BACKGROUND Studies have suggested that atrial fibrillation (AF) in patients with rheumatic diseases (RD) may be due to inflammation. AIM To determine the highest association of AF among hospitalized RD patients and to determine morbidity and mortality associated with AF in hospitalized patients with RD. METHODS The National inpatient sample database from October 2015 to December 2017 was analyzed to identify hospitalized patients with RD with and without AF. A subgroup analysis was performed comparing outcomes of AF among different RD. RESULTS The prevalence of AF was 23.9% among all patients with RD ( n = 3949203). Among the RD subgroup, the prevalence of AF was highest in polymyalgia rheumatica (33.2%), gout (30.2%), and pseudogout (27.1%). After adjusting for comorbidities, the odds of having AF were increased with gout (1.25), vasculitis (1.19), polymyalgia rheumatica (1.15), dermatopolymyositis (1.14), psoriatic arthropathy (1.12), lupus (1.09), rheumatoid arthritis (1.05) and pseudogout (1.04). In contrast, enteropathic arthropathy (0.44), scleroderma (0.96), ankylosing spondylitis (0.96), and Sjorgen’s syndrome (0.94) had a decreased association of AF. The mortality, length of stay, and hospitalization costs were higher in patients with RD having AF vs without AF. Among the RD subgroup, the highest mortality was found with scleroderma (4.8%), followed by vasculitis (4%) and dermatopolymyositis (3.5%). CONCLUSION A highest association of AF was found with gout followed by vasculitis, and polymyalgia rheumatica when compared to other RD. Mortality was two-fold higher in patients with RD with AF.

Lemierre's syndrome is a rare but potentially severe complication of bacterial infections that usually affects previously healthy adolescents and young adults. It commonly presents as septic thrombophlebitis of the internal jugular vein and bacteremia following a recent oropharyngeal infection. The most commonly isolated organisms are Fusobacterium necrophorum, followed by Fusobacterium nucleatum and other anaerobes. Atypical Lemierre's syndrome is characterized by thrombophlebitis at sites distant from the head and neck veins and is far less encountered than typical Lemierre's syndrome. Here, we present a case of an elderly African American female with pylephlebitis, a rare abdominal variant of Lemierre's syndrome with extensive portal vein, splenic vein, and mesenteric vein thrombosis following perforated diverticulitis and resultant F. nucleatum bacteremia. She demonstrated complete recovery following appropriate long-term intravenous antibiotics and anticoagulation. This case calls attention to the re-emergence of the rare manifestation of this forgotten disease and highlights improved outcomes with prompt recognition and early treatment.

Background Atrial fibrillation (Afib) is a common cardiac manifestation of hyperthyroidism. The data regarding outcomes of Afib with and without hyperthyroidism are lacking. Hypothesis We hypothesized that patients with Afib and hyperthyroidism have better clinical outcomes, compared with Afib patients without hyperthyroidism. Methods We queried the National Inpatient Sample database for years 2015‐2017 using Validated ICD‐10‐CM codes for Afib and hyperthyroidism. Patients were separated into two groups, Afib with hyperthyroidism and without hyperthyroidism. Results The study was conducted with 68 095 278 patients. A total of 9 727 295 Afib patients were identified, 90 635 (0.9%) had hyperthyroidism. The prevalence of hyperthyroidism was higher in patients with Afib (0.9% vs 0.4%, P < .001), compared with patients without Afib. Using multivariate regression analysis adjusting for various confounding factors, the odds ratio of Afib with hyperthyroidism was 2.08 (CI 2.07‐2.10; P < .0001). Afib patients with hyperthyroidism were younger (71 vs 75 years, P < .0001) and more likely to be female (64% vs 47%; P < .0001) as compared with Afib patients without hyperthyroidism. Afib patients with hyperthyroidism had lower prevalence of CAD (36% vs 44%, P < .0001), cardiomyopathy (24.1% vs 25.9%, P < .0001), valvular disease (6.9% vs 7.4%, P < .0001), hypertension (60.7% vs 64.4%, P < .0001), diabetes mellitus (29% vs 32%, P < .0001) and obstructive sleep apnea (10.5% vs 12.2%, P < .0001). Afib with hyperthyroidism had lower hospitalization cost ($14 968 ± 21 871 vs $15 955 ± 22 233, P < .0001), shorter mean length of stay (5.7 ± 6.6 vs 5.9 ± 6.6 days, P < .0001) and lower in‐hospital mortality (3.3% vs 4.8%, P < .0001. The disposition to home was higher in Afib with hyperthyroidism patients (51% vs 42; P < .0001). Conclusion Hyperthyroidism is associated with Afib in both univariate and multivariate analysis. Afib patients with hyperthyroidism have better clinical outcomes, compared with Afib patients without hyperthyroidism.

