Johnston Memorial Hospital

Abstract Introduction/Rationale Multiple reports have linked the increased risk of venous thromboembolism (VTE) as a complication in patients with interstitial lung disease (ILD), yet the reports are limited across ILD subtypes. This study aimed to evaluate and compare VTE incidence and associated risk factors between idiopathic ILD and connective tissue disease-associated interstitial lung disease (CTD-ILD) during hospitalization. Methods ILD patients were analyzed using 2016-2020 National Inpatient Sample (NIS) data, distinguishing idiopathic ILD from CTD-ILD. The primary outcome was VTE incidence, including pulmonary thromboembolism (PE) and deep vein thrombosis (DVT), and secondary outcomes included in-hospital mortality, intensive care unit (ICU) admissions, length of stay (LOS), and total hospital charge (THC). Univariate and multivariate logistic regression were used to adjust for common confounders such as sex, age, race, tobacco use, varicose veins, and other comorbidities. Results Among 4,675,914 patients hospitalized with ILD, 82,015 developed VTE. CTD-ILD patients with VTE represented 6.9% of the cohort. The mean age in patients who had a VTE event with CTD-ILD patients was 67.7 years represented by 68.5% females, versus 69.9 years in idiopathic ILD patients with a VTE event, of which 46.9% were females (p < 0.001). In patients with CTD-ILD, the incidence of DVT and PE respectively was 1.79%, and 0.41% compared to 1.47%, and 0.26% in idiopathic ILD patients. CTD-ILD was significantly associated with VTE with an aOR of 1.23, (95% CI [1.16, 1.32], p < 0.001) while adjusting for cofounders. However, the CTD-ILD group showed no significant association with in-hospital mortality (p = 0.06), and ICU admissions were lower in comparison to the idiopathic ILD group (aOR=0.48, 95% CI [0.4, 0.58], p < 0.001) on multivariate analysis. The mean LOS was longer in idiopathic ILD patients with VTE, accounting for 11 days versus 8.4 days for CTD-ILD patients with VTE, and their THC was higher, with 145,292 dollars vs 101,478 dollars. Conclusion Our results highlight the need for tailored VTE prophylaxis strategies and close monitoring for VTE risk in patients with CTD-ILD. Further studies should explore other risk factors for the development of VTE in this population.

Abstract Disclosure: C. Buchanan: None. C. Ellenburg: None. M. Beasey: None. Background: Hyperthyroidism, nephrogenic diabetes insipidus, and hyperparathyroidism are all well-documented adverse effects of long-term lithium therapy. This report highlights a rare case of these three endocrinologic adverse effects occurring concurrently. Clinical Case: A 47-year-old man on long-term lithium therapy for bipolar disorder presented with slurred speech, fatigue, new tremor, and generalized muscle weakness. Laboratory testing was consistent with lithium toxicity with serum lithium level of 2.22 mmol/L (0.60-1.50). Thyrotoxicosis was present with a free T4 of 3.2 ng/dL (0.6-1.1) and TSH of 0.04 µlU/mL (0.24-5.60). CT of the neck revealed mild enlargement and heterogeneity of the left lobe of the thyroid gland. Methimazole was started. Calcium corrected for albumin was elevated at 12.4 mg/dL (8.6-10.0) and PTH was also elevated at 146.0 pg/mL (12.0-88.0). Serum sodium was elevated at 160 mmol/L (136-145) with urine osmolality of 327 mOsm/kg. DDAVP was trialed in addition to IV hypotonic fluids, although it had little effect. Acetazolamide was started a few days later with subsequent normalization of the serum sodium level. Acetazolamide was later discontinued in favor of hydrochlorothiazide because of the development of non-anion-gap metabolic acidosis. A dose of zoledronic acid was given and cinacalcet was started. Serum calcium normalized over the following week. The patient acutely developed right upper quadrant abdominal pain, nausea, and emesis on hospital day 13. Lipase was elevated at 575 u/L (11-82). CT of the abdomen demonstrated moderate inflammatory changes along the pancreas and duodenum. Acute pancreatitis was diagnosed. There were no gallstones or acute biliary tract abnormalities seen on ultrasound. The patient’s symptoms gradually improved and he was discharged from the hospital after a total of 18 days. Lithium was discontinued indefinitely. TSH and free T4 normalized within 3 months. He had continued to require hydrochlorothiazide, methimazole, and cinacalcet at the time of his 3-month primary care follow-up appointment. Conclusion: Despite its efficacy and widespread use in mood stabilization, lithium has a narrow therapeutic window and is strongly associated with several serious, sometimes irreversible, adverse effects. Routine monitoring of lithium levels, serum calcium, and thyroid hormone levels is required. Lapses in routine monitoring may, as in this case, result in significant morbidity and prolonged hospitalization. Presentation: 6/1/2024

