Simultaneous presence of massive chyloperitoneum and chylothorax and its successful management

The incidence of massive chylous ascites and chylothorax after aortofemoral bypass grafting (AFBG) procedure is unknown. Leakage of chyle results in severe malnutrition and infection which can be life threatening. Because of the rarity of disease, the definitive guideline on management of such extensive accumulation of chyle is lacking. We present a case of a 68- year-old gentleman who developed large chylous ascites and chylous pleural effusions causing respiratory distress. His history was significant for aortofemoral bypass graft procedure 8 weeks prior to index presentation. He was successfully managed with chylous fluid drainage, judicious use of diuretics, adherence to a low-fat diet, and supplementation with medium-chain triglycerides

The HOSPITAL score and LACE index as predictors of 30 day readmission in a retrospective study at a university-affiliated community hospital

Introduction Hospital readmissions are common, expensive, and a key target of the Medicare Value Based Purchasing (VBP) program. Validated risk assessment tools such as the HOSPITAL score and LACE index have been developed to identify patients at high risk of hospital readmission so they can be targeted for interventions aimed at reducing the rate of readmission. This study aims to evaluate the utility of HOSPITAL score and LACE index for predicting hospital readmission within 30 days in a moderate-sized university affiliated hospital in the midwestern United States. Materials and Methods All adult medical patients who underwent one or more ICD-10 defined procedures discharged from the SIU-SOM Hospitalist service from Memorial Medical Center (MMC) from October 15, 2015 to March 16, 2016, were studied retrospectively to determine if the HOSPITAL score and LACE index were a significant predictors of hospital readmission within 30 days. Results During the study period, 463 discharges were recorded for the hospitalist service. The analysis includes data for the 432 discharges. Patients who died during the hospital stay, were transferred to another hospital, or left against medical advice were excluded. Of these patients, 35 (8%) were readmitted to the same hospital within 30 days. A receiver operating characteristic evaluation of the HOSPITAL score for this patient population shows a C statistic of 0.75 (95% CI [0.67–0.83]), indicating good discrimination for hospital readmission. The Brier score for the HOSPITAL score in this setting was 0.069, indicating good overall performance. The Hosmer–Lemeshow goodness of fit test shows a χ2 value of 3.71 with a p value of 0.59. A receiver operating characteristic evaluation of the LACE index for this patient population shows a C statistic of 0.58 (95% CI [0.48–0.68]), indicating poor discrimination for hospital readmission. The Brier score for the LACE index in this setting was 0.082, indicating good overall performance. The Hosmer–Lemeshow goodness of fit test shows a χ2 value of 4.97 with a p value of 0.66. Discussion This single center retrospective study indicates that the HOSPITAL score has superior discriminatory ability when compared to the LACE index as a predictor of hospital readmission within 30 days at a medium-sized university-affiliated teaching hospital. Conclusions The internationally validated HOSPITAL score may be superior to the LACE index in moderate-sized community hospitals to identify patients at high risk of hospital readmission within 30 days

Reducing 30-Day Rehospitalization Rates Using a Transition of Care Clinic Model in a Single Medical Center

Background. Rehospitalization for medical patients is common. Multiple interventions of varying complexity have been shown to be effective in achieving that goal with variable results in the literature. For medical patients discharged home, no single intervention implemented alone has been shown to have a sustainable effect in preventing rehospitalization. Objective. To study the effect of a transition of care clinic model on the 30-day rehospitalization rate in a single medical center. Methods. Retrospective observational analysis of adult patients discharged home from Memorial Medical Center from September 1, 2014, through December 31, 2014. The primary outcome was to compare hospital readmission rates between patients who followed up with a transition of care (TOC) clinic and those who did not. Results. The study population included 378 patient discharges. A total of 40 patients (10.6%) were readmitted to the hospital within 30 days of discharge. Patients who attended the TOC clinic had a significantly lower 30-day readmission rates (3.8% versus 11.7%). A Cox regression analysis showed that the TOC clinic attendance had a significant negative predication for readmission (HR 0.186, 95% CI 0.038–0.898, P=0.038). Conclusion. Adopting a TOC model after discharging medical patients has reduced the readmission rates in our study

A fractured inferior vena cava filter strut migrating to the left pulmonary artery

Inferior vena cava filters are increasingly used in patients with recurrent venous thromboembolism who are contraindicated to anticoagulation. Migration of a broken strut to the pulmonary artery is a very rare complication of these filters. We report the case of an 83-year-old female who experienced this complication with the migratory strut remaining in the same position for years. This case provides evidence that such filters probably have higher rates of complications than what has been thought that remain asymptomatic. The indications and the management of complications of such devices need to be studied further

