Persistent Left Superior Vena Cava Leading to Stroke.

Persistent Left Superior Vena Cava Leading to Stroke.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 1007A
Malhotra A, Boppana VS, Martinez-Balzano C, Orellana A

SESSION TYPE: Miscellaneous Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM – 02:30 PMINTRODUCTION: Ischemic stroke has a high morbidity and mortality. Cardio-embolic phenomena secondary to congenital anomalies is a common cause of ischemic stroke in the younger population. We present a case of persistent left superior vena cava (PLSVC) leading to stroke.CASE PRESENTATION: A 54-year-old gentleman with congenital bilateral cleft lip, cleft palate and deafness was transferred to our hospital. Patient was mechanically ventilated, after an elective right hip arthroplasty for respiratory depression from opioids, and reportedly had some involuntary movements. MRI brain revealed subacute right posterior cerebral artery and anterior cerebral artery infarcts. Doppler showed acute deep venous thrombosis (DVT) of left lower extremity. Interestingly, a Chest X-ray done for the confirmation of peripherally inserted central catheter (PICC) placement showed its tip projecting over the left heart border. PLSVC was suspected but arterial catheterization of the PICC could not be excluded, so a blood gas was done which showed oxygen level of 35 mmHg, confirming venous placement. CT angiogram also revealed a PLSVC with a catheter in it along with right upper lobe pulmonary embolism. Trans-esophageal echocardiogram (TEE) with bubble study showed agitated saline injected in the left arm entering the right atrium from the area of the dilated coronary sinus, confirming PLSVC. No left atrial thrombus was seen. The patient was treated with low molecular weight heparin and warfarin and was discharged home on warfarin after extensive physical rehabilitation.DISCUSSION: PLSVC is the most common anomaly involving central venous return in the thorax with a prevalence of 0.3% in the general population. Approximately 50-70% of these patients are at risk of paradoxical embolism because of accompanying lesions like atrial septal defect, unroofed coronary sinus, or direct communication of the vein to the left atrium. Contrast TEE with left antecubital vein contrast injection is the best diagnostic modality for PLSVC. Our patient is thought to have had a paradoxical embolism reaching the systemic circulation secondary to the PSLVC, causing stroke.CONCLUSIONS: PLSVC needs to be considered as a cause of stroke in the younger population. Coordination between cardiologist, neurologist and radiologist is the key to diagnosis and management of PLSVC.1) Hutyra M, Skala T, Sanak D, et al: Persistent left superior vena cava connected through the left upper pulmonary vein to the left atrium: An unusual pathway for paradoxical embolization and a rare cause of recurrent transient ischaemic attack. Eur J Echocardiogr 11:E35, 20102) Tak T, Crouch E, Drake GB: Persistent left superior vena cava: Incidence, significance and clinical correlates. Int J Cardiol 82:91-93, 2002DISCLOSURE: The following authors have nothing to disclose: Akshiv Malhotra, V Subbarao Boppana, Carlos Martinez-Balzano, Anna OrellanaNo Product/Research Disclosure InformationSUNY Upstate Medical University, Syracuse, NY. HubMed – rehab

Rehospitalization Rates and Clinical Characteristics of Patients Enrolled in a Transition of Care Program Following Hospitalization for Congestive Heart Failure.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 114A
Carlin B, Wiles K, Easley D