Lung cancer can lead to hypercoagulability that causes thromboembolic events such as pulmonary emboli, deep vein thrombosis, ischemic strokes, and non-bacterial thrombotic endocarditis. While it is not uncommon for cancer to cause thromboembolic events, it is unusual for thrombotic events to be the first manifestation of cancer. In the following report, we review the case of a 59-year-old woman who presented with melena and abdominal pain. She had a pertinent history of multiple thromboembolisms while on anticoagulation four months before this presentation. Upon admission, it was discovered that the patient had new pulmonary emboli, and further workup revealed that her gastrointestinal symptoms were due to ischemic colitis. While initial imaging showed no evident masses that would heighten suspicion of cancer, she had persistent abdominal lymphadenopathy. Therefore, she also underwent an abdominal lymph node biopsy which revealed metastatic lung adenocarcinoma, a possible cause of her hypercoagulable state. This case report highlights the importance of considering malignancy in the differential of a patient with recurrent thromboembolismand raises the question of whether standardized screening for malignancy in patients with multiple thromboembolic events would be beneficial.

Enasidenib is an FDA-approved isocitrate dehydrogenase 2 (IDH2) inhibitor, which is used in the treatment of acute myeloid leukemia (AML). We present a case of AML with an IDH2 mutation treated with a regimen of enasidenib and 5-azacitidine, where thyroiditis was noted to be a part of differentiation syndrome. The patient is a 77-year-old woman with IDH2-mutated AML who had initially been started on 100 mg of enasidenib and then presented with dyspnea and was diagnosed with pleural effusion – a common presentation with enasidenib – but was also noted to have thyroiditis. She was started on steroids, but due to continued hyperbilirubinemia and thyroiditis, her dose of enasidenib was reduced to half, which resulted in clinical improvement. This case demonstrates thyroiditis as one of the rare manifestations in the treatment of AML with enasidenib-induced differentiation syndrome.

We conducted a systematic review to evaluate the comparative effectiveness of educational interventions on health care professionals' situation awareness (SA). We searched MEDLINE, CINAHL, HW Wilson, ERIC, Scopus, EMBASE, PsycINFO, psycARTICLES, Psychology and Behavioural Science Collection and the Cochrane library. Articles that reported a targeted SA intervention or a broader intervention incorporating SA, and an objective outcome measure of SA were included. Thirty-nine articles were eligible for inclusion, of these 4 reported targeted SA interventions. Simulation-based education (SBE) was the most prevalent educational modality (31 articles). Meta-analysis of trial designs (19 articles) yielded a pooled moderate effect size of 0.61 (95% confidence interval = 0.17 to 1.06, P = 0.007, I = 42%) in favor of SBE as compared with other modalities and a nonsignificant moderate effect in favor of additional nontechnical skills training (effect size = 0.54, 95% confidence interval = 0.18 to 1.26, P = 0.14, I = 63%). Though constrained by the number of articles eligible for inclusion, our results suggest that in comparison with other modalities, SBE yields better SA outcomes.

