While medical advancements over the past century have enabled patients to live longer with serious illness, they have also prolonged the dying process while shifting the location of end-of-life care away from home and into acute care settings. This article reflects on what makes certain deaths "good" and "bad" in the hospital setting.
Purtscher-like retinopathy is a rare chorioretinopathy associated with a non-traumatic inciting event including acute pancreatitis, renal failure, long-bone injury, chest compression, connective tissue diseases and hematologic disorders. We present the case of a 33-year-old woman with abdominal pain and visual changes that was diagnosed with acute pancreatitis. Fundoscopic examination revealed bilateral diffuse flame hemorrhages and retinal whitening (Purtscher flecken), which were diagnostic of Purtscher-like retinopathy secondary to acute pancreatitis. The patient improved without intravenous or intravitreal corticosteroid administration. Follow up at 5 and 8 months revealed improved vision, complete resolution of the retinal pathology with residual inner retinal thickening on ocular coherence tomography (OCT), consistent with sustained retinal damage. Given that Purtscher-like retinopathy is associated with higher morbidity and mortality rates in patients with acute pancreatitis, high suspicion of this pathology and a thorough clinical assessment are imperative. Since half of the patients suffer life-long visual changes, further research is required for the development of efficacious treatment options.
Staphylococcus lugdunensis is a coagulase-negative staphylococcus (CoNS) that constitutes normal skin flora and is often read as a contaminant when isolated in blood cultures. In recent years S. lugdunensis has been increasingly recognized as a true pathogen causing a spectrum of infections from benign skin and soft tissue infections to bacteremia, bone and joint infections, and endocarditis. A significant role in the pathogenesis of infections is played by the ability of the organism to form biofilms that allow it to attach itself to foreign objects such as pacemakers, prosthetic valves, and orthopedic implants. The mortality rate in infective endocarditis caused by S. lugdunensis has been as high as 38.8 % making it as virulent as Staphylococcus aureus reported in the literature. It requires aggressive antibiotics and optimal source control, including surgical debridement and valve replacement if indicated. We present a case of S.lugdunensis infective endocarditis in a patient with an automatic implantable cardioverter defibrillator (AICD). The patient presented with lower back pain for three weeks and was found to have a right psoas abscess and S.lugdunensis bacteremia, with a vegetation on the right ventricular defibrillator wire requiring device explantation and prolonged antibiotic treatment.
Hypercalcemia is typically associated with primary hyperparathyroidism, malignancy, vitamin D intoxication, and granulomatous disease; however, it can also be associated with a neuroendocrine tumor that secretes vasoactive intestinal polypeptide (VIP). A 74-year-old woman with a history of hypothyroidism and nephrolithiasis presented to her primary care physician with a chief complaint of diarrhea and was found to have mild hypercalcemia. A Hypercalcemia workup was initiated, and the patient was ultimately found to have elevated VIP. Although a discrete pancreatic mass was not identified, an endoscopic ultrasound with fine needle aspiration revealed a VIPoma. She was then referred to hepatobiliary surgery for the removal of the tumor. As VIPoma has a poor prognosis, early recognition and treatment are essential for improving patient outcomes.
Amyloidosis is often known as "the great imitator," as the clinical diagnosis of AL amyloidosis is quite challenging and often delayed, given multi-organ involvement. We present a unique case of an elderly male who presented with an eight-month history of progressive lower extremity edema and dyspnea and was admitted for syncope, anasarca, and severe dyspnea. He was diagnosed with renal failure, nephrotic syndrome, a large renal mass, and severe non-ischemic cardiomyopathy. A renal resection was performed, and renal cell carcinoma (RCC) and light chain (AL) amyloidosis were diagnosed.
