Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a rare form of idiopathic interstitial pneumonia. The disease is characterized by fibrosis of the pleura and subpleural lung parenchyma predominantly affecting the upper lobes. Various triggers have been proposed as inciting factors in the development of the disease. Diagnosis is made clinically in conjunction with radiographic findings and histopathology when available. There are no known effective treatment options and several cases of lung transplantation have been reported. We report a case of an 86-year-old female who presented to the emergency department with worsening dyspnea and hypoxia. She had a history of unexplained pneumomediastinum and a 20 - 25 pounds unintentional weight loss over 10 months. Computed tomography (CT) of the chest without contrast revealed radiographic evidence of IPPFE. Despite symptomatic management with antibiotics, diuretics, and steroids, her condition continued to deteriorate. Unfortunately, our patient was not a candidate for a lung transplant. She was transitioned to hospice care and succumbed to her disease. IPPFE is a rare disease with an unknown prevalence. It has a median survival rate of 2 years. Usually, there is an overlap with interstitial lung diseases, making it challenging to diagnose. There are only a few cases reported in the literature, and there are currently no guidelines available on the appropriate management of this debilitating disease. We recommend more cases be reported, and further research is done to establish better criteria for diagnosis and management.

Background and Aims Pancreatic necrosis is an independent predictor of morbidity and mortality among patients with acute pancreatitis. We compared the safety and outcomes of 3 techniques including endoscopic necrosectomy, fluoroscopy-guided percutaneous necrosectomy by an interventional radiologist, and surgical necrosectomy. Methods Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent pancreatic necrosectomy from 2016 to 2019. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System. Results Of the 2,281 patients meeting the selection criteria, the method of pancreatic necrosectomy was as follows: endoscopy (n=672), percutaneous (n=1,338), and surgery (n=271). Compared to surgery, the rate of mortality was lowest for endoscopy (hazard ratio (HR) 0.27; 95% CI 0.08-0.90; P = 0.033) followed by percutaneous (HR 0.44; 95% CI, 0.20-0.98; P =0.045). Endoscopy was associated with less post-procedure bleeding compared to percutaneous and surgical necrosectomy (P<0.001), as well as lower rates of post-procedure renal failure (P<0.001) and respiratory failure (P=0.002). Endoscopy was associated with average shorter lengths of stay and total hospital costs when compared with percutaneous and surgical approaches, respectively (20.1 vs 25.8 vs 38.3 days; P <0.001) and ($57K vs $76K vs $123K; P<0.001). Conclusions Endoscopic necrosectomy is associated with significantly lower risk of inpatient mortality, adverse events, length of stay, and cost when compared to percutaneous and surgical approaches.

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The presence of gas and free air in the extraluminal space of the intestines is known as pneumatosis intestinalis (PI). There are many different causes of this finding, including gastrointestinal, pulmonary, autoimmune, and many more. It is often difficult to differentiate the etiology and clinical importance of the radiographic evidence on pneumatosis intestinalis due to the unclear pathophysiology causing the disease. To complicate things further, the ominous sign of portal venous gas poses the question of whether surgical intervention is needed. We report two cases both with clinical and radiographic evidence of secondary pneumatosis intestinalis with an associated sinister finding of portal venous gas. The cases differ by urgent surgical intervention versus observation before surgery. In this case series, we emphasize the importance of recognizing the radiographic finding and stress the need for further research to standardize a plan of care, including indications for surgery. We encourage more cases like this to be reported to aid in diagnosing and treating this condition early on with the aim of improving the mortality associated with it.

Introduction: Permanent pacemakers are frequently used to treat disorders of cardiac rhythms. Recently, intracardiac (leadless) pacemakers offer potential treatment with an alternative insertion procedure due to their novel design. Literature comparing hospitalization outcomes between the devices is scarce. We aim to assess the impact of intracardiac pacemakers on readmissions and hospitalization trends. Methods: We analyzed the National Readmissions Database (NRD) from 2016 to 2019 seeking patients admitted for sick sinus syndrome, second-degree or third-degree AV block who received either a transvenous pacemaker or an intracardiac pacemaker. Patients were stratified by device type and assessed for 30-day readmissions, inpatient mortality, and length of stay. Descriptive statistics, Cox proportional hazards and multivariate regressions were used to compare the groups. Results: During the studied period, 21,782 patients met the inclusion criteria. Transvenous pacemakers were implanted in 17,677 patients and intracardiac pacemakers implanted in 4,017 patients. The mean age was 81.07 years, and 45.52% were female. No statistical difference was noted for readmissions (HR 1.14, 95% CI 0.92 - 1.41, p = 0.225) and inpatient mortality (HR 1.36, 95% CI 0.71 - 2.62, p = 0.352) between transvenous and intracardiac groups. Kaplan-Meier curves for readmission and mortality are presented in Figure 1A and 1B, respectively. Multivariate linear regression revealed that length of stay was 0.54 (95% CI 0.26 - 0.83, p < 0.001) days longer for intracardiac group. Conclusion: Hospitalization outcomes associated with intracardiac pacemakers are comparable to traditional transvenous pacemakers. Patients may benefit from the use of this new device without incurring additional resource utilization. Further studies are needed to compare long term outcomes between transvenous and intracardiac pacemakers.