Improving Clinical Documentation in an Academic Setting: A Multidisciplinary Team Approach Focused on the Physician's Perspective.

EXECUTIVE SUMMARY: This research article discusses the results of a pilot study at a large academic medical center to appropriately describe patient severity and the likelihood of mortality. In this study, we compare two projects, both of which use a clinical document specialist (CDS). The control case measures documentation quality using an attending physician-focused model. This model, supplemented by a CDS who requests additional documentation on a post hoc basis, is measured against an intervention where a CDS offers suggestions in real time during rounds with residents and attending physicians.Our findings indicate that documentation training with real-time feedback by a CDS results in higher levels of medical staff participation and a significant increase in submitted physician charges. Additionally, we note that documentation improvement projects do not eliminate coding problems; rather, they support a better alignment between patient state and documentation of that state. Although physicians are key players in the provision of care and the revenue cycle, the physician perspective is missing in the current discourse about documentation. Where quality, profitability, education, teamwork, and profiling drive documentation improvement, ensuring that we understand the problem from both ends is crucial to documentation improvement projects. Therefore, there is a need for more research on the impact of such programs beyond the facility.

An enigmatic presentation of Escherichia coli endocarditis: Emphasizing the role of brain magnetic resonance imaging.

Key Clinical Message: Infective endocarditis should be considered in any febrile individual with acute onset neurological symptoms. If suspicion is high, a negative brain computed tomography does not virtually exclude embolism, and magnetic resonance imaging is warranted. Abstract: A diagnosis of infective endocarditis (IE) is often delayed, particularly in those infected with unusual organisms. Hereby, we report a case of a female patient presented with dysarthria, confusion, and altered mental status after being treated for Escherichia coli bacteremia. Computed tomography of the brain was unrevealing; however, scattered embolic phenomena were visualized on magnetic resonance imaging (MRI). The case underscores the importance of clinical awareness, particularly in the setting of unusual microorganisms, and the role of brain MRI in the diagnosis of IE.

A Massive Right Atrial Mass in Chronic Myelogenous Leukaemia: A Case Report and Literature Review.

Right atrial masses are rare and diagnosis can be difficult unless histopathological specimens are obtained. In addition, the clinical course is not well documented, thereby making diagnosis and management challenging. The mass can be associated with haemodynamic instability with the potential to cause obstructive shock and embolism. We present the case of a young woman with untreated chronic myelogenous leukaemia with a massive haemodynamically significant right atrial mass. The usefulness of multimodality imaging and a multidisciplinary approach for diagnosing and treating this condition is highlighted. LEARNING POINTS: Right atrial mass is rare and can lead to pulmonary embolism and haemodynamic instability.As chronic myelogenous leukaemia is associated with an increased risk of thromboembolism, thrombus should be considered in the differential diagnosis of intracardiac masses.Multimodality imaging is indicated to guide diagnosis and appropriate management; in case of diagnostic uncertainty, histopathology may be needed to obtain a definitive diagnosis.

Anomalous Aortic Origin of the Right Coronary Artery: A Case Report and Review of the Literature.

Patients with symptomatic or malignant anomalous aortic origin of the right coronary artery (AAORCA) warrant surgical treatment to decrease morbidity and mortality. Various surgical techniques have been implemented including unroofing, reimplantation and bypass grafting. A 43-year-old woman presented with intermittent chest pain due to malignant AAORCA and received saphenous bypass grafting, instead of reimplantation, due to intraoperative spasm. LEARNING POINTS: Various surgical methods are available for the management of anomalous aortic origin of the right coronary artery (AAORCA), preferably unroofing when the intramural segment can be identified.Hypoplasia of the proximal segment, an acute take-off angle, and close proximity to the intercoronary pillar or commissure are limitations to unroofing, and alternative approaches are more appropriate.Coronary artery bypass graft, with either arterial or venous graft, can be performed when unroofing and reimplantation are not feasible. Measuring the distal anastomosis flow may help with a decision regarding native coronary artery ligation. It remains undetermined whether arterial or venous grafts provide superior outcomes.

LASER endovascular atherectomy with secondary stenting of technically challenging calcified celiac trunk stenosis.

Endovascular therapy for chronic mesenteric ischemia is a proven, feasible alternative approach to open surgical repair with significantly lower morbidity and mortality. A clinical dilemma is encountered when technically challenging lesions are encountered during the procedure. We present here an 86 year-old woman who had intractable abdominal pain with postprandial exacerbation. The patient had successful endovascular light amplification by stimulated emission of radiation atherectomy of a highly calcified celiac truck, showing the feasibility of this technique.

Postpartum depression and apical ballooning syndrome (takotsubo syndrome).

