Naples Community Hospital Healthcare System

BackgroundCardiac biomarkers are minimally incorporated into current aortic valve guidelines, except for elevated BNP (B‐type natriuretic peptide) in asymptomatic severe aortic stenosis. This prospective observational cohort studied how pretranscatheter aortic valve implantation (TAVI) NT‐proBNP (N‐terminal proBNP) and hs‐cTnT (high‐sensitivity cardiac troponin T) relate to mortality, quality of life, and functional outcomes after TAVI.MethodsThis is a prospective cohort study of 173 patients undergoing TAVI at a large medical center in the United States between January 1, 2020, and January 1, 2022. NT‐pro‐BNP and hs‐cTnT, Kansas City Cardiomyopathy Questionnaire, 6‐minute walk distance, and mortality were surveilled pre TAVI, and at 30 days, 1 year, and 2 years post TAVI. The patients represented a real‐world cohort of patients receiving TAVI.ResultsTwo‐year mortality for the entire cohort was 7.51% (13/173). In univariable analysis, higher baseline NT‐pro‐BNP and hs‐cTnT were predictors of mortality at 2 years after TAVI. After adjusting for covariables, baseline hs‐cTnT demonstrated a clinically meaningful association with mortality (P=0.058; odds ratio [OR], 2.74 [95% CI, 0.967–7.734]). In multivariable analysis, a combination variable of tertiled baseline hs‐cTnT and NT‐pro‐BNP was a significant predictor of 2‐year mortality; specifically, 2‐year mortality rates stratified by combined score values of 6, 5, 4, 3, and 2 were 16.1%, 13.8%, 7.3%, 0%, and 0%, respectively.ConclusionsThose with an elevated combination biomarker variable—NT‐pro‐BNP >357 pg/mL and hs‐cTnT >14.1 ng/L—should be most rigorously surveilled and managed before and after TAVI with more frequent and comprehensive outpatient visits for medical optimization of cardiac and noncardiac disease states.

A 40-year-old female with a past medical history of beta thalassemia minor presented to the ED with an intractable headache, nausea, and vomiting. A CT head without IV contrast was performed that was negative for any signs of subarachnoid hemorrhage, or thrombotic etiology. The patient presented 48 hours later and was found to have cerebral venous thrombosis (CVT). She was subsequently taken for mechanical thrombectomy. Despite mechanical thrombectomy, her intracranial pressure (ICP) continued to rise. The patient underwent neurosurgical intervention with placement of external ventricular drain (EVD). Despite EVD placement, pressure continued to rise intracranially. The patient then went for a repeat thrombectomy, which was unsuccessful as clots continued to reaccumulate. No existing tool or measurement can lead to better outcomes regarding CVT cases. It is possible that with improved imaging modalities, early diagnosis is possible with high clinical suspicion, but further data needs to be collected. Per our literature review, there is no existing data regarding reaccumulating of clot burden despite intervention. This case represents the need for a broader discussion about risk stratification to identify quantifiable measures for better patient outcomes.

Abstract Background: Situs inversus is a rare congenital condition, occurring in approximately 1 in 8,000 live births, defined as a total or partial mirror-image reversal of the thoracic and abdominal organs. Associated conditions include primary ciliary dyskinesia (Kartagener syndrome), congenital heart defects, and a variety of gastrointestinal anomalies. Given that situs inversus is often associated with normal life expectancy, it is commonly discovered as an incidental imaging finding. In the age of navigational bronchoscopy wherein CT guided airway planning is critical to procedural success, it is important to be aware of airway anatomy whether these are congenital anomalies or post-surgical changes. Here, we present a case of situs inversus that highlights the importance of pre-procedural planning when performing bronchoscopy on complex anatomy. Case: A 47-year-old female with a history of Kartagener syndrome, bronchiectasis, dextrocardia, a right aortic arch, and abdominal situs inversus (Fig 1), presented for elective robotic assisted bronchoscopy (RAB) for evaluation of abnormal CT chest. Chest CT demonstrated a left lower lobe area of focal bronchiectasis with airway thickening and nodularity and right lower lobe area of medial atelectasis (Fig 2). A robotic assisted bronchoscopy utilizing the Intuitive Ion system was planned and performed. A virtual bronchoscopy image was generated using the planning software (Fig 3), which demonstrates the airway situs inversus of the entire bronchial tree. Indeed, the airway was pictured with the right mainstem bronchus appearing as the mirror image of a left main stem (Fig 4 image 2), when viewing the right upper lobe, again the mirror of the normal anatomic left upper lobe is appreciated and the left upper and lower were also mirror images of the normal anatomical right airways (Fig 4, image 5-8). Ultimately, pathology and cultures were negative for malignancy, and the area that was evaluated was likely a result of focal bronchiectasis with mucus plugging. Discussion: Implementation of robotic bronchoscopy techniques with advanced pre-procedure planning is now more than ever becoming common practice for lung nodule biopsy. Each case should be planned carefully to prepare for the best strategic approach and to anticipate possible endobronchial pathology, case-specific risk factors, and anatomical variations. This is an extreme and interesting case of airway variation and demonstrates how planning software was successfully utilized for accurate RAB navigation.

