Social Media Trends, Dry Scooping, and Extensive Esophageal Ulcerations.

We describe a case of severe odynophagia and dysphagia caused by dry scooping of multi-ingredient pre-workout powder (MIPS) with diffuse esophageal ulcerations on upper endoscopy. Dry scooping refers to ingesting work out supplements without the recommended doses of solvent. This trend has been the subject of TikTok and other social media sites aimed at enhancing workout performance. While caustic ingestions leading to esophageal ulcers and strictures are well known, dry scooping ingestion of pre-workout powder as an etiology has not been described. Though caffeine may be the predominant content in such powders, the exact composition and ratios of other constituents, including amino acids, are less clear. Complete abstinence from ingestion of the pre-workout formulation and the use of a proton pump inhibitor therapy led to significant clinical and endoscopic recovery over a 4-week period. A thorough history of ingestions, including supplements, is critical when unraveling emerging etiologies of esophageal ulcerations.

Ceftaroline as salvage therapy for complicated MRSA bacteremia: case series and analysis.

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) is a major cause of morbidity and mortality in hospitalized patients. Ceftaroline fosamil (CPT) is the only available beta-lactam antibiotic with in vitro and in vivo activities against MRSA. There is currently limited clinical experience with CPT in complicated MRSA BSI. MATERIALS AND METHODS: We report a series of eight patients, including three whose strains had reduced susceptibility to vancomycin. RESULTS: CPT monotherapy was successfully used as salvage therapy for complicated MRSA BSI. The median time to documented clearance was 7 days. CONCLUSION: Ceftaroline monotherapy is effective for clearance of refractory MRSA BSI related to implanted devices, endocarditis, and orthopedic infections.

Normal lipase drug-induced pancreatitis: a novel finding.

Acute pancreatitis (AP) in the setting of a normal serum amylase has been previously reported in the literature. Serum lipase on the other hand has a negative predictive value approaching 100% and therefore is an excellent test to rule out AP in the emergency department. The occurrence of AP with a normal lipase is extremely rare and has never been reported in the setting of drug-induced pancreatitis. Thiazide diuretics have been implicated as a cause of pancreatic injury via a number of proposed mechanisms. However, all such cases have been in the setting of elevated serum amylase or lipase. We report the first case of radiographically proven hydrochlorothiazide-induced pancreatitis with a normal lipase.

A case-control study of length of stay outliers.

OBJECTIVES: Inpatients with extended length of stay (LOS), referred to as LOS outliers, pose a challenge to health systems by contributing to high costs while assuming all the risks associated with hospital-acquired conditions. Limited research has been conducted within the US health system to better define LOS outliers and the risk factors for becoming an outlier in the setting of inpatient medicine stays. STUDY DESIGN: This was a retrospective study on adult inpatient admissions to the general medicine service of a university hospital from September 2015 to August 2016. Cases were defined as patients with observed LOS 3 SD above predicted. Controls were defined as those who stayed within 3 SD of predicted LOS. METHODS: A total of 108 LOS outliers were identified through the University Health System Consortium, and 72 were matched with inlier controls by principal diagnosis and disease severity. RESULTS: Compared with their inlier controls, outliers stayed 32.41 days longer and cost $77,228 more per stay. There were higher odds of being an outlier observed for patients with a history of smoking (odds ratio [OR], 29.5; 95% CI, 2.9-301.3), in-hospital complications (OR, 17.6; 95% CI, 3.5-88.6), hospital-acquired infections (OR, 7.2; 95% CI, 1.7-31.4), and discharge to a facility (OR, 11.5; 95% CI, 2.6-50.0). CONCLUSIONS: In-hospital complications, hospital-acquired infections, and discharge to a facility are all predictors of not only increasing hospital days for patients but also increasing the risk of becoming LOS outliers, who stay disproportionately longer and use disproportionately more resources than predicted.

Medicine Residents are Unprepared to Effectively Treat Patients with Obesity: Results from a U.S. Internal Medicine Residency Survey.

BACKGROUND: In an obesity epidemic, physicians are unprepared to treat patients with obesity. The objective of this study was to understand how obesity is currently addressed in United States (U.S.) Internal Medicine (IM) residency programs and benchmark the degree to which curricula incorporate topics pertaining to the recently developed Obesity Medicine Education Collaborative (OMEC) competencies. METHODS: Invitations to complete an online survey were sent via postal mail to U.S IM residency programs in 2018. Descriptive analyzes were performed. RESULTS: Directors/associate directors from 81 IM residencies completed the online survey out of 501 programs (16.2%). Although obesity was an intentional educational objective for most programs (66.7%), only 2.5% of respondents believed their residents are "very prepared" to manage obesity. Formal rotation opportunities in obesity are limited, and at best, only one-third (34.6%) of programs reported any one of the core obesity competencies are covered to "a great extent." Many programs reported psychosocial components of obesity (40.7%), weight stigma (44.4%), etiological aspects of obesity (64.2%) and pharmacological treatment of obesity (43.2%) were covered to "very little extent" or "not at all." Lack of room in the curriculum and lack of faculty expertise are the greatest barriers to integrating obesity education; only 39.5% of residency programs have discussed incorporating or expanding formal obesity education. CONCLUSIONS: Our study found the current obesity curricula within U.S. IM residency programs do not adequately cover important aspects that address the growing obesity epidemic, suggesting that obesity education is not enough of a priority for IM residency programs to formalize and implement within their curricula.