The serum osmolar gap, defined as the difference between measured osmolality and calculated osmolarity, is a convenient method to screen for toxins in serum. In normal circumstances, the difference between the two is 6–10 mol/kg. Typical contributors to serum osmolarity are sodium bicarbonate, sodium chloride, glucose and urea. An elevated gap, defined as a difference >10 mol/kg, can occur if a sufficient quantity of an additional solute other than those mentioned above is present in the serum or there are inaccuracies in sodium measurement secondary to hyperlipidaemia and hyperproteinaemia. An elevated serum osmolar gap should thus prompt clinicians to check for toxic alcohol levels. Treatment with fomepizole should not be delayed if suspicion is high. Isolated diabetic ketoacidosis can occasionally present with an elevated osmolar gap in the absence of concomitant alcohol ingestion. This finding is attributed to the production of acetone and glycerol.  We describe the case of a 62-year-old man presenting with diabetic ketoacidosis/hyperosmolar hyperglycaemic state and an elevated osmolar gap in the absence of toxic alcohol ingestion.

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Introduction: Penetrating Aortic Ulcer (PUA) is an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows hematoma formation within the medial layer of the aortic wall. As per our literature review, only one case of PUA causing hemopericardium has been reported. Case Presentation 66-year-old male with an unknown past medical history was bought in by the emergency medical services following a cardiac arrest. Initial rhythm was pulseless electrical activity and return of spontaneous circulation was achieved after ten mins of cardio-pulmonary resuscitation on the field. Initial echocardiogram was significant for a 4.6 cm ascending aorta with large hemopericardium causing tamponade physiology. CT chest with contrast revealed an ectatic ascending aorta with mild irregularity along the posteromedial wall, concerning for aortic leak secondary to a penetrating aortic ulcer (as indicated by the yellow arrow in the image below). Controlled pericardiocentesis was planned as a bridging therapy while awaiting transfer to a specialized cardiothoracic unit. But, the systolic blood pressure (SBP) rose to 170 mmHg when the chest tube was first inserted, worsening the hemopericardium. The patient's condition rapidly deteriorated, causing another cardiac arrest and death. Discussion The recommended treatment for Type A and B PUA-associated Intra Mural Hematoma is urgent surgical aortic graft placement. For hemodynamically unstable patients who cannot be taken for urgent surgery, The 2015 European Society of Cardiology guidelines recommend controlled pericardiocentesis to maintain a target SBP of 90 mmHg as a temporary measure. Conclusion In addition to aortic dissection, PAU should be considered in the differentials of patients with dilated ascending aorta and hemopericardium. An acute rise in blood pressure above 90 mmHg during pericardiocentesis is associated with worsening tamponade.

The growing prevalence of obesity in the USA has resulted in increased consumption of weight loss products that promote fat metabolism. Dietary supplements used for weight loss contain a wide variety of ingredients but the amount of scientific information available on these ingredients varies considerably. Such supplements have documented and undocumented adverse effects. Although the FDA frequently issues health advisories, the health consequences of consuming supplements are often overlooked by the general public. A common supplement used for weight loss is Hydroxycut. The ingredients used in the different forms of Hydroxycut products vary but generally include caffeine and green tea extract, which are responsible for a wide range of adverse effects. We present the case of 41-year-old man with a medical history of polysubstance abuse who developed acute compartment syndrome in the setting of rhabdomyolysis from prolonged immobilisation and the use of Hydroxycut. This case demonstrates the possible adverse effects of consuming weight loss herbal supplements like Hydroxycut. Healthcare professionals and consumers are encouraged to report serious adverse events or product quality problems with the use of these supplements to the FDA's MedWatch adverse event reporting program.