Background Diabetic ketoacidosis (DKA) is a common and serious complication of diabetes, often requiring hospitalization and intensive care. Fluid resuscitation is a cornerstone of DKA management, with traditional guidelines recommending isotonic normal saline (NS) for initial volume replacement. Recent studies, however, suggest that large volumes of NS may lead to undesirable outcomes such as hyperchloremic metabolic acidosis. This study investigates the effects of large-volume NS resuscitation on clinical outcomes in DKA management, comparing it to other fluids, such as lactated Ringers (LR). Objective To evaluate whether large-volume resuscitation with isotonic normal saline (NS) is associated with prolonged ICU length of stay (LOS), increased time on insulin infusion, and higher rates of non-anion gap metabolic acidosis in patients with DKA. Materials and methods This was a single-center, retrospective, observational study conducted at Naples Comprehensive Healthcare System. We reviewed electronic medical records of patients diagnosed with DKA, defined bypH <7.3, bicarbonate <18, and anion gap >12. The primary outcome was ICU LOS, and secondary outcomes included overall length of stay, insulin infusion duration after DKA resolution, and incidence of non-anion gap metabolic acidosis after DKA resolution. Patients were grouped by the amount of NS received during resuscitation: 0L, 1L, 2L, and ≥3L. Statistical analyses included analysis of variance (ANOVA), t-tests, and chi-square tests to compare outcomes between groups. Results A total of 109 patients were included in the study. The mean age was 51.34 years, and the cohort consisted of 43.1% females and 56.9% males.There was no significant difference in ICU LOS between patients who received 0L and 1L of NS. However, patients who received 2L (p=0.0249) and ≥3L (p=0.00065) had significantly longer ICU LOS compared to those who received 0L of NS.No significant difference in overall LOS was also observed across all groups (p=0.894). Patients who received ≥3L of NS had a significantly longer duration of insulin infusion compared to those who received 0L (p=0.0101) after DKA anion gap closure while a significant increase in the incidence of non-anion gap acidosis after DKA resolution was observed in patients receiving ≥2L of NS (p=0.0000). Conclusion This study suggests that large-volume resuscitation with isotonic NS in DKA patients is associated with increased ICU length of stay, prolonged insulin infusion, and a higher incidence of non-anion gap metabolic acidosis. These findings support the use of balanced crystalloids, such as lactated Ringers, for initial resuscitation in DKA patients, as they may reduce the risk of complications related to hyperchloremia and improve clinical outcomes. Further prospective studies are needed to confirm these findings and guide fluid management protocols in DKA.

