Labban, Mohamad El

Abstract Background Acute respiratory failure is one of the most common causes of hospitalizations in the US. By 2030, the number of Americans with dementia is expected to reach nearly 9 million and 12 million in 2040. Dementia increases the risk of respiratory illnesses, including pneumonia. This study delves into the intricate interplay between dementia and acute respiratory failure. Methods Our retrospective study analyzed adult patients with acute respiratory failure and secondary diagnosis of dementia using ICD-10 codes in the National Inpatient Sample (NIS) Database from 2017 to 2020. An analysis was conducted on various demographic factors such as age, race, and gender. The study's primary endpoint was mortality, with mechanical ventilation, tracheostomy, and length of stay as secondary endpoints. To account for other variables that could have affected the results, we utilized a multivariate logistic regression with p < 0.05 considered significant. Results The study included 1,795,630 patients admitted with ARF, 112,175 of whom had dementia. The mean age in the dementia group was 80 years, compared to 65 years in the control group. Additionally, 62% of the dementia group were females, while the control group had 55% females. 73% of both groups were Caucasian white. Comorbidities observed in the dementia group include hypertension (81% vs. 72%), diabetes mellitus (36% vs. 35%), supraventricular tachycardia (29% vs. 20%), and sepsis (6% vs. 5%) with p-value less than 0.01. Rates and odds of mortality were higher in the dementia group (15,704 (14%) vs. 151,511 (9%), p-value < 0.01, aOR 1.08, p-value < 0.01). Patients with dementia had lower rates of in-hospital mechanical ventilation, but higher adjusted odds (27% vs. 28%; p < 0.01; aOR + 1.2, p < 0.01). Patients with dementia had lower rates and adjusted odds of undergoing a tracheostomy during their stay (762 (0.7) vs. 16,834 (1), p-value < 0.01, aOR 0.91 p-value 0.33).. Patients with dementia had a longer length of stay (LOS) than those without, with a mean difference of + 0.3 days and p-value < 0.01. Conclusions Clinicians should be aware that dementia was found to be an independent risk factor for mortality in patients admitted with acute respiratory failure.

Introduction Acute chest syndrome (ACS) is a clinical presentation of fever, chest pain, pulmonary symptoms, and new infiltrates on lung imaging. It affects nearly 50% of patients with sickle cell disease during their lifetime and often leads to hospitalization. The mortality rate is variable ranging from 3 to 9 %. and depends on several factors. We aimed to identify the clinical and epidemiological characteristics of patients admitted with ACS on a national scale and factors affecting clinical outcomes in inpatient setting. Methods: We utilized the National Inpatient Sample (NIS) database 2019 for the purpose of this study. Using this database, we identified patients with a principle diagnosis of ACS using International Classification of Diseases (ICD-10) codes. Data on demographic characteristics such as age, sex, race, insurance type were collected. Additionally, we selected clinically significant medical comorbidities such as asthma, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), chronic kidney disease (CKD), heart failure, hypertension, diabetes mellitus (DM), sepsis, obesity, and others. The primary endpoint of this study was to identify factors influencing all-cause mortality, while the secondary endpoint was to identify factors influencing mechanical intubation, in-patient blood transfusion, and length of stay. We used multivariate logistic regression analysis to adjust for confounders. A p value of ≤0.05 considered statistically significant. Results: Baseline Characteristics Our analysis consisted of 22,459 patients who were admitted with principal diagnosis of ACS. 49.5% were female and 50.5% were male. Mean age was 30.5 years. African American race was predominant (92%) with sickle cell Hb-SS disease (87%). Major insurance payer was Medicaid (47%) followed by Medicare (27%) and then private insurance (21%). Asthma was the most common comorbidities (24%) and majority of patient had Charlson Comorbidity Index (CCI) score of zero (55%). The details of clinical and epidemiological characteristics are shown in Table 1. Clinical outcomes and factors influencing mortality Only 0.89% patient died of ACS. Average length of stay was 6.86 days. 34% of the patient required packed red blood cell (pRBC) transfusion. 3.2% needed mechanical ventilation. In multivariate analysis, factors associated with mortality included age of patient, CCI and sepsis. Younger patient had higher odds of mortality however this was not statistically significant. There was no difference in mortality with sex, race and insurance status of the patients. Factors affecting inpatient transfusion, mechanical ventilation and length of stay Female, higher CCI score and sepsis on admission were associated with higher needs of inpatient pRBC transfusion. Within race, White (OR 3.16, CI 1.44-6.93, P &lt;0.01) and Hispanics (OR 2.68, CI 1.59-4.51, P&lt;0.01) had higher odds of receiving transfusion compared to African Americans (OR 1.84, CI: 1.17-2.89, P &lt;0.01). Similarly patient with sepsis, supraventricular tachycardia had more odds of needing mechanical ventilation. Patient's insurance status was also related to increased odds of intubation. Comorbidities such as asthma and CAD were not associated with need of mechanical ventilation and in fact our study shows they had less odd of needing mechanical ventilation. Length of stay was influenced by several of epidemiological and clinical comorbidities. Females had less odds of longer length of stay compared to male (OR: 0.65, P &lt;0.01). Comorbidities such as asthma, heart failure, CAD, DM2 and hypertension did not increase the length of stay while patients with sepsis and high CCI score had higher odds of hospitalization for extended period of time. The details are in Table 2. Conclusion We found mortality was 0.89% in patients admitted with ACS compared to 3 to 9% previously reported. Sepsis and CCI were one of the predictors for odds of having higher mortality, need of blood transfusion, mechanical ventilation and increased length of stay in patient with ACS. Female, White and Hispanic had higher odds of needing transfusion then African Americans. Comorbidities such as asthma, heart failure, CAD, DM 2 and hypertension did not increase the odds of prolonged hospital stay.

