Adherence to Appropriate Nutrition in Acute Alcoholic Hepatitis is Low.

Malnutrition is a common cause of impeding recovery in patients with acute alcoholic hepatitis (AAH). Previous reports have shown that appropriate nutritional supplementation reduce short and long-term mortality in patients with AAH. Despite these clear recommendations, the element of nutrition in AAH is often neglected. We designed a quality improvement project to evaluate and improve compliance with appropriate nutrition in patients presenting with AAH at our institution. Patients admitted with AAH between December 2015 to December 2016 were included. Our primary outcome was compliance with appropriate nutrition. Secondary outcomes included nutrition consultation and hepatology consultation. A total of fifty-four patients were included. Nine of the 53 patients (17%) received high calorie and high protein diets. Hepatology was consulted in 72% (38/53) of the patients, and 21% (8/38) of these patients received appropriate nutrition as compared to only 8.3% (1/12) in whom hepatology was not consulted. Nutrition was consulted in 55% (29/53) of these patients and 67% (19/28) of those patients received appropriate nutrition. In conclusion, our compliance of appropriate nutrition in AAH is low. Our initial investigation suggests that hepatology and nutrition consultation improved compliance with appropriate nutrition. The next step will be to implement protocolized care for appropriate nutrition in AAH by incorporating consultation of hepatology and nutrition services, assess the effect on adherence to appropriate nutrition, and determine the impact on patient outcomes.

Development of a Train-the-Trainer Quality Improvement Curriculum.

Introduction: Quality improvement (QI) curricula are required for clinical disciplines at all training levels. Despite this, faculty educators often feel inadequately prepared to perform QI functions and thus lack the skills necessary to teach QI to learners. We aimed to improve faculty QI skills so they could oversee didactic curricula and experiential QI projects. Methods: We developed a train-the-trainer curriculum for faculty within medicine, nursing, and allied health that was delivered as a 2-hour interactive workshop. Core concepts included QI methodologies, measurement, implementation, and scholarship. Prior to the workshop, attendees completed a baseline knowledge test and a self-assessment of their confidence in teaching QI. Both assessments were repeated 1 month and 6 months postworkshop. Participants also completed a course evaluation. Results: We report on our experience after two workshops with 23 participants total. Baseline median knowledge test percentage correct was 36%. This increased to 77% at 1 month and remained at 57% at 6 months. Self-assessment ratings of QI teaching skills increased consistently from baseline to 1 month to 6 months, with all respondents reporting feeling some confidence or very confident by the end of the study period. The course overall was rated very good or excellent by 91% of attendees. Discussion: A focused QI train-the-trainer curriculum can sustainably improve faculty knowledge and self-ratings of QI teaching skills. Participants rated the interactive 2-hour workshop highly. Its materials can be easily adapted across disciplines and clinical departments to increase the number of faculty competent to facilitate didactic and experiential QI training.

Convalescing: Reflections in a Post-pandemic World.

The COVID-19 pandemic brought with it many hardships to the world as a whole. Mass infection and casualties due to disease state were rampant, which affected many families. Lockdown drove up the incidence of depression and isolated people from their loved ones. The toll on the general population was high, as was the toll on the medical community, a subset of the general population. It was a time of death and devastation, with supply chain issues creating personal protective equipment shortages and staffing being affected by illness, fear, age, and expertise. Despite the constraints, many places were able to rally staff together to provide adequate staffing for healthcare delivery purposes to serve our communities. Cross-specialty collaboration in the outpatient and inpatient setting as well as the use of technology aided our service to our community to help persevere through the many surges of the pandemic and come out with lessons learned as well as reflections.

Feasibility and Effectiveness of a Quality Improvement Curriculum for Combined Medicine Subspecialty Fellows.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires training in quality improvement (QI) yet many programs struggle to incorporate appropriate content. Small fellowship programs may find it particularly difficult, limited by a lack of well-trained faculty. We report on the feasibility and effectiveness of a consolidated curriculum for subspecialty fellowship programs. METHODS: Two QI experts were identified to design a curriculum. Interactive didactic sessions were created to guide development and implementation of fellow QI projects. All projects culminated in abstract/poster presentation. RESULTS: Seven of 10 eligible fellowships participated. Twenty-four projects were completed with 70% reaching improvement in process measures. Trainees improved confidence in 11 of 12 QI domains. Program directors stated enhancement in QI education with 100% recommending program continuation. CONCLUSIONS: Consolidating teaching efforts with existing QI experts can lead to an effective QI curriculum for fellowship programs. This model can be expanded to other graduate medical education trainees as a means to increase QI proficiency.

A Curious Case of Rectal Ejaculation.

