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We report an initial episode of post-streptococcal reactive arthritis (PRSA) in a 61-year-old male with group A streptococcal (GAS) bacteremia. The disease is commonly reported in young children and young adults. Additionally, this patient exemplifies the nonlinear boundaries of acute rheumatic fever (ARF) and PRSA, bringing into question whether they are truly distinct disease entities. These two conditions oftentimes present in similar fashions, making it difficult for clinicians to determine a specific diagnosis. We highlight the importance of recognizing ARF versus PRSA as an incorrect diagnosis can lead to the development of harmful complications including rheumatic heart disease (RHD).
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PURPOSE: Clinic members reported slower patient flow in the mornings at a multidisciplinary oncology clinic. This study identified the causes of clinic bottlenecking via analysis of patient schedules and transit times, then corrected discrepancies through a quality improvement program. METHODS: Transit times were measured using tracking cards handed out at check-in, marked by each clinic member throughout the encounter, and collected upon discharge. Data were analyzed for differences between morning and afternoon patients, and a Pareto chart was formulated to assess for discrepancies in distribution. Repeat plan-do-study-act (PDSA) cycles were conducted, implementing two changes to redistribute appointments to optimize clinic workflow. RESULTS: A total of 2951 patient appointments were analyzed: 589 at baseline, 277 following an initial intervention, and 2085 following a subsequent intervention. Analysis of patient transit times revealed no significant differences between morning and afternoon patient groups (t-test, p=.13-.99), with no transit interval markedly longer than others (t-test, p=.32-.83). However, upon evaluation of appointment times, a maldistribution was noted with 57% of patients concentrated between 9:00 am to 12:00 pm, accounting for the perception of bottlenecking. An initial intervention offering patients afternoon appointments on a voluntary basis was insufficient for rebalancing distribution (chi-square test, p=.299); however, an electronic medical record (EMR) intervention with rigid appointment templates was successful (chi-square test, p<.001). CONCLUSION: An imbalance of appointment times contributed to the perception of slow clinic throughput. This study emphasizes the importance of systematically investigating even consensus observations for validity prior to costly interventions. Furthermore, these results support the utility of information technology in optimizing clinic workflow.
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Tissue oxygenation often plays a significant role in disease and is an essential design consideration for tissue engineering. Here, oxygen diffusion profiles of porcine aortic and mitral valve leaflets were determined using an oxygen diffusion chamber in conjunction with computational models. Results from these studies revealed the differences between aortic and mitral valve leaflet diffusion profiles and suggested that diffusion alone was insufficient for normal oxygen delivery in mitral valves. During fibrotic valve disease, leaflet thickening due to abnormal extracellular matrix is likely to reduce regional oxygen availability. To assess the impact of low oxygen levels on valve behaviour, whole leaflet organ cultures were created to induce leaflet hypoxia. These studies revealed a loss of layer stratification and elevated levels of hypoxia inducible factor 1-alpha in both aortic and mitral valve hypoxic groups. Mitral valves also exhibited altered expression of angiogenic factors in response to low oxygen environments when compared with normoxic groups. Hypoxia affected aortic and mitral valves differently, and mitral valves appeared to show a stenotic, rheumatic phenotype accompanied by significant cell death. These results indicate that hypoxia could be a factor in mid to late valve disease progression, especially with the reduction in chondromodulin-1 expression shown by hypoxic mitral valves.