Metastatic Klebsiella Pneumoniae in an Immunocompetent Patient: A Rare, Atypical Presentation of Klebsiella Syndrome.

Metastatic Klebsiella pneumoniae (MKP) is a rare, atypical presentation of Klebsiella syndrome. The disease primarily affects patients with underlying immunocompromised status, but its prevalence in immunocompetent patients without any underlying illness is rare. We present a rare case of MKP in a 41-year-old Caucasian male without prior comorbidities who presented with blurry vision and was found to have MKP. The current case report also discusses the diagnostic modalities, complications, and treatment options of MKP.

Pulmonary Aspergilloma in a Young Immunocompetent Female: A Rare Clinical Dilemma.

Depending on the host's immunological and respiratory systems, Aspergillus can induce infectious and allergic diseases. Most of the spread occurs in immunocompromised people, whereas aggressive disorder in immunocompetent patients is unusual. We report the case of a 19-year-old female who had shortness of breath, right-sided chest discomfort, and intermittent hemoptysis for six months before being diagnosed with pulmonary aspergilloma. The initial chest x-ray revealed a massive right pneumothorax and a 7.2 cm rounded opacity in the right lower lung. A subsequent computed tomography (CT) chest with contrast revealed a 6.7 cm cavitating mass occupying the right lower lobe. An open right thoracotomy and right lower lobectomy showed a cavitary fungus ball with septate branching hyphae and subsequent methenamine silver staining consistent with Aspergillus in conjunction with a positive Aspergillus antigen. We strongly suggest that pulmonary aspergillosis should be suspected regardless of age or immunocompetence in patients with prolonged cough, hemoptysis, unilateral chest discomfort, and pneumothorax.

Colorectal Cancer Screening Challenges in the Recent Afghan Refugee Population: A Comprehensive Review Article.

Colorectal cancer (CRC) is more prevalent in south-central Asian countries, particularly the Afghan population. Screening for CRC in the Afghan population has always been challenging, primarily due to the tribal and social cultures, lack of facilities, and lack of education. The United States (US) will soon face a significantly massive influx of Afghan refugees. It becomes imperative to initiate and implement effective measures regarding CRC screening in these refugee populations. The current review article aims to identify the most likely challenges faced for CRC screening in this Afghan refugee population in the US and address the possible measures to overcome these challenges.

Isolated pulmonary valve endocarditis: truth or myth?

Pulmonary valve (PV) infective endocarditis (IE) is an extremely rare disease that involves normal as well as abnormal valves. This condition mostly occurs in patients with underlying predisposing factors. It could be missed if patients do not present with typical features of right-sided endocarditis or in the absence of classic risk factors. The case presented here did not have any known risk factors for IE until surgery and presented mainly with fever, weight loss, and musculoskeletal symptoms.

Hospital readmissions in decompensated cirrhotics: Factors pointing toward a prevention strategy.

AIM: To reduce readmissions and improve patient outcomes in cirrhotic patients through better understanding of readmission predictors. METHODS: We performed a single-center retrospective study of patients admitted with decompensated cirrhosis from January 1, 2011 to December 31, 2013 (n = 222). Primary outcomes were time to first readmission and 30-d readmission rate due to complications of cirrhosis. Clinical and demographic data were collected to help describe predictors of readmission, along with care coordination measures such as post-discharge status and outpatient follow-up. Univariate and multivariate analyses were performed to describe variables associated with readmission. RESULTS: One hundred thirty-two patients (59.4%) were readmitted at least once during the study period. Median time to first and second readmissions were 54 and 93 d, respectively. Thirty and 90-d readmission rates were 20.7 and 30.1 percent, respectively. Predictors of 30-d readmission included education level, hepatic encephalopathy at index, ALT more than upper normal limit and Medicare coverage. There were no statistically significant differences in readmission rates when stratified by discharge disposition, outpatient follow-up provider or time to first outpatient visit. CONCLUSION: Readmissions are challenging aspect of care for cirrhotic patients and risk continues beyond 30 d. More initiatives are needed to develop enhanced, longitudinal post-discharge systems.

