An Unusual Presentation of Stroke and Reperfusion: A Case Report.

Intravenous tissue plasminogen activator (tPA) is a mainstay of therapy in acute ischemic stroke but transient neurologic changes related to reperfusion have not been well described. One of the authors (ISN) experienced a cardioembolic stroke due to apical hypertrophic cardiomyopathy with a left ventricular apical aneurysm. He received tPA and we describe his unusual cognitive symptoms during the infusion. The patient's presenting neurologic deficit improved with tPA, suggesting reperfusion. His subsequent restlessness, disorientation, and déjà vu lasted about 10 minutes and resolved spontaneously. Imaging studies confirmed an ischemic infarction in the left posterior cerebral artery (PCA) distribution. Cardiac events, including arrhythmias related to coronary reperfusion after myocardial infarction, are well described. Neurologic events due to reperfusion have not been previously described in patients with stroke. We describe a case of transient neurologic symptoms during revascularization of an embolic stroke.

Coexisting Thyroiditis and Carditis in a Patient With Lyme Disease: Looking for a Unifying Diagnosis.

Background/Objective: Lyme disease, the most common vector-borne infection in the United States, causes multisystem inflammation. We describe a patient who presented with symptoms of Lyme disease, carditis, and thyroiditis. Case Report: A 53-year-old woman developed fatigue and dyspnea on exertion 1 month after returning from a trip to Delaware. Her electrocardiogram (ECG) showed first-degree atrioventricular (AV) block with a P-R interval up to 392 milliseconds, in the setting of elevated free thyroxine and undetectable thyroid-stimulating hormone levels. Lyme serology was positive. She was hospitalized and started on ceftriaxone. During the second day of hospitalization, AV block worsened to second-degree Mobitz type II but converted back to first-degree AV block after a few hours. Her 24-hour I-123 thyroid uptake and scan revealed markedly diminished I-123 uptake of 1.2%. On day 4, the P-R interval improved, and she was discharged on doxycycline for 3 weeks. P-R interval on ECG and repeated thyroid function tests were normal after finishing antibiotic treatment. Discussion: In our patient, known exposure to the vector, a classic rash on the chest, improvement in the symptoms, and normalization of thyroid function tests after antibiotic therapy support Lyme infection as a cause of carditis and painless, autoimmune thyroiditis. Conclusion: Our case highlights the importance of considering Lyme disease as a cause of painless, autoimmune thyroiditis, especially in patients with concurrent cardiovascular involvement.

Early Experience With Neutralizing Monoclonal Antibody Therapy for COVID-19: Retrospective Cohort Survival Analysis and Descriptive Study.

BACKGROUND: Neutralizing monoclonal antibody (MAB) therapies may benefit patients with mild to moderate COVID-19 at high risk for progressing to severe COVID-19 or hospitalization. Studies documenting approaches to deliver MAB infusions and demonstrating their efficacy are lacking. OBJECTIVE: We describe our experience and the outcomes of almost 3000 patients who received MAB infusion therapy at Northwell Health, a large integrated health care system in New York. METHODS: This is a descriptive study of adult patients who received MAB therapy between November 20, 2020, to January 31, 2021, and a retrospective cohort survival analysis comparing patients who received MAB therapy prior to admission versus those who did not. A multivariable Cox model with inverse probability weighting according to the propensity score including covariates (sociodemographic, comorbidities, and presenting vital signs) was used. The primary outcome was in-hospital mortality; additional evaluations included emergency department use and hospitalization within 28 days of a positive COVID-19 test for patients who received MAB therapy. RESULTS: During the study period, 2818 adult patients received MAB infusion. Following therapy and within 28 days of a COVID-19 test, 123 (4.4%) patients presented to the emergency department and were released, and 145 (5.1%) patients were hospitalized. These 145 patients were compared with 200 controls who were eligible for but did not receive MAB therapy and were hospitalized. In the MAB group, 16 (11%) patients met the primary outcome of in-hospital mortality, versus 21 (10.5%) in the control group. In an unadjusted Cox model, the hazard ratio (HR) for time to in-hospital mortality for the MAB group was 1.38 (95% CI 0.696-2.719). Models adjusting for demographics (HR 1.1, 95% CI 0.53-2.23), demographics and Charlson Comorbidity Index (HR 1.22, 95% CI 0.573-2.59), and with inverse probability weighting according to propensity scores (HR 1.19, 95% CI 0.619-2.29) did not demonstrate significance. The hospitalization rate was 4.4% for patients who received MAB therapy within 0 to 4 days, 5% within 5 to 7 days, and 6.1% in ≥8 days of symptom onset (P=.15). CONCLUSIONS: Establishing the capability to provide neutralizing MAB infusion therapy requires substantial planning and coordination. Although this therapy may be an important treatment option for early mild to moderate COVID-19 in patients who are at high risk, further investigations are needed to define the optimal timing of MAB treatment to reduce hospitalization and mortality.

