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DIAGNOSING MYCOBACTERIUM TUBERCULOSIS BACTEREMIA IN AN IMMUNOCOMPROMISED FEMALE [Meeting Abstract]

Kassapidis, Vickie; Jrada, Morris; Aye, Myint
ISI:000567143601354
ISSN: 0884-8734
CID: 5264612

Promoting high-value practice by standardizing communication between the hospitalist and primary care provider during hospitalization [Meeting Abstract]

Moussa, M; Mahowald, C; Okamura, C; Ksovreli, O; Aye, M; Weerahandi, H
Statement of Problem Or Question (One Sentence): The increasing complexity of admitted patients, shorter hospital stays and post-acute care adverse events demand a more sophisticated and effective coordination of care between hospitalists and Primary care providers (PCPS). Objectives of Program/Intervention (No More Than Three Objectives): 1. Standardizing communication between Hospitalist and PCP during hospitalization will lower the rate of readmission due to lack of PCP follow up and post-acute care adverse events. 2. Implementing this practice into our daily workflow will improve PCP satisfaction and increase referrals to our institution. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We reviewed a root-cause survey of 30 day readmissions between 1/2018-4/2018 as well as readmission rates for each of our hospitalists. We surveyed our PCPS' satisfaction with communication experiences with our hospitalist group. Finally, we conducted a semi-structured interview of the hospitalist with the lowest readmission (8% vs 12% average for other hospitalists) and highest PCP satisfaction rates, Dr. A, to develop best practices for closed loop communication. Based on this data, we designed a protocol and piloted on 5/1/2018, where the hospitalist contacts the PCP via phone call on admission and delivers a discharge narrative to the PCP via our EMR's routing capability. We used a trackable smart phrase to document the communication. For the prospective phase, we will operationalize these best practices in a study group, Family Health Center PCPS. A control group (community PCPS) will receive usual practice. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We will compare readmission rates between the study group and control group, monitoring the proportion and absolute number of readmissions attributed to no PCP follow up or medication errors. Follow up satisfaction surveys will be sent to the PCPS 6 months after our revised communication practice. Finally, we will monitor the hospitalists' compliance with the smart phrase. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): A review of our institution's 30 day readmissions between 1/2018-4/2018 found that 19% were attributed to lack of PCP/outpatient provider follow-up. Surveys of our community PCPS showed 70% reported being contacted by the hospitalist group in less than 25% of the time. Results from Dr. A's interview revealed that after her encounter with the patient, she calls the patient's PCP highlighting the admitting diagnosis, significant events, pertinent labs, imaging and medications. Dr. A then delivers a discharge narrative to the PCP on the day of discharge highlighting any medication changes, incidental findings and follow up. On a random audit of 100 charts between 5/1/2018-10/30/2018 our preliminary data show that there was 88% compliance with using the smart phrase by the hospitalists. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Using a "positive deviance" approach, we identified best practices for hospitalist-PCP closed loop communication to develop an intervention to improve this aspect of care. If we are successful in reducing readmission rates and improving PCP satisfaction, we will expand to all of our PCPS and ultimately expand to other services to implement this program as best practice
EMBASE:629003928
ISSN: 1525-1497
CID: 4052712

Symptomatic copper deficiency in a patient with remote gastric bypass surgery [Meeting Abstract]

Atkinson, E C; Jrada, M; Aye, M; Okamura, C
Learning Objective #1: Recognize vitamin deficiencies in a gastric bypass patient Learning Objective #2: Treat copper deficiency CASE: A 61 year old female with a past medical history of depression, hypothyroidism, dementia, profound insomnia, and remote history of gastric bypass presented with chronic dizziness and orthostatic hypotension with recurrent falls. She had multiple hospital admissions for dizziness, gait instability and falls. Associated symptoms included nausea and vomiting, fatigue, weakness, hypotension, hypoglycemia with low insulin levels, and worsening tingling and numbness in both legs. She denied using zinc containing denture cream or cold tablets. In the ED, her vital signs were stable and blood work was significant for pancytopenia, with a WBC count of 2.2, hemoglobin of 9.4 and platelets of 137. The levels of many vitamins and minerals were checked given her history of gastric bypass and she was found to have a normal iron level with transferrin saturation of 33%, normal levels of vitamins B1, B6, B9, B12, and selenium (58) and low levels of copper, ceruloplasmin, zinc, and vitamin D. CT and MRI of the brain were negative for acute pathology but significant for severe left temporal atrophy and overall global volume loss. Following admission, she was given intravenous fluids for persistent hypotension with eventual resolution after increasing her home dose of fludrocortisone and starting her on vitamin supplementation for her noted deficiency. She was discharged on a multivitamin with minerals daily, 50,000 units of Vitamin D weekly, 220mg of zinc sulfate twice daily, and 4mg of copper three times a day with close bariatric specialist follow up. IMPACT/DISCUSSION: Copper plays an essential role in the synthesis of many proteins and its deficiency can cause a variety different symptoms. Symptomatic copper deficiency is rare but can be seen in patients with a remote history of bariatric surgeries. In these patients, absorption of many minerals, including copper, is disrupted and supplementation may be necessary to prevent deficiency. This patient had been suffering from pancytopenia with a normal iron panel, which can be due to copper deficiency. Copper is a required cofactor in iron oxidation during hematopoiesis and its deficiency therefore Results in anemia. Patients with hypocupremia may present with gait abnormalities from myelopathy, as noted in our patient. Additionally, imaging showed cerebral atrophy, possibly related to demyelination, which can be seen in patients with Menkes Disease, a mutation causing defects in copper absorption. Despite having these symptoms for years, her copper levels had not been checked prior, which delayed the diagnosis of copper deficiency.
Conclusion(s): Many of the symptoms of copper deficiency are nonspecific, which may delay diagnosis until after many hospital re-admissions. It is essential to always consider copper deficiency in a patient with chronic neurologic symptoms and anemia with a remote history of gastric bypass surgery
EMBASE:629003604
ISSN: 1525-1497
CID: 4052812

Kikuchi Disease: The Great Masquerador - A Case Report and Review of the Literature

Humphreys, Sarah; Oikonomou, Katerina G; Ward, Nicholas; Aye, Myint
ORIGINAL:0016558
ISSN: 2471-8041
CID: 5431102

Klebsiella Pneumoniae Liver Abscess: A Case Series of Six Asian Patients

Oikonomou, Katerina G; Aye, Myint
BACKGROUND Liver abscesses represent a serious infection of hepatic parenchyma and are associated with significant morbidity and mortality. The emergence of a new hypervirulent variant of Klebsiella pneumoniae, which can cause serious infections in the Asian population, is under investigation. We report a case series of six Asian patients hospitalized at our institution from January 2013 to November 2015 for liver abscess due to Klebsiella pneumoniae. CASE REPORT Charts of six Asian patients were retrospectively reviewed. Four patients were male and two were female. The mean age was 53 years (range: 35-64 years). All patients had no known past medical history of immunodeficiency. Three patients had multiple liver abscesses at the time of initial presentation. In five patients, the source of entry of the pathogenic microorganism was unknown and in one patient the suspected source of entry was the gastrointestinal tract. In three patients there was also concomitant Klebsiella pneumoniae bacteremia. The mean duration of antibiotic treatment was seven weeks and the mean duration of hospital stay was 13.5 days. CONCLUSIONS Liver abscess should always be included in the differential diagnosis in cases of sepsis without obvious source and/or in the clinical scenarios of fever, abdominal pain, and liver lesions.
PMCID:5687124
PMID: 28947732
ISSN: 1941-5923
CID: 2717672