Diagnostic and Therapeutic Yield of Endoscopy in Patients with Elevated INR and Gastrointestinal Bleeding.

BACKGROUND: Gastrointestinal bleeding is a well-known risk of systemic anticoagulation. However, bleeding in the setting of supratherapeutic anticoagulation may have a milder natural history than unprovoked bleeding. It is a common clinical gestalt that endoscopy is common, but bleeding source identification or intervention is uncommon, yet few data exist to inform this clinical impression. Consequently, we sought to examine our institutional experience with gastrointestinal bleeding in the setting of supratherapeutic international normalized ratio (INR) with the aim of identifying predictors of endoscopically identifiable lesions, interventions, and outcomes. METHODS: A retrospective review was conducted at a tertiary referral academic medical center to identify patients presenting with gastrointestinal bleeding in the setting of warfarin and a supratherapeutic INR (>3.5) who underwent an endoscopic procedure. Relevant clinical covariates, endoscopic findings, need for intervention, and outcomes were collected by review of the medical record. Logistic regression adjusting for potential confounders identified predictors of endoscopically significant lesions as well as intervention and outcomes. RESULTS: A total of 134 patients with INR 3.5 or greater (mean 5.5, range 3.5-17.1) presented with symptoms of gastrointestinal bleeding, most commonly as melena or symptomatic anemia. Antiplatelet agents were used by 54% of patients, and 60% of patients were on concomitant acid suppression on admission. Procedures included esophagogastroduodenoscopy (upper endoscopy; EGD) (n = 128), colonoscopy (n = 73), and video capsule endoscopy (n = 32). Active bleeding at first EGD or colonoscopy was found in only 19 patients (18%), with endoscopic intervention in only 26 patients (25%). At a critical threshold of INR 7.5 at presentation, the likelihood of finding an endoscopically significant lesion fell to <20%. On multivariate logistic regression, concomitant antiplatelet therapy (odds ratio [OR] 2.59; 95% confidence interval [CI], 1.13-5.94), timing of EGD within 12 hours of presentation (OR 3.71; 95% CI, 1.05-13.08), and INR level (OR 0.79; 95% CI, 0.64-0.98) were the only significant independent predictors of identifying a source of bleeding. A risk score incorporating these covariates performed modestly in identifying risk of significant finding on EGD (area under the curve 0.68). We found no association between identification of a significant lesion at EGD and future readmission for gastrointestinal bleeding. CONCLUSION: This study demonstrates that the relationship between INR elevation and identification of a bleeding source or endoscopic intervention at EGD are indeed antiparallel. Concomitant antiplatelet therapy increases the likelihood of bleeding source identification and intervention, as does EGD within 12 hours of presentation. However, regardless of source identification or endoscopic intervention, important clinical outcomes were unchanged, suggesting that decisions about endoscopy should be made on a case-by-case basis, particularly in patients with INR > 7.5. Future prospective studies on appropriate indications and timing of endoscopy in such patients are warranted.

Electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis.

BACKGROUND: We define electronic consultations ("e-consults") as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was to systematically review and summarize the literature describing the use and effects of e-consults. METHODS: We searched PubMed, EMBASE, the Cochrane Library, and CINAHL for studies related to e-consults published between 1990 through December 2014. Three reviewers identified empirical studies and system descriptions, including articles on systems that used a shared EHR or web-based platform, connected providers in the same health system, were used for two-way provider communication, and were text-based. RESULTS: Our final review included 27 articles. Twenty-two were research studies and five were system descriptions. Eighteen originated from one of three sites with well-developed e-consult programs. Most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. E-consultations are used in a variety of ways within and across medical centers. They provide timely access to specialty care and are well-received by primary care providers. DISCUSSION: E-consults are feasible in a variety of settings, flexible in their application, and facilitate timely specialty advice. More extensive and rigorous studies are needed to inform the e-consult process and describe its effect on access to specialty visits, cost and clinical outcomes.