Faculty Bibliography

Learning Objective #1: Recognize pancreatic-enteric fistulization as a rare complication of pancreatitis Learning Objective #2: Define the mechanisms for fistula formation in hemorrhagic pseudocysts CASE: The patient is a 31-year-old female with a past medical history of systemic lupus erythematosus complicated by end stage renal disease on dialysis, and pancreatitis complicated by pseudocyst formation, presenting with acute onset abdominal pain, nausea, and vomiting. On presentation, she was afebrile and hemodynamically stable with exam notable for diffuse abdominal tenderness and voluntary guarding without rebound. CT abdomen and pelvis showed hemorrhage into the known pancreatic tail pseudocyst with interval enlargement from 8 to 12 cm. CTAngiogram obtained four days after the onset of abdominal pain showed an open fistula between the pseudocyst and transverse colon, without evidence of active arterial bleeding. The patient then had two episodes of bright red blood per rectum. She became tachycardic and hypotensive with labs notable for a one-point hemoglobin drop from 9.7 to 8.5. She was triaged to the surgical ICU and underwent urgent exploratory laparotomy with transverse colectomy, partial pancreatectomy, and splenectomy, followed by staged colostomy creation. IMPACT/DISCUSSION: Fistulization of pancreatic pseudocysts is an extremely rare complication, occurring in less than 3% of cases, and can involve a variety of abdominal organs. Connections with sources other than the colon often cause spontaneous drainage and resolution of symptoms, and thus do not require surgery. However, communication with the colon can lead to other complications such as hemorrhage and sepsis, as seen in this case, which require definitive management. A proximal diverting colostomy is standard practice in order to prevent further backup of fecal matter into the pseudocyst and prevent rupture into the abdominal cavity. Multiple mechanisms have been proposed to explain the cause of hemorrhage and rupture of pancreatic pseudocysts. These mechanisms include the presence of severe inflammation due to activated lytic enzymes of the pancreas, as well as persistent compression of blood vessels due to mass effect. Colonopancreatic fistula formation in the case of our patient with lupus is likely secondary to the pro-inflammatory environment compounded by high wall pressures and suppressed healing mechanisms due to chronic steroid use.
Conclusion(s): Given the gravity of a missed diagnosis, hospitalists must keep complications of pancreatic pseudocysts on their differential for patients with known pathology and acute abdominal pain. Management strategies differ based on the type of complication, however, urgent operative management is key in certain cases of fistula formation, especially when it involves the colon as in our patient

Background: Diagnostic errors have a significant impact on our health care system with cognitive errors contributing to the majority of cases. Educators have theorized that interventions grounded in dual process theory (DPT) may improve the clinical reasoning (CR) process of physicians but little empirical evidence of this theory exists.
Method(s): This study was a quasi-experimental design in the New York University Internal Medicine Residency Program from June 2017- January 2018. We implemented two educational interventions in CR grounded in DPT during this 6-month period, leading to a natural experiment with three groups: no intervention (N = 25), partial intervention (received part 1, N = 23), and full intervention (received part 1 and part 2, N = 23). The educational interventions covered the concepts of DPT, impact of diagnostic errors, and case-based discussions introducing techniques to develop fast and slow thinking. We used the diagnostic thinking inventory (DTI) at baseline (a 41 item self-assessment questionnaire to assess one's approach to CR). At 6 months, participants completed a follow-up DTI and a post-survey assessing their ability to apply concepts to cases as well as workplace experiences of CR teaching. Participants who completed pre- and post-surveys were included in the analysis. Case examples were scored by two independent reviewers blinded to group status (Table). Differences between groups were analyzed using a one-way analysis of variance.
Result(s): Those in the full intervention group reported more teaching of DPT on attending rounds and in conference than the partial intervention and no intervention groups (60% often or always taught compared to 25% and 8.3%, p = 0.002; 73.3% often or always taught compared to 58.3% and 33.3%, p = 0.033, respectively). Otherwise workplace experiences were not significantly different between the groups. There was a significant difference between groups in ability to apply concepts to cases with a medium to large effect size (Table). There was also a significant difference in giving case examples in problem representation format with a large effect size (Table). There was no significant difference in change in DTI scores (mean change in score no intervention 7.0 (SD 16.3), partial intervention 8.8 (SD 9.8), full intervention 7.8 (SD 12.0), p = 0.946).
Conclusion(s): This study provides evidence that interns who participated in a CR curriculum grounded in DPT were effective in applying principles of CR in cases from their own clinical practice and supports the argument that we should be designing educational interventions in CR grounded in DPT. Subsequent studies would need to assess further impact on patient outcomes. (Figure Presented)

