Patient: Male, 58Final Diagnosis: Bacterial meningitisSymptoms: Altered mental status • headache • neck stiffness • vomitingMedication: —Clinical Procedure: —Specialty: Infectious DiseasesObjective:Rare diseaseBackground:Gradenigo’s syndrome includes the triad of suppurative otitis media, ipsilateral sixth (abducens) cranial nerve palsy and facial pain in the distribution of the fifth (trigeminal) cranial nerve. Gradenigo’s syndrome is rare, and the diagnosis is easily overlooked. This case is the first to report Gradenigo’s syndrome presenting with meningitis on a background of chronic suppurative otitis media (CSOM) and petrous apicitis (apical petrositis).Case Report:A 58-year-old male African American presented with headaches and confusion. Magnetic resonance imaging (MRI) of the head showed petrous apicitis with mastoiditis and abscess formation in the cerebellomedullary cistern (cisterna magna). The case was complicated by the development of palsy of the fourth (trochlear) cranial nerve, fifth (trigeminal) cranial nerve, and sixth (abducens) cranial nerve, with radiological changes indicating infection involving the seventh (facial) cranial nerve, and eighth (vestibulocochlear) cranial nerve. Cerebrospinal fluid (CSF) culture results were positive for Klebsiella pneumoniae, sensitive to ceftriaxone. The patient improved with surgery that included a left mastoidectomy and debridement of the petrous apex, followed by a ten-week course of antibiotics. Follow-up MRI showed resolution of the infection.Conclusions:This report is of an atypical case of Gradenigo’s syndrome. It is important to recognize that the classical triad of Gradenigo’s syndrome, suppurative otitis media, ipsilateral sixth (abducens) cranial nerve palsy and facial pain in the distribution of the fifth (trigeminal) cranial nerve, may also involve chronic suppurative otitis media (CSOM), which may lead to involvement of other cranial nerves, petrous apicitis (apical petrositis), and bacterial meningitis.
Heart failure–related recurrent hospitalizations are widely recognized as a source of burden to both patients and the health system. Hospital discharges represent a transition of care and can often become a catalyst for readmission. One strategy in reducing this burden is the implementation of dedicated heart failure clinics. We conducted a retrospective review of all patients discharged from an inner city safety-net public hospital with a discharge diagnosis of heart failure. Patients followed in the Heart Clinic (HC) were compared to those with standard follow-up. All included cases were followed for 30 days after discharge to determine whether an all-cause readmission occurred. There were 258 patient discharges with an overall sicker population in the HC cohort. The HC group had a better event-free survival with a 67.1% reduction in readmission (log rank *p < .05). In concluding, a dedicated heart failure clinic reduced 30-day readmissions for patients who were discharged after having an acute exacerbation of heart failure.
Perioperative outcome of colorectal surgery in Trinidad and Tobago is comparable to the developed countries as evaluated by the CR-POSSUM. Patients presenting for emergency surgery and those with advanced stages of cancer had higher perioperative mortality.
Rheumatoid arthritis (RA) patients have nearly twice the risk of cardiovascular disease (CVD) compared to the general population. We aimed to assess, in a predominantly Black population, the prevalence of traditional and RA-specific CVD risk factors and therapeutic patterns. Utilizing ICD codes, we identified 503 RA patients ≥18 years old who were seen from 2010 to 2017. Of them, 88.5% were Black, 87.9% were women and 29.4% were smokers. CVD risk factors (obesity, diabetes, hypertension, dyslipidemia) were higher than in previously reported White RA cohorts. Eighty-seven percent of the patients had at least one traditional CVD risk factor, 37% had three or more traditional CVD risk factors and 58% had RA-specific risk factors (seropositive RA, >10 years of disease, joint erosions, elevated inflammatory markers, extra-articular disease, body mass index (BMI) < 20). CV outcomes (coronary artery disease/myocardial infarction, heart failure, atrial fibrillation and stroke) were comparable to published reports. Higher steroid use, which increases CVD risk, and lesser utilization of biologics (decrease CV risk) were also observed. Our Black RA cohort had higher rates of traditional CVD risk factors, in addition to chronic inflammation from aggressive RA, which places our patients at a higher risk for CVD outcomes, calling for revised risk stratification strategies and effective interventions to address comorbidities in this vulnerable population.
Introduction:
Heart failure (HF) related hospitalizations contribute to the ever-increasing financial burden of chronic disease. There are approximately 6.5 million individuals in the US with HF, with an estimated annual cost of $39 billion. Within the arsenal of strategies developed to curb this trend, pharmacological therapy has shown to be very effective. Whilst many drugs are favored for their ability to reduce mortality and morbidity, neprilysin-inhibitors (ARNI) have recently shown to reduce 30-day readmissions in patients with HF, presenting an expanded indication to favor its usage.
Methods:
A retrospective review of patients discharged from the Kings County Hospital Center from October 1
st
2017 to June 30
th
2018 with a diagnosis of heart failure was conducted. Inclusion required follow up in the Heart Health Clinic at Kings County Hospital and discharge therapy with a beta-blocker and either an ACE-I, ARB or ARNI. Patients were divided into 2 groups, those continued on an ACE-i/ARB versus those who were transitioned to an ARNI. The end outcome was a 30-day all-cause readmission for heart failure at any point after enrollment. Time to event was calculated using the date the drug was started. If the drug was started prior to being enrolled, we used the date that the patient was enrolled in the study. Demographic data was extracted via chart review and analyzed by descriptive statistics. A Kaplan-Meier survival analysis was done to compare the time-to-event between both study cohorts.
Results:
There were 101 patient discharges. There was no statistically significant age or gender difference between cohorts. The mean age in the ARNI group was 60.4 and in the ACE-i/ARB group was 64.7. A 30-day readmission occurred in 3 (10.7%) of the 28 patients in the intervention group, compared with 21 (28.8%) of the 73 patients with ACE-i/ARB therapy. The patients transitioned to ARNI therapy had a better event free survival with a 62.8% reduction in 30-day readmission events (log rank p=0.046).
Conclusion:
There is statistically significant reduction in 30-day all-cause readmission following the initiation of ARNI therapy in the treatment for HF. While this trend was shown in a prospective post-hoc analysis of the initial PARADIGM-HF trial, our study presents a unique patient benefit group. Kings County Hospital serves as a safety net hospital that has a large volume of uninsured, low socioeconomic status patients, with a large African American influence, and compounded social and environmental factors that make them highly prone to CHF readmissions. It underscores the need for clinically useful strategies to reduce the burden of CHF related readmissions especially for hospitals located in low socioeconomic areas at risk for penalties.
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