Abstract Background: Diaphragmatic paralysis can present with orthopnea. We report a unique presentation of bilateral diaphragmatic paralysis, an uncommon diagnosis secondary to an unusual cause, brachial plexitis. This report thoroughly describes the patient’s presentation, workup, management, and outcome. It also reviews the literature on diaphragmatic paralysis and Parsonage-Turner syndrome. Case presentation: A 50-year-old male patient developed insidious orthopnea associated with left shoulder and neck pain over three months with no associated symptoms. On examination, marked dyspnea was observed when the patient was asked to lie down; breath sounds were present and symmetrical, and the neurological examination was normal. The chest radiograph showed an elevated right hemidiaphragm. Echocardiogram was normal. There was a 63% positional reduction in Forced Vital Capacity and maximal inspiratory and expiratory pressures on pulmonary function testing. The electromyogram was consistent with neuromuscular weakness involving both brachial plexus and diaphragmatic muscle (Parsonage and Turner syndrome). Conclusions: Compared to unilateral, bilateral diaphragmatic paralysis may be more challenging to diagnose. On PFT, reduced maximal respiratory pressures, especially the maximal inspiratory pressure, are suggestive. Parsonage-Turner syndrome is rare, usually with unilateral diaphragmatic paralysis, but bilateral cases have been reported.

Abstract Background: Ventilator-associated pneumonia (VAP) is one of the leading causes of mortality in patients with critical care illness. Since obesity is highly prevalent, we wanted to study its impact on the outcomes of patients who develop VAP. Methods: Using the National Inpatient Sample (NIS) Database from 2017 to 2020, we conducted a retrospective study of adult patients with a principal diagnosis of VAP with a secondary diagnosis with or without obesity according to ICD-10 codes. Several demographics, including age, race, and gender, were analyzed. The primary endpoint was mortality, while the secondary endpoints included tracheostomy, length of stay in days, and patient charge in dollars. Multivariate logistic regression model analysis was used to adjust for confounders, with a p-value less than 0.05 considered statistically significant. Results: The study included 3832 patients with VAP, 395 of whom had obesity. The mean age in both groups was around 58 years, and 68% of the group with obesity were females compared to 40% in the control group. Statistically significant comorbidities in the obesity group included a Charlson Comorbidity Index score of three and above, Diabetes Mellitus, Hypertension, and chronic kidney disease. Rates and odds of mortality were not significantly higher in the collective obesity group 39 (10%) vs. 336 (8.5%), p-value 0.62, aOR 1.41, p-value 0.39). The rates and odds of tracheostomy were higher in the obesity group but not statistically significant. Obese patients were also found to have a longer and more expensive hospitalization. Conclusions: Obesity was not found to be an independent risk factor for worse outcomes in patients who develop VAP in the intensive care unit.

