MultiCare Good Samaritan Hospital

Inflammation of the myocardium (myocarditis), pericardium (pericarditis), or both (myopericarditis) is a rare but potentially lethal side effect of mesalamine, a drug widely used in the treatment of inflammatory bowel disease (IBD).A 64-year-old female with a history of ulcerative colitis on mesalamine presented with dyspnea and chest pain. The patient was found to have mild to moderate pericardial effusion with signs of pericarditis. Further workup revealed positive rheumatoid factor, antineutrophil cytoplasmic autoantibody, cytoplasmic (c-ANCA), and antinuclear antibodies (ANA), raising suspicion for rheumatoid-associated pericarditis. She was discharged with a prednisone taper and an outpatient rheumatology follow-up. However, the patient presented again in three months with similar complaints and was found to have recurrent pericarditis. On this admission, mesalamine-induced pericarditis was considered in the differential diagnosis, and it was stopped on discharge. On a three-month follow-up, the patient showed complete resolution.Mesalamine-induced pericarditis is a rare side effect of this drug, and prompt recognition and appropriate intervention are important to prevent the progression of the inflammation and avoid adverse cardiovascular outcomes. The association of IBD with extra-intestinal cardiac manifestations can delay early diagnosis and treatment.

INTRODUCTION: Despite advancement in surgical techniques, biliary complications following liver transplant (LT) remain a major cause of morbidity and mortality for which endoscopic retrograde cholangiopancreatography (ERCP) remains the preferred treatment. We aim to determine the hospitalization trend, predictors, mortality, and morbidity risks in patients who receive ERCP after LT from a nationally representative sample. METHODS: he study cohort was derived from the Nationwide Inpatient Sample (NIS) for the years 2002-2014. Adult hospitalizations with LT status were identified using International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM) diagnosis codes and ERCP were identified by ICD-9-CM procedure codes. We then utilized the Cochran Armitage trend test and multivariate survey logistic regression to analyze temporal trends, predictors, and outcomes. RESULTS: Out of total 358,445 hospitalizations among LT patients, ERCP was performed in 8452 (2.36%) hospitalizations. The utilization of ERCP increased from 473 (0.05%) in 2002 to 775 (0.09%) in 2014. Among the patients who received ERCP, mean age was 54 (1.3), 64.5% were males, 67.5% whites, 16.6% Hispanics, and 8.5% African American. Among the patients who received ERCP, 7.7% were discharged to a facility and 1.1% died during the hospitalization. In multivariate analysis, age (10-year increase) (OR 1.32, 95% CI 1.09–1.61; P < 0.001), Hispanic race (OR 1.27, 95% CI 1.04–1.54; P 0.01), uninsured (OR 1.32; 95% CI 1.15–1.52; P < 0.001) and west region (OR 1.83; 95% CI 1.42–2.35; P < 0.001) were significantly associated with higher odds of ERCP utilization. However rural and non teaching hospitals were associated with lower odds of ERCP utilization. CONCLUSION: In our study we were able to delineate the epidemiology of ERCP among liver transplant patients. We noted that there has been an increase in ERCP procedures over the years among LT patients along with the discrepancies among demographics,regions and hospital types.

INTRODUCTION: Deliberate sharp foreign body ingestions (FBI) usually present as endoscopic emergencies, associated with high health care cost. These are associated with risks of perforation, leading to mediastinitis or peritonitis. We describe the case of a 38-year-old female with recurrent admission for deliberate ingestion of sharp foreign bodies and challenges associated with retrieval and prevention. CASE DESCRIPTION/METHODS: A 38-year-old female with borderline personality disorder presented to the emergency room with abdominal pain and nausea. She admitted to ingesting sharp foreign bodies, including razor blades and needles. On physical examination, she appeared stable with mild epigastric tenderness but no guarding or rebound tenderness. CT scan of the abdomen revealed radiopaque objects in her stomach and duodenum (Figure 1). There was no sign of visceral perforation. Urgent EGD revealed ingested sharp foreign bodies which were successfully retrieved using Rat Tooth forceps, snares and use of long overtube to protect the esophageal mucosa (Figures 2A and 2B). The patient had been admitted to the hospital numerous times with similar presentation. Her first hospital admission with foreign body insertion into body was 16 years ago when she had ingested paper clip and an open safety pin. In 2019 alone, she had undergone 23 CT scans for investigation of ingested foreign bodies and EGD 9 times. DISCUSSION: Current guidelines recommend emergent removal (within 2–6 hours) of foreign objects which are sharp, cause obstruction in esophagus or battery in the esophagus. Urgent removal (within 24 hours) is indicated for magnets within endoscopic reach, non-sharp objects in esophagus or sharp/pointed in the stomach or duodenum. Surgical consultation should be sought if the sharp objects fail to progress more than 72 hours or patients develop symptoms and signs of bowel perforation. Rat-tooth and alligator forceps, polypectomy snare, triprong grasper, Dormia basket, Roth net, and magnetic probes are used for retrieval. To prevent mucosal injury and protect airway during retrieval process, devices such as an overtube, can be used, as was done in our case for retrieval of razor blade. Repeated endoscopic removal of foreign can cause positive reinforcement to dysfunctional behaviors and hence resulting in recurrent and more complex ingestions. Early and aggressive multidisciplinary approach which includes psychiatry consultation, behavioral therapies and pharmacotherapies remain crucial.Figure 1.: CT scan showing razor blade in stomach.Figure 2.: A-Ingested sharp objects. B- Use of Overtube for removal.

