Hospitalist Co-Management of a Vascular Surgery Service Improves Quality Outcomes and Reduces Cost.

BACKGROUND: Hospitalists can be instrumental in management of inpatients with multiple comorbidities requiring complex medical care such as vascular surgery patients, as well as an expertise in health care delivery. We instituted a unique hospitalist co-management program and assessed length of stay, 30-day readmission rates and mortality, and performed an overall cost-analysis. METHODS: Hospitalist co-management of vascular surgery inpatients was implemented beginning April 2019, and data was studied until March 2020. We compared this data to an eight-month period prior to implementing co-management (7/2018 - 3/2019). Patient-related outcomes that were assessed include length of stay, re-admission index, mortality index, case-mix index. Cost-analysis was performed to look at indirect and direct cost of care. RESULTS: A total of 1,062 patients were included in the study 520 pre co-management and 542 patients were post-comanagement. Baseline case-mix index was 2.47, and post-comanagement was 2.46 (P >0.05). In terms of average length of stay (aLOS), the baseline aLOS was 5.16 days per patient, while after co-management it was significantly decreased by 1.25 days to 3.91 days (P <0.05). This improvement in length of stay opened an average of 2.4 telemetry beds per day. Similarly, excess days per patient which reflects the expected length of stay based on comorbidities, improved from -0.59 to -1.65, an improvement of -1.46. CONCLUSIONS: Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings. The overall average variable direct cost decreased by $1,732 per patient.

A rare case of a novel coagulase negative Staphylococcus native valve endocarditis in a 28-year-old male.

Coagulase negative staphylococci (CoNS) are an emerging cause of native valve endocarditis in community and healthcare settings. We describe a case of a 28-year-old man with no significant risk factors who presented with Staphylococcus pettenkoferi native valve endocarditis. During our patient's initial hospitalization, he was treated for CoNS bacteraemia and subsequently discharged after a protracted hospital course with a transthoracic echocardiogram (TTE) showing no valvular vegetations. However, during the course of his second hospitalization, speciation identified S. pettenkoferi and transoesophageal echocardiogram (TEE) showed aortic valve perforations with new regurgitation raising concern for left sided endocarditis. We postulate that our patient may have been infected with the same CoNS species causing aortic valve endocarditis during his initial hospitalization. This case highlights the importance of recognizing CoNS as a possible causative bacterium in NVE, as well as the importance of obtaining a TEE when evaluating a patient for suspected endocarditis.

Eikenella Corrodens and Streptococcus anginosus co-infection causing skull base osteomyelitis and internal carotid artery lesion.

A 35-year-old male presented with headaches and fevers. MRI of his head showed skull-based infection of the clivus extended to the right internal carotid artery. Blood and sinus cultures were positive for Eikenella corrodens and Streptococcus anginosus. He had intravenous antibiotics and sinus washout. The patient had full neurological recovery following this.

Streptococcus Oralis meningitis from right sphenoid Meningoencephalocele and cerebrospinal fluid leak.

BACKGROUND: Streptococcus oralis belongs to the Streptococcus mitis group and is part of the normal flora of the nasal and oropharynx (Koneman et al., The Gram-positive cocci part II: streptococci, enterococci and the 'Streptococcus-like' bacteria. Color atlas and textbook of diagnostic microbiology, 1997). Streptococcus oralis is implicated in meningitis in patients with decreased immune function or from surgical manipulation of the central nervous system. We report a unique case of meningitis by Streptococcus oralis in a 58-year-old patient with cerebral spinal fluid leak due to right sphenoid meningoencephalocele. CASE PRESENTATION: A 58-year-old female presented in the emergency department due to altered mental status, fevers, and nuchal rigidity. Blood cultures were positive for Streptococcus oralis. Magnetic resonance stereotactic imaging of head with intravenous gadolinium showed debris in lateral ventricle occipital horn and dural thickening/enhancement consistent with meningitis. There was also a right sphenoidal roof defect, and meningoencephalocele with cerebrospinal fluid leak as a result. The patient was treated with ceftriaxone and had endoscopic endonasal repair of defect. She had complete neurologic recovery 3 months later. CONCLUSIONS: Cerebrospinal fluid leak puts patients at increased risk for meningitis. Our case is unique in highlighting Streptococcus oralis as the organism implicated in meningitis due to cerebrospinal fluid leak.

A cerebral mass in a patient with Churg Strauss syndrome.

BACKGROUND: Differential diagnosis of mass brain lesions with surrounding peripheral-ring enhancement includes infections, tumours, demyelinating diseases, and vascular lesions such as infarcts or haematomas METHODS: This paper is the case report of a 72-year-old Caucasian female patient who presented with a subacute onset neurologic deficit and a heterogeneous cerebral mass, an imaging finding worrisome for malignancy. CONCLUSION: More specific brain imaging is necessary to differentiate between different diseases, especially malignant CNS tumours and abscesses. Specific risk factor identification is important but cannot replace stereotactic aspiration of pus for accurate microbiologic diagnosis and initiation of targeted antimicrobial treatment of cerebral abscesses.