A case report of multiple abscesses caused by Streptococcus intermedius

Streptococcus intermedius is a beta-hemolytic, non-motile, catalase-negative, gram-positive member of the Streptococcus anginosus group. When compared to other members of this group like S. anginosus and Streptococcus constellatus, S. intermedius infections are more substantial. In this case, we present a 47-year-old male patient who was found to have S. intermedius abscesses in his lungs, liver, and brain. The treatment of choice for these abscesses is a combination of drainage, surgery, and antibiotic therapy.

Zieve Syndrome: A Clinical Triad, or Perchance a Quartet?

Zieve syndrome presents with a triad of hemolytic anemia, unexplained jaundice, and hyperlipidemia secondary to alcohol use/alcohol-induced liver injury, highlighting hemolytic anemia as the hallmark feature. Zieve syndrome is more common than originally perceived as its incidence is estimated to be 1 in 1600 admissions, but its mechanism is still poorly understood. This is a case of a 29-year-old man who developed Zieve syndrome shortly after admission for pancreatitis secondary to alcohol use disorder. Early diagnosis is important to reduce unnecessary tests and interventions. Further studies should be considered to evaluate the association between Zieve syndrome and pancreatitis.

Hakuna mycotic aneurysm, Streptococcus salivarius does not always mean "no worries"

Streptococcus salivarius, an easily missed and commonly disregarded Viridians strep species, is usually written off as a culture contaminant, but has been implicated as a rare cause of bacterial endocarditis with serious complications. It is a normal commensal microorganism of the mouth and gut, S. salivarius is usually harmless and even demonstrates anti-inflammatory properties. However, the literature about the complications of a S. salivarius bacteremia remains unclear. This case highlights a patient with mycotic aneurysms due to infective endocarditis in the setting of S. salivarius bacteremia.

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Streptococcus salivarius is easily missed and usually a culture contaminant, but it is also a rare cause of bacterial endocarditis with serious complications.

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Infective endocarditis is diagnosed based on the modified Duke's criteria and commonly presents with a low-grade fever, a new onset heart murmur, petechiae, subungual hemorrhages, Janeway lesions, Osler nodes, or Roth spots.

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It is critical to recognize S. salivarius's role in bacterial endocarditis and its serious complications; therefore, rapid identification and treatment with antibiotics are imperative to avoid complications.

Chasing the dragon and stumbling upon an octopus: A case of heroin-induced leukoencephalopathy and reverse takotsubo cardiomyopathy

The practice of heating heroin and inhaling its vapors, commonly referred to as “chasing the dragon” has been around for decades, but only gained popularity in the United States in the 1990s. Since then, there have been many documented cases of heroin-induced leukoencephalopathy (HIL) and takotsubo cardiomyopathy (TTC). This case highlights a patient with a history of heroin inhalation who presented with multiple neurological features, including bilateral upper and lower extremity weakness, blurry vision and slurred speech. Symptoms progressively worsened over the course of multiple weeks and brain imaging was consistent with toxic leukoencephalopathy secondary to heroin inhalation. Medical course was complicated by a rare associated feature of HIL: reverse Takotsubo cardiomyopathy (rTTC). Transesophageal echocardiogram demonstrated a classic basal hypokinesis and ballooning characteristic of rTTC. The patient's symptoms were treated as currently there is no guideline directed therapy for HIL or rTTC. This case demonstrated a rare and significant complication of heroin inhalation: HIL and rTTC and described potential therapies currently being studied.

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Heroin-induced leukoencephalopathy (HIL) is a rare neurological complication with possible contribution to the development of reverse Takotsubo cardiomyopathy (rTTC).

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HIL is a neurologic disorder associated with inhaling heroin vapors. The pathophysiology is poorly understood at this time, but the condition appears to affect mainly white matter in the brain, differentiating from other types of leukoencephalopathies.

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The diagnosis of rTTC is based on the presence of left ventricular basal hypokinesis or akinesis, acute electrocardiogram abnormalities or elevated troponin levels in the absence of any obstructive coronary disease or myocarditis.

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While there is currently no treatment regimen for HIL, antioxidants such as vitamin A, C, E, zinc, coenzyme q10, and selenium are usually recommended. However, further studies need to be conducted to assess the efficacy of the antioxidants in these patient populations.