Rectal-prostate fistulas are uncommon anatomical connections between the prostatic urethra and rectum that are typically iatrogenic but can also result from other underlying pathology. Here, we present a unique case of a rectal-prostate fistula causing the rectal passage of sperm. A 33-year-old male with a history of illicit drug use presented with five days of testicular pain and a substantial amount of sperm passage from his rectum with ejaculation for the past two years. Computed tomography and voiding cystourethrogram (VCUG) of the pelvis revealed evidence of a rectal-prostate fistula. He was treated with piperacillin-tazobactam, and a surgical fistula repair was performed. Further investigation divulged a three-week comatose state due to cocaine and phencyclidine intoxication two years prior with documentation suggesting a traumatic Foley catheter placement and strong suspicion for premature balloon dilation in the prostatic urethra. Repeat VCUG revealed resolution of the fistula with mildly reduced antegrade ejaculatory volume. Cases secondary to Foley catheter placement have not been previously reported in the literature. Even though urethral catheters have been shown to be effective tools in healthcare, it is crucial for clinicians to recognize the numerous potential complications that oftentimes become an afterthought to many providers. This case not only highlights a rare complication of catheter use but also emphasizes the importance of provider mindfulness when utilizing seemingly benign therapies such as Foley catheters.

Clinical Characteristics and Outcomes in Immune Checkpoint Inhibitor Therapy-Associated Myocarditis.

Immune checkpoint inhibitor (ICI) therapy has played an important role in the treatment of several groups of cancers. Although a life prolonging treatment, many side effects have been shown with ICI therapy. This study looked at individual level clinical characteristics and outcomes with ICI therapy in patients who developed ICI-related myocarditis. A comprehensive review of the National Library of Medicine PubMed database was performed. Inclusion criteria were all studies that were composed of case reports and case series of individual patients undergoing ICI therapy that developed myocarditis. To appreciate individual patient level data, observational studies, clinical trials, systematic reviews, and meta-analyses were excluded. Our search yielded 333 results with 71 cases reviewed of ICI therapy-related myocarditis. The findings included an average age of 68 years, higher incidence in men, and pretreatment cardiac history of hypertension. Melanoma was the most prevalent malignancy with nivolumab being the most used ICI therapy. Heart failure was the most prevalent adverse event that was co-prevalent with myocarditis. Corticosteroid therapy alone was the most utilized therapy to treat ICI-related myocarditis. Mortality was seen in nearly half of the patient population. Our study reviewed the preexisting literature of prior reported myocarditis secondary to ICI therapy. Periodic surveillance should be performed by the cardio-oncologist and internist. Due to the expanding role of ICI therapy in treating a variety of cancer patients, appreciation of its impact on the development of myocarditis is needed.

A recommendation for earlier screening of type 2 diabetes mellitus within the US population: A cross-sectional analysis of NHIS data.

Diabetes is a leading cause of morbidity and mortality in the US. Current USPSTF guidelines recommend screening asymptomatic, overweight patients greater than 40 years. Our study showed that » of patients with type 2 diabetes were diagnosed prior to 40 years. Therefore, we recommend lowering the screening age for diabetes.

Improving adherence for management of acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Clinical practice guidelines recommend 40-60 mg of prednisone equivalent for 10-14 days for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). However, the amount of corticosteroid prescribed varies widely in clinical practice. Using the electronic health record, we implemented an evidence-based order set to standardize treatment of patients hospitalized with acute exacerbations of COPD. METHODS: This is a pre- and post-intervention study on patients hospitalized between January 1, 2009 and September 30, 2012 with primary discharge diagnosis of COPD (International Classification of Diseases, 9(th) Revision code: 491.xx, 492.xx, and 496) and receipt of at least one dose of corticosteroid at our tertiary care hospital. Data on baseline demographics, dose of corticosteroid in prednisone equivalent administered during the first 48 hours and during the entire hospitalizations were collected from the electronic health record. Evidence-based guidelines were used to build and implement acute exacerbations of COPD management electronic ordersets in our electronic health record, Epic (Verona, WI). We divided the study into 2 time periods (January 1, 2009 through February 28, 2011 as pre- [n = 203] and March 1, 2011 through September 30, 2012 as post-intervention periods [n = 217]). The primary outcome measure was corticosteroid dose administered in the first 48 hours. Secondary outcome measures were corticosteroid dosage during the entire hospitalization, length of stay, hospital follow-up rates, and 30-day readmission rates. RESULTS: A total of 420 patients with acute exacerbations of COPD were included in the study. In the post-intervention period, the median amount of corticosteroid used in the first 48 hours was significantly reduced (306.2 mg vs 156.25 mg, P < .0001), as was that used during the entire hospitalization (352.5 mg vs 175 mg, P < .0001). There was no difference in hospital follow-up rates, length of stay, or 30-day readmission rates between the 2 periods. CONCLUSIONS: Evidence-based electronic ordersets improve compliance with clinical practice guidelines and reduce the total dose of corticosteroid administered in patients hospitalized with acute exacerbations of COPD.