ImageI used the 80-20 rule in medical school. It was a secret strategy if you were asked a percentage question by the attending. You answered 20 percent if you thought it was unlikely and 80 percent if it was more likely. A different 80-20 rule works in economics known as Pareto's Principle. Italian economist Vilfredo Pareto observed in 1906 that 20 percent of the people in Italy owned 80 percent of the wealth. (See FastLinks.) That applies to the wealth distribution in the United States in 2007, too, with 20 percent of the population owning 85 percent of the wealth. (See FastLinks.) It is said in business that 80 percent of your profits comes from 20 percent of your customers, and this applies to medicine as well. Twenty percent of the population incurred 80 percent of the health care expenses in 2004. (See FastLinks.) One percent of the population generated 22 percent of the health care expenses. Apply this to your emergency department; is it possible that one percent of your ED population generates 22 percent of the charges? Our numbers showed that five percent of our ED patients accounted for 22 percent of our annual visits in 2010-2011. We found on chart review that there were duplicate workups, unnecessary tests, preventable admissions, and a lack of coordinated care. Perhaps the time has come for us as emergency physicians to recognize the full impact our actions can have in these populations and on the overall economics of health care.ImageMy business partner and fellow emergency physician, Brian Dawson, MD, and I created a program, Align, to hold our own department accountable for our top ED visitors. We identified barriers such as illiteracy, lack of transportation, and need for a primary physician or pain management specialist. We created premade care plans addressing the individual needs of each frequent patient in collaboration with their own specialists, primary care physicians, and our emergency physicians. These care plans are delivered instantly and electronically to the physician when they sign up for the patient. Our follow-up nurse is automatically notified of their visit, and will call patients after ED discharge to arrange follow-up and review discharge information. She also contacts the inpatient case manager to optimize discharge planning if the patient is admitted. These patients are called on a regular basis, and the lines of communication remain open with their primary providers. By recognizing these patients on arrival as our managed population and tailoring our care to their unique needs, we have seen a 55 percent reduction in visit counts and a 60 percent reduction in charges. We also found that these patients now spend less time in our ED when they do visit; visits are 27 percent shorter on average. We no longer have to spend our valuable time reviewing previous CT scans and discharge summaries. This awareness of the patients' past, present, and future health care needs has led to greater satisfaction for our patients and our providers, and limited some frustrating encounters. Our program is set up to identify patients as they become frequent visitors so we are proactive in managing this unique population. Initially, we chose the top 25 visitors over one year, and we now add patients when they reach a threshold of more than three visits in one month or six visits in four months, which would qualify the patient as a “highly frequent emergency department user.” (Ann Emerg Med 2012 60[1]:24.) We practice in a small hospital of 112 beds in a small town with 7,000 people with a relatively busy ED with 29 beds and slightly more than 40,000 annual patient visits. We have improved our distribution since deploying Align: five percent of our patients now make up 17 percent of the visits, down from 22 percent. Think of the impact we could have if each of our departments managed our frequent visitors with greater awareness. Email me directly with any questions, suggestions, or comments: [email protected]. FastLinks Read more about Pareto's Principle at http://bit.ly/W8nLV. The article, “Occupy Wall Street and the Rhetoric of Equality,” is available at http://onforb.es/ZhzphI. Read “The High Concentration of U.S. Health Care Expenditures. June 2006” at http://1.usa.gov/13JaE1R.

We report the case of a 64-year-old man who developed a rapid, right-sided pleural effusion. On initial presentation to the emergency room, the patient had fever and flank pain consistent with a ureteral obstruction (due to a bladder tumor) and associated hydronephrosis that had required previous placement of a pericutaneous nephrostomy tube. After a 10-day stay in the hospital, the patient's urine output ceased. Symptomatic dyspnea with radiographic evidence of a new pleural effusion soon followed. Urinothorax was the etiology of the effusion.

According to Krusen's Handbook of Physical Medicine and Rehabilitation, topical application of ultrasound exerts only an indirect and adjunctive effect as deep-heat treatment. In support of this idea the extensibility of an isolated tendon in a heated water bath is described. The significance of this experiment as a biological phenomenon has never been critically examined. In this article the existence of a segmental reflex is proposed. Such a segmental paradigm is in keeping with the segmental organization and evolution of the locomotor system. It is further suggested that ultrasound and related therapy, if applied segmentally, may have a curative effect.