A Quality Improvement Project to Reduce Rapid Response System Inequities for Patients with Limited English Proficiency at a Quaternary Academic Medical Center.

BACKGROUND: Recognition of clinically deteriorating hospitalized patients with activation of rapid response (RR) systems can prevent patient harm. Patients with limited English proficiency (LEP), however, experience less benefit from RR systems than do their English-speaking counterparts. OBJECTIVE: To improve outcomes among hospitalized LEP patients experiencing clinical deteriorations. DESIGN: Quasi-experimental pre-post design using quality improvement (QI) statistics. PARTICIPANTS: All adult hospitalized non-intensive care patients with LEP who were admitted to a large academic medical center from May 2021 through March 2023 and experienced RR system activation were included in the evaluation. All patients included after May 2022 were exposed to the intervention. INTERVENTIONS: Implementation of a modified RR system for LEP patients in May 2022 that included electronic dashboard monitoring of early warning scores (EWSs) based on electronic medical record data; RR nurse initiation of consults or full RR system activation; and systematic engagement of interpreters. MAIN MEASURES: Process of care measures included monthly rates of RR system activation, critical response nurse consultations, and disease severity scores prior to activation. Main outcomes included average post-RR system activation length of stay, escalation of care, and in-hospital mortality. Analyses used QI statistics to identify special cause variation in pre-post control charts based on monthly data aggregates. KEY RESULTS: In total, 222 patients experienced at least one RR system activation during the study period. We saw no special cause variation for process measures, or for length of hospitalization or escalation of care. There was, however, special cause variation in mortality rates with an overall pre-post decrease in average monthly mortality from 7.42% (n = 8/107) to 6.09% (n = 7/115). CONCLUSIONS: In this pilot study, prioritized tracking, utilization of EWS-triggered evaluations, and interpreter integration into the RR system for LEP patients were feasible to implement and showed promise for reducing post-RR system activation mortality.

Dedifferentiated liposarcoma with heterologous rhabdomyosarcomatous differentiation in the bone marrow.

We present a case of advanced well-differentiated liposarcoma transforming to dedifferentiated liposarcoma in the bone marrow.Our patient presented with 5 weeks of worsening flank pain. He was found to have profound leukocytosis, thrombocytopenia, and normocytic anemia. Imaging showed a dominant retrocaval mass concerning for viable disease. Bone marrow biopsy revealed dedifferentiated liposarcoma with heterologous rhabdomyosarcomatous differentiation. He underwent 3 cycles of eribulin and subsequently developed complications of his increasingly aggressive liposarcoma. He was transitioned to hospice care and died 3 months after initial bone marrow biopsy. While exceedingly rare, it is possible for liposarcoma to metastasize to the bone marrow and cause rapid progression to death. In patients with high-grade liposarcoma, new cytopenia, leukocytosis, elevated granulocyte colony stimulating factor, and/or leukoerythroblasosis on peripheral smear should prompt bone marrow biopsy for early detection of this rare disease entity.

A Rare Case of Hydralazine-Induced Diffuse Alveolar Hemorrhage.

Hydralazine-induced anti-neutrophil cytoplasmic antibody (ANCA) vasculitis may occur any time after hydralazine initiation. General internists should recognize diffuse alveolar hemorrhage (DAH) as a rare complication of this condition, as early treatment reduces the associated high risk of mortality. We describe the case of an 82-year-old female with diastolic heart failure who presented with a one-month history of worsening dyspnea on exertion and a one-week history of scant hemoptysis and fatigue. Her medications included aspirin and hydralazine. She was hypoxic with bilateral expiratory wheezes on exam. Labs showed new anemia, elevated creatinine, proteinuria, and hematuria. Chest computed tomography showed asymmetric bilateral upper lobe ground-glass attenuation superimposed on interlobular septal thickening and intralobular lines. Further testing showed anti-nuclear antibody, positive ANCA, perinuclear ANCA (p-ANCA), and anti-myeloperoxidase ANCA (anti-MPO-ANCA). Renal biopsy revealed MPO-ANCA, pauci-immune, necrotizing, and crescentic glomerulonephritis. She was diagnosed with DAH secondary to hydralazine-induced ANCA-associated vasculitis (AAV). Hydralazine is an anti-hypertensive medication with known potential for autoimmune reactions. Of these, AAV is a rare sequela mediated by anti-MPO and most commonly affects the kidneys. In rare circumstances, patients with AAV can develop pulmonary-renal syndrome, resulting in both glomerulonephritis and DAH with an associated high risk of mortality. Diagnosis requires a high index of suspicion in patients with acute kidney injury of unclear etiology. Early diagnosis through immune work-up and kidney biopsy should be pursued, as prompt recognition of the vasculitis, cessation of hydralazine, immunosuppression, and early plasma exchange are essential to an improved prognosis.