A case of isolated sinus bradycardia as an unusual presentation of adrenal insufficiency

Introduction

Sinus bradycardia is a common entity encountered in clinical practice. The differential diagnosis is quite broad; it can be an incidental finding in otherwise healthy adults or the first clue to a lethal pathology.

Case presentation

This case highlights a patient who presented with symptomatic sinus bradycardia, which resulted in syncope requiring admission for permanent pacemaker implantation and later found to have an underlying adrenal insufficiency (AI). Patient's underlying hyponatremia was corrected but bradycardia persisted and after the initiation of steroids, bradycardia resolved. Therefore, the likely culprit for bradycardia was AI.

Discussion

Multiple disease processes that manifest with sinus bradycardia are commonly due to the increased vagal tone or the presence of intrinsic conduction disorders. Sinus bradycardia is a common clinical finding with a broad differential including intrinsic and extrinsic causes of sinus node dysfunction or AV block.

Conclusion

It is imperative for clinicians to be aware of rare etiologies for underlying symptomatic bradycardia. While extremely effective at preventing symptomatic bradycardia, avoiding a pacemaker by correcting the underlying etiology of symptomatic bradycardia may improve quality of life and avoid an unnecessary procedure.

Rare Adult Subtype of Rhabdomyosarcoma, a Common Childhood Soft Tissue Carcinoma

Rhabdomyosarcoma is a malignant soft tissue sarcoma of primitive mesenchymal cells, showing varying degrees of striated skeletal muscle cell differentiation. It is a very common cancer of childhood and adolescence, but rarely seen in the adult population. Here, we present a case of a 33-year-old male presented with a poorly differentiated desmin positive alveolar rhabdomyosarcoma in the left arm. The prognosis of alveolar rhabdomyosarcoma in adults is very poor, frequently detected at advanced stages or with metastases. The alveolar subtype in particular has been found to have a more aggressive course with a high rate of metastasis. Recent studies have shown that using pediatric treatment guidelines resulted in better survival outcomes and local control, but the survival rates are still below that of the pediatric population. Newer studies are looking into using specific molecular markers for more targeted therapy in hopes of further improving survival rates in the adult population.

Characteristics and outcomes of COVID-19 patients in New York City's public hospital system

BACKGROUND

New York City (NYC) bore the greatest burden of COVID-19 in the United States early in the pandemic. In this case series, we describe characteristics and outcomes of racially and ethnically diverse patients tested for and hospitalized with COVID-19 in New York City's public hospital system.

METHODS

We reviewed the electronic health records of all patients who received a SARS-CoV-2 test between March 5 and April 9, 2020, with follow up through April 16, 2020. The primary outcomes were a positive test, hospitalization, and death. Demographics and comorbidities were also assessed.

RESULTS

22254 patients were tested for SARS-CoV-2. 13442 (61%) were positive; among those, the median age was 52.7 years (interquartile range [IQR] 39.5-64.5), 7481 (56%) were male, 3518 (26%) were Black, and 4593 (34%) were Hispanic. Nearly half (4669, 46%) had at least one chronic disease (27% diabetes, 30% hypertension, and 21% cardiovascular disease). Of those testing positive, 6248 (46%) were hospitalized. The median age was 61.6 years (IQR 49.7-72.9); 3851 (62%) were male, 1950 (31%) were Black, and 2102 (34%) were Hispanic. More than half (3269, 53%) had at least one chronic disease (33% diabetes, 37% hypertension, 24% cardiovascular disease, 11% chronic kidney disease). 1724 (28%) hospitalized patients died. The median age was 71.0 years (IQR 60.0, 80.9); 1087 (63%) were male, 506 (29%) were Black, and 528 (31%) were Hispanic. Chronic diseases were common (35% diabetes, 37% hypertension, 28% cardiovascular disease, 15% chronic kidney disease). Male sex, older age, diabetes, cardiac history, and chronic kidney disease were significantly associated with testing positive, hospitalization, and death. Racial/ethnic disparities were observed across all outcomes.

CONCLUSIONS AND RELEVANCE

This is the largest and most racially/ethnically diverse case series of patients tested and hospitalized for COVID-19 in New York City to date. Our findings highlight disparities in outcomes that can inform prevention and testing recommendations.