The Use of Online Physician Training Can Improve Patient Experience and Physician Burnout.

The authors tested the efficacy of an integrated approach to improving patient experience and physician burnout using a 24-week online training program coupled with a physician engagement strategy. Physicians from different disciplines were randomized to intervention (n = 30) and control (n = 33) groups. Patient experience, physician burnout, and satisfaction data were assessed using patient and provider surveys. Comparisons were made pre and post intervention, and between the groups. Intervention group mean scores increased (+1.40 points) while control group scores dropped (-0.11 points; P = .039). Scores on physician burnout surveys for the intervention group improved in all areas and changes in 2 domains were statistically significant. In all, 73.5% of physicians felt the program was effective. This integrated intervention enhanced patient experience scores and positively affected physicians' level of burnout, and physicians believed this exercise was useful.

Clinical Quality and Patient Experience in the Adult Ambulatory Setting.

Quality and patient experience are important dimensions of care delivery. The extent to which they are related in the adult outpatient setting is unknown. This brief study utilized data from a large integrated health system over a 1-year period in 2015 and measured the degree of correlation between physicians' patient experience scores and 8 standardized quality metrics. These quality measures were paired into similar groups to create 4 composite measures: outcome, screening, vaccination, and adherence. Measures of outcome ( r = 0.20, P = .06), vaccination ( r = 0.12, P = .26), and adherence ( r = -0.04, P = .75) were not significantly correlated with patient experience; screening ( r = 0.29, P = .006) was minimally correlated with patient experience. Overall, this study found minimal correlation between measures of patient experience and clinical quality in the outpatient setting. Measurement of both of these domains is essential to understanding patterns of care.

Factors Influencing Patient Satisfaction in Plastic Surgery: A Nationwide Analysis.

BACKGROUND: Patient satisfaction surveys are an increasingly important part of health care, influencing the practice of physicians. Press Ganey has developed tools to assess physician and department performance that are used by 50 percent of hospitals in the United States and over 10,000 health care organizations. The authors sought to evaluate the factors that influence patient satisfaction in plastic surgery patients both locally and nationally. METHODS: A 24-item Press Ganey survey was distributed to patients of 686 participating plastic surgeons nationwide, including those at the authors' home institution. The responses from January to December of 2016 were analyzed retrospectively with Pearson correlation coefficients. The items "likelihood to recommend provider" and "likelihood to recommend practice" were correlated to all other items of the survey, as these items have been shown to be surrogates for overall satisfaction. RESULTS: There were 411 survey responses from patients in the Northwell Health System and 36,836 responses from patients nationally. Items that were not well correlated (r < 0.5) with "likelihood to recommend practice" or "provider" were items such as wait time and courtesy of registration staff. The items that were best correlated (r > 0.8) with "likelihood to recommend practice" or "provider" were the patient's confidence in the care provider and the provider's concern for questions. All correlations were statistically significant (p < 0.001). CONCLUSION: In an evolving patient centric culture, the patient's confidence and trust of the provider is more important than perception of the provider's office environment to maintaining patient loyalty and market share.

Community healthcare delivery post-Hurricane Sandy: lessons from a mobile health unit.

In the aftermath of Hurricane Sandy the North Shore LIJ Health System (NS-LIJ HS) organized and launched its first mobile health unit (MHU) operation to some of New York's hardest hit communities including Queens County and Long Island, NY. This document describes the initiation, operational strategies, outcomes and challenges of the NS-LIJ HS community relief effort using a MHU. The operation was divided into four phases: (1) community needs assessment, (2) MHU preparation, (3) staff recruitment and (4) program evaluation and feedback. From November 16th through March 21st, 2013 the Health System launched the MHU over 64 days serving 1,160 individuals with an age range of 3 months to 91 years. Vaccination requests were the most commonly encountered issue, and the most common complaint was upper respiratory illness. The MHU is an effective resource for delivering healthcare to displaced individuals in the aftermath of natural disaster. Future directions include the provision of psychosocial services, evaluating strategies for timely retreat of the unit and methods for effective transitions of care.

Data-driven interdisciplinary interventions to improve inpatient pain management.

