Early palliative care referral may improve end-of-life care in end-stage liver disease patients: A retrospective analysis from a non-transplant center.

BACKGROUND: Patients with end-stage liver disease (ESLD) who are not transplant candidates often have a trajectory of rapid decline and death similar to patients with stage IV cancer. Palliative care (PC) services have been shown to be underutilized for such patients. Most studies examining the role of PC in ESLD have been done at transplant centers. Thus, determining the utilization and benefit of PC at a non-transplant tertiary center may help establish a standard of care in the management of patients with ESLD not eligible for transplant. METHODS: We conducted a retrospective analysis of adult (>18 years) patients with ESLD admitted to Rochester Regional Health (RRH) system hospitals from 2012 to 2021. Patients were divided into groups based on the presence or absence of PC involvement. Baseline characteristics were recorded. The impact of PC was assessed by comparing the number of hospitalizations before and after the involvement of PC, comparing code status changes, health care proxy (HCP) assignments, Aspira catheter placements, and frequency of repeated paracentesis. RESULTS: In our analysis of 576 patients, 41.1% (237 patients) received a PC consult (PC group), while 58.9% (339 patients) did not (no-PC group). Baseline characteristics were comparable. However, their mean number of admissions significantly decreased (15.66 vs. 3.49, p < 0.001) after PC involvement. Full code status was more prevalent in the no-PC group (67.8% vs. 18.6%, p < 0.001), while comfort care code status was more common in the PC group (59.9% vs. 20.6%, p < 0.001). Changes in code status were significantly higher in the PC group (77.6% vs. 29.2%, p < 0.001). The PC group had a significantly higher mortality rate (83.1% vs. 46.4%, p < 0.01). Patients in the PC group had a higher likelihood of having an assigned HCP (63.7% vs. 37.5%, p < 0.001). PC referral was associated with more frequent use of an Aspira catheter (5.9% vs. 0.9%, p < 0.001) and more frequent paracentesis (30.8% vs. 16.8%, p < 0.001). CONCLUSIONS: In conclusion, our study provides compelling evidence of the diverse advantages of palliative care for patients with end-stage liver disease, including reduced admissions, improved goals of care, code status modifications, enhanced healthcare proxy assignments, and targeted interventions. These findings highlight the potential significance of early integration of palliative care in the disease trajectory to provide comprehensive, patient-centered care that addresses the unique needs and preferences of individuals with advanced liver disease.

Disseminated Mycobacterium gordonae infection in an immunocompetent host.

Mycobacterium gordonae is a slow-growing mycobacterium that is the least pathogenic of the mycobacteria. Infection with M. gordonae is most commonly reported in immunocompromised patients. We present a rare case of M. gordonae infection in an immunocompetent individual. A 37-year-old woman was found to have a pulmonary nodule in the left upper lobe. The patient denied any respiratory symptoms, including cough, sputum production, fever, chest pain, or shortness of breath. The patient was a lifetime nonsmoker. Physical examination was normal. Computed tomography (CT) scan of the chest revealed several discrete pleural-based inflammatory infiltrates bilaterally. The patient was treated with oral amoxicillin-clavulinic acid initially and a repeat CT scan chest was scheduled after 2 weeks. Laboratory data were nonsignificant. Repeat CT scan did not show any resolution. Patient positron emission tomography scan revealed marked hypermetabolic uptake involving bilateral parenchymal nodules, mediastinal lymph nodes, and the spleen. A thoracotomy with biopsy of the left upper lobe nodule revealed necrotizing granulomatous pneumonitis with rare acid-fast bacilli. Cultures were positive for M. gordonae. The patient was started on a multidrug regimen of azithromycin, rifampin, and ciprofloxacin, based on drug sensitivities, for 12 months. Repeat CT scan and positron emission tomography scan after treatment showed complete resolution. The patient has remained disease-free 5 years after treatment. Instead of always dismissing M. gordonae as a contaminant, we should include it in our differential diagnosis of pulmonary infection in both immunocompetent and immunocompromised hosts. Further studies are needed to understand the pathogenesis of M. gordonae infection in humans.

Mobile physician reporting of clinically significant events-a novel way to improve handoff communication and supervision of resident on call activities.

OBJECTIVES: Reporting of clinically significant events represents an important mechanism by which patient safety problems may be identified and corrected. However, time pressure and cumbersome report entry procedures have discouraged the full participation of physicians. To improve the process, our internal medicine training program developed an easy-to-use mobile platform that combines the reporting process with patient sign-out. METHODS: Between August 25, 2011, and January 25, 2012, our trainees entered clinically significant events into i-touch/i-phone/i-pad based devices functioning in wireless-synchrony with our desktop application. Events were collected into daily reports that were sent from the handoff system to program leaders and attending physicians to plan for rounds and to correct safety problems. RESULTS: Using the mobile module, residents entered 31 reportable events per month versus the 12 events per month that were reported via desktop during a previous 6-month study period. CONCLUSIONS: Advances in information technology now permit clinically significant events that take place during "off hours" to be identified and reported (via handoff) to next providers and to supervisors via collated reports. This information permits hospital leaders to correct safety issues quickly and effectively, while attending physicians are able to use information gleaned from the reports to optimize rounding plans and to provide additional oversight of trainee on call patient management decisions.