Characteristics and Outcomes of COVID-19 Patients in New York City's Public Hospital System

Background New York City (NYC) has borne the greatest burden of COVID-19 in the United States, but information about characteristics and outcomes of racially/ethnically diverse individuals tested and hospitalized for COVID-19 remains limited. In this case series, we describe characteristics and outcomes of patients tested for and hospitalized with COVID-19 in New York City's public hospital system. Methods We reviewed the electronic health records of all patients who received a SARS-CoV-2 test between March 5 and April 9, 2020, with follow up through April 16, 2020. The primary outcomes were a positive test, hospitalization, and death. Demographics and comorbidities were also assessed. Results 22254 patients were tested for SARS-CoV-2. 13442 (61%) were positive; among those, the median age was 52.7 years (interquartile range [IQR] 39.5-64.5), 7481 (56%) were male, 3518 (26%) were Black, and 4593 (34%) were Hispanic. Nearly half (4669, 46%) had at least one chronic disease (27% diabetes, 30% hypertension, and 21% cardiovascular disease). Of those testing positive, 6248 (46%) were hospitalized. The median age was 61.6 years (IQR 49.7-72.9); 3851 (62%) were male, 1950 (31%) were Black, and 2102 (34%) were Hispanic. More than half (3269, 53%) had at least one chronic disease (33% diabetes, 37% hypertension, 24% cardiovascular disease, 11% chronic kidney disease). 1724 (28%) hospitalized patients died. The median age was 71.0 years (IQR 60.0, 80.9); 1087 (63%) were male, 506 (29%) were Black, and 528 (31%) were Hispanic. Chronic diseases were common (35% diabetes, 37% hypertension, 28% cardiovascular disease, 15% chronic kidney disease). Male sex, older age, diabetes, cardiac history, and chronic kidney disease were significantly associated with testing positive, hospitalization, and death. Racial/ethnic disparities were observed across all outcomes. Conclusions and Relevance This is the largest and most racially/ethnically diverse case series of patients tested and hospitalized for COVID-19 in the United States to date. Our findings highlight disparities in outcomes that can inform prevention and testing recommendations.

Isolated supra-cardiac partial anomalous pulmonary venous connection causing right heart failure

Right heart failure (RHF) has been overlooked as left heart failure has predominated. One of the many causes of RHF is partial anomalous pulmonary venous connection (PAPVC), an extremely rare entity in nature. Physicians should consider the unusual causes of RHF after ruling out the common causes.

ID: 3: MORBIDITY AND MORTALITY OF CONGESTIVE HEART FAILURE IN TRAUMA PATIENTS: A RETROSPECTIVE CHART ANALTSIS

Background

Cardiovascular morbidity and mortality in heart failure (HF) patients comprise a major health and economic burden, especially when readmission rate and length of stay are considered. With increasing life expectancy, HF prevalence continues to increase. Diseases such as diabetes mellitus, hypertension and ischemic heart disease continue to be the leading causes of HF. Current data suggests that HF is the most common cause for hospital admission in patients older than 65 years.

Objective

In this study, we sought out to compare the morbidity, mortality, 30-day readmission rate and length of stay in trauma patients who have a pre-existing history of HF to those who do not have a history of HF. Additionally, we emphasize the effect of different cardiac variables in the HF group such as the pathophysiology of HF (HF with preserved ejection fraction [HFpEF] vs. HF with reduced ejection fraction [HFrEF]) and the etiology of HFrEF (ischemic vs. nonischemic).

Methods

A retrospective chart analysis of 8,137 patients who were admitted to our hospital between 2005–2013 secondary to trauma with an Injury Severity Score<30. Data was extracted using ICD-9 codes. Neurotrauma patients were excluded.

Results

Of 8,137 trauma patients, 334 had pre-existing HF, of which 169 had HFpEF while 165 had HFrEF). Of the 165 HFrEF cases, 121 were ischemic in etiology vs. 44 nonischemic. Of 334 patients, 81 patients (24%) were readmitted within 30 days vs. 1,068 (14%) of the non-HF patients (95% CI 1.52–2.25, RR: 1.85, p<0.0001). Of the 81 readmitted HF patients, 64 had HFpEF while 35 had HFrEF. There was no statistical significance observed in any of the endpoints in the HFpEF versus. HFrEF groups (figure 1 and table 1). Mortality, 30-day readmission and length of stay were all significantly higher in the ischemic vs. non-ischemic HFrEF group (figure 1 and table 2).