Background: Hospitalized patients frequently require various medical procedures, including lumbar punctures, paracenteses, and pulmonary drains, with significant annual volumes in the U.S. While bedside procedures are generally safe, their complication rates range from 0.1% to 3%, depending on the procedure. The Medicine Bedside Procedure Service (MBPS) at the Medical College of Wisconsin/Froedtert Health System was established as a standalone service in 2015 to enhance the training of Internal Medicine (IM) residents in common bedside procedures and Point of Care Ultrasound (POCUS), while also aiming to reduce patient wait times for procedures and length of hospital stays. Objective: The study aimed to evaluate the development and implementation of the MBPS, focusing on the characteristics of the first 12,000 procedural encounters, the educational impact on IM residents, and the service's effects on patient outcomes. Methods: This retrospective study analyzed 12,387 procedural encounters involving 6,942 unique patients from September 2015 to June 2022. Patient demographics were assessed, including age, sex, race, language, payer status, and comorbidities. Descriptive statistics were utilized to summarize the data, including means and standard deviations for continuous variables and frequencies for categorical variables. Results: The patient demographic indicated a predominance of males (53.1%), non-Hispanic Whites (68.8%), and a significant portion covered by Medicaid (71.6%). The average patient age was 64.7 years. The MBPS performed an average of 5.2 procedures per day, with paracentesis (34.6%), thoracentesis (27.3%), and lumbar puncture (21.1%) being the most common procedures. The overall complication rate was low at 0.3%, with the majority of complications occurring in thoracentesis (56%). Conclusions: The MBPS has contributed to the educational development of IM residents, evidenced by their increased proficiency and procedural certification rates, while also improving patient outcomes, including reduced lengths of stay and hospital costs. The service has optimized patient flow and increased satisfaction through timely and safe procedural care. Despite challenges in fostering a supportive culture for bedside procedures and ensuring effective communication with interventional radiology, the MBPS exemplifies the advantages of bedside procedures. Moving forward, plans include expanding into outpatient settings and incorporating advanced POCUS capabilities to enhance diagnostic and therapeutic decision-making at the bedside. Limitations of this single-center study and lack of comparative groups suggest the need for further research to validate these findings across diverse healthcare settings.

Abstract Disclosure: N. Solano: None. D. Baboun: None. A. Granados: None. A. Carrillo-Iregui: None. Introduction: Hereditary fructose intolerance (HFI) is an uncommon autosomal recessive metabolic disorder characterized by a deficiency of aldolase B, a crucial enzyme involved in fructose metabolism. This deficiency causes an accumulation of fructose-1-phosphate, which triggers a cascade of metabolic disturbances including hypoglycemia, lactic acidosis, and hepatic dysfunction. If left untreated, HFI can lead to severe complications, including liver failure and even death. Diagnosing HFI can be challenging due to its nonspecific clinical presentation and the absence of routine screening tests. Case presentation: A 4-year-old girl was referred from an outside hospital for hypoglycemia requiring intravenous dextrose infusion. The patient became lethargic 30 minutes after consuming a honey-based cough syrup. Upon presentation to the emergency department, her blood glucose level was 41 mg/dL. Her past medical history revealed an episode of lethargy and persistent vomiting at age 21 months, coinciding with an intussusception. A finger blood glucose test at the time was undetectable, and further evaluation revealed metabolic acidosis, elevated liver enzymes, and a normal ammonia level. Plasma amino acid, acylcarnitine, carnitine, urine acylglycine, carnitine, and urine organic acid levels were all within normal limits. Fatty acid oxidation and glycogen storage disease panels were also negative. On inquiry into her dietary habits, her parents recalled she would spit fruits out whenever tasting them, suggesting an innate aversion to fructose-rich foods. Initial comprehensive inpatient workup, including a critical sample, yielded no definitive results. She underwent a strict 24-hour inpatient fast and remained asymptomatic, with blood glucose levels above 65 mg/dL, ruling out hyperinsulinism. A broader next-generation sequencing (NGS) hypoglycemia panel was ordered, which identified a heterozygous pathogenic variant, c.178C&amp;gt;T (p.Arg60*) maternally inherited, and a likely pathogenic variant, c.379+1G&amp;gt;T (Splice donor) paternally inherited, in the aldolase B gene. Both confirmed the diagnosis of hereditary fructose intolerance (HFI). The family received comprehensive dietary and genetic counseling. Conclusion: HFI is an uncommon but potentially life-threatening inborn error of metabolism. Maintaining a high index of suspicion, considering a broad differential diagnosis, and obtaining a detailed dietary history, including fruit consumption, are crucial for identifying and managing HFI in infants and children with unexplained hypoglycemia. This case highlights the importance of early diagnosis and dietary intervention to prevent severe complications in patients with HFI. Additionally, it emphasizes the need for comprehensive dietary counseling and education for patients' families to ensure lifelong adherence to a fructose-restricted diet. Presentation: 6/2/2024