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  • Enhancing safety in the ischaemic and haemorrhagic stroke population: exploring the efficacy of self-releasing chair alarm belts
    Weppner, Justin; Gee, Alaric; Mesina, Kevin (BMJ, 2024-02-21)
    Introduction A quality improvement study evaluated the effectiveness of implementing self-releasing chair alarm belts in an inpatient rehabilitation facility (IRF) for patients who had a stroke. The objective of this study is to assess the effectiveness of self-releasing chair alarms as a chair-level fall preventive tool in patients who had a stroke in the IRF setting. Methods A preintervention and postintervention quality improvement study was conducted in an IRF to address the high rate of falls in the stroke population. Falls from wheelchairs were identified as a significant concern, leading to the implementation of self-releasing safety belts (Posey HeadStart Notification Sensor Belts) with alarm systems as an intervention. In the preintervention phase (July 2021 to January 2022) falls from chairs while on standard fall precautions were recorded to establish a baseline. In the intervention phase, the self-releasing chair alarm belts were introduced along with standard fall precautions. The postintervention phase spanned from February 2022 to July 2022. Results In the preintervention phase, 20 out of 86 stroke subjects experienced a total of 30 falls from chairs. However, in the postintervention phase, only one subject experienced a fall from a chair out of 104 stroke subjects. The mean percentage of subjects involved in falls decreased from 24±11.4% to 1±0.4% (p<0.00001), and the mean fall rate per 1000 patient days declined from 4.6±2 to 0.2±0.1 (p<0.0001). Conclusions The implementation of self-releasing chair alarm belts significantly reduced falls from chairs among patients who had a stroke in the IRF setting. These findings highlight the effectiveness of this intervention in improving patient safety and fall prevention in IRFs.
  • Antibiotic exposure is associated with decreased risk of psychiatric disorders
    Kerman, Ilan A.; Glover, Matthew E.; Lin, Yezhe; West, Jennifer L.; Hanlon, Alexandra L.; Kablinger, Anita S.; Clinton, Sarah M. (Frontiers, 2024-01-08)
    Objective: This study sought to investigate the relationship between antibiotic exposure and subsequent risk of psychiatric disorders. Methods: This retrospective cohort study used a national database of 69 million patients from 54 large healthcare organizations. We identified a cohort of 20,214 (42.5% male; 57.9 ± 15.1 years old [mean ± SD]) adults without prior neuropsychiatric diagnoses who received antibiotics during hospitalization. Matched controls included 41,555 (39.6% male; 57.3 ± 15.5 years old) hospitalized adults without antibiotic exposure. The two cohorts were balanced for potential confounders, including demographics and variables with potential to affect: the microbiome, mental health, medical comorbidity, and overall health status. Data were stratified by age and by sex, and outcome measures were assessed starting 6 months after hospital discharge. Results: Antibiotic exposure was consistently associated with a significant decrease in the risk of novel mood disorders and anxiety and stressor-related disorders in: men (mood (OR 0.84, 95% CI 0.77, 0.91), anxiety (OR 0.88, 95% CI 0.82, 0.95), women (mood (OR 0.94, 95% CI 0.89,1.00), anxiety (OR 0.93, 95% CI 0.88, 0.98), those who are 26–49 years old (mood (OR 0.87, 95% CI 0.80, 0.94), anxiety (OR 0.90, 95% CI 0.84, 0.97)), and in those ≥50 years old (mood (OR 0.91, 95% CI 0.86, 0.97), anxiety (OR 0.92, 95% CI 0.87, 0.97). Risk of intentional harm and suicidality was decreased in men (OR 0.73, 95% CI 0.55, 0.98) and in those ≥50 years old (OR 0.67, 95% CI 0.49, 0.92). Risk of psychotic disorders was also decreased in subjects ≥50 years old (OR 0.83, 95 CI: 0.69, 0.99). Conclusion: Use of antibiotics in the inpatient setting is associated with protective effects against multiple psychiatric outcomes in an age- and sex-dependent manner.
