INTRODUCTION: Chylous ascites refers to the accumulation of milky-appearing fluid in the peritoneal cavity. A triglyceride count >200 mg/dL in the ascites fluid is considered diagnostic. Recognition of this clinical entity is important, as first line management focuses on dietary changes as opposed to the use of diuretics. CASE DESCRIPTION/METHODS: A 38-year-old female with Von Hippel-Lindau syndrome presented to the emergency department complaining of progressively worsening abdominal distention and pain. Two months prior to presentation, she underwent left radical nephrectomy for renal cell carcinoma. Post-operatively, she developed a right-sided chylothorax requiring two thoracenteses. On exam, she was afebrile, hemodynamically stable, and had a distended abdomen with tenderness to palpation in the bilateral lumbar regions. Imaging of the abdomen revealed moderate to large volume ascites. A diagnostic paracentesis was performed to rule-out spontaneous bacterial peritonitis, and milk-like fluid was aspirated. Cytology was negative for malignant cells, and fluid studies were consistent with chylous ascites; the triglyceride level was 1779 mg/dL. The patient received education on a fat-free diet and was discharged home. She developed pain and re-accumulation of ascites fluid a month later and underwent a repeat paracentesis. After consultation with a dietician and her outpatient gastroenterologist, she was placed on a peptide-based semi-elemental formula twice a day and an additional no-fat meal. She had no signs of fluid re-accumulation at follow-up visits. DISCUSSION: Chylous ascites is rare, with an estimated incidence of 1 in 20,000 admissions. It can be due to trauma, including surgery, or non-traumatic causes such as malignancy or cirrhosis. In the setting of nephrectomy, the incidence is between 3.8-5.1%, and the cause is likely due to either adhesions or extrinsic compression of lymphatic vessels. Diagnosis is made via paracentesis. Treatment aims to avoid loss of fluids and electrolytes, malnutrition, and immunoglobulins. First-line therapy involves dietary modifications, e.g. a high-protein, low-fat diet with medium-chain triglycerides which can directly be absorbed by enterocytes and bypass lymphatic vessels. Lack of improvement may necessitate pharmacotherapy with medications such as orlistat, octreotide, or etilefrine. Bowel rest and total parenteral nutrition may be considered as well. Percutaneous embolization, TIPS, peritovenous shunts, or surgery are reserved for refractory ascites.

BackgroundUncontrolled hyperglycemia in hospitalized patients, with or without diabetes mellitus, is associated with many adverse outcomes. Resident physicians are the primary managers of inpatient glycemic control (IGC) in many academic and community medical centers; however, no validated survey tools related to their perceptions and knowledge of IGC are currently available. As identification of common barriers to successful IGC amongst resident physicians may help foster better educational interventions (ultimately leading to improvements in IGC and patient care), we sought to construct and preliminarily evaluate such a survey tool.MethodsWe developed the IGC questionnaire (IGCQ) by using previously published but unvalidated survey tools related to physician perspectives on inpatient glycemic control as a framework. We administered the IGCQ to a cohort of resident physicians from the University of Mississippi Medical Center, University of Louisville, Emory University, and the University of Virginia. We then used classical test theory and Rasch Partial Credit Model analyses to preliminarily evaluate and revise the IGCQ. The final survey tool contains 16 total items and three answer-choice categories for most items.ResultsTwohundred forty-six of 438 (56.2%) eligible resident physicians completed the IGCQ during various phases of development.ConclusionsWe constructed and preliminarily evaluated the IGCQ, a survey tool that may be useful for future research into resident physician perceptions and knowledge of IGC. Future studies could seek to externally validate the IGCQ and then utilize the survey tool in pre- and post-intervention assessments.

Objective: In this descriptive study, we evaluated perceptions and knowledge of inpatient glycemic control among resident physicians. Methods: We performed this study at four academic medical centers: the University of Mississippi Medical Center, University of Virginia Health System, University of Louisville Health Sciences Center, and Emory University. We designed a questionnaire, and Institutional Review Board approval was granted at each institution prior to study initiation. We then administered the questionnaire to Internal Medicine and Medicine-Pediatric resident physicians. Results: A total of 246 of 438 (56.2%) eligible resident physicians completed the Inpatient Glycemic Control Questionnaire (IGCQ). Most respondents (85.4%) reported feeling comfortable treating and managing inpatient hyperglycemia, and a majority (66.3%) agreed they had received adequate education. Despite self-reported comfort with knowledge, only 51.2% of respondents could identify appropriate glycemic targets in critically ill patients. Only 45.5% correctly identified appropriate inpatient random glycemic target values in noncritically ill patients, and only 34.1% of respondents knew appropriate preprandial glycemic targets in noncritically ill patients. A small majority (54.1%) were able to identify the correct fingerstick glucose value that defines hypoglycemia. System issues were the most commonly cited barrier to successful inpatient glycemic control. Conclusion: Most respondents reported feeling comfortable managing inpatient hyperglycemia but had difficulty identifying appropriate inpatient glycemic target values. Future interventions could utilize the IGCQ as a pre- and postassessment tool and focus on early resident education along with improving system environments to aid in successful inpatient glycemic control.

