Devesh Rai

Diagnostic Approach to Left Ventricular Hypertrophy: A Review

Torsemide shows no benefit over furosemide for mortality or HF hospitalization.

Antimicrobial susceptibility profiling of carbapenem resistant gram-negative bacilli with special reference to ceftazidime-avibactam and ceftriaxone-sulbactam with EDTA

Background: Increased morbidity and mortality rates attributable to multidrug resistant organisms (MDROs) such as carbapenem resistant organisms (CROs) are being increasingly reported ultimately leading to limited therapeutic options. Several potential strategies are being explored to develop new antibiotics for Carbapenem-resistant organisms. Methods: This was a retrospective study where Antimicrobial susceptibility testing for CZA and CSDE was done using the Kirby-Bauer disc diffusion method. Patient’s clinical conditions were assessed by the clinician and demographic details were recorded in the hospital EMR system. The outcome was decided based on the therapeutic effect of the antibiotics on the patients via primary and secondary endpoints. Results: A total of 150 patients were included in the study, 41 (27.3%) were susceptible to CSDE and turned culture negative. The antibiotic susceptibility patterns of different antibiotics were compared against each other, especially with CZA and CSDE. Conclusions: Colistin is still the drug with maximum susceptibility against the gram negative bacterial infections although CSDE and CZA are the novel antibiotics and show promising results and may be used on a case to case basis depending on the pharmacokinetics and pharmacodynamics which could be the limiting factor at times restricting use of Colistin.

How much time do internal medicine residents spend on self-directed learning and on which resources: a multi-center study

Increased clinical demands and newer means of self-directed learning (SDL) necessitate an understanding of how medical residents are supporting their learning. To examine the patterns of SDL engagement among internal medicine residents, their attitudes and behaviors with various resources, and evaluate the relationship between the clinical learning environment (CLE) and the time residents allocate to SDL and types of resources. This cross-sectional study used a systematic questionnaire informed by previous qualitative research on SDL among internal medicine residents. Internal medicine (IM) residents from 10 residency programs across the United States participated, providing a diverse representation of geographical and institutional contexts. Residents were asked to estimate weekly hours spent on SDL during their last clinical rotation, on which resources, and then to rank the usefulness of each resource. The survey also measured several variables, including attitudes and behaviors after using the resource they perceived to be the most useful, and the influence of training level, residency program type, clinical rotation, and number of hours worked clinically per week on reported time spent on SDL and types of resources. The response rate was 69.5% (783/1,126). Residents dedicated a mean of 18.2 (SD 18.6) hours per week (median of 10.5 hours per week) to SDL. Community-based programs reported more hours of SDL. There was no difference in hours spent on SDL based on the last clinical rotation, number of hours worked clinically, or PGY level. Senior residents favored digital resources, like podcasts, and were less likely to use traditional resources, like textbooks than interns. Our findings underscore the substantial time residents devote to SDL. In light of these results, educators and healthcare systems will need to work together to better support residents in optimizing the complex clinical learning environment.

Knowledge, Attitude and Practice Towards Needle Stick Injury and Significance of HBV Vaccination at Cancer Institutes: Basic Work Up Before Implementing Effective Nsi Management Protocols

Introduction: Hospital staff directly involved in patient care are at high risk of occupational exposure to Needle stick injury (NSI). Doctors, Nurses and Housekeeping (HK) staff are the most common health care categories affected physically, financially and socially by NSI. The main objective of the study was to determine NSI prevalence and associated risk factors at a cancer setup and evaluate misconceptions and knowledge gap regarding its prevention and management along with HBV vaccination status among various health care categories and hospital administration. A cross sectional questionnaire-b Materials & Method: ased survey was conducted among doctors, nurses, HK staff, technicians, hospital administration, phlebotomists and pharmacists at tertiary care cancer institutes from January 2022 to October 2023. The overall prevalence of NSI among surveyed health care staff w Results: as 40.58% affecting 29.4% of surveyed staff of which multiple episodes of NSI were commonly observed among doctors and nurses during working at emergency ward, ICU or IPD wards. Majority of doctors and nurses acquired NSI during sample collection and performing procedures, while HK staff got injured during handling and disposal of sharp biomedical waste. Among surveyed staff, 60.2 % were vaccinated for HBV, of which 90% of doctors, 76.5% of nurses, 70.2 % of technicians and only 28.7% of HK staff have completed the vaccination schedule. Among vaccinated staff, 65. 8% of them were not aware about their anti-HBsAg titre. Performance of awareness and training sessions to Discussion: wards handling of NSI and HBV vaccination is suboptimal. Administration and concerned authorities of the hospital need to strengthen these activities with some innovative, practical and user-friendly approaches. Such surveys must be performed by concerned hospital authorities to increase awareness, assess improvement, understand real time deficiencies and implement customized protocols for achieving the safe working environment at health care institutions.

Impact of right ventricular failure on the outcomes of acute inferior wall myocardial infarction

Trifecta aortic bioprosthesis shows ~5% structural valve failure rate at 5 years.

Iatrogenic ASD closure linked to ~65% higher in-hospital mortality after TMVR, but not TEER.

Late TAVR shows no difference in in-hospital mortality versus early TAVR in acute heart failure.

Intracardiac thrombosis in COVID-19 inpatients is linked to ~232% higher in-hospital mortality.

ICE-guided mitral TEER shows similar in-hospital mortality compared to TEE guidance.

Delayed cardioversion links to ~79% more acute heart failure versus early cardioversion with similar inpatient mortality.