  • Rare Occurrence of Extradigital Glomangioma in the Prepatellar Bursa of a 40-Year-Old: A Case Study
    Crawford, Dylan C.; O'Malley, Michael; Samuel, Linsen T. (Indian Orthopaedic Research Group, 2022-07)
    INTRODUCTION: A solitary subcutaneous mass can be a common clinical finding for patients symptomatic for knee pain, especially when direct pressure by kneeling on the anterior aspect of the knee causes pain. CASE REPORT: We present a 40-year-old who noticed a small fluid filled mass that has become progressively larger and more painful over the past 7 years. The patient's primary complaint was sharp pain with direct contact. Ultimately, a surgical excision was performed to remove the mass. The histopathological report came back as a glomangioma, a subtype of a glomus tumor. To the best of our knowledge, this is the youngest reported case of a glomangioma of the knee. CONCLUSION: Glomus tumors found on the digital and subungual regions of patients are a common clinical finding. An extradigital occurrence of a glomangioma, a subtype of a glomus tumor, is rarely found, especially in younger patients. Therefore, a histopathological examination must be done after the removal of any subcutaneous mass.
  • Complicated Post-Partum HELLP Syndrome Causing Acute Renal Failure and a Spontaneous Acute Subdural Hematoma
    Shah, Farhan; Patel, Niel; Patel, Brijesh B. (Springer, 2021-02-08)
    HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and thrombocytopenia. It is a devastating illness that typically occurs in the third trimester of gestation. We present a unique case of complicated post-partum HELLP syndrome. The patient was a 34-year-old Caucasian G1PO woman at 40 weeks' gestational age who presented for induction of labor. She underwent successful vaginal delivery. However, postoperatively the patient developed HELLP syndrome complicated by acute renal failure. She was transferred to the intensive care unit, where her renal function continued to decline, ultimately necessitating hemodialysis. She subsequently spontaneously developed an acute subdural hematoma. Most cases of HELLP syndrome occur in the third trimester, whereas fewer manifest post-partum. The pathophysiology of HELLP syndrome is poorly understood. While the defining organ of injury in HELLP syndrome is the liver, both kidney injury and spontaneous subdural hematomas can occur, as seen in this patient. The gold standard therapy for HELLP syndrome is prompt delivery of the fetus. HELLP syndrome continues to be a serious constellation of symptoms that can affect women late in their gestational period. As illustrated in this case report, prompt diagnosis of HELLP syndrome and appropriate management is critical.
  • The Lung Point Sign, not Pathognomonic of a Pneumothorax
    Aziz, Sameh G.; Patel, Brijesh B.; Ie, Susanti R.; Rubio, Edmundo R. (Ultrasound Quarterly, 2016-09-01)
    Since the development of portable ultrasonography equipment, this technology has provided clinicians the ability to evaluate a variety of lung pathology at the bedside, but we are still learning how to accurately interpret the acquired images. Adequate interpretation and recognition of certain signs is crucial to diagnosing pathological processes. In addition, such signs must be adequately correlated with the patient's medical condition. For instance, the "lung point sign" has been traditionally considered to be pathognomonic for the presence of a pneumothorax, yet such finding may be present in patients with bullous lung disease without a pneumothorax. We present a case of an 83-year-old man with underlying chronic obstructive pulmonary disease. Bedside ultrasonography identified a "lung point sign" initially suggesting a possible pneumothorax. Further evaluation demonstrated absence of pneumothorax, with the patient having a large bulla. To our knowledge, this is the first case reported demonstrating that the "lung point sign" is not always indicative of a pneumothorax. We discuss the importance of both clinical correlation and understanding of the underlying pathophysiology when reviewing ultrasound images to accurately interpret ultrasound findings.
  • Introduction of a formative assessment tool in a post-graduate training program in India: a mixed methods evaluation
    Douglass, Katherine; Ahluwalia, Tania; McKiernan, Brianna; Patel, Heena; Powell, Natasha; Keller, Jacob; Toy, Serkan (2024-03-01)
    Background: Our institution has longstanding post-graduate education and training partnership programs in Emergency Medicine (EM) across India. A programmatic challenge has been the integration and uptake of evidence-based medicine and lifelong learning concepts. Formative assessment (FA) is intended to enable learners to monitor learning, identify strengths and weaknesses, and target areas of growth. As part of a program improvement initiative, we introduced an online FA tool to existing summative assessments. This study investigates how the FA tool was used and perceived by trainees. Methods: 246 trainees across 19 sites were given access to the FA tool. Usage metrics were monitored over 12 months. Semi-structured interviews were conducted in person with trainees using a purposive sampling methodology. A hybrid thematic analysis approach was used to determine themes. Interviews were coded independently by two blinded researchers using NVivo software. The study was deemed exempt by our institutional review board. Results: There was high variability in trainees’ utilization of the FA tool. Trainees who used the FA tool more performed better on summative exams (r = 0.35, p < 0.001). Qualitative analysis revealed that trainees were motivated to learn for improved clinical knowledge and to be a good physician, not only passing exams. Benefits of the tool included the relationship to clinical practice and thorough explanation of answers, while disadvantages included topics unrelated to India. Conclusion: The integration of a FA tool has provided positive outcomes for trainees in EM education programs in India. Lessons learned may apply globally to other contexts and programs.