Impact of an evidence-based medicine curriculum on resident use of electronic resources: a randomized controlled study.

BACKGROUND: Evidence-based medicine (EBM) is widely taught in residency, but evidence for effectiveness of EBM teaching on changing residents' behavior is limited. OBJECTIVE: To investigate the impact of an EBM curriculum on residents' use of evidence-based resources in a simulated clinical experience. DESIGN/PARTICIPANTS: Fifty medicine residents randomized to an EBM teaching or control group. MEASUREMENTS: A validated test of EBM knowledge (Fresno test) was administered before and after intervention. Post intervention, residents twice completed a Web-based, multiple-choice instrument (15 items) comprised of clinical vignettes, first without then with access to electronic resources. Use of electronic resources was tracked using ProxyPlus software. Within group pre-post differences and between group post-test differences were examined. RESULTS: There was more improvement in EBM knowledge (100-point scale) for the intervention group compared to the control group (mean score increase 22 vs. 12, p = 0.012). In the simulated clinical experience, the most commonly accessed resources were Ovid (71% of residents accessed) and InfoPOEMs (62%) for the EBM group and UptoDate (67%) and MDConsult (58%) for the control group. Residents in the EBM group were more likely to use evidence-based resources than the control group. Performance on clinical vignettes was similar between the groups both at baseline (p = 0.19) and with access to information resources (p = 0.89). CONCLUSIONS: EBM teaching improved EBM knowledge and increased use of evidence-based resources by residents, but did not improve performance on Web-based clinical vignettes. Future studies will need to examine impact of EBM teaching on clinical outcomes.

Questionable hospital chart documentation practices by physicians.

BACKGROUND: Physicians, influenced by various pressures, may document information in patient records that they did not personally observe. OBJECTIVE: To evaluate the hospital chart documentation practices of internists and internal medicine sub-specialists in the Northeastern United States. DESIGN: An anonymous mail survey questionnaire. PARTICIPANTS: One thousand one hundred twenty-six randomly selected internists and internal medicine sub-specialists. MEASUREMENTS: Responses to questions describing their own hospital chart documentation practices, those they observed among their colleagues, and ratings of the importance of possible influences. RESULTS: Response rate was 43%. Fifty-nine percent (59%) of physicians reported personally engaging in one or more of six questionable documentation scenarios. Forty percent (40%, CI; 37%-43%) indicated that they recorded laboratory notes in patient records based on information that they did not personally obtain, while 6% (CI; 5%-8%) admitted to writing notes on patients not personally seen or examined. The corresponding percentages reported for their colleagues were 52% (CI; 49%-56%) and 22% (CI; 20%-25%), respectively. Increased rates of documentation lapses were significantly associated with working directly with residents and/or fellows (OR = 1.71, CI; 1.30-2.25), younger age (OR for 10 year age decrease = 1.35, CI; 1.19-1.53), white race (OR = 1.47, CI; 1.08-2.00), and graduation from US medical schools (OR = 1.75, CI; 1.31-2.34). CONCLUSION: Most physicians report having engaged in questionable hospital chart documentation. This practice is more common among physicians who are younger, working with house staff, and graduates of US medical schools.

Posterior reversible encephalopathy syndrome in alcoholic hepatitis: Hepatic encephalopathy a common theme.

Posterior reversible encephalopathy syndrome (PRES) is a neuro-radiologic diagnosis that has become more widely recognized and reported over the past few decades. As such, there are a number of known risk factors that contribute to the development of this syndrome, including volatile blood pressures, renal failure, cytotoxic drugs, autoimmune disorders, pre-eclampsia, and eclampsia. This report documents the first reported case of PRES in a patient with severe alcoholic hepatitis with hepatic encephalopathy and delves into a molecular pathophysiology of the syndrome.

Reimbursement denial and reversal by health plans at a university hospital.

PURPOSE: Denial and downgrading of reimbursement for hospital days are two strategies utilized by health plans to maintain profitability. The goal of this study was to describe patterns of discounted reimbursement at a university hospital. METHODS: We performed a retrospective cohort study of consecutive per diem patients hospitalized in 1999. We defined a discounted day as a day fully denied or downgraded and a reversal day as a day reimbursed at a higher level after appeal. The study outcomes included the probability of a discounted day and the probability of a discounted day to be later reversed. Covariance logistic regression was used to compare these outcomes by plan and physician specialty after adjusting for age, sex, race, length of stay, and diagnosis. Correlations with plan characteristics were analyzed. RESULTS: Of 59,265 hospital days, 6074 days (10.2%) were initially denied or downgraded. On appeal, 1755 discounted days (28.9%) were reversed. The percentage of days discounted per plan ranged from 1.2% to 18.8% (P <0.001), whereas the percentage of discounted days that were later reversed ranged from 23.2% to 85.3% (P <0.001). The qualitative magnitude of these associations and statistical significance were unchanged in adjusted models. Strong correlations were found between the adjusted odds ratio for a discounted day and net profit margin (R = 0.81) and medical loss ratio (R = -0.77). CONCLUSION: Denials and downgrades are frequent, with marked variation by health plan. More profitable plans had higher denial and discount rates. Evidence-based standards for denials and downgrades are needed to maintain optimal patient care and the fiscal health of hospitals and health plans.