation is often looking for free air under the diaphragm on an upright abdominal x-ray to evaluate for pneumoperitoneum.1 We would not see this finding in our patient because she had pneumoretroperitoneum, where the gas pattern is different from that of pneumoperitoneum.5 Ultimately, CT scan showed retroperitoneal air tracking along the aorta and inferior vena cava (IVC) (Figures 1 and 2). She underwent exploratory laparotomy with creation of a diverting end descending colostomy. Colonoscopy-related perforation (CRP) is rare; the incidence ranges from 0.016% to 0.2% following diagnostic procedures and up to 5%, if the colonoscopy is therapeutic.2-4 Rectal perforations, as in this case, have been reported to have an incidence ranging from 0.003% to 0.01%.2, 6 CRP can be managed conservatively or surgically. It is important to note that up to 31% of patients with CRP present for treatment more than 24 h after their colonoscopy.3, 4

Abrupt baclofen withdrawal may be life-threatening with varied neuropsychiatricmanifestations. We present a case of baclofen withdrawal necessitating intubation. A58-year-old female with a history of undiagnosed muscle spasticity presented withworsening extremities tremors, paresthesia, and weakness for 2 days. Initial vitalsincluded temperature 103 F, tachycardia, hypertension, and tachypnea. Examination revealedcoarse tremors of all extremities. Inflammatory markers, blood, and urine culture werenegative. Head and spine imaging were non-diagnostic. Meningitis and seizure were ruledout. She continued worsening with hallucinations, hyperpyrexia, ocular clonus, andprofound muscle rigidity. The patient was intubated for respiratory distress andtransferred to intensive care unit (ICU). Further history revealed running out of oralbaclofen 3 days ago. Baclofen was restarted with symptomatic improvement. The patient wasextubated after 2 days and discharged to a rehabilitation facility. Oral or intrathecalbaclofen is thought to inhibit spinal nerves reducing muscle spasm and pain. Abruptstoppage causes activation of dopamine and noradrenergic receptors causing muscle spasms,tremors, hyperpyrexia, delusions, hallucination, and delirium. Severe cases can mimicmeningoencephalitis, seizure disorder, or neuroleptic malignant syndrome. Symptoms usuallydevelop in 1 to 3 days of cessation and can be life-threatening if unrecognized timely.Treatment includes supportive therapy, re-administration of baclofen, or use ofbenzodiazepines, propofol, dexmedetomidine; however, no specific guidelines have beenestablished. To the knowledge of the authors, this is the first case of oral baclofenwithdrawal requiring intubation. We found only 3 reported cases of intrathecal baclofenwithdrawal necessitating intubation.

ABSTRACT Introduction Mitral annulus calcification (MAC) is a chronic, non-inflammatory, degenerative mechanism of the fibrous base of the mitral valve. While MAC was originally thought to be an age-related degenerative process, there is evidence that other mechanisms, such as atherosclerosis and abnormal calcium phosphorus metabolism, also contribute to the development of MAC. Areas covered This paper summarizes, existing perception of clinically valid definition of MAC and the pathophysiological processes that lead to the development of MAC and the diagnostic implications of this disease entity. Expert opinion Minimal evidence exists on the natural history and progression of MAC. Characterization of MAC progression and identification of predisposing risk factors can help to validate hypotheses. MAC is most commonly asymptomatic and incidental finding. Echocardiography is the primary imaging modality for identification and characterization of MAC and associated mitral valve (MV) disease. For patients with an indication for MV surgery, computed tomography (CT) is a complementary imaging modality for MAC. MAC is generally recognized by its characteristic density, location, and shape on echocardiography and CT, unusual variants are sometimes confused with other lesions.

Introduction: Catheter ablation is widely accepted intervention for atrial fibrillation (AF), but data is limited on contemporary trends in major complications and mortality due to the procedure. Methods: HCUP’s Nationwide inpatient sample (NIS) database was utilized from 2011-14 to identify the AF patients treated with Catheter Ablation using ICD-9- CM codes. χ 2 test was utilized to compare categorical variables, the student’s t-test for continuous variables and hierarchical mixed-effects logistic regression models for multivariate predictors of post-procedural complications. Results: In total 50,969 patients were identified undergoing AF ablation during the study period (37.6% female, 51.4 age ≥ 65). Overall complication rate was 5.5% with relative increase over study period (+56.4%, p < 0.001). In subgroup analysis of complication trends significant relative increase seen in respiratory (+352.7%, p < 0.001), neurological (+43.9%, p = 0.003) and vascular (+38.7%, p = 0.003) complications. While cardiac complications (+9.1%, p = 0.323) and In-hospital mortality (+ 60%, p = 0.173) showed insignificant change. On multivariate analysis of mortality and complication significant increased risk was associated with female gender (OR, 95% CI, p-value) (1.40, 1.17-1.68, p < 0.001), as well as higher comorbidity burden (CCI ≥ 1). While higher hospital volume (≥ 50 procedures) was associated with significantly decreased complication rates. Conclusions: Patients undergoing AF ablation showed an insignificant change in mortality, with increase trends of complication. Which was likely related to higher comorbidity burden over study period.

Introduction: Heart failure with preserved ejection fraction(HFpEF) is a syndromemwith limited treatment modalities. Our control over 30 day readmissions and readmission outcomes is limited. Methods: HCUP’s Nationwide Readmissions Database (NRD) from 2013-14 was used for HFpEF related hospitalizations using ICD-9- CM diagnostic code:428.3x in primary diagnosis field. 30-day readmissions were identified and classified into two groups: same-hospital readmissions and different-hospital readmissions. A comparative analysis was conducted focused on three metrics - mortality, length of stay (LOS) and cost of hospitalization. We used hierarchical two-level modeling and propensity score matching to adjust for confounders. Results: Of the 94,988 readmitted patients (age >65 years: 79%, Females: 61.45%) - 76,665 (80.70%) to the same hospital and rest to different hospitals. After adjusting extensive list of confounders, same hospital readmission was associated with better outcomes including in hospital mortality (OR: 0.73, 95% CI: 0.66 - 0.80, p<0.001), LOS (Days: -1.14, 95% CI: -1.31 - -0.97, p<0.001), Cost of care ($: -4208, 95% CI: - 4681 - -3734, p<0.001). For validation of our results, we ran propensity score matching, showed similar results - in hospital mortality (6.23% vs 8.07%), LOS (6.30 ± 0.08 vs 7.47 ± 0.095), Cost of care (14042.7 ± 215.7 vs 18685.4 ± 279.2). Post hoc high-risk subgroup analysis were conducted and showed similar results (Figure). Number needed to treat (for mortality) was 74 patients. Up to ~ 100 million dollars could have been saved over 2 years. Conclusions: Considering scale of problem and limited option to prevent worse outcomes, Simple interventions such as redirecting patient to same hospital as previous admission would be beneficial.