Shigella sonnei Bacteremia Presenting With Profound Hepatic Dysfunction

Worldwide, Shigellosis is a significant public health issue, associated with nearly one million deaths annually. About half a million cases of Shigella infection are reported annually in the United States. Shigella bacteremia is uncommon and generally seen in children and immunocompromised adults. We present a case of a Shigella sonnei bacteremia with marked hepatic derangement in a 27-yearold previously healthy homosexual male with history of Roux-en-Y gastric bypass, who presented to the emergency room with a 4-day history of loose watery stool, abdominal cramps, nausea and vomiting, and yellow skin of 2-day duration. He reports similar diarrhea illness in two close contacts in preceding days. On examination, he was fully oriented but dehydrated, icteric, and febrile. Laboratory data revealed WBC of 2200/L, elevated AST and ALT (201 IU/L, 73 IU/L resp.), normal alkaline phosphatase, elevated total and direct bilirubin of 8.2 mg/dL and 4.4 mg/dL, albumin of 3.2 g/dL, INR of 2.9, prothrombin time of 31.7, and platelet of 96,000/L. Workup for infectious, autoimmune and medication-induced hepatitis, Wilson’s disease, and hemochromatosis was negative. Abdominal ultrasound and computed tomography of the abdomen showed hepatic steatosis and right-sided colitis. Stool and blood cultures were positive for Shigella sonnei. He was treated with ciprofloxacin with improvement in liver function. Followup blood test 4 months later was within normal limits

Primary Mesenteric Carcinoid Tumor Presenting with Carcinoid Syndrome

Neuroendocrine neoplasms (NENs) are a diverse group of tumors arising throughout the body with a common origin from neuroendocrine cells. Well-differentiated NENs, also known as neuroendocrine tumors (NETs), are generally indolent and are often found incidentally, while poorly differentiated tumors are more aggressive. Carcinoid tumors are NETs arising from the gastrointestinal tract and less commonly from the lungs, thymus, and kidneys. NETs in the mesentery arise from metastasis from primary tumor, and carcinoid syndrome in this setting results from concomitant metastasis to the liver. Primary mesenteric carcinoid tumors are very rare. We present a 64-year-old man with carcinoid syndrome from a mesenteric carcinoid tumor without evidence of liver metastasis or other primary tumor sites

Refractory Abdominal Pain in a Patient with Chronic Lymphocytic Leukemia: Be Wary of Acquired Angioedema due to C1 Esterase Inhibitor Deficiency.

Acquired angioedema due to C1 inhibitor deficiency (C1INH-AAE) is a rare and potentially fatal syndrome of bradykinin-mediated angioedema characterized by episodes of angioedema without urticaria. It typically manifests with nonpitting edema of the skin and edema in the gastrointestinal (GI) tract mucosa or upper airway. Edema of the upper airway and tongue may lead to life-threatening asphyxiation. C1INH-AAE is typically under-diagnosed because of its rarity and its propensity to mimic more common abdominal conditions and allergic reactions. In this article, we present the case of a 62-year-old male with a history of recently diagnosed chronic lymphocytic leukemia (CLL) who presented to our hospital with recurrent abdominal pain, initially suspected to hav

Leveraging mobile health technology towards Achieving Universal Health Coverage in Nigeria

Universal Health Coverage (UHC) is ensuring everyone has access to quality health services needed without suffering any financial hardship. Most African countries including Nigeria are striving to meet this target since the declaration but so far, as of 2020, Nigeria has only made little progress in achieving this goal which was declared to be achieved by 2030. Meanwhile, incorporating Mobile health technology (mHealth) has prospective benefits for achieving UHC by improving access to health care services particularly for those in hard-to-reach communities, enhancing knowledge and access to health information for health workers and communities leading to; increase in productivity of the health workforce, and access to quality healthcare services. Although mHealth has good prospect of promoting the achievement of UHC in Nigeria but there are limitations of poor power supply, poor data collection from evidence-based researches, and restricted access to mobile phones and internet especially in core rural communities in Nigeria. We aim to discuss how mHealth can be leveraged on in promoting achievement of UHC and the challenges associated with incorporating appropriate technology in the Nigerian healthcare system

Time to initiation of antiresorptive agents in multiple myeloma to reduce skeletal related events