  • Acute onset apathy in the context of malignancy: a case report
    Samarbafzadeh, Ehsan; Adikey, Archana; Alee Koloukani, Sahar (2021-05-03)
  • Characterization and LDL-C management in a cohort of high and very high cardiovascular risk patients: The PORTRAIT-DYS study
    Gavina, Cristina; Seabra-Carvalho, Daniel; Aguiar, Carlos; Anastassopoulou, Anastassia; Teixeira, Carla; Ruivo, Jorge A.; Almeida, Élia; Luz-Duarte, Leonor; Corte-Real, Ana; Canelas-Pais, Mariana; Taveira-Gomes, Tiago (Wiley, 2023-11-06)
    Aim: This study aims to characterize sociodemographic and clinical characteristics, use of lipid-lowering therapies (LLTs), and low-density lipoprotein cholesterol (LDL-C) control in a population with increased cardiovascular (CV) risk. Methods: A cross-sectional observational study that uses electronic health records of patients from one hospital and across 14 primary care health centers in the North of Portugal, spanning from 2000 to 2020 (index date). Patients presented at least (i) 1 year of clinical data before inclusion, (ii) one primary care appointment 3 years before the index date, and (iii) sufficient data for CV risk classification. Patients were divided into three cohorts: high CV risk; atherosclerotic cardiovascular disease (ASCVD) risk equivalents without established ASCVD; evidence of ASCVD. CV risk and LDL-C control were defined by the 2019 and 2016 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) dyslipidemia guidelines. Results: A total of 51 609 patients were included, with 23 457 patients classified as high CV risk, 19 864 with ASCVD equivalents, and 8288 with evidence of ASCVD. LDL-C control with 2016 ESC/EAS guidelines was 32%, 10%, and 18% for each group, respectively. Considering the ESC/EAS 2019 guidelines control level was even lower: 7%, 3%, and 7% for the same cohorts, respectively. Patients without any LLT prescribed ranged from 37% in the high CV risk group to 15% in patients with evidence of ASCVD. Conclusion: We found that LDL-C control was very low in patients at higher risk of CV events. An alarming gap between guidelines on dyslipidemia management and clinical implementation persists, even in those at very high risk or with established ASCVD.
  • Prognostic Factors and Nomogram for Choroid Plexus Tumors: A Population-Based Retrospective Surveillance, Epidemiology, and End Results Database Analysis
    Bhutada, Abhishek S.; Adhikari, Srijan; Cuoco, Joshua A.; In, Alexander; Rogers, Cara M.; Jane, John A.; Marvin, Eric A. (MDPI, 2024-01-31)
    Background: Choroid plexus tumors (CPTs) are rare neoplasms found in the central nervous system, comprising 1% of all brain tumors. These tumors include choroid plexus papilloma (CPP), atypical choroid plexus papilloma (aCPP), and choroid plexus carcinoma (CPC). Although gross total resection for choroid plexus papillomas (CPPs) is associated with long-term survival, there is a scarcity of prospective data concerning the role and sequence of neoadjuvant therapy in treating aCPP and CPC. Methods: From the years 2000 to 2019, 679 patients with CPT were identified from the Surveillance, Epidemiology, and End Result (SEER) database. Among these patients, 456 patients had CPP, 75 patients had aCPP, and 142 patients had CPC. Univariate and multivariable Cox proportional hazard models were run to identify variables that had a significant impact on the primary endpoint of overall survival (OS). A predictive nomogram was built for patients with CPC to predict 5-year and 10-year survival probability. Results: Histology was a significant predictor of OS, with 5-year OS rates of 90, 79, and 61% for CPP, aCPP, and CPC, respectively. Older age and African American race were prognostic for worse OS for patients with CPP. Older age was also associated with reduced OS for patients with aCPP. American Indian/Alaskan Native race was linked to poorer OS for patients with CPC. Overall, treatment with gross total resection or subtotal resection had no difference in OS in patients with CPP or aCPP. Meanwhile, in patients with CPC, gross total resection (GTR) was associated with significantly better OS than subtotal resection (STR) only. However, there is no difference in OS between patients that receive GTR and patients that receive STR with adjuvant therapy. The nomogram for CPC considers types of treatments received. It demonstrates acceptable accuracy in estimating survival probability at 5-year and 10-year intervals, with a C-index of 0.608 (95% CI of 0.446 to 0.77). Conclusions: This is the largest study on CPT to date and highlights the optimal treatment strategies for these rare tumors. Overall, there is no difference in OS with GTR vs. STR in CPP or aCPP. Furthermore, OS is equivalent for CPC with GTR and STR plus adjuvant therapy.