BACKGROUND: Acute cardiac complications occur occasionally during pregnancy and in the immediate postpartum period. Some of these cardiac scenarios are rare and provide a diagnostic challenge. We report a case of apical ballooning syndrome (ABS), also known as takotsubo cardiomyopathy or broken-heart syndrome, in a postpartum patient. CASE: A 32-year-old multigravid woman presented at 17 days after delivery with chest pain typical for cardiac ischemic pain. Her prior obstetrical history included two uncomplicated vaginal deliveries, and the current postpartum period had been uncomplicated until the time of presentation. Cardiac catheterization was performed and showed normal coronary blood vessels with no evidence of coronary artery occlusion. Left ventricular systolic function was moderately depressed, with an ejection fraction of 45%. The patient had full recovery of myocardial function in less than 40 days, with a subsequent echocardiogram during that time showing a normal ejection fraction of 65%. CONCLUSION: Apical ballooning syndrome is a rare reversible cardiac condition that should be differentiated from ischemic and peripartum cardiomyopathy, especially in the immediate postpartum period.

Reactive Thrombocytosis Associated with Acute Myocardial Infarction following STEMI with Percutaneous Coronary Intervention.

The etiology of thrombocytosis can be classified into reactive and essential forms. The rate of thromboembolic events is higher in essential thrombocytosis, and these events include strokes, transient ischemic attacks, retinal artery or retinal vein occlusions, digital ischemia, and acute coronary syndrome. In a study of 732 medical and surgical patients with thrombocytosis, 88% had reactive thrombocytosis. Patients with reactive thrombocytosis do not require cytoreductive medications or antiplatelet treatment. We report a healthy 40-year-old man without any medical problems who developed a new episode of myocardial infarction associated with thrombocytosis after an episode of myocardial infarction followed by percutaneous coronary intervention. He had thrombocytosis, and his platelet function test did not reveal adequate inhibition. To treat his acute coronary syndrome, therapeutic enoxaparin was added, and clopidrogel was substituted with ticagrelor. We decided to start hydroxyurea to reduce platelets counts. Enoxaparin and hydroxyurea were discontinued when platelet count returned to baseline. JAK-2 and BCR/ABL mutations were negative. This case report highlights a clinical dilemma (reactive thrombocytosis), which is challenging in terms of management and pathophysiology.

Monophasic synovial sarcoma presenting as mitral valve obstruction.

We report the case of a 26-year-old man who experienced progressive left-sided chest pain and 2 episodes of near-syncope. Studies revealed a 15-cm mass in the upper left lung, a 10-cm mass in the medial base of the left lung, and a 5-cm left atrial mass that involved the left lung, infiltrated the left pulmonary vein, and prolapsed into the mitral valve, causing intermittent obstruction. The patient underwent surgical excision of the left atrial tumor. Pathologic evaluation confirmed the diagnosis of monophasic synovial sarcoma.To our knowledge, this is only the 3rd report of left atrial invasion and resultant mitral valve obstruction from a synovial sarcoma that infiltrated the pulmonary vein. We believe that this is the 1st documented case of a metastatic left atrial synovial sarcoma in monophasic form.

Closure of a giant saphenous vein graft aneurysm with embolization coil.

Aneurysms of saphenous vein grafts (SVGs) to coronary arteries are rare, usually asymptomatic and found incidentally. We report a case of an 84-year-old female who was found to have 8.1 x 8.4 cm aneurysm of an SVG to obtuse marginal (OM) artery. The aneurysm was prior to the distal anastamosis but no flow into the OM artery was noted. Cook Tornado Embolization Coils were used successfully to occlude the SVG proximal to the aneurysm. No complications occurred. The use of embolization coils is an effective and safe method for aneurysm occlusion when the anatomy is suitable and especially when patient is high risk for repeat surgical intervention.

Coronary artery aneurysms in Behçet's disease.

Behçet's disease is a rare chronic autoimmune vasculitis with characteristic skin findings. Vascular involvement generally affects veins more than arteries, and coronary arterial involvement is extremely uncommon. Here we report the significant coronary artery aneurysms detected in a 41-year-old man with Behçet's disease who had been in remission for 13 years. Our case illustrates the necessity of initial non-invasive cardiac assessment of patients with Behçet's disease.

Aortic coarctation complicated with multiple saccular aortic aneurysms.

Aortic coarctation is a congenital malformation of the aorta that should be diagnosed and corrected early in life. The natural history of unrepaired coarctation of the aorta includes the development of systemic hypertension and subsequent morbidity and death from cardiovascular disease. Here, we present a case with replacement of the aortic arch and its branches by tortuous multilobulated aneurysms as a result of untreated aortic coarctation.

Left circumflex coronary artery to hepatic vein fistula: a case report and brief review of coronary vasculogenesis.