PurposeCurrent treatment guidelines strongly support the use of antiresorptive therapy in patients with newly diagnosed multiple myeloma (NDMM) with the goal of preventing skeletal related events (SRE). Despite these concrete, data-driven recommendations, the impact of delays in antiresorptive initiation in NDMM patients is understudied. Through a multicenter retrospective study, we examined the impact of delays in antiresorptive initiation on the rates of SREs. We furthered our exploration of this topic in a separate retrospective analysis with a focus on reasons for delays in antiresorptive therapy initiation.MethodsElectronic health records from two large academic institutions were used to identify patients with NDMM between July 1, 2016, and June 30, 2019. Exclusion criteria included patients with previous antiresorptive use and patients never prescribed antiresorptives. Time to antiresorptive initiation and its subsequent impact on the rate of SREs was analyzed using hazard ratios. A follow up, single-center retrospective study was conducted using EHR data with an emphasis on the identification of barriers to antiresorptive initiation. Here, descriptive, and inferential statistics were used to identify variables that have a statistically significant impact on antiresorptive initiation.ResultsA total of 759 patients with newly diagnosed MM met inclusion criteria for our multicenter study. Our study found that a delay in initiation of anti-resorptive therapy of greater than 31 days from diagnosis resulted in an increased risk for SRE with a hazard ratio of 1.654 (95% CI: 1.054-2.598; p-value = 0.029). In our follow up study, a total of 45.6% of patients with newly diagnosed MM were prescribed antiresorptive therapy, while 59% of patients with identified lytic lesions on screening imaging received anti-resorptive therapy. Statistically insignificant differences were observed in the time to initiation of anti-resorptive therapy based on health insurance. Variables such as race and gender were not found to have a statistically significant relationship with delays in antiresorptive initiation.ConclusionsPatients with NDMM should be initiated on antiresorptive therapy without delay to minimize the rates of SREs, and clinicians should be diligent in anticipating delays in initiation such as need for dental clearance and renal disease

Effectiveness of Clinical Decision Support for Hypercoagulable Evaluations in One Hospital

Introduction: Venous Thromboembolism (VTE) is a potentially life-threatening disorder that may be provoked by venous stasis, endothelial injury or hypercoagulable states. Workups for hypercoagulable states are frequently undertaken, but tests performed are often either not indicated (if performed in older patients, provoked VTE) or uninterpretable ( if functional tests are ordered while patient anticoagulated or with active thrombus). Clinical decision support at point of order entry has the potential to prevent this unnecessary testing. As part of a larger QI project to improve care of VTE patients, we studied the impact of clinical decision support embedded in order sets, measuring the rates of appropriate hypercoagulable evaluations as a primary outcome. Intervention: This study was undertaken from February 2013 - May 2015, and the effects of intervention were subsequently measured until May 2017. Hypercoagulable workups were defined as appropriate when ordered in patients who are \u3c 45 years of age with unprovoked thrombus for all tests (gene and functional tests); and patients without active thrombi or anticoagulants for functional tests. A new order set was developed on the hospital health information system for VTE admissions. The order set provided evidenced-based guidance for ordering work-up. The order set was rolled out in April 2015, after extensive education of health care providers. Outcome: Over the 2 years after the addition of the clinical decision support intervention, there was a reduction of the total number of hypercoagulable state work-ups from 21% pre-intervention to 15.7% post intervention, the average number of inappropriate tests reduced from 33 to 14 per month - a 57% reduction. Cost savings realized per month from the intervention was approximately $4,500 (pre-intervention:$9,050.73, post-intervention $4,569.98; P - 0.0004) and totaled about$117,000 over 26 months post intervention. Conclusion: Clinical decision support interventions may result in a sustained decrease in unnecessary hypercoagulable workups

Assessing disparities in engagement in a post-discharge virtual visit follow-up program.