  • Noninvasive neuromodulation of subregions of the human insula differentially affect pain processing and heart-rate variability: a within-subjects pseudo-randomized trial
    Legon, Wynn; Strohman, Andrew; In, Alexander; Payne, Brighton (Wolters Kluwer Health, Inc., 2024-02-01)
    The insula is an intriguing target for pain modulation. Unfortunately, it lies deep to the cortex making spatially specific noninvasive access difficult. Here, we leverage the high spatial resolution and deep penetration depth of low-intensity focused ultrasound (LIFU) to nonsurgically modulate the anterior insula (AI) or posterior insula (PI) in humans for effect on subjective pain ratings, electroencephalographic (EEG) contact heat–evoked potentials, as well as autonomic measures including heart-rate variability (HRV). In a within-subjects, repeated-measures, pseudo-randomized trial design, 23 healthy volunteers received brief noxious heat pain stimuli to the dorsum of their right hand during continuous heart-rate, electrodermal, electrocardiography and EEG recording. Low-intensity focused ultrasound was delivered to the AI (anterior short gyrus), PI (posterior longus gyrus), or under an inert Sham condition. The primary outcome measure was pain rating. Low-intensity focused ultrasound to both AI and PI similarly reduced pain ratings but had differential effects on EEG activity. Low-intensity focused ultrasound to PI affected earlier EEG amplitudes, whereas LIFU to AI affected later EEG amplitudes. Only LIFU to the AI affected HRV as indexed by an increase in SD of N-N intervals and mean HRV low-frequency power. Taken together, LIFU is an effective noninvasive method to individually target subregions of the insula in humans for site-specific effects on brain biomarkers of pain processing and autonomic reactivity that translates to reduced perceived pain to a transient heat stimulus.
  • Anti-inflammatory cytokine stimulation of HMC3 cells: Proteome dataset
    Ahuja, Shreya; Lazar, Iulia M. (Elsevier, 2023-07-20)
    The immunoprotective functions of microglia in the brain are mediated by the inflammatory M1 phenotype. This phenotype is challenged by anti-inflammatory cytokines which polarize the microglia cells to an immunosuppressive M2 phenotype, a trait that is often exploited by cancer cells to evade immune recognition and promote tumor growth. Investigating the molecular determinants of this behavior is crucial for advancing the understanding of the mechanisms that cancer cells use to escape immune attack. In this article, we describe liquid chromatography (LC)-mass spectrometry (MS)/proteomic data acquired with an EASY-nanoLC 1200-Q ExactiveTM OrbitrapTM mass spectrometer that reflect the response of human microglia cells (HMC3) to stimulation with potential cancer-released anti-inflammatory cytokines known to be key players in promoting tumorigenesis in the brain (IL-4, IL-13, IL-10, TGFB and MCP-1). The MS files were processed with the Proteome Discoverer v.2.4 software package. The cell culture conditions, the sample preparation protocols, the MS acquisition parameters, and the data processing approach are described in detail. The RAW and processed MS files associated with this work were deposited in the PRIDE partner repository of the ProteomeXchange Consortium with the dataset identifiers PXD023163 and PXD023166, and the analyzed data in the Mendeley Data cloud-based repository with DOI 10.17632/fvhw2zwt5d.1. The biological interpretation of the data can be accessed in the research article “Systems-Level Proteomics Evaluation of Microglia Response to Tumor-Supportive Anti-inflammatory Cytokines” (Shreya Ahuja and Iulia M. Lazar, Frontiers in Immunology 2021 [1]). The proteome data described in this article will benefit researchers who are either interested in re-processing the data with alternative search engines and filtering criteria, and/or exploring the data in more depth to advance the understanding of cancer progression and the discovery of novel biomarkers or drug targets.