Pain during hospitalization and dissatisfaction with pain management are common. This project consisted of 4 phases: identifying a pain numeric rating scale (NRS) metric associated with patient satisfaction, identifying independent predictors of maximum NRS, implementing interventions, and evaluating trends in NRS and satisfaction. Maximum NRS was inversely associated with favorable pain satisfaction for both efficacy (n = 4062, χ(2) = 66.2, P < .001) and staff efforts (n = 4067, χ(2) = 30.3, P < .001). Independent predictors of moderate-to-severe maximum NRS were younger age, female sex, longer hospital stay, admitting department, psychoactive medications, and 10 diagnostic codes. After interventions, moderate-to-severe maximum NRS declined by 3.6% per quarter in 2010 compared with 2009. Satisfaction data demonstrated improvements in nursing units meeting goals (5.3% per quarter, r (2) = 0.67) and favorable satisfaction answers (0.36% per quarter, r (2) = 0.31). Moderate-to-severe maximum NRS was an independent predictor of lower likelihood of hospital discharge (likelihood ratio = 0.62; 95% confidence interval = 0.61-0.64). Targeted interventions were associated with improved inpatient pain management.

Improving quality in healthcare: start with the patient.

In the decade since the Institute of Medicine released To Err Is Human, patient harm from medical errors is still widespread. Healthcare has not undergone the transformative change that is needed to reduce medical errors and improve quality. This article discusses patient-centeredness as an organizing principle for transforming healthcare. We also describe important efforts that depict the shift from a provider-focused system to one that is more patient-centered. Finally, the article discusses challenges for the future and the importance of involving patients in the quest to deliver safe, quality care.

Decision-making in percutaneous coronary intervention: a survey.

BACKGROUND: Few researchers have examined the perceptions of physicians referring cases for angiography regarding the degree to which collaboration occurs during percutaneous coronary intervention (PCI) decision-making. We sought to determine perceptions of physicians concerning their involvement in PCI decisions in cases they had referred to the cardiac catheterization laboratory at a major academic medical center. METHODS: An anonymous survey was mailed to internal medicine faculty members at a major academic medical center. The survey elicited whether responders perceived that they were included in decision-making regarding PCI, and whether they considered such collaboration to be the best process of decision-making. RESULTS: Of the 378 surveys mailed, 35% (133) were returned. Among responding non-cardiologists, 89% indicated that in most cases, PCI decisions were made solely by the interventionalist at the time of the angiogram. Among cardiologists, 92% indicated that they discussed the findings with the interventionalist prior to any PCI decisions. When asked what they considered the best process by which PCI decisions are made, 66% of non-cardiologists answered that they would prefer collaboration between either themselves or a non-interventional cardiologist and the interventionalist. Among cardiologists, 95% agreed that a collaborative approach is best. CONCLUSION: Both non-cardiologists and cardiologists felt that involving another decision-maker, either the referring physician or a non-interventional cardiologist, would be the best way to make PCI decisions. Among cardiologists, there was more concordance between what they believed was the best process for making decisions regarding PCI and what they perceived to be the actual process.

Multimodal characterization of a large right atrial mass after surgical repair of an atrial septal defect.

A 43-year-old woman with exertional dyspnea and a history of surgically repaired atrial septal defect was referred for a transthoracic echocardiogram, which demonstrated a large, mobile mass in her right atrium. The mass was further characterized with contrast transesophageal echocardiography (TEE) and delayed enhancement MRI, which together suggested a thrombus, attached to the eustachian valve and prolapsing through the tricuspid valve. The mass was resected and the diagnosis confirmed on histopathologic examination. This case illustrates the utility of a multimodal approach in characterizing cardiac masses.

Reducing excessive medication administration in hospitalized adults with renal dysfunction.

Medication errors are common and harm hospitalized patients. The authors designed and implemented an automated system to complement an existing computerized order entry system by detecting the administration of excessive doses of medication to adult in-patients with renal insufficiency. Its impact, in combination with feedback to prescribers, was evaluated in 3 participating nursing units and compared with the remainder of a tertiary care academic medical center. The baseline rate of excessive dosing was 23.2% of administered medications requiring adjustment for renal insufficiency given to patients with renal impairment on the participating units and 23.6% in the rest of the hospital. The rate fell to 17.3% with nurse feedback and 16.8% with pharmacist feedback in the participating units (P<.05 for each, relative to baseline). The rates of excessive dosing for the same time periods were 26.1% and 24.8% in the rest of the hospital. Automated detection and routine feedback can reduce the rate of excessive administration of medication in hospitalized adults with renal insufficiency.