A 49-year-old lady with history of polysubstance use disorder, recurrent cutaneous abscesses, spinal diskitis and septic thrombophlebitis presented to the emergency room with complaints of intermittent fevers, worsening right hip pain and bilateral lower extremity edema. A month before the presentation, she had left another hospital against medical advice after being diagnosed with Methicillin-resistant Staphylococcus aureus bacteremia and right hip septic arthritis. Post discharge, she was off antibiotics, but continued heroin and methamphetamine use. On admission, she had right hip chronic osteomyelitis and was also in acute renal failure with evidence of nephrotic range proteinuria. Her renal biopsy subsequently revealed acute tubular necrosis and secondary (AA) amyloidosis with the classic apple green birefringence and positive immunohistochemical stain for serum amyloid A protein. Secondary amyloidosis, where there is deposition of fibrils composed of fragments of the acute phase reactant - serum amyloid A protein, often complicates chronic diseases with ongoing or recurring inflammation like spondyloarthropathies, inflammatory bowel disease and heredofamilial periodic fever syndromes.Epidemiological studies now indicate that chronic inflammation as noted in illicit drug users, especially heroin users is on the rise as the etiology for AA amyloidosis in some parts of the developed world. The most common organ system involved in AA amyloidosis is the kidney. Given the opioid epidemic, clinicians are more likely to encounter similar cases of secondary amyloidosis.

Patients and families can make informed decisions at the end-of-life if they have had discussions regarding their wishes, but this is not regularly done due to poor understanding of advance directives (AD). The objective was to evaluate the effectiveness of an AD video to educate patients in both the inpatient and outpatient settings. A prospective, nonrandomized, pre/post-survey design study of 45 patients was conducted. Patients in clinics (n=37) and hospital (n=8) were asked to complete surveys measuring baseline understanding, completion, and discussions of AD prior to viewing the video. Patients viewed the video and completed similar surveys for feedback on the effectiveness of the video education. Patients felt the video was informative and helpful and stated more of an urgency to complete AD with increased perceived understanding of the forms. Prior to the educational video, 66.7% of patients stated they had discussed AD with their loved ones, while only 29% stated they had discussed these with their provider. Only 44.4% of participants had completed AD forms, and the majority (70.3%) wanted more information. Participants stated that viewing the video increased their desire to complete AD (78.6%), felt they had enough information to have these discussions and complete the forms (97.6%), and rated the video very highly (mean rank of 8.8 of 10). AD video education is helpful to patients, improving perceived understanding of AD and increasing patients' intent to discuss and complete AD with family and providers.

Functional written communication, an important goal in the rehabilitation of persons with tetraplegia, frequently is met through the use of personal computers and alternative computer access systems. To make informed decisions about alternative access systems, the therapist needs information on the efficacy of the available choices. The purpose of this study was to investigate the effectiveness of two commercially available systems for text entry, the traditional mouthstick and the Prentke Romich HeadMaster. Participants were a 25-year-old man and 76-year-old woman who both functioned at a C5 neurological level. Neither participant had previous experience with either system for text entry. A single-subject research design was used whereby Participant 1 experienced six phases of treatment (i.e., CBCBCB, where C = mouthstick and B = HeadMaster), and Participant 2 experienced four phases of treatment (i.e., BCBC). Participant 1 achieved a maximum rate of text entry of 5.85 wpm with both the HeadMaster and the mouthstick, whereas Participant 2 achieved a maximum rate of 7.15 wpm with the mouthstick and 4.85 wpm with the HeadMaster. Results from this study were similar to the results from previous comparison studies of persons with severe disabilities who had no experience with alternative computer access systems. Both participants were able to use both systems successfully; however, their respective rates of text entry were too slow to be functional in most employment situations.