100 Background: Transitions of care are a frequent focus of quality improvement initiatives. In attempt to improve upon the transitions of care for oncology patients, our institution implemented a post discharge virtual visit follow-up program. Previous studies have suggested that socioeconomic status impacts engagement in technology based interventions. Herein, we report the impact of socio-economic status based on area deprivation index (ADI) on engagement with the program. Methods: All patients admitted to the elective chemotherapy service were included. Retrospective analysis of characteristics of each participant was conducted. Data included eligibility (access to the internet, appropriate device, English language proficiency, ability to set up video visit and a patient portal account) for video visit, interest in participating, completion of the visit and any interventions performed during the visit. In addition, ADI was calculated for each individual. Patients were classified into quartiles based on ADI (quartiles increased with ADI). Chi squared testing was performed to assess whether socioeconomic status affected enrollment in video visits. Simple descriptive analysis was also performed. Results: One hundred seven unique patients were included for review. Of these, 33 (31%), 39 (36%), 16 (15%) and 19 (18%) were in quartile(Q) 1, 2, 3 and 4 respectively. Eligibility per quartile was 29 (88%), 34(87%), 13(81%), and 15(83%). ADI quartile did not significantly affect virtual visit eligibility (p = .50). A total of 91 patients (85%) were eligible for video visits; of these, 46 patients declined. Of the 46 patients that declined 9 (19%), 20 (43%), 8 (17%), and 9 (19%) were in Q1, Q2, Q3 and Q4 respectively. Fifteen patients cited technology issues as reasons for declining telehealth visits - 10 (67%) from Q1 and Q2 and 5 (33%) from Q3 and Q4. The vast majority cited lack of interest as reason for declining. Conclusions: ADI as a measure of socioeconomic status did not significantly affect eligibility for or enrollment in video visits. This may be explained by more ubiquitous access to internet services in a large urban setting. Current research is currently being conducted to understand patient barriers to engagement in virtual visits. </jats:p

A Case of Rituximab-Induced Necrotizing Fasciitis and a Review of the Literature

Necrotizing fasciitis is a fulminant soft tissue infection characterized by rapid progression and high mortality. Rituximab is a generally well-tolerated immunosuppresive medication used for B-cell malignancies and some rheumatological disorders. We report a case of a 69-year-old male with chronic lymphocytic leukemia who suffered necrotizing fasciitis of his left lower extremity secondary to Clostridium septicum 7 weeks after treatment with rituximab. Despite immediate intravenous antimicrobial therapy and emergent fasciotomy with extensive debridement, his hospital course was complicated by septic shock and he required an above-the-knee amputation. Physicians need to be aware of the possibility of necrotizing fasciitis in patients presenting with skin infections after rituximab therapy

Effectiveness of Clinical Decision Support for Reducing Unnecessary Hypercoagulability Evaluations in a Large Community Hospital

Background: Venous Thromboembolism (VTE) is a potentially life-threatening disorder and in some cases, is related to underlying hypercoagulability which may be congenital or acquired. Guidelines suggest performing extensive work -up for hypercoagulability only in select patients: those with close family history of VTE at young age ( \u3c 45), young age at first VTE ( Methods: Clinical decision support in the form of a new cascading order set was developed on the hospital’s Electronic Medical Records (EMR) for VTE admissions. A section of the order set provided evidenced-based guidance for ordering hypercoagulable work-up in real time by providing relevant prompts (age, provoked/unprovoked, active thrombus, anticoagulation) at the point of order entry. Tests were also grouped based on the prompts so that gene tests alone or gene tests and functional tests were auto-selected based on the response to the prompts. For measuring its effectiveness, hypercoagulable workups were defined as appropriate when ordered in patients who are \u3c 45 years of age with unprovoked thrombus. In addition, functional tests had to be performed only in patients without active thrombi or anticoagulants. Tests that did not meet these criteria were deemed inappropriate. The order set was rolled out in April 2015, after extensive education of health care providers and the effects of intervention on appropriate test ordering were subsequently measured until May 2017. The 12 month period preceding the roll-out was used as the baseline year (pre-intervention). Our primary outcome measure was the average monthly number of patients with inappropriate work-ups and average cost savings per month was the secondary measure, using current costs of laboratory tests. All data was collected from reports generated on the Hospital EMR. Results: Over the 2 years after the addition of the clinical decision support intervention, there was a reduction of the average number of patients with inappropriate hypercoagulable state work-ups from 33 per month ( pre-intervention) to 14 per month (post intervention) – a 57% reduction. Cost savings realized per month from the intervention was $4,500 per month on average (pre-intervention:$9,050.73, post-intervention $4,569.98; P – 0.0004) and totaled about$117,000 over 26 months post intervention. Conclusions: Clinical decision support interventions may result in a sustained decrease in unnecessary hypercoagulable workups