Journal of Brown hospital medicine最新文献

Reduced gallbladder ejection fraction (GBEF) with normal laboratory tests and no gallstones on ultrasound can be attributed to conditions such as biliary dyskinesia, chronic acalculous cholecystitis, cystic duct syndrome, sphincter of Oddi dysfunction, and subclinical biliary stricture. We present a case of a patient with chronic right upper quadrant pain, diagnosed with reduced GBEF, normal labs, and no gallstones. The patient's symptoms resolved after endoscopic retrograde cholangiopancreatography and sphincterotomy, revealing a mild, non-obstructive stricture in the middle third of the common bile duct. This case underscores the importance of considering ERCP and sphincterotomy as diagnostic and therapeutic options before opting for cholecystectomy in patients with reduced GBEF and normal lab results, potentially avoiding unnecessary surgical interventions.

Sarcomatoid cancer of unknown primary site is an aggressive and rare clinical entity associated with poor patient outcomes. We describe a case of a 69-year-old woman who presented with low back pain, right leg weakness, urinary retention, and weight loss. Spinal imaging revealed a soft tissue mass at the right sacral ala infiltrating the S2-S4 neural foramina, with multifocal marrow replacement of the lumbosacral spine and adjacent bilateral iliac bones. Metastatic workup revealed additional lesions of the cervicothoracic spine, left proximal tibia and distal femur, and bilateral pulmonary nodules. Needle biopsy of the sacral mass was consistent with spindle cell carcinoma, a subtype of sarcomatoid carcinoma. IHC staining was positive for GATA3, suggesting mammary or urothelial origin. However, random bladder biopsies obtained at cystoscopy were negative for malignancy and no other discernable primary tumor was identified on full body imaging. This case highlights a rare histologic type of cancer - sarcomatoid carcinoma of unknown primary site (SCUP) in a patient that presented with cauda equina syndrome. Our patient was offered palliative radiation for symptom relief but elected to pursue hospice after the first radiation session. She passed away at a hospice facility within a few months after discharge from the hospital.

Background: Hospitalized patients frequently require various medical procedures, including lumbar punctures, paracenteses, and pulmonary drains, with significant annual volumes in the U.S. While bedside procedures are generally safe, their complication rates range from 0.1% to 3%, depending on the procedure. The Medicine Bedside Procedure Service (MBPS) at the Medical College of Wisconsin/Froedtert Health System was established as a standalone service in 2015 to enhance the training of Internal Medicine (IM) residents in common bedside procedures and Point of Care Ultrasound (POCUS), while also aiming to reduce patient wait times for procedures and length of hospital stays. Objective: The study aimed to evaluate the development and implementation of the MBPS, focusing on the characteristics of the first 12,000 procedural encounters, the educational impact on IM residents, and the service's effects on patient outcomes. Methods: This retrospective study analyzed 12,387 procedural encounters involving 6,942 unique patients from September 2015 to June 2022. Patient demographics were assessed, including age, sex, race, language, payer status, and comorbidities. Descriptive statistics were utilized to summarize the data, including means and standard deviations for continuous variables and frequencies for categorical variables. Results: The patient demographic indicated a predominance of males (53.1%), non-Hispanic Whites (68.8%), and a significant portion covered by Medicaid (71.6%). The average patient age was 64.7 years. The MBPS performed an average of 5.2 procedures per day, with paracentesis (34.6%), thoracentesis (27.3%), and lumbar puncture (21.1%) being the most common procedures. The overall complication rate was low at 0.3%, with the majority of complications occurring in thoracentesis (56%). Conclusions: The MBPS has contributed to the educational development of IM residents, evidenced by their increased proficiency and procedural certification rates, while also improving patient outcomes, including reduced lengths of stay and hospital costs. The service has optimized patient flow and increased satisfaction through timely and safe procedural care. Despite challenges in fostering a supportive culture for bedside procedures and ensuring effective communication with interventional radiology, the MBPS exemplifies the advantages of bedside procedures. Moving forward, plans include expanding into outpatient settings and incorporating advanced POCUS capabilities to enhance diagnostic and therapeutic decision-making at the bedside. Limitations of this single-center study and lack of comparative groups suggest the need for further research to validate these findings across diverse healthcare settings.