Conclusions

In our trauma population, HF patients had a significantly higher morbidity, mortality and 30-day readmission rate when compared to non-HF patients. The pathophysiology of HF (HFpEF vs. HFrEF) did not seem to play a role. However, after subgroup analysis of the HFrEF group based on etiology, all endpoints including mortality, readmission and length of stay were significantly higher in the ischemic HFrEF subgroup rendering this entity higher importance when treating trauma patients with pre-existing HF.

Abstract ID: 3 Figure 1

ID: 1: STATINS DECREASE MORTALITY RATE AND LENGTH OF HOSPITALIZATION IN HEART FAILURE PATIENTS

Introduction

Many theories and clinical trials have attempted to address the effect of low-density lipoprotein (LDL) lowering in chronic congestive heart failure (CHF). Several studies have demonstrated that higher lipid and lipoprotein levels, including total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides, are associated with significantly improved outcomes in HF of both ischemic and nonischemic etiologies.

Hypothesis

In light of the association between high cholesterol levels and improved survival in HF, statin or other lipid-lowering therapy in HF remains controversial. In this study we evaluated the outcome of statins use in HF patients.

Method

We performed a retrospective chart analysis of 1,616 patients who were admitted to the hospital from 2005 to 2012 due to decompensated HF. 781 patients had HFrEF and 780 patients had HFpEF. The medications of all patients with HFrEF and HFpEF were reviewed. Each of HFrEF and HFpEF patients were divided into two groups: Statin-treated and non-Statin treated. The 30-day readmission rate, mortality rate and LOS were subsequently determined.

Results

Of the 1616 patients with decompensated HF, 776 patients had heart failure with preserved ejection fraction [HFpEF] and 780 patients had HFrEF. After the medications for each group were standardized, the 30-day readmission rate and mortality rate in the HFpEF versus HFrEF groups who received statin therapy did not differ (p=0.9 and 0.3, respectively).

The HFpEF patients who received statin therapy had a lower mortality rate comparing to the non-statin therapy group (OR: 0.2, 95% CI: 0.1–0.5, p<0.001). Furthermore, LOS was significantly lower in the HFpEF statin therapy group 5.4 days versus 6.8 days in the HFpEF non-statin group (p<0.001). 30-day readmission rate did not differ between the two groups (p=0.9).

The HFrEF patients who received statin therapy had a lower mortality rate comparing to HFrEF patients who did not receive statin therapy (OR: 0.3, 95% CI: 0.1–0.6, p<0.001). Additionally, LOS was significantly lower in the HFrEF statin therapy group 5.4 days versus 7 days in the HFrEF non-statin therapy group (p=0.04). 30-day readmission rate did not differ between the two groups (p=0.9).

Conclusion

Our study showed that statin therapy was associated with both a lower mortality rate and LOS among both HFpEF and HFrEF patients. However, the benefit of statin use on 30-day readmission rate did not differ between the two groups of HF patients.

ID: 68: CORONARY ARTERY DISEASE AND ACUTE CORONARY SYNDROME IN PATIENTS ≤40 YEAR OLD

Background

Coronary artery disease (CAD) in the younger adult population has been commonly under-represented in clinical practice and research studies given its early latent asymptomatic course, in addition to the underestimation of this population's CHD lifetime risk by commonly used CHD risk predictors such as Framingham's score.

Objective

To assess the risk factor profile for premature coronary artery disease CAD and ACS presentation in younger adults.

Methods

Retrospective chart analysis of 393 patient's ≤40 years old admitted from 2005 to 2014 for chest pain and underwent coronary angiography. The implication of modifiable risk factors and non-modifiable risk factors were evaluated in those with obstructive CAD (LM stenosis of ≥50% or stenosis of ≥70% in a major epicardial vessel), non-obstructive CAD (≥1 stenosis ≥20% but no stenosis ≥70%) and normal coronaries (no stenosis >20%). Additionally we evaluated the impact of the same risk factors on ACS presentation (NSTEMI vs STEMI) and the extent of CAD (single-vessel/multi vessel).

Results

Of 9012 patients who underwent cardiac catheterization, 393 (4.3%) patients were ≤40 years old.

Out of 393, 212 (54%) had CAD (153 obstructive versus 59 non-obstructive) while 185 (46%) had normal coronaries.

Fifty two (25%) patients presented with STEMI while 140 (66%) patients presented with NSTEMI.

Of 153 patients with obstructive CAD, 87 (57%) patients had single vessel disease vs 66 (43%) multiple vessel disease.