SESSION TYPE: Heart Failure PostersPRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM – 02:30 PMPURPOSE: To evaluate the outcomes of a home-care based, respiratory therapist centered transition of care program on rehospitalization rates for patients hospitalized with CHF who require supplemental oxygen following hospital discharge. To evaluate the clinical characteristics of the patients enrolled in the program.METHODS: Patients with CHF who required supplemental oxygen therapy on hospital discharge were entered into a post hospitalization transition of care program {Discharge, Assessment and Summary @ Home (D.A.S.H., Klingensmith HealthCare, Ford City , PA)]. All patients were receiving supplemental oxygen therapy on discharge. The program consists of face to face visits by a respiratory therapist with the patient on days 2, 7, and 30 following hospital discharge. The visits are supplemented by a series of care coordinator phone interviews. Education, behavior modification, skills training, oxygen titration during performance of activities of daily living, clinical assessment, and adherence data collection are components of the program. The 30 day readmission rates following discharge for all patients entered into the program over a two year period (March 2010 through March 2012) were evaluated.RESULTS: 24 consecutive patients with CHF from 23 different hospitals were enrolled into the program and completed the thirty day program. The thirty day readmission rate (all cause) for this group was 0 (0%). Twelve (50%) had a Borg scale score for dyspnea greater than 3. Eleven (46%) of the 24 did not have a followup physician/primary care provider visit during the 30 day period. Two (8%) were entered into a rehabilitation program. Twenty two (91%) remembered receiving the influenza vaccine and seventeen (71%) remembered receiving the pneumococcal vaccine.CONCLUSIONS: The use of this patient centered management program resulted in a decrease in the 30 day readmission rates (compared to historical controls) for those patients with CHF who required supplemental oxygen therapy. Followup physician visits and entry into rehabilitation are provided in less than half of the instances following discharge.CLINICAL IMPLICATIONS: A patient centered transition of care program can be succesfully used to help reduce the 30 day readmission rates for patients following hospitalization for an exacerbation of their underlying CHF.DISCLOSURE: Kim Wiles: Employee: Klingensmith HealthCareDan Easley: Employee: Klingensmith HealthCareThe following authors have nothing to disclose: Brian CarlinNo Product/Research Disclosure InformationDrexel University School of Medicine, Pittsburgh, PA. HubMed – rehab

Disseminated Achromobacter xylosoxidans Infection in an Immunocompromised Host.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 170A
Hasan N, Kavuru M

SESSION TYPE: Infectious Disease Case Report Posters IIPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM – 02:30 PMINTRODUCTION: A. xylosoxidans is a catalase-positive, oxidase-positive, gram-negative bacillus that inhabits a variety of aqueous environments. It has been described as small outbreaks as well as in immunocompromised hosts. We describe a case of disseminated A. xylosoxidans infections in patient on Rituximab treatment.CASE PRESENTATION: 56 year old woman was admitted to the hospital for fever and progressive dyspnea over 2 weeks. Her past medical history was significant for Mantle cell lymphoma status post autologous stem cell transplant (SCT) in 2009 and haploidentical SCT in 2010. She was on Rituximab through her right chest port for recurrence of lymphoma in her right hip. Her temperature was 103 degree fahrenheit and she had a leucocytosis of 14,000/microL. Chest roentgenogram showed a new left loculated effusion. Initial blood cultures were positive for gram negative rods. Echocardiogram showed a large pericardial effusion. She was started on intravenous vancomycin and aztreonam (she was penicillin allergic). Her respiratory status deteriorated quickly requiring mechanical ventilation. Left sided thoracentesis was performed, the fluid was exudative and grew A. Xylosoxidans. Blood cultures finalized to be A. Xylosoxidans as well. The organism was oxidase positive and grew in anaerobic bottle only. It was resistant to aztreonam and ciprofloxacin, while sensitive to gentamicin, ceftazidime, meropenem and tobramycin. The patient was managed with switching aztreonam to intravenous meropenem. A video assisted thoracoscopic surgery, left chest decortication, pericardial window and port removal was done in the operating room. Pericardial fluid also grew A. xylosoxidans. A right pleural effusion later developed which was managed with therapeutic thoracentesis; fluid was sterile. Further ICU course included tracheostomy and gastrostomy tube placement followed by a prolonged hospitalization and discharge to rehabilitation.DISCUSSION: A. Xylosoxidans is a very uncommon cause bacteremia. The mortality is reportedly low with catheter related bacteremia but high with clinical syndromes like pneumonia and endocarditis. In our case, the infection was likely port related but resulted in acute respiratory distress syndrome from pneumonia; and empyema, requiring surgical treatment. Pericarditis with A. xylosoxidans bacteremia has not been previously reported. The organism is known to be resistant to aminoglycosides but was sensitive in our case. The severity of illness, development of pericarditis, sensitivity pattern and good clinical outcome are unique to our case.CONCLUSIONS: A. Xylosoxidans bacteremia in an immunocompromised host can be life threatening. Pneumonia, empyema and pericarditis are potential complications. Choice of intravenous antibiotics and surgical management as appropriate are important for a favorable outcome.1) Duggan et al, Achromobacter xylosoxidans bacteremia: Report of four cases and review of literature. Clin Inf Dis 1996;23 569-76DISCLOSURE: The following authors have nothing to disclose: Naveed Hasan, Mani KavuruNo Product/Research Disclosure InformationThomas Jefferson University Hospital, Philadelphia, PA. HubMed – rehab