Background: This study aims to describe contextual factors that influence and contribute to sick leave in healthcare, especially in hospital settings. This review would provide a valuable, comprehensive, and evidence-based resource for readers interested in effective human resource management and healthcare or hospital workforce planning. This review referred to studies on the determinants of absenteeism in the healthcare setting. Methods: To ensure that pertinent papers (2004 – 2022) were identified, a literature search was performed searching Google Scholar, Econ Lit, PubMed, ResearchGate, ScienceDirect, Emerald Insight, Scopus, Medline, PsychInfo, and Web of Science. All abstracts were screened to identify papers that empirically investigated contextual factors of work absence in healthcare populations. A total of 126 papers were initially identified. These were reduced to 61 papers using pre-determined inclusion and exclusion criteria. Results: Contextual factors such as nature of work, cultural expectations, economic conditions, and seasonality have moderately strong associations with absence. There is a negative relationship between high psychological demands and work-related absenteeism. The key factors associated with sickness absence in healthcare staff were long hours worked, night shifts, changing rostering patterns, work overload and stress, physically demanding roles, poor social support. Other contextual factors such as cultural norms and expectations that support poor attendance reflected strong association with absence levels. Economic conditions are negatively associated with absenteeism as a result of job security fears. Absenteeism is more pronounced during winter and school holidays. Conclusions: The review concluded that interventions such as screening the prior attendance levels of potential employees would assist greatly in terms of absenteeism rates, while monitoring current absence patterns of existing employees will negate the development of cultural norms in the workplace. Many of the contextual related variables associated with high levels of absenteeism are reducible with the development of screening and monitoring tools.
Hydrothorax is an uncommon but established complication of peritoneal dialysis, usually arising from pleuroperitoneal leak. There is currently no consensus on definitive testing or management. Thoracentesis, sclerosing agents, and either temporary or permanent discontinuation of peritoneal dialysis in favor of hemodialysis are often considered. We report an unusual case of right-sided PD-associated hydrothorax in a 54-year-old female with a history of hypertension and anemia, who presented without chest pain or dyspnea but rather with fatigue and syncope. We review the current literature on this etiology regarding underlying causes, as well as best practices for diagnosis and treatment.
The classical prototype of Varicella Zoster Virus (VZV) associated vasculopathy is contralateral hemiplegia after herpes zoster ophthalmicus. We describe a 30-year-old patient with no vascular risk factors who presented with a lacunar stroke and was found to have focal intracranial stenosis. He presented again one and a half months later with new findings suggestive of progressive multifocal intracranial stenoses. Although vasculitis was suspected initially, varicella zoster virus reactivity raised the possibility of VZV associated vasculopathy. This case serves as a reminder to suspect this type of vasculopathy even in immunocompetent patients with no cutaneous manifestations. Intracranial stenosis affecting M1 of the middle cerebral artery and the distal portion of the internal carotid artery is common in VZV vasculopathy and should hint toward the diagnosis as shown in this case.
Immune checkpoint inhibitors (ICIs) have revolutionized the field of medical oncology. This class of medications block molecules responsible for inhibiting the immune response to cancer, allowing for immune system activation, tumor recognition and destruction of cancer cells. A unique side-effect of these drugs involves the immune-mediated destruction of healthy tissue, known as immune-related adverse events (irAEs). One example is the autoimmune destruction of renal tissue associated with development of acute interstitial nephritis (AIN). Here, we present a case of a patient with metastatic bladder cancer treated with an ICI who developed AIN that was refractory to glucocorticoid therapy and salvaged by mycophenolate mofetil. The case illustrates the unique mechanism by which toxicity can occur, demonstrates the concept of delayed irAEs, and highlights the prolonged, durable responses patients with cancer can have to immunotherapy, even after treatment is discontinued.
Methylphenidate (MPH) is a sympathomimetic stimulant used to manage adult narcolepsy and attention deficit hyperactivity disorder (ADHD), which is frequently abused. We present the case of a 37-year-old female who developed acute right ventricle (RV) failure after the self-injection of IV MPH. While difficult to prove causation, the temporal relationship between self-injection and symptom onset suggests a role for MPH in this patient’s acute RV failure. Other causes for acute RV failure were ruled out: she had no prior history of PH, ECG was not consistent with ischemia, computed tomography angiography (CTA) was negative for pulmonary embolism (PE), and Right heart catheterization (RHC) was not consistent with left ventricular failure. While there are case reports of persistent PH with chronic IV MPH use, this case describes the only reported incident of transient acute RV failure after IV MPH use.