Abstract Introduction Managing atrial fibrillation (AF) in patients with obstructive sleep apnea (OSA) is challenging and often associated with worse outcomes. Non-alcoholic fatty liver disease (NAFLD) is shown to be associated with increased cardiovascular morbidity and mortality. The effect of NAFLD on AF in patients with OSA is not well studied. This study aims to investigate this association in hospitalized patients. Methods We queried the National Inpatient Sample (NIS) between 2017-2020 for adult patients hospitalized for AF with history of OSA & had NAFLD. The primary outcome was in-hospital mortality. The secondary outcomes were cardiogenic shock, gastrointestinal bleeding (GIB), cardiac arrest, invasive mechanical ventilation (IMV) and length of stay (LOS). Multivariable logistic and Poisson regression analyses were used to estimate clinical outcomes. Outcomes were adjusted for age, gender, race, heart failure, diabetes, CKD, chronic respiratory failure, stroke and history of MI. P-value &lt; 0.05 was statistically significant. Results We identified 1,843,865 hospitalizations for AF with history of OSA: NAFLD in 61,235 (3.4%). AF with OSA and NAFLD vs. no NAFLD had mean age 68.4 vs. 70.6, males 65.2% vs. 64.1%, white 78.2% vs. 80.2%, black 9.3% vs. 10.2%, obesity 45.7% vs. 46.5%, heart failure 69.2% vs. 59.6%, diabetes 59.2% vs. 51.1%, anemia 23.5% vs. 17.2%, CKD 52.4% vs. 40% and COPD 38.2% vs. 39.1%. In-hospital mortality was 11.4% in the NAFLD group vs. 2.5% in the non-NAFLD group (aOR 5.2, P&lt; 0.001). NAFLD vs. non-NAFLD groups had GIB 9.4% vs. 4.5% (aOR 2.1, P&lt; 0.001), cardiac arrest 3.4% vs. 0.9% (aOR 3.4, P&lt; 0.001), cardiogenic shock 7% vs. 1.2% (aOR 4.9, P&lt; 0.001), IMV 10.9% vs. 3.4% (aOR 3.3, P&lt; 0.001) and LOS 7.7 vs. 5.6 (aIRR 1.27, P&lt; 0.001). Conclusion Our study shows that NAFLD has worsened the outcomes of patients admitted with AF and has history of OSA. The fivefold increase in in-hospital mortality is likely related to the increase in in-hospital hemorrhagic events and cardiac arrest. Clinicians should be aware of this association. Further research is needed to mitigate the detrimental effect of liver disease on OSA and AF patients. Support (if any)

Abstract Introduction There is evidence of increased risk of admission with influenza in patients with untreated obstructive sleep apnea (OSA). There is however limited evidence of the impact of OSA on patients admitted with influenza pneumonia. We aim to study this association on a nationwide scale. Methods Using the National Inpatient Sample (NIS) Database from 2017 to 2020, a retrospective study of adult patients with principal diagnosis of influenza viral pneumonia with secondary diagnosis with or without obstructive sleep apnea (OSA) according to ICD-10 codes. Several demographics, including age, race, and gender, were analyzed. The primary endpoint was mortality, while the secondary endpoints included mechanical intubation, length of stay in days, and patient charge in dollars. Multivariate logistic regression model analysis was used to adjust for confounders, with a p value less than 0.05 considered statically significant. Results The study included 174,339 patients admitted with an influenza pneumonia, 13,094 of which had OSA. The Mean age for patients with and without OSA was 67 and 70 years, respectively. In the OSA group, 48% were females compared to 55% in the non-OSA group. Around 73% in both groups were Caucasian white. Statistically significant comorbidities noticed in the OSA group included chronic kidney disease (29% vs. 22%), Diabetes Mellitus (48% vs. 31%), COPD (47% vs. 31%) . In-hospital mortality rate was not higher in the OSA group with statistical significance (2.1% vs. 2.3%, p =0.48). The adjusted Odds ratio was 0.51 without statistical significance. In-hospital mechanical ventilation and tracheotomy rates were higher in the OSA group with statistical significance (5.3 % vs. 3.7%, p &lt; 0.01) (0.31 % vs. 0.12%, p 0.013 ) however the adjusted odds ratio was not statistically significant in either (aOR 1.27, p value 0.14). (aOR 0.9, p value 0.98). The length of stay was higher in the OSA group (5.5 vs. 4.9 days, adjusted means +0.4 days, p value 0.04) Patients in the OSA group had a higher total charge (59,949$ vs. 44,091$, adjusted means +1,997$ p value 0.45) Conclusion Patients admitted with influenza viral pneumonia with associated OSA were not found to have worse clinical outcomes and a higher economic burden. Support (if any)

