A Multidisciplinary Quality Improvement Program to Improve Diabetes Care at a Free Clinic.

OBJECTIVE: To evaluate the effectiveness of an intensive, multidisciplinary patient-centered approach involving a pharmacist and a dietician in a population of uninsured free clinic patients with diabetes and hypertension. METHODS:  A single-center retrospective chart review of a quality improvement project. All patients had diagnoses of diabetes and hypertension and a most recent hemoglobin A1c ≥ 9.0%. Patients met individually with a pharmacist and a dietician during 6 encounters over 12 months. The pharmacist made medication changes, encouraged lifestyle reflections, and helped patients create and track self-management goals. The dietician helped patients plan strategies for diet and exercise. The primary outcome was a change in mean hemoglobin A1c. RESULTS: Of 30 enrolled patients, 17 completed three months of treatment, and seven completed 12 months. The 17 patients who completed three months of treatment had the following characteristics: mean age 55.5 years; mean hemoglobin A1c 11.5%; 82% were taking two or more antidiabetic medications; 59% were taking two or more antihypertensive medications. Significant reductions in mean hemoglobin A1c values were observed at three months (-3.4%, P<0.0001) and twelve months (-4.0%, P=0.0156). Reductions in systolic blood pressure were also observed at three months (-6 mmHg, P=0.1060) and twelve months (-17 mmHg, P=0.2188). CONCLUSIONS: Large and significant hemoglobin A1c reductions were observed in free clinic patients with diabetes refractory to traditional medical management. Goal-oriented patient empowerment effectively improves a wide range of patient outcomes in the free clinic setting. Other free clinics can implement this collaborative, multidisciplinary model with access to similar personnel.

Double Superior Vena Cava Due to Persistent Left Superior Vena Cava Incidentally Identified on Central Venous Catheterization: A Case Report.

BACKGROUND Persistent left superior vena cava (PLSVC) results in a double superior vena cava (SVC), and although it is rare, this is the most common venous anomaly of the thorax. PSLVC arises from the junction of the left subclavian and internal jugular veins. It is identified on the left side of the mediastinum adjacent to the aortic arch, and it usually drains into the right atrium through the coronary sinus. This report presents the case of a 40-year-old man with an incidental finding of double SVC due to PSLVC identified on hospital admission following a motor vehicle collision. CASE REPORT A 40-year-old man was found to have a double SVC due to PLSVC upon chest radiography during hospital admission for injuries related to motor vehicle trauma. The discovery was made following placement of a central venous catheter (CVC) down the left-sided SVC and into the coronary sinus. The patient suffered no harm as a result. The diagnosis was made by chest radiography and confirmed by computed tomography angiography. CONCLUSIONS PSLVC is an uncommon condition that can complicate common procedures and therefore must be well-understood by physicians across many medical and surgical specialties. Although PLSVC may be asymptomatic, as in this case, in some patients PLSVC presents as atrial fibrillation or with nonspecific cardiac symptoms. Therefore, all patients identified with PLSVC should be investigated to exclude associated cardiac abnormalities and arrythmias, and before the placement of central venous access devices.

Erythrodermic mycosis fungoides with large cell transformation: An unusual and complicated case.

Mycosis fungoides is the most common cutaneous T-cell lymphoma. It presents a diagnostic challenge due to resemblance with many other dermatologic conditions. The disease typically follows a progression from patches to plaques to skin-based tumors with potential for visceral involvement. Diagnosis is made by clinical presentation and histology. When early diagnosis is made, there is an estimated 88% five-year survival. This report details a 60-year-old Black man diagnosed with stage IIIA mycosis fungoides with a severe degree of cutaneous involvement. This case is unique due to the aggressive large cell transformation and rapid progression to death within 18 months of diagnosis. We highlight the challenge of diagnosing, treating, and monitoring the therapeutic response of mycosis fungoides. Finally, this case calls for a multi-disciplinary approach to treatment and to include mycosis fungoides on the differential diagnosis for patients presenting with a variety of vague, recurrent cutaneous symptoms, especially with patchy dyspigmentation or plaques.

Pleural Effusion as the Initial Presentation of Gastric Adenocarcinoma: A Case Report.