When compared to patients with normal coronaries patients with CAD were more likely to be smokers (p<0.0001), dyslipidemia (p<0.0001), Diabetic (p<0.0001) cocaine users (p 0.4) have a family history of premature CHD (<0.0001) and be males (p<0.0001) (figure=1).

Smokers were more likely to present with acute coronary syndrome; 5 times more likely to present with STEMI (p<0.0001) and 1.7 with NSTEMI (p 0.0003) compared to the control group.

When compared head to head, smokers were 2.2 times more likely to present with STEMI compared to NSTEMI (p<0.001).

Smoking also, alone and with another risk factor increased the risk of obstructive versus no obstructive CAD (p=0.04 and 0.015, respectively).

No significant difference was noted in the single vessel vs multi vessel CAD subgroups.

Coronary artery disease was highest in South Asian population (38.4%), followed by Hispanic (13.7%), African-American (10%) and Caucasian (9%). The main in risk factors in African–American was Hyperlipidemia +/− Diabetes (47.8%) while the main risk factors in Hispanic and white were smoking alone (24.14% and 47.4% respectively). In East Asia population, Smoking with hyperlipidemia was the main risk factors (44%).

Conclusion

In our population of young adults, smoking as a single risk factor was the most prevalent for earlier CAD. It was also associated with more STEMIs and obstructive CAD. Healthcare intervention in the general population through screening, counseling and education regarding smoking cessation is warranted to reduce premature coronary artery disease.

Abstract ID: 68 Figure 1

ID: 12: THE ROLE OF ALCOHOL ABUSE AND TOBACCO USE IN THE INCIDENCE OF EARLY ACUTE CORONAY SYNDROME

Background

Tobacco abuse and alcohol dependence have been established as risk factors for atherosclerotic heart disease (ASHD). Their potential synergistic effect, however, have not been previously evaluated.

Abstract ID: 12 Table 1Alcohol abuse/ DependenceAlcoholic abuse (n=172)Alcoholic- Smoker (n=51)Alcoholic Non-Smoker (n=121)Mean age (years)55.151.156.195% CI(52–58)(48–54.2)(54.6–57.6)Non-Alcohol abuse/DependenceNon-Alcoholic (n=7904)Non-Alcoholic Smoker (n=909)Non-alcoholic Non-smoker (n=6995)Mean age (years)63.856.371.395% CI(63.6–63.9)(55–57.7)(71–71.6)p Value<0.0010.02<0.001

Objective/Purpose

To investigate the synergistic role of alcohol abuse/dependence and tobacco use in the early incidence of ACS.

Methods

A retrospective chart analyses of 8076 patients diagnosed with ACS between 2000 to 2014, defined by ICD-9 codes for acute MI, alcohol abuse/dependence and tobacco use. Average age of ACS was calculated for the general population. Patients were then divided into 4 subgroups based on alcohol abuse/dependence and tobacco use status as follows: non-alcoholic non-smokers, non-alcoholic smokers, alcoholic non-smokers and alcoholic smokers.

Results

The mean age of our 8076 ACS patients population was ∼59.5 (95% CI 59.2–59.8). Patients with history of alcohol abuse/dependence appeared to develop ACS ∼8.7 years younger than their non-alcoholic counterparts. When tobacco use is incorporated as a risk factor, those with both alcohol abuse/dependence and tobacco use seemed to develop ACS ∼5 years earlier than those with history of either alone, and ∼20 years earlier when compared to those with neither alcohol abuse/dependence nor tobacco use.

(table 1 summarizes mean age of ACS incidence in our study subgroups).

Conclusions

Alcohol abuse/dependence appears to be a risk factor for earlier ACS. In our population, the average age of ACS incidence in alcoholic patients was significantly earlier than non-alcoholic patients. Furthermore, alcoholic patients who also used tobacco developed ACS at an even younger age when compared to those who had history of either alcohol abuse/dependence or tobacco use alone, suggesting a possible synergistic effect of these two risk factors in developing early ACS. Healthcare intervention in this population through screening, counseling and education regarding alcohol abuse/dependence and smoking cession is warranted to reduce early ACS.

ID: 4: OUTCOMES IN CONGESTIVE HEART FAILURE PATIENTS UNDERGOING TRANSFEMORAL VERSUS TRANSRADIAL CARDIAC CATHETRIZATION: RESTROSPECTIVE CHART ANALYSIS

Background

Several studies addressed outcomes in terms of NACE and MACE in patients undergoing transradial vs tranfemoral cardiac catheterization. However, data on core quality measures such as length of stay and rehospitalization rates is lacking in the congestive heart failure population.