  • Widespread Community Transmission of Hepatitis A Virus Following an Outbreak at a Local Restaurant-Virginia, September 2021-September 2022
    Helmick, Meagan J.; Morrow, Cynthia B.; White, J. Hope; Bordwine, Paige (Centers for Disease Control and Prevention, 2023-04-07)
    What is already known about this topic? U.S. hepatitis A incidence has been increasing since 2016. What is added by this report? In 2021, a hepatitis A outbreak in Virginia traced to an unvaccinated food handler resulted in 51 cases, 31 hospitalizations, and three deaths. As of September 30, 2022, an additional 98 community hepatitis A cases had been reported in the Roanoke City and Alleghany Health Districts. What are the implications for public health practice? Public health partnerships with businesses and other community partners (e.g., harm reduction programs) might increase hepatitis A vaccination among persons at risk for this infection, while also reducing the stigmatization of hepatitis A-associated risk factors.
  • Delayed presentation of food protein-induced enterocolitis syndrome (FPIES) to okra in a toddler
    Hall, Hunter; Anvari, Sara; Schultz, Fallon; Ojuola, Olubukola; Rider, Nicholas L. (2024-02-03)
    Background: Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E (IgE) -mediated food allergy predominantly observed in infants and characterized by the delayed onset of vomiting following ingestion of a trigger food. An increase in research and clinical consideration of FPIES has led to the discovery of unique deviations from the standard FPIES triggers and presentations. Case presentation: A 34-month-old female patient with a history of consuming okra daily presented to medical attention after developing classic FPIES symptoms to okra beginning at 14-months of age. Conclusions: Recently, awareness about the varied nature of FPIES clinical presentation has come to light. This case is the first to describe FPIES to the fruit okra that developed over a 12-month time span after previously tolerating the food. This case serves to emphasize the importance of understanding the range of FPIES symptoms to improve recognition and expedite best practice recommendations.
  • Changes in Clinical Management Following 14-Day Ambulatory ECG Monitoring Following Emergency Department Evaluation for Unexplained Syncope
    Moore, Andrew B.; Gershon, Colin; Fiske, Christa; Sun, Benjamin; Nazer, Babek; Kea, Bory (Elsevier, 2024-01-23)
  • Neurocognitive Correlates of Clinical Decision Making: A Pilot Study Using Electroencephalography
    Toy, Serkan; Shafiei, Somayeh B.; Ozsoy, Sahin; Abernathy, James; Bozdemir, Eda; Rau, Kristofer K.; Schwengel, Deborah A. (MDPI, 2023-11-30)
    The development of sound clinical reasoning, while essential for optimal patient care, can be quite an elusive process. Researchers typically rely on a self-report or observational measures to study decision making, but clinicians’ reasoning processes may not be apparent to themselves or outside observers. This study explored electroencephalography (EEG) to examine neurocognitive correlates of clinical decision making during a simulated American Board of Anesthesiology-style standardized oral exam. Eight novice anesthesiology residents and eight fellows who had recently passed their board exams were included in the study. Measures included EEG recordings from each participant, demographic information, self-reported cognitive load, and observed performance. To examine neurocognitive correlates of clinical decision making, power spectral density (PSD) and functional connectivity between pairs of EEG channels were analyzed. Although both groups reported similar cognitive load (p = 0.840), fellows outperformed novices based on performance scores (p < 0.001). PSD showed no significant differences between the groups. Several coherence features showed significant differences between fellows and residents, mostly related to the channels within the frontal, between the frontal and parietal, and between the frontal and temporal areas. The functional connectivity patterns found in this study could provide some clues for future hypothesis-driven studies in examining the underlying cognitive processes that lead to better clinical reasoning.