Coronary artery fistulas are rare coronary artery anomalies. Their clinical significance varies from a long asymptomatic course to overt heart failure and death. They are often detected incidentally with diagnostic coronary angiograms. Cardiologists increasingly encounter coronary artery fistulas secondary to recent improvements in cardiovascular imaging modalities. Management is still controversial, especially in asymptomatic cases with less significant shunts. Here, we describe a 62-year-old woman with a left circumflex artery to hepatic vein fistula found on coronary angiography. The patient is being managed conservatively using nuclear imaging studies and echocardiographic evaluation.

Do comorbid psychiatric disorders contribute to the pathogenesis of tako-tsubo syndrome? A review of pathogenesis.

Patients with tako-tsubo cardiomyopathy have unusual characteristics, including a disproportionate occurrence in postmenopausal women and a strong association with mental and physical stress. These patients present with chest pain, abnormal electrocardiographic findings, and myocardial enzyme leaks. They appear to have acute coronary syndrome but have normal epicardial coronary vessels and reversible left ventricular dysfunction. High circulating levels of catecholamines likely cause this syndrome through direct injury of myocardial cells. The frequent occurrence in postmenopausal women has not been explained. This association might reflect changes in autonomic control of the cardiovascular system and in baroreceptor sensitivity in postmenopausal women. Women in this age group also have a high frequency of both depression and anxiety. These 2 psychiatric diagnoses are associated with episodic symptoms, including acute panic attacks, which can be associated with catecholamine release in the heart. Therefore, tako-tsubo cardiomyopathy may occur in postmenopausal women as a consequence of comorbid psychiatric diagnoses and normal age-related changes in autonomic control of the cardiovascular system. This hypothesis warrants prospective case-control studies.

Transient left ventricular apical ballooning during dobutamine myocardial perfusion imaging.

The transient left ventricular apical ballooning is characterized by wall motion abnormalities involving the apex in the absence of obstructive coronary disease. It is precipitated by acute emotional or physical stress and is most often reported in post-menopausal women. We report a case of transient left ventricular "apical ballooning" without significant coronary artery disease precipitated by high dose dobutamine infusion during pharmacological stress myocardial perfusion imaging. The unique feature of our case was precipitation by chemical stress rather than emotional/physical stress.

Synergistic interactions between Ca2+ entries through L-type Ca2+ channels and Na+-Ca2+ exchanger in normal and failing rat heart.

We used confocal Ca2+ imaging and the patch-clamp technique to investigate the interplay between Ca2+ entries through L-type Ca2+ channels (LCCs) and reverse-mode Na+-Ca2+ exchange (NCX) in activating Ca2+-induced Ca2+ release (CICR) from the sarcoplasmic reticulum (SR) in cardiac myocytes from normal and failing rat hearts. In normal myocytes exposed to N(6),2'-O-dibutyryl adenosine-3',5'-cyclic monophosphate (db-cAMP, membrane-permeable form of cAMP), the bell-shaped voltage dependence of cytosolic Ca2+ transients was dramatically broadened due to activation of SR Ca2+ release at high membrane potentials (30-120 mV). This broadening of Ca2+-transient voltage dependence could be prevented by KB-R7943, an inhibitor of the reverse-mode NCX. Trans-sarcolemmal Ca2+ entries were measured fluorometrically in myocytes during depolarizing steps to high membrane potentials. The total Ca2+ entry (deltaF(Tot)) was separated into two Ca2+ entry components, LCC-mediated (deltaF(LCC)) and NCX-mediated (deltaF(NCX)), by exposing the cells to the specific inhibitors of LCCs and reverse-mode NCX, nifedipine and KB-R7943, respectively. In the absence of protein kinase A (PKA) stimulation the amplitude of the Ca2+-inflow signal (deltaF(Tot)) corresponded to the arithmetic sum of the amplitudes of the KB-R7943- and nifedipine-resistant components (deltaF(Tot)=deltaF(LCC)+deltaF(NCX)). PKA activation resulted in significant increases in deltaF(Tot) and deltaF(LCC). Paradoxically, deltaF(Tot) became approximately threefold larger than the sum of the deltaF(NCX) and deltaF(LCC) components. In myocytes from failing hearts, stimulation of PKA failed to induce a shift in Ca2+ release voltage dependence toward more positive membrane potentials. Although the total and NCX-mediated Ca2+ entries were increased again, deltaF(Tot) did not significantly exceed the sum of deltaF(LCC) and deltaF(NCX). We conclude that the LCC and NCX Ca2+-entry pathways interact synergistically to trigger SR Ca2+ release on depolarization to positive membrane potentials in PKA-stimulated cardiac muscle. In heart failure, this new form of Ca2+ release is diminished and may potentially account for the compromised contractile performance and reduced functional reserve in failing hearts.

Embolus in transit.

A patient who presented with recurrent syncopal episodes was discovered to have a right-sided heart mass, which was revealed as an embolus in transit resulting in a lethal pulmonary embolic event. The initial focus of etiology on tumor rather than thrombus was misleading. A higher index of suspicion of thrombus in right heart mass may help future patients receive more directed therapy.