BACKGROUND Gastric adenocarcinoma is a common malignancy, representing the third most common cause of cancer-related death globally. Most patients are initially asymptomatic, but as the cancer progresses, patients typically present with vague gastrointestinal complaints, including early satiety, heart burn, vomiting, or abdominal pain. Metastatic gastric cancer is relatively uncommon, with ~26% of patients having metastasis to a single site and 13% having metastases to multiple sites. The most common site of metastasis is the liver, followed by peritoneum, lung, and bone. CASE REPORT In this case report we describe a 73-year-old man who presented with shortness of breath, found to have large hiatal hernia along with segmental branch pulmonary embolism, bilateral pleural effusion, and diffuse interlobular septal thickening. The pleural effusion was later found to be malignant in nature and the patient was diagnosed with metastatic stage IV infiltrative gastric adenocarcinoma with metastasis to the lung and bone. Notably, the patient had no hepatic involvement. CONCLUSIONS This represents a unique case, as only 2% of malignant pleural effusions are attributable to gastric cancer. Furthermore, malignant pleural effusion is an extremely rare initial presentation of gastric adenocarcinoma, especially without liver involvement, with few existing cases documented in the literature. This case demonstrates that gastric cancer should be included on the differential diagnosis as a rare cause of pleural effusion.

Impact of educational instruction on medical student performance in simulation patient.

Objectives: This study aimed to evaluate the effects, and timing of, a video educational intervention on medical student performance in manikin-based simulation patient encounters. Methods: This prospective mixed-methods study was conducted as part of the University of Toledo College of Medicine and Life Sciences undergraduate medical curriculum. One hundred sixty-six students second-year students participated in two simulations on a single day in September 2021. A 7-minute video intervention outlining the clinical diagnostic approach to pulmonary complaints was implemented. Students were randomized into 32 groups which were divided into two cohorts. One received the video prior to simulation-1 (n=83) and the other between simulation-1 and simulation-2 (n=83). Each simulation was recorded and assessed using a 44-point standardized checklist. Comparative analysis to determine differences in performance scores was performed using independent t-tests and paired t-tests. Results: Independent t-tests revealed the video-prior cohort performed better in simulation-1 (t(30)= 2.27, p= .03), however in simulation-2 no significant difference was observed between the cohorts. Paired t-test analysis revealed the video-between cohort had significant improvement from simulation-1 to simulation-2 (t(15)= 3.06, p = .01); no significant difference was found for the video-prior cohort. Less prompting was seen in simulation-2 among both the video-prior (t(15)= -2.83, p= .01) and video-between cohorts (t(15)= -2.18, p= .04). Conclusions: Simulation training, and targeted educational interventions, facilitate medical students to become clinically competent practitioners. Our findings indicate that guided video instruction advances students' clinical performance greater than learning through simulation alone. To confirm these findings, similar investigations in other clinical training exercises should be considered.

The association between operating margin and surgical diversity at Critical Access Hospitals.

CONTEXT: Surgical volume is correlated with increased hospital profitability, yet many Critical Access Hospitals (CAHs) offer few or no inpatient surgical services. OBJECTIVES: This study aims to investigate the impact of the presence of different inpatient surgical services on CAH profitability. METHODS: The study design was a cross-sectional analysis of financial data from the most recent fiscal year (FY) of 1299 CAHs. Multiple linear regression was utilized to assess how the operating margin was affected by the number of different inpatient surgical services offered per hospital. Covariates known to be associated with hospital profitability included occupancy rate, case mix index (CMI), system affiliation, ownership status (public, private, or nonprofit), and geographic region. RESULTS: The regression model for the CAH operating margin returned an R2 value of 0.18. Each additional inpatient surgical service corresponded to a 1.5% increase in operating margin (p=0.0413). Each 10% increase in occupancy rate and 0.1 increase in CMI corresponded to a 0.9% increase in operating margin (p=0.0032 and p=0.0176, respectively). The number of surgical services offered per CAH showed positive correlations with occupancy rate (r=0.23, p<0.0001) and CMI (r=0.59, p<0.0001). CONCLUSIONS: A positive correlation exists between operating margin and the diversity of inpatient surgical specialties available at CAHs. Furthermore, providing surgery allows CAHs to accommodate higher occupancy rates and case mixes, both of which are significantly and positively correlated with CAH operating margin.

Assessment of Glycemic Control at St. Luke's Free Medical Clinic: Retrospective Chart Review.

