Faculty Bibliography

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

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.

BACKGROUND: Deficiencies in physical examination skills among medical students, housestaff, and even faculty have been reported for decades, though specifics on how to address this deficit are lacking. METHODS: Our institution has made a commitment to improving key physical examination competencies across our general medicine faculty. Development of the Merrin Bedside Teaching Program was guided by a comprehensive needs assessment and based on a learner-centered educational model. First, selected faculty fellows achieve expertise through mentorship with a master clinician. They then develop a bedside teaching curriculum in the selected domain and conclude by delivering the curriculum to peer faculty. RESULTS: We have developed curricula in examination of the heart, shoulder, knee, and skin. Currently, curricula are being developed in the examination of the lungs, critical care bedside rounds, and motivational interviewing. Curricula are integrated with educational activities of the internal medicine residency and medical school whenever possible. CONCLUSIONS: A hospitalist-led physical examination curriculum is an innovative way to address deficits in physical exam skills at all levels of training, engenders enthusiasm for skills development from faculty and learners, offers scholarship opportunities to general medicine faculty, encourages collaboration within and between institutions, and augments the education of residents and medical students. Journal of Hospital Medicine 2012. (c) 2012 Society of Hospital Medicine.