  • Residency Program Directors' Views on Research Conducted During Medical School: A National Survey
    Wolfson, Rachel K.; Fairchild, Paige C.; Bahner, Ingrid; Baxa, Dwayne M.; Birnbaum, Deborah R.; Chaudhry, Sarwat I.; Chretien, Katherine C.; Defranco, Donald B.; Deptola, Amber Z.; Laconte, Leslie E. W.; Lin, Jenny J.; Lee, Leslie Petch; Powers, Maureen A.; Ropson, Ira J.; Sankaran, Saumya M.; Sawarynski, Kara E.; Sozio, Stephen M. (Association of American Medical Colleges, 2023-04-21)
    Purpose: With the United States Medical Licensing Examination Step 1 transition to pass/fail in 2022, uncertainty exists regarding how other residency application components, including research conducted during medical school, will inform interview and ranking decisions. The authors explore program director (PD) views on medical student research, the importance of disseminating that work, and the translatable skill set of research participation. Method: Surveys were distributed to all U.S. residency PDs and remained open from August to November 2021 to query the importance of research participation in assessing applicants, whether certain types of research were more valued, productivity measures that reflect meaningful research participation, and traits for which research serves as a proxy. The survey also queried whether research would be more important without a numeric Step 1 score and the importance of research vs other application components. Results: A total of 885 responses from 393 institutions were received. Ten PDs indicated that research is not considered when reviewing applicants, leaving 875 responses for analysis. Among 873 PDs (2 nonrespondents), 358 (41.0%) replied that meaningful research participation will be more important in offering interviews. A total of 164 of 304 most competitive specialties (53.9%) reported increased research importance compared with 99 of 282 competitive (35.1%) and 95 of 287 least competitive (33.1%) specialties. PDs reported that meaningful research participation demonstrated intellectual curiosity (545 [62.3%]), critical and analytical thinking skills (482 [55.1%]), and self-directed learning skills (455 [52.0%]). PDs from the most competitive specialties were significantly more likely to indicate that they value basic science research vs PDs from the least competitive specialties. Conclusions: This study demonstrates how PDs value research in their review of applicants, what they perceive research represents in an applicant, and how these views are shifting as the Step 1 exam transitions to pass/fail.
  • Protecting Teams Through the Pandemic
    Carver, M. Colette; Frazier, Tricia (2022-04-28)
    Leading with TEAM - mantra Protect our team - Protect our patients - Protect our business Consistent foundational support focused on the team 1. Wellbeing 2. Bidirectional communication 3. Workforce planning and development FCM tailwinds going into pandemic High functioning leadership team at all levels Well positioned clinics geographically - Family Medicine, Internal Medicine, Urgent Care Centers Serve as regional: COVID-19 vaccination hubs COVID-19 Testing and Infusion centers
  • Improving Care Transitions Through Risk Reduction with Machine Learning Support
    Carver, M. Colette; Jones, Nate; Djuric, Dan; Butt, Caroline; Markham, Carla; Brookman, Jeremy; Reece, Chanda; Smith, Jamie (2020-04-15)
    Problem: The ambulatory care management team at Carilion Clinic lacked the necessary tools to demonstrate readmission risk reduction for patients undergoing care transitions. Purpose: This quality improvement project aimed to determine if implementing a real-time workflow management system which supported the prioritization, intervention tracking, and coordination of transitions of care, would result in readmission avoidance through risk reduction. Background: The Accountable Care Strategies team implemented an electronic Transition Tracking Tool (T3), as one aspect of Carilion’s readmission reduction program. Evidence from the literature: Approximately 20% of Medicare beneficiaries are readmitted within 30 days following hospital or facility-based care (Fischer et al., 2014). Many health systems across the country have developed strategies to reduce hospital readmissions after the passage of the Patient Protection and Affordable Care Act and its requirement for the implementation of a Hospital Readmissions Reduction Program (ACA, 2010). While there are a variety of readmission risk stratification tools used to identify patients, the predictive performance of these tools, according to Kansagara et al., (2011), has been marginal due in part to the complex factors contributing to a readmission. These researchers recommend incorporating a larger data set to include social determinants of health (Kansagara et al., 2011). Patient’s social determinants have a significant impact on their readmission risk, thus ambulatory programs which address these factors are essential (Calvillo-King et al., 2013). EBP Question: (1) Is there an impact on