Adult-onset Still's Disease (AOSD) is a rare autoimmune disorder causing systemic inflammation that presents with a rash, fever, polyarthritis, and a characteristic serum hyperferritinemia. There is a complex relationship between infections and autoimmune disease, however, the association of AOSD with lyme disease is not well established. Here we present a case of AOSD in a 29-year-old male with a recent history of lyme disease. After ruling out infection and malignancy, a diagnosis of AOSD was made. From this report, we aim to raise more awareness for AOSD and recommend providers consider this diagnosis as a potential sequela of lyme disease.

Pancreatic neuroendocrine tumor (pNET) is a rare condition which may present with abdominal pain, dyspepsia, and jaundice. pNETs that do not produce hormones are considered non-functioning and are associated with morbidity through metastasis to nearby organs or mass effect. Metastatic pNET lesions have a propensity to bleed and may lead to significant hemorrhage. We present a case of an older adult who presented with an abdominal wall hematoma in the setting of metastatic pNET. This was resolved with embolization of nearby arteries and subsequent management of pNET with octreotide. This case highlights the importance of recognizing acutely deteriorating progressions of initially stable malignancies.

The Lentiform Fork sign is an imaging finding on brain MRI described by bilateral, symmetric hyperintensities in the basal ganglia. It is described in the setting of metabolic acidosis of many etiologies and is a sign of vasogenic edema. Both imaging findings and symptoms are often reversible with correction of the acidosis and removal of any identifiable triggers. We report a case of confusion and ataxic gait in a patient with end stage renal disease and ongoing metformin use. The mechanism of metformin-induced encephalopathy remains unclear, but could be due to vulnerability of mitochondria to metformin within the lentiform nuclei.

In-situ thrombosis of the pulmonary artery is a filling defect in a pulmonary artery and is often mislabeled as the most common cause of a pulmonary artery filling defect, an embolism. Thrombus in-situ has been associated with chronic pleural effusions, pulmonary resections, infections and other souces of chronic inflammation, it has not been described as occuring with rounded atelectasis. Herein, we present a rare case of a pulmonary artery thrombus in-situ adjacent to rounded atelectasis; this case underscores the necessity for careful assessment and advocates for heightened awareness of in-situ thrombus as a differential diagnosis when assessing for pulmonary embolisms.

This article highlights key insights and potential challenges in the management of central line-associated bloodstream infections.

Frequently admitted patients (i.e., 'high utilizers') comprise a small percentage of all patients yet consume a relatively large proportion of hospital resources. This quality improvement project aimed to reduce hospital resource utilization by implementing individualized care plans (ICPs) for high utilizers. An electronic health record (EHR) report identified high utilizers. A hospitalist workgroup then selected patients who were relatively young with frequent low-risk admissions. The workgroup created and documented ICPs in the EHR, then linked to the ICPs from numerous locations. For the selected patients, total admissions per year were reduced from 125 to 41 (-67%) and days per year in hospital from 497 to 219 (-56%), while length of stay was increased from 4 to 5.4 (+26%) days. Implementation of ICPs can allow high utilizers to spend more time at home, while simultaneously freeing up valuable hospital resources for the community. Making ICPs easily accessible is key to success.

Emotional intelligence is crucial for hospitalists as it enhances their ability to manage complex patient interactions, collaborate with healthcare teams, and navigate the emotional demands of patient care. Physicians with high emotional intelligence are better equipped to recognize and respond to patients' emotions, fostering trust and improving communication, which can lead to better patient outcomes. Additionally, emotional intelligence helps physicians cope with stress, alleviate burnout, and manage difficult conversations with patients and families, contributing to a more compassionate and effective care environment.