Method

A retrospective chart analysis of 9,320 patients who were admitted to the hospital for chest pain and underwent cardiac catheterization. Based on ICD-9 codes, we included only patients with Congestive Heart Failure (CHF) with an Ejection Fracture ≤40 (HFrEF). We compared readmission rate and Length of stay in patients who underwent Transradial cardiac catheterization vs Transfemoral cardiac catheterization.

Results

Of a total 9,320 patients undergoing diagnostic coronary angiography, 800 patients had HFrEF. Four hundred patients underwent Transradial cardiac catheterization and 400 patients underwent Transfemoral cardiac catheterization. In the transfemoral cardiac catheterization group, 37 (9%) were readmitted within 30 days of discharge while 17 (4%) patients of 400 patients who underwent transradial cardiac catheterization were readmitted within 30 days of discharged (Odds ratio: 2.3, 95% CI: 1.8–3, p value 0.005).

Length of stay was ∼5.2 days in transradial catheterization vs. ∼6 days in Transfemoral catheterization group (p 0.4).

Conclusion

In our study population, transradial cardiac catheterization in HFrEF patients seemed to have a better outcome when compared to transfemoral cardiac catheterization in terms of 30-days readmission rate. Length of hospital stay was higher in the transfemoral group but did not achieve statistical significance, however. Larger studies that may also include patients with heart failure with preserved ejection fraction (HFpEF) are needed to investigate factors that may contribute to such outcomes.

ID: 14: DIGITALIS INCREASES THE 30-DAY READMISSION RATE IN PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION

Introduction

Digitalis has been used for over 200 years to treat patients with heart failure (HF). Evidence from clinical trials supports the use of digitalis in patients with HF due to left ventricular (LV) systolic dysfunction, particularly in patients with more advanced symptoms. However, there is no evidence that digitalis improves survival.

Hypothesis

We evaluated the role of digitalis use in the 30-day readmission rate, mortality rate and length of stay (LOS) in patients with heart failure and reduced ejection fraction (HFrEF).

Methods

We performed a retrospective chart analysis of 1,616 patients who were admitted to the hospital from 2005 to 2012 due to decompensated HF. 781 patients had HFrEF. The medications of all 781 patients with HFrEF were reviewed. The HFrEF patients were divided into two groups: digitalis-treated and non-digitalis treated. The 30-day readmission rate, mortality rate and LOS were subsequently determined.

Results

Of the 781 patients with HFrEF, 196 (25%) did receive digitalis treatment versus 584 (75%) did not receive Digitalis treatment. After the other medications in each group were standardized, the digitalis-treatment HFrEF group had a higher 30-day readmission rate compared to the non-digitalis treatment HFrEF group (OR: 1.5, 95% CI: 1.1–2.2, p=0.04). The morality rate and LOS between the digitalis-treatment and non-digitalis treatment groups did not differ (p=0.7 and 0.4, respectively).

Conclusion

Our study confirmed that digitalis use in HFrEF does not improve the survival rate and length of stay. However, our study showed that digitalis use can increase the 30-day readmission rate.

Phlebotomy for pulmonary edema in dialysis patients

STUDY OBJECTIVE

To assess the efficacy of phlebotomy in the treatment of pulmonary edema in hemodialysis patients.

PROCEDURE

Maintenance hemodialysis patients presenting to the emergency room in respiratory distress from apparent pulmonary edema were assessed with regard to clinical response, change in blood pressure, change in hematocrit, and interval until the next hemodialysis treatment,

RESULTS

Twenty-one patients underwent phlebotomy and seventeen improved markedly and did not require intubation or emergent dialysis. Hemodialysis was initiated 15.6 +/- 13.6 SD hours later. Four were able to have their treatment 24 or more hours later. Thirteen of 21 (62%) were hypertensive at the time of treatment and blood pressure tended to normalize in this subset. Four of 21 (19%) developed transient hypotension without permanent sequelae. Pre-mean hematocrit = 25.0 + 6.0 and post phlebotomy = 22.6 + 4.6 SD. All patients receiving phlebotomy survived to hospital discharge.

CONCLUSION

Phlebotomy can often obviate the need for intubation or emergent dialysis in ESRD patients presenting with pulmonary edema.