**Background:** Inpatient cardiac arrest care had to be adapted to meet the needs of patients and providers during the COVID-19 pandemic. Providers working in the emergency department and in the inpatient setting have acquired extensive experience and expertise in caring for patients with COVID-19 related cardiac arrest. We summarize recent reports relevant to clinicians on inpatient cardiac arrest care, provider and patient safety, and effective use of resources. **Methods:** We performed literature searches of the PubMed database on inpatient cardiac arrest, COVID-19, healthcare-associated coronavirus transmission, and others. The authors’ collections of lived experience as inpatient care providers and clinically useful materials gathered during the pandemic were included. **Results:** We summarize current knowledge about cardiac arrest in COVID-19 relevant to hospitalist practice, describe lessons learned to date, and provide practical guidance for addressing cardiopulmonary resuscitation for patients with COVID-19. We discuss literature on risk factors for cardiac arrest in patients with COVID-19; risk of infection for rescuers performing resuscitation in patients with COVID-19 and mitigation strategies; goals of care during cardiac arrest in a patient with COVID-19; reducing the risk of exposure to rescuers (including pre–cardiac arrest care); reducing cross-contamination during cardiac arrest in patients with COVID-19; prioritizing oxygenation and ventilation strategies with lower aerosolization risk; maximizing resources during cardiac arrest in patients with COVID-19; and post–cardiac arrest care. **Conclusions:** Advances made in the care of inpatient cardiac arrest patients during the COVID-19 include domains of patient risk stratification, provider safety, advance directives, and others. Lessons in the management of inpatient cardiac arrest learned during this pandemic are likely to applicable to future pandemics.
Background: COVID-19 has been disruptive to inpatient medical care. While changes in prevalence of inpatient diagnoses have been published, little has been published about the impact on learner exposure to various diagnoses. Such changes are likely impacted by national and global trends, as well as local disease prevalence and policies. We hypothesized that the electronic medical record (EMR) may offer a tool to track learner experiences as they evolve in a time of rapid change. Methods: The top 20 most common diagnoses between April-July 2019 vs April-July 2020 on the resident inpatient internal medicine service were extracted from the Epic EMR and compared. This data was analyzed using a chi squared test and Bonferroni correction to identify statistically significant changes in case distribution in this time frame. Changes over this period were also compared for the nonteaching service. Results: The resident teaching service saw a statistically significant decrease in pulmonary cases (13% vs 2%, p < 0.005) from 2019 to 2020. Acute exacerbation of chronic obstructive pulmonary disease (COPD) and pneumonia, previously the 5th and 7th most common diagnoses in the 2019 period, dropped off the top twenty list for the teaching service. These 2 diagnoses remained on the non-teaching common encounter list, suggesting that COVID-19-related service/team assignments rather than disease prevalence may be a factor. There was also a statistically significant increase from 2019 to 2020 in cases pertaining to substance use intoxication on both teaching and non-teaching teams (0 vs 0.05 and 0 vs 0.02, respectively), mirroring trends in national data. Conclusion: Use of the EMR was able to rapidly identify changes in the most common diagnoses on the teaching service. This may be a tool to monitor the inpatient experience of learners over time, particularly in times of rapid local, regional, or global change.
**Objective**: Review preoperative risk stratification encounters performed by a hospital medicine consult service at a tertiary academic medical center to better characterize practice patterns and evaluate the need to standardize our approach to risk assessment. **Methods**: Retrospective chart review of 200 randomly selected patients representing approximately 40% of all patients seen by the hospital medicine consult service from 2019-2020. **Results**: Of the 200 charts reviewed, there were 71 preoperative risk assessments performed and 8 distinct approaches utilized. The most common risk stratification tool used was the Revised Cardiac Risk Index (RCRI), followed by the American College of Surgeons-Surgical Risk Calculator (ACS-SRC) and then the Gupta Myocardial Infarction and Cardiac Arrest calculator. 19 encounters (27%) used multiple risk stratification tools, while 11 encounters (15%) were not consistent with American College of Cardiology/American Heart Association guidelines. **Conclusion**: Significant heterogeneity exists within preoperative risk stratification practices in this single-center study. Follow-up work remains to promote standardization in approach and documentation.
Botulism is a potentially deadly neuroparalytic disease that affects all age groups; it is highly challenging to diagnose due to its nonspecific symptoms. Infant botulism is the most common form of botulism in the United States, followed by foodborne and wound botulism. Since most patients require hospitalization, it is imperative that both adult and pediatric physicians recognize its symptoms. Patients with severe forms of botulism typically present early after toxin ingestion and progress rapidly. Although rare in the United States, botulism remains a public health concern since even one case may predict an outbreak. This review summarizes the typical clinical course of botulism and recommendations for diagnosis and management.
Tuberculosis (TB) is the leading infectious cause of secondary spontaneous pneumothorax (SSP), a potentially life-threatening complication. The clinical presentation of TB-associated SSP is highly variable, although most patients present emergently with respiratory symptoms and pleuritic pain. Here, we present a case of TB-associated SSP that was clinically silent.