BACKGROUND: A free clinic is a health care delivery model that provides primary care and pharmaceutical services exclusively to uninsured patients. With a multidisciplinary volunteer clinical staff, which includes physicians, social workers, dieticians, and osteopathic medical students, St. Luke's Free Medical Clinic (SLFMC) cares for over 1700 patients annually in Spartanburg, South Carolina. OBJECTIVE: This study aims to measure the change, over time, in patient hemoglobin A1c measurements at the SLFMC to quantify the success of the clinic's diabetes treatment program. METHODS: A prospective-retrospective chart review of patients (n=140) enrolled at the SLFMC between January 1, 2018, and January 1, 2021, was performed. Patients were stratified as having controlled (hemoglobin A1c<7.0, n=53) or uncontrolled (hemoglobin A1c≥7.0, n=87) diabetes relative to a therapeutic hemoglobin A1c target of 7.0, which is recommended by the American Diabetes Association. For both controlled and uncontrolled groups, baseline hemoglobin A1c values were compared to subsequent readings using a Wilcoxon matched-pairs signed rank test. Results from the SLFMC population were compared to the published literature on hemoglobin A1c from other free clinics. RESULTS: Patients with uncontrolled diabetes experienced significant reductions in median hemoglobin A1c at both 6 months (P=.006) and 1 year (P=.002) from baseline. Patients with controlled diabetes showed no significant changes. Black and Hispanic patients with uncontrolled diabetes experienced a 1.0% mean improvement in hemoglobin A1c over the study window. The SLFMC's wholly uninsured patient population showed a population rate of controlled diabetes (42%), which was similar to recent nationwide averages for adults with diabetes (51% to 56%), as reported by the National Health and Nutrition Examination Survey. The clinic's Hispanic population (n=47) showed the greatest average improvement in hemoglobin A1c of any ethnic group from baseline. Additionally, 61% of the SLFMC's Black population (n=33) achieved a hemoglobin A1c of <7.0 by the end of the study window, which surpassed the nationwide averages for glycemic control. CONCLUSIONS: We present free clinic hemoglobin A1c outcomes obtained through a retrospective chart review. Uninsured patients treated for diabetes at the SLFMC show a reduction in hemoglobin A1c, which is comparable to nationwide standards, although average hemoglobin A1c levels in this study were higher than nationwide averages. Black and Hispanic patients with uncontrolled diabetes showed a mean 1% improvement in hemoglobin A1c levels. These results represent some of the first in the literature emerging from a free clinic that is not affiliated with a major medical school.

Treatment of duodenal lipoma with robotic-assisted transverse duodenotomy: A case report of novel approach.

INTRODUCTION AND IMPORTANCE: Lipomas are the third most common benign tumor of the gastrointestinal (GI) tract, typically occurring in the colon or small intestine. Less than 100 cases of symptomatic duodenal lipomas have been reported. Symptoms include non-specific upper GI complaints of heartburn, fullness, or abdominal pain. This report highlights the rarity of symptomatic duodenal lipomas, lack of specific treatment guidelines, and adds to surgical literature a new treatment approach. CASE PRESENTATION: A 53-year-old Caucasian woman presented with 2-year history with main concerns for early satiety and constipation. CT scan with contrast of the abdomen and pelvis demonstrated a duodenal mass. Differential diagnosis included duodenal lipoma versus stricture, and IBS. Subsequent EGD revealed a 4 cm transverse duodenal submucosal mass. Endoscopic removal was deemed too great a risk of bleeding. Pre-operatively, the patient expressed frustration as the patient was tolerating only a liquid diet with one bowel movement weekly. Treatment with robotic assisted transverse duodenotomy was performed, with final pathology of benign lipomatous tissue. Post-operatively the patient had immediate relief of symptoms which persisted at 2-week and 4-month follow-ups. CLINICAL DISCUSSION: This case demonstrates 3 primary learning points. First, duodenal lipomas should be included in the differential of vague upper GI symptoms. Second, we propose that surgeons consider treatment of duodenal lipomas utilizing robotic assisted approach. Third, we document the first robotic-assisted transverse duodenotomy for duodenal lipomas. CONCLUSION: Clinicians should consider duodenal lipoma for patients with vague abdominal symptoms. We present a case of successful treatment with robotic-assisted transverse duodenotomy.

The Value Surgical Services Bring to Critical Access Hospitals.

Purpose Critical Access Hospitals (CAHs) serve rural populations and receive government subsidies to compensate for their relatively high overhead costs and low occupancy rates. Twenty-nine percent of all hospitalizations in the United States include a surgical procedure, and hospitalizations involving surgery accounted for nearly half of all hospital revenue in 2011. This study aims to determine the value surgical services bring to CAHs and their impact on the viability of these facilities.  Methods Public access data from the American Hospital Directory (AHD) was analyzed about each hospital's revenue and surgical services offered. Excel was utilized to randomly select 300 CAHs from a pool of 1350 CAHs based on a 95% confidence interval and a 5% margin of error. Linear regression models were fit to the data evaluating the association of net income with the number of surgical services offered per hospital and the association of total margin with the number of surgical services offered per hospital. Models were adjusted for location, occupancy rate, and case mix index.  Findings The linear regression model demonstrated that for every additional surgical service provided by a CAH, the hospital net income increased by $630,528 (p=0.0032). A similar trend was observed when modeling profitability. The total margin increased 0.73% for each additional surgical service added, albeit without statistical significance (p=0.1342). CAHs providing two or three surgical services showed tighter group variance than those not offering surgery or only offering one surgical service.  Conclusions Net income was significantly correlated to the number of surgical services offered at CAHs. Furthermore, CAHs offering more surgical services seem to have more predictable profits than those offering less surgical services. CAHs would financially benefit from offering more or expanding surgical services at their facilities.