readmission for a patient who undergoes risk reduction strategies by a nurse using an automated patient prioritization tool with predictive interventions? Methods: The ambulatory care management team uses a relationship-based model, partnering with patients in self-care which is grounded in Dorothea Orem’s Theory of Self-Care (Petiprin, 2016). The aim is to support personal agency in the achievement of effective self-management. A tool was needed to replace a manual system, which could identify and prioritize at risk patients and track interventions and readmissions. A real-time data system was implemented called T3, it aggregates patients from both in and out of network hospitals. T3 also ingests information from Jvion, a machine learning platform that provides a readmission risk scoring and associated interventions. A dashboard displays patients and their risk scores, along with recommended interventions. Ambulatory nurses working remotely select a patient for outreach, review machine-recommended interventions and use nursing judgement for a patient-centric approach. Readmissions prevented are recorded using specific criteria. Outcomes: On average 2200 patient were managed each month and received risk reduction interventions. Over 11 months 212 patients had a readmission prevented. With the average cost of a hospital stay at $11,200.00, these 212 prevented readmission would have cost well over 2 million dollars. Most importantly the team saved patients from sustaining additional health complications due to a readmission. Implications for practice: Health systems focusing on readmission reduction need to consider using a predictive tool which incorporates social determinants of health and recommends targeted interventions. Prioritizing discharged patients, managing and tracking interventions, and recording readmissions prevented by ambulatory nurses will demonstrate improved quality of care transitions. References: (avail)
  • Metastatic Plasmacytoid Urothelial Carcinoma Masquerading as a Primary Signet Ring Cell Carcinoma of the Duodenum
    Mir, Adil S.; Mouchli, Mohamad; Lebel, David P.; Grider, Douglas J. (Springer, 2023-08)
    Plasmacytoid urothelial carcinoma can histologically mimic gastrointestinal signet ring cell carcinoma, a potential diagnostic pitfall resulting in improper clinical management. We present a rare case of a malignant duodenal ulcer due to metastasis from plasmacytoid urothelial carcinoma. Only by histological and retrospective immunohistochemical comparison with the primary bladder tumor was this revealed as a metastasis from a plasmacytoid urothelial carcinoma. This case report highlights the importance of clinical correlation and comparison with any previous pathology specimens, the limitations of immunohistochemical staining, and the utilization of both old and new immunohistochemical tools when differentiating signet ring cell carcinomas of primary sites versus potential metastases.
  • C-reactive Protein Levels in Patients With Autoimmune Hypothyroidism Before and After Levothyroxine Treatment
    Vudu, Stela; Behnke, Andrew J. (Springer, 2023-12-20)
    Background: Hypothyroidism is one of the most common endocrine disorders. Most patients with hypothyroidism have autoimmune thyroiditis (Hashimoto's), characterized by elevated concentrations of anti-thyroperoxidase (ATPO) antibodies. Both overt hypothyroidism (OH) and subclinical hypothyroidism (SH) have been associated with cardiovascular risk factors, including markers of inflammation. High-sensitivity C-reactive protein (hs-CRP) is a veridical marker of systemic inflammation. Even a minor increase in hs-CRP is considered a cardiovascular risk; therefore, evidence of a beneficial effect of levothyroxine treatment on hs-CRP could be an argument in favor of therapy for SH. Aim: To assess hs-CRP levels in patients with hypothyroidism and evaluate levothyroxine treatment's effect on hs-CRP. Study design: This is a cohort study in which patients with hypothyroidism were evaluated before and after treatment with levothyroxine. Methods: 37 patients (17 with OH and 20 with SH) and 38 healthy controls were included in the study. hs-CRP was measured at the baseline visit, then after 2 and 4 months of levothyroxine therapy at a dose necessary to achieve euthyroidism as evidenced by a normal level of thyroid-stimulating hormone (TSH). Results: hs-CRP was significantly increased in OH (p < 0.001) and SH (p = 0.001) at baseline as compared to controls. hs-CRP significantly decreased in SH (2.2±1.6 mg/L at baseline visit, 1.4±1.1 mg/L after 2 months of levothyroxine treatment, P = 0.017) and tended to decrease in OH (2.3±1.6 mg/L at baseline visit, 1.6±1.1 mg/L after 4 months of levothyroxine treatment, P = 0.067*). Conclusions: Patients with hypothyroidism have increased hs-CRP levels compared to a healthy control group and, thereby, a moderately increased cardiovascular risk. Achievement of euthyroidism by levothyroxine treatment decreased the levels of hs-CRP in patients with hypothyroidism.