Abstract P149: Prevalence, Trend And Clinical Outcomes Of Hypertensive Urgency And Emergency Before And During The Covid-19 Pandemic: A Comparative Nationwide Analysis (2019 Vs. 2020)

Background: Data on the prevalence trend and clinical outcomes of hypertensive urgency and emergency during the COVID-19 pandemic remains limited. Hence, we aim to compare the prevalence of hypertensive urgency and emergency between the years 2019 and 2020 and compare the clinical outcomes between both years. Methods: We used the National Inpatient Sample (2019-2020) to obtain all patients with hypertensive urgency (ICD-10: I160) and emergency (ICD-10: I161). We excluded all patients who tested positive for COVID-19 infection. We measured the trends annually in 4 quarters. Multivariate logistic regression was used to measure the adjusted outcomes. Results: We found a total of 188,801 patients with hypertensive urgency (2019: 95,731 - 2020: 93,070) and 112,257 patients with hypertensive emergency (2019: 55,456 - 2020: 56,801). The trend in hypertensive urgency showed a significant drop in the second and fourth quarters of the year 2020 (p<0.01), Figure 1 . On multivariate logistic regression, the in-hospital mortality odds among hypertensive emergencies were higher in the year 2020 (aOR 1.08, 95%CI [1.01-1.15]) with no difference in hypertensive urgency. Other complications included hemorrhagic shock, ischemic stroke and acute kidney injury (AKI) were worse among hypertensive emergencies in the year 2020, Figure 1 . There were no differences in the length of stay in both years, regardless of the severity of hypertension. Conclusion: Hypertension urgency was less in the second and fourth quarters in the year 2020. The overall in-hospital complications were worse for hypertensive emergencies in the year 2020 including mortality, hemorrhagic and ischemic stroke and AKI.

Delayed cardioversion linked to ~79% greater acute heart failure risk vs early cardioversion in AF.

COVID-19 Infection Is Associated With Increased In-Hospital Mortality and Complications in Patients With Acute Heart Failure: Insight From National Inpatient Sample (2020)

COVID-19 infection in patients with AHF is associated with significantly higher in-hospital mortality, need for mechanical ventilation, septic shock, and AKI along with higher resource utilization. Predictors for mortality in AHF patients during the COVID-19 pandemic, COVID-19 infection, patients with end-stage heart failure, and atrial fibrillation. Studies on the impact of vaccination against COVID-19 in AHF patients are needed.

COVID-19 during delivery is linked to ~33% higher risk of preeclampsia alongside severe cardiovascular complications.

A gastro-pericardial fistula secondary to gastric cancer can present as a rare STEMI mimicker due to pneumopericardium causing pneumatic compression of the right coronary artery.

Comparative analysis of conventional and direct antimicrobial susceptibility testing of blood cultures in a tertiary care cancer hospital: the way forward

Bloodstream infections (BSI) are associated with high mortality rates, especially in immunocompromised patients. Identifying pathogens early and selecting appropriate antimicrobials to treat BSI is integral in reducing the mortality rate. There is a need to reduce the turnaround time (TAT) of pathogen identification as well as to accelerate the antimicrobial susceptibility testing (AST) of blood cultures, which can be achieved by following relevant identification methods and performing the direct AST (DAST) by the disk diffusion method. In this study, blood samples were collected from patients with suspected bacteremia/septicemia, and aseptic precautions were taken to prevent contamination. Samples containing gram-negative bacilli (GNB) were then analyzed by DAST and conventional AST (CAST). We tested 118 GNB-positive isolates in total to compare the results of DAST and CAST. DAST and CAST showed good categorical agreement (CA) for various groups of microorganisms: 98.9% and 99.6% for Enterobacterales and Pseudomonas spp., respectively. Early detection of pathogens in blood along with the determination of their antibiotic susceptibility patterns is a need of the hour. By performing DAST on positive blood culture broth, clinical teams can obtain the information necessary for switching from empirical therapy to definitive treatment one day faster. This rapid identification of the pathogen, along with corresponding AST results, will help clinicians to accelerate targeted antimicrobial therapy for critical patients and, thus, reduce mortality and morbidity rates in patients with bloodstream infections.

Impella 5.5 support triggers recurrent retroperitoneal bleeding presenting as obscure back pain.

Introduction: We present a case of spontaneous retroperitoneal bleed that presented as back pain until it required multiple transfusions. Case presentation: A 66-year-old gentleman with past medical history of only dyslipidemia, presented with chest pain and was found to have an anterior wall ST-elevation myocardial infarction. He underwent stenting to proximal LAD and was found to be in cardiogenic shock with elevated biventricular filling pressures and ejection fraction of 5-10%. IABP was inserted, which had to be upgraded to axillary Impella 5.5 the next day, and LVAD workup was initiated. He gradually improved with decreasing Impella needs when he started complaining of back pain 5 days into his admission. At the same time, his Impella requirements started to go up. He went on to develop sweating, pallor & hemodynamic compromise. Since he was on anticoagulation due to Impella, a CT scan was obtained, which showed a spontaneous left-sided retroperitoneal bleed (F1) (IABP had been on the right side) and drop in hemoglobin from 15.8 mg/dl on admission to 7.2 mg/dl. He went on to develop hemorrhagic shock requiring massive blood product transfusion with subsequent vessel embolization by interventional radiology. Afterwards, he continued to improve, and Impella was eventually removed. Later in the course, he had another drop in hemoglobin & was taken back for CT, which showed expanding retroperitoneal hematoma (F2). Hematology team was consulted due to 2 spontaneous bleeds; however, no underlying bleeding disorder was suspected. He stabilized; was weaned off of Impella and, was subsequently discharged on milrinone infusion. Conclusions: We conclude that providers highly suspect retroperitoneal bleeds in the proper clinical setting for optimum patient care.

Emergent surgical thrombectomy and PFO closure were performed in an 80-year-old woman presenting with a rare paradoxical thrombus in transit through a PFO and massive pulmonary embolism.