Learning Objective #1: Recognize how to diagnose tick-borne co-infections based on clinical presentation and lab findings. CASE: A 43-year-old man presented with one month of progressively worsening malaise and polyarthralgias to the point that he could not walk or hold utensils. He reported that shortly after removing a tick from his thigh while in upstate New York he developed fevers, anorexia, dizziness, and memory problems in addition to the rheumatic symptoms above. He denied any rashes or inflamed joints. On exam he was ill-appearing, had a fever of 102F but had no rashes, no joint erythema or effusions, and no cardiac murmurs. Laboratory values were significant for a hemoglobin of 9.2 g/dL, iron level of 55mu g/dL, total iron binding capacity of 247mu g/dL, a ferritin of 372 ng/mL, an erythrocyte sedimentation rate of 124 mm/hr, and a c-reactive protein of 116 mg/L. A peripheral smear was negative for hemolysis or Maltese crosses suggestive of babesiosis. EKG and imaging studies were unremarkable. On admission, he was started empirically on doxycycline for presumed tick-borne illness without coverage for babesiosis due to the negative peripheral smear and hemolysis labs. Over the course of his hospitalization the patient's fatigue slowly improved and by follow up one week later he was completely asymptomatic. His Lyme and anaplasma titers both returned positive. IMPACT: Rates of co-infection with babesiosis and anaplasmosis range from 4-28 percent in endemic regions of the United States. Lyme disease is a tick-borne illness transmitted by the Ixodes scapularis tick in Eastern and North Central regions of North America. I. scapularis is also the vector for Babesia microti and Anaplasma phagocytophilum. Those who are co-infected have similar clinical manifestations including malaise, fever, myalgias, and arthral-gias, but can have more prolonged courses and severe symptoms. DISCUSSION: Our patient presented with non-specific malaise, a largely unremarkable physical exam and an isolated anemia without any evidence of hemolysis. Babesiosis may cause hemolysis and anaplasmosis may cause leukopenia, thrombocytopenia, and elevated transaminases. Typically patients present with the rash of erythema migrans without remembering a tick bite, however the rash is only present in 80% of cases. Absence of rash and unusually severe rheumatic complaints should not decrease the suspicion for tick-borne illnesses under otherwise typical circumstances. Serologic testing was warranted due to the absence of an erythema migrans rash, and a history of travel to an endemic region with possible exposure to multiple tick-borne illnesses. Empiric therapy is indicated while definitive testing is pending

Learning Objective #1: Recognize the complications of Legionella Pneumonia CASE: A 40 yo woman with well-controlled HIV (last CD4 in the 700's uL with, an undetectable viral load) and CKD (Cr of 1.5 mg/dL) presented with fevers, productive cough, and diarrhea for 10 days. On presentation, she was febrile to 102.9F, tachycardic to 104 bpm, and hypoxic to SpO2 of 90-92%. Physical exam was notable for decreased breath sounds in the right lower lobe. Initial studies revealed a sodium of 125 mEq/L, AST/ALT elevation to 1200 IU/L/400s IU/L, BUN/Creatinine of 81md/dL/8.6 mg/dL, and positive Urine Legionella. Her creatinine continued to uptrend, with a creatinine phosphoki-nase (CPK) of 8580 U/L on HOD3. She was treated with IV hydration and urine alkalization. Urgent dialysis and kidney biopsy were considered, however, patient's creatinine stabilized. Patient completed a 14 day course of Azithromycin, with improvement in her AKI, with her creatine downtrending to 3.7 mg/dL and her CPK to 372 U/L. IMPACT: The wide ranging consequences of Legionnaires' Disease (LD) on the lungs, liver, and kidneys is well documented. However, the prevalence and severity of the broad spectrum of LD in HIV patients has not been thoroughly investigated. Our patient was infected with HIV. We believe that this fact contributed to the severe clinical course, characterized by rhabdomyolysis and acute renal failure. DISCUSSION: This is a case of LD in an HIV+ patient characterized by pneumonia, hyponatremia, transaminitis, and acute reversible renal failure from non-traumatic rhabdomyolysis. LD is a bacterial pneumonia, with multi-organ complications. ARF, specifically rhabdomyolysis is an infrequently recognized complication of LD; which is associated with increased mortality. Risk factors for LD include chronic lung disease, cigarette smoking, and immunosuppression. HIV-infected individuals are at an increased risk for pulmonary infections. Legionella pneumonia is estimated to be responsible for 20% of all adult HIV-associated pneumonias as compared to 15% in the general population. HIV-infected patients present with a more severe clinical presentation compared to HIV-negative individuals. One retrospective study, compares the clinical features and outcome of LD between 64 HIV-negative and 15 HIV-positive patients (mean CD4 count 340 uL). In the HIV patient group, there were higher reports of laboratory abnormalities (CPK, hyponatremia, LFTs), bilateral lung involvement on imaging, and an increase in respiratory failure and mortality. One proposed theory includes a blunted TH1 response in the setting of HIV infection. Legionella pneumophila is a facultative intracellular pathogen, which replicates inside macrophages. Cell mediated immunity or TH1-CD4 helper cells are essential in clearing the infection from the body. TH1-CD4 helper cells are the primary source of interferon alpha, which helps decrease cellular nutrients, including iron, leading to apoptosis and cellular lysis, ultimately preventing Legionella from thriving

BACKGROUND: Understanding the mechanism of unplanned hospital readmissions is necessary for accurate prediction and prevention. OBJECTIVE: To identify specific mechanisms of unplanned readmissions through medical narratives obtained from chart reviews. DESIGN: Retrospective chart review. SETTING: Urban tertiary care hospital. PATIENTS: Two hundred seventy patients accounted for 335 unplanned 7-day readmissions between July 2010 and July 2011. MEASUREMENTS: Readmissions were classified into 1 of 5 distinct categories. RESULTS: Readmitted subjects were more likely to have had a longer length of stay during the first admission compared to nonreadmitted patients. Readmissions due to unpredictable/unpreventable complications or unrelated events constituted the highest percentage at 46%. Readmissions due to patient factors such as substance abuse, signing out against medical advice, or nonadherence to the treatment plan constituted 31%. Readmissions designated as preventable accounted for 24%. Among preventable readmissions, the most common cause was incomplete management of the index diagnosis. The interobserver level of agreement across the 5 major categories was substantial. CONCLUSIONS: We found through detailed chart review of patients readmitted within 7 days to an urban teaching hospital that the majority of readmissions were not avoidable and were often due to unpredictable or unpreventable complications of the primary diagnosis from the index hospitalization or to patient behaviors that contradicted the treatment plan. These results question the value of readmissions as a valid metric of quality and support future interventions in hospital systems to reduce preventable readmissions. Journal of Hospital Medicine 2015. (c) 2015 Society of Hospital Medicine.