OBJECTIVES:To examine changes in the rate of glucagon prescribing within an internal medicine resident clinic following pharmacist-led interventions and to analyze glucagon prescribing patterns. SETTING:Urban, internal medicine residency teaching clinic. PRACTICE DESCRIPTION:Providers in the teaching clinic include internal medicine residents, supervised by faculty attending physicians. The pharmacy team consists of students, residents, and faculty pharmacists. PRACTICE INNOVATION:This uncontrolled quality improvement project consisted of a first analysis (September 2016 to August 2017) and a second analysis (September 2016 to January 2018) to determine the difference in rate of glucagon prescribing. Patients were at least 18 years old with a diagnosis of type 1 or type 2 diabetes mellitus (T1DM and T2DM) and managed with basal insulin plus at least one dose of bolus insulin or with premixed insulin. Pharmacist-led interventions included 2 distinct educational sessions about glucagon prescription for the residents and faculty members, and implementation of standardized written communication for recommendations. EVALUATION:Data collected were analyzed with rates and descriptive statistics. RESULTS:Of the patients with T1DM and T2DM who were included and deemed eligible for glucagon, 9 of 188 (4.79%) during first analysis versus 27 of 203 (13.30%) during second analysis were prescribed glucagon-an 8.51% increase. Hypoglycemia not leading to hospitalization (44.44%) was the primary trigger for glucagon prescribing, and the peak prescribing month was October 2017 (25.93%). CONCLUSION:Pharmacist-led intervention was associated with an increased rate of glucagon prescribing for patients with T1DM and T2DM within the resident teaching clinic. To improve further on the results, the research team plans to perform subsequent Plan, Do, Study, Act cycles to continuously improve the rate of prescriptions for at-risk patients. Overall, this project could encourage other pharmacy teams to evaluate strategies to increase glucagon prescribing and to evaluate clinical outcomes within outpatient primary care clinics.

This study examines the relationships of depression, anxiety, and stress with adherence to self-management behaviors and diabetes measures in 42 African American adults with type 2 diabetes (T2D). Participants were recruited from an outpatient clinic located in an urban area of a midsized city in the southeastern USA. The mean age of the sample was 54.9 years (SD = 9.9) and the majority of the participants were female (73.2%), high school graduates (55.3%), unemployed (70.7%), and publicly insured (77.8%). Each participant completed a demographic survey and the Depression, Anxiety and Stress Scale 21. Adherence to self-management behaviors (physical activity, diet, and medication use) was assessed using surveys and self-reports. Glycated hemoglobin (A1c) and body mass index (BMI) were obtained from participants’ medical records at the time of the participants’ clinic visits. Depression, anxiety, and stress were not significantly correlated with self-management behaviors. Depression (r = 0.38, p = 0.03), anxiety (r = 0.56, p = 0.001), and stress (r = 0.36, p = 0.04) were positively correlated with A1c. The greater the dietary risk assessment score, the higher the A1c (r = 0.34, p = 0.05). Anxiety was the strongest correlate of A1c followed by depression, stress, and dietary risk assessment. Future studies to confirm this study’s findings in a larger sample are warranted. Interventions to mitigate the effects of these correlates should be designed and tested to improve health outcomes in African American adults with T2D.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Guideline-discordant care of COPD is not uncommon. Further, there is a push to incorporate quality improvement (QI) training into internal medicine (IM) residency curricula. This study compared quality of care of COPD patients in an IM residents’ clinic and a pulmonary fellows’ clinic and, subsequently, the results of a quality improvement program in the residents’ clinic. Pre-intervention rates of quality measure adherence were compared between the IM teaching clinic (n = 451) and pulmonary fellows’ clinic (n = 177). Patient encounters in the residents’ teaching clinic after quality improvement intervention (n = 119) were reviewed and compared with pre-intervention data. Prior to intervention, fellows were significantly more likely to offer smoking cessation counseling (p = 0.024) and document spirometry showing airway obstruction (p < 0.001). Smoking cessation counseling, pneumococcal vaccination, and diagnosis of COPD by spirometry were targets for QI. A single-cycle, resident-led QI project was initiated. After, residents numerically improved in the utilization of spirometry (66.5% vs. 74.8%) and smoking cessation counseling (81.8% vs. 86.6%), and significantly improved rates of pneumococcal vaccination (p = 0.024). One cycle of resident-led QI significantly improved the rates of pneumococcal vaccination, with numerical improvement in other areas of COPD care.