Abstract Introduction Obstructive Sleep Apnea (OSA) is prevalent in heart failure and is associated with cardiovascular and all-cause mortality. The evidence is growing that Non-Alcoholic Fatty Liver Disease (NAFLD) is associated with increased cardiovascular morbidity and mortality. There is limited scientific evidence of clinical outcomes in patients with Acute Heart Failure (AHF), OSA and NAFLD. Therefore, we sought to investigate this population. Methods We queried the National Inpatient Sample (NIS) between 2017-2020 for adult patients hospitalized for AHF with history of OSA & had NAFLD. The primary outcome was in-hospital mortality. The secondary outcomes were in-hospital cardiogenic shock, gastrointestinal bleeding (GIB), cardiac arrest, invasive mechanical ventilation (IMV) and length of stay (LOS). Multivariable logistic and Poisson regression analyses were used to estimate clinical outcomes. P-value &lt; 0.05 was statistically significant. Results We identified 1,029,785 hospitalizations for AHF with history of OSA: NAFLD in 138,415 (3.7%). AHF with OSA and NAFLD vs. no NAFLD had mean age 65.8 vs. 67.9, males 62.2% vs. 59.2%, Caucasian race 71.6% vs. 68.7%, obesity 50.8%, 55.6%, atrial fibrillation 53.6% vs. 50.5%, diabetes 61.3% vs. 60.4%, anemia 24.8% vs. 20.3%, CKD 56.9% vs. 51.7 and COPD 42.7% vs. 48%. In-hospital mortality was 11.9% in the NAFLD group vs. 2.6% in the non-NAFLD group (aOR 5.2, P&lt; 0.001). AHF and OSA with NAFLD vs. non-NAFLD groups had GIB 6.4% vs. 2.8% (aOR 2.4, P&lt; 0.001), cardiac arrest 4% vs. 1.1% (aOR 3.7, P&lt; 0.001), cardiogenic shock 13.1% vs. 2.6% (aOR 5.2, P&lt; 0.001), IMV 13.2% vs. 5% (aOR 2.9, P&lt; 0.001) and LOS 9.1 vs. 6.6 days (aIRR 1.3, P&lt; 0.001). Conclusion In patients with OSA admitted for AHF, NAFLD is independently associated with five times higher odds of in-hospital mortality. It's also associated with a significantly higher incidence of cardiac arrest, cardiogenic shock, IMV and increased hospital LOS. The NAFLD group patients were younger, less obese, with more anemia and CKD. The chronic inflammatory process and humoral dysregulation associated with OSA and NAFLD would induce worsening outcomes of AHF hospitalization. Further research is needed on the impact of OSA optimization in patients with heart failure and NAFLD. Support (if any)

A 35-year-old male greenhouse worker presented with myalgia, fatigue, and fever. Initially, he was thought to have an unspecified viral infection and was treated with conservative therapy. However, the patient’s symptoms persisted, and he reported additional symptoms of mild abdominal pain and headaches. Laboratory evaluation was significant for elevated liver enzymes. Due to concern for acute hepatitis and persistent fever the patient was hospitalized. During his hospital course, no infectious etiology was found to explain his symptoms. After discharge from the hospital, additional testing showed positive serology for Q fever IgG phase II antibody (1:8192) and phase II antibody IgM (> 1:2048). He was treated with doxycycline and had a good clinical response. Upon follow-up, he had worsening Phase I IgG serologies. Transesophageal echo demonstrated vegetations consistent with endocarditis.