Cetuximab-Associated Crescentic Diffuse Proliferative Glomerulonephritis

Cetuximab-induced nephrotoxicity is very rare, occurring in less than 1% of colorectal cancer patients and not defined in other populations. We report a rare case of crescentic diffuse proliferative glomerulonephritis (GN) that developed in close temporal association with cetuximab treatment. A 65-year-old female recently completed chemotherapy with cetuximab treatment for moderately differentiated oral squamous cell carcinoma. She was admitted with acute renal failure and nephrotic-range proteinuria. Laboratory data showed serum creatinine of 6.6 mg/dl and urinalysis showed proteinuria, moderate hemoglobinuria, hyaline casts (41/LPF), WBC (28/HPF), and RBC (81/HPF). Serologic studies were negative for ANA, anti-GBM, ANCA, hepatitis B, and hepatitis C. Serum C3 and C4 level were normal. Renal biopsy showed crescentic diffuse proliferative GN with focal features of thrombotic microangiopathy. Patient was started on cyclophosphamide and steroids. Her renal function did not improve on day 8 and she was started on hemodialysis. Previous reports suggest that EGFR-targeting medications can possibly trigger or exacerbate an IgA-mediated glomerular process leading to renal failure. This case suggests that cetuximab therapy may have triggered or exacerbated a severe glomerular injury with an unfavorable outcome. Treating physicians should maintain a high degree of caution and monitor renal function in patients on EGFR inhibitors

A Case Report Describing a Rare Presentation of Simultaneous Occurrence of MPO-ANCA-Associated Vasculitis and Rheumatoid Arthritis

Background. Renal-limited myeloperoxidase vasculitis with simultaneous rheumatoid arthritis is reported as a rare occurrence. Review of literature suggests that most patients had a diagnosis of rheumatoid arthritis for several years prior to presenting with renal failure from myeloperoxidase vasculitis. Case Presentation. A 58-year-old Caucasian male presented to the hospital experiencing malaise, fevers, decreased oral intake, nausea, and vomiting for one week duration. His past medical history consisted of newly diagnosed but untreated rheumatoid arthritis, hypertension, and non-insulin-dependent diabetes mellitus. He was found to have acute renal failure, proteinuria, and hypoglycemia. Standard therapy, including intravenous fluids, did not improve his acute renal failure. A vasculitis workup resulted in a positive myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA). Renal biopsy revealed crescentic glomerulonephritis (GN) pauci-immune type, suggestive of MPO-ANCA-associated vasculitis (MPO-AAV). Treatment consisted of prednisone, cyclophosphamide, and seven cycles of plasmapheresis, in addition to hemodialysis for uremia. Upon discharge, he received hemodialysis for another week and continued treatment with cyclophosphamide and prednisone. Conclusion. Patients with longstanding rheumatoid arthritis may develop renal failure due to nonsteroidal anti-inflammatory medication use and AA type amyloidosis; however, necrotizing glomerulonephritis with crescent formation has been rarely reported. This stresses the importance of early recognition and swift initiation of treatment

Cetuximab-Associated Crescentic Diffuse Proliferative Glomerulonephritis

Cetuximab-induced nephrotoxicity is very rare, occurring in less than 1% of colorectal cancer patients and not defined in other populations. We report a rare case of crescentic diffuse proliferative glomerulonephritis (GN) that developed in close temporal association with cetuximab treatment. A 65-year-old female recently completed chemotherapy with cetuximab treatment for moderately differentiated oral squamous cell carcinoma. She was admitted with acute renal failure and nephrotic-range proteinuria. Laboratory data showed serum creatinine of 6.6 mg/dl and urinalysis showed proteinuria, moderate hemoglobinuria, hyaline casts (41/LPF), WBC (28/HPF), and RBC (81/HPF). Serologic studies were negative for ANA, anti-GBM, ANCA, hepatitis B, and hepatitis C. Serum C3 and C4 level were normal. Renal biopsy showed crescentic diffuse proliferative GN with focal features of thrombotic microangiopathy. Patient was started on cyclophosphamide and steroids. Her renal function did not improve on day 8 and she was started on hemodialysis. Previous reports suggest that EGFR-targeting medications can possibly trigger or exacerbate an IgA-mediated glomerular process leading to renal failure. This case suggests that cetuximab therapy may have triggered or exacerbated a severe glomerular injury with an unfavorable outcome. Treating physicians should maintain a high degree of caution and monitor renal function in patients on EGFR inhibitors

Disseminated Tuberculosis Presenting as Baker’s Cyst Infection

In the absence of coexisting immunocompromised state and lack of specific symptoms a reactivation of treated mycobacterial tuberculosis (MTB) infection is generally not considered in the differential diagnosis of leg pain. We present a unique case of disseminated tuberculosis presenting as an infected Baker’s cyst in a 73-year-old immunocompetent male