Effect of Impaired Pulmonary Function on Mortality Among U.S. Adults With Metabolic Syndrome.

Chest. 2012 Oct 1; 142(4_MeetingAbstracts): 786A
Chowdhury A, Patel D

SESSION TYPE: Physiology/PFTs/ Rehabilitation IPRESENTED ON: Sunday, October 21, 2012 at 01:15 PM – 02:45 PMPURPOSE: Metabolic syndrome and its various components have been reported to be associated with impaired pulmonary function and systemic inflammation. Data on the effect of impaired pulmonary function on mortality among metabolic syndrome patients is inadequate. The purpose of our study was to determine the effect of impaired pulmonary function on all-cause, cardiovascular and respiratory cause related mortality among adults with metabolic syndrome.METHODS: We selected adults with metabolic syndrome, age between 18 to 75 years who were non-smokers and had no cardiovascular or lung disease from the Third National Health and Nutrition Examination Survey. All adults with Metabolic syndrome were divided into 3 groups depending on spirometry results- normal , restrictive(FEV1/FVC>0.7 and predicted FVC<80%) or obstructive( FEV1/FVC<0.7) pulmonary impairment. Multivariate Logistic Regression analysis adjusted for age, sex, and ethnicity was used to compare various mortality rates among the 3 groups.RESULTS: Among the patients with metabolic syndrome (n=2564) the prevalence of restrictive and obstructive lung impairment was estimated to be 10% and 11.1% respectively. Impaired lung function was more prevalent in older population. After adjusting for age, sex and ethnicity the restrictive pulmonary impairment was associated with higher all-cause mortality (33.0% vs 15.5%, OR= 2.08 CI: 1.52-2.84, P<0.0001), cardiovascular mortality (12.0% vs 4.7%, OR= 2.10 CI: 1.35-3.26, P<0.0001), respiratory cause related mortality (3.89% vs 1.0%, OR= 2.94 CI: 1.35-6.38, P=0.006) compared to adults with normal lung function. Obstructive lung function was found to be associated with higher all-cause mortality (42.1% vs 15.5%, OR= 1.29 CI: 1.11-1.49, P=0.0001) but not with cardiovascular mortality (13.5% vs 4.7%, OR=1.18 CI:0.95-1.46, P=0.11) and respiratory cause related mortality (2.4% vs 1.0%, OR= 0.94 CI: 0.59-1.48, P=0.79) after adjusting for age, sex and ethnicity.CONCLUSIONS: Impaired pulmonary function particularly restrictive pattern was found to be associated with higher mortality among adults with metabolic syndrome.CLINICAL IMPLICATIONS: In adults with metabolic syndrome screening pulmonary function tests should be encouraged and further research is needed to determine the efficacy of primary preventive strategies in adults with metabolic syndrome and impaired pulmonary function.DISCLOSURE: The following authors have nothing to disclose: Anindita Chowdhury, Dhaval PatelNo Product/Research Disclosure InformationWashington Hospital Center, Washington, DC. HubMed – rehab