SESSION TITLE: Airways 1 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: Misdiagnosis and guideline-discordant care of chronic obstructive pulmonary disease (COPD) is not uncommon in the primary care setting. Further, there has been a push to incorporate quality improvement (QI) training into internal medicine residency curricula. Our group sought to assess if a resident-led QI project could improve the rate of guideline-based care provided to COPD patients seen in an internal medicine resident teaching (AIM) clinic. METHODS: Pre-intervention rates of quality measure adherence were determined by review of the records of 451 AIM clinic patients with a billing code of COPD from 2010-2014. Smoking cessation counseling, pneumococcal vaccination, and diagnosis of COPD by spirometry or pulmonary function testing (PFT) were identified as measures requiring improvement. A resident-led QI intervention was initiated, consisting of a 15-minute PowerPoint presentation on COPD quality measures, an e-mail to residents presenting baseline performance data, and cards with quality targets posted in the resident teaching clinic. Adherence to the above quality measures in the subsequent 119 patients following QI intervention with a diagnosis of COPD was assessed and compared to pre-intervention data. Stata 10 (Stata Corp, College Station, Texas) was used for statistical analysis and P value < 0.05 was considered statistically significant. RESULTS: Smoking cessation counseling was offered to 86.6% of patients after QI intervention, compared to 81.8% pre-intervention (p = 0.360). The rate of pneumococcal vaccination improved to 72.3% from 61% in the pre-intervention cohort (p = 0.024). There was a non-significant trend towards an increase in the number of patients diagnosed COPD who underwent spirometric testing to 74.8% post-intervention from 66.5% (p = 0.085). CONCLUSIONS: One cycle of resident-led QI significantly improved the rates of pneumococcal vaccination provided to COPD patients in an internal medicine residents’ teaching clinic. There was a non- significant trend towards improvement in using spirometry or PFTs in diagnosis of COPD and offering smoking cessation counseling to active smokers. CLINICAL IMPLICATIONS: The above QI project performed by a group of internal medicine residents demonstrates measurable improvement in the quality of care of COPD patients amongst their peers. This is important in promoting increased adherence to COPD guidelines overlooked in general medicine practice. Our study also demonstrates a successful QI project developed by and directed at internal medicine trainees. DISCLOSURE: The following authors have nothing to disclose: Robert Burkes, Takudzwa Mkorombindo, Udit Chaddha, Alok Bhatt, Nancy Kubiak, Karim El-Kersh, Rodrigo Cavallazzi No Product/Research Disclosure Information

The purpose of this study was to determine the effect of a motivational interviewing intervention (MII) on regimen adherence and diabetes markers among African Americans with diabetes. Sixty-two participants were assigned to the usual care (UC; n = 36) or MII (n = 26) groups. UC participants received the usual clinic care. MII participants received a maximum of six motivational interviewing (MI) sessions over 3 months. Outcome variables were obtained at baseline and 3-month follow-up. Data were obtained using medical records, self-reports, and glucose monitor and accelerometer print-outs. MII significantly increased the odds of participants adhering to recommended physical activity level (66.7% vs. 38.8%, odds ratio = 2.92, 95% confidence interval = [1.6, 14.3], p = .018) and significantly decreased glucose levels (p = .043) and body mass index (p = .046) over time when compared with UC. Findings support using MI as an intervention for improving health outcomes and regimen adherence rates among the study population.

Objective The objective of this study was to examine the relationships of demographic characteristics with diabetes biomarkers and physical activity adherence in African American adults with type 2 diabetes mellitus. Methods Data for this secondary analysis were collected in a controlled trial conducted at an ambulatory internal medicine clinic located in a mid-sized metropolitan area in the southeastern USA. Demographic information was obtained at baseline for all participants receiving a motivational interviewing intervention. Diabetes biomarkers and physical activity adherence were measured at baseline and 3-month follow-up. Results Being female, older, and having a higher education significantly predicted a decrease in serum glucose over time. Being female and older significantly predicted a slower decrease in body mass index over time. Being younger and more educated significantly predicted probability of improved physical activity adherence. Conclusion Although older African American women had a significant decrease in serum glucose over time, they experienced a slower decrease in their body mass indices and were less likely to adhere to physical activity recommendations. Specific attention should be paid to the demographic characteristics of African Americans with type 2 diabetes mellitus in order to promote optimal clinical outcomes in this vulnerable population. This approach to treatment planning opens a window into the micro-level processes by which social determinants lead to a better response to treatment.

Attracting and retaining bright and motivated physicians remains a high priority for academia. Historically, the recruitment of trainees into academia and the retention of junior faculty have been suboptimal. To learn more about the perceived obstacles that discourage the pursuit of academic careers, a Workshop on Academic Career Pathways was conducted during the 2011 Southern Regional Meetings held in New Orleans. The audience included mainly residents and fellows as well as junior and senior faculties. Speakers described career options in academic medicine focusing on the clinician-investigator and the clinician-educator tracks. Afterward, the audience was asked to identify perceived obstacles to recruitment and retention in academic medicine. The group identified 10 major obstacles in 3 categories: financial challenges, personal mentoring and academic skills acquisition. This article summarizes the workshop proceedings and ends with recommendations to chairs and department leaders for improving recruitment and retention in academic medicine based on the discussion.