A Rare Case of Olmesartan-Associated Enteropathy Successfully Managed With Steroid Taper.

Olmesartan is a commonly used antihypertensive medication belonging to the class of angiotensin II receptor blockers. Though generally well-tolerated, olmesartan can rarely cause olmesartan-associated enteropathy (OAE) with non-bloody diarrhea, weight loss, abdominal pain, and vomiting. Patients may develop enteropathy months to years after drug initiation. In severe cases, patients may develop complications that require hospitalization. Diagnosis is often delayed due to unfamiliarity of OAE, nonspecific presenting symptoms, and normal-appearing gross endoscopic findings. Esophagogastroduodenoscopy (EGD) with biopsy is essential to the diagnosis, showing sprue-like enteropathy with intestinal villous atrophy and mucosal inflammation. This report describes a case of a 70-year-old man who presented with three months of profuse watery diarrhea and 40-pound unintentional weight loss. After an extensive workup, including EGD with duodenal biopsies, the patient was diagnosed with OAE. The biopsies showed findings consistent with acute and chronic duodenitis, mucosal desquamation and ulceration, blunting of villi, and a sprue-like pattern with neutrophils. Celiac serologies and anti-enterocyte antibodies were negative, further supporting the diagnosis of OAE. Complete resolution of symptoms was achieved by discontinuing olmesartan and administering a steroid taper. Considering the frequent use of olmesartan, the increasing occurrence of OAE, and the wide range of associated symptoms, it is crucial for providers to recognize OAE and consider early discontinuation of olmesartan. This approach can help prevent further intestinal damage, protracted symptoms, unnecessary diagnostic tests, and financial burdens on both patients and the healthcare system.

Food Insecurity Leading to Superior Mesenteric Artery Syndrome Managed Successfully with Endoscopic Gastrojejunostomy Stent.

BACKGROUND Food insecurity describes the lack of adequate and reliable access to food due to insufficient resources. The condition affects over one-quarter of the world's population and is exacerbated by factors such as conflicts, climate variability, rising costs of nutritious food, and economic slumps; these challenges are amplified by poverty and inequality. Food insecurity is associated with many negative health outcomes, such as iron deficiency anemia, poor oral health, and stunting of growth in children. CASE REPORT We present the case of a patient who had significant weight loss related to food insecurity then developed a rare adverse health outcome: superior mesenteric artery (SMA) syndrome. SMA syndrome is a condition in which reduction in the angle formed by the proximal SMA and aorta, most commonly from decreased mesenteric fat in the setting of significant weight loss, leads to compression of the third portion of the duodenum and resulting bowel obstruction. The patient underwent successful treatment with a novel approach: endoscopic placement of a gastrojejunostomy stent. CONCLUSIONS Food insecurity remains a wide-ranging public health issue that can have direct impact on the clinical outcomes of individuals. We describe SMA syndrome as a rare adverse outcome in a food insecure individual, adding to the growing list of health consequences associated with this condition. We also highlight endoscopic placement of a gastrojejunostomy stent as an emerging alternative to surgical treatment of SMA syndrome. The success of the procedure in this patient adds to the body of evidence supporting its efficacy and safety profile for this population.

The role of language barriers on efficacy of rapid response teams.

OBJECTIVES: Rapid response (RR) systems are associated with decreased hospital mortality. Systemic biases and inequities can negatively impact RR outcomes. Language barriers between patients and providers are associated with worse outcomes, but it is unknown if language barriers are associated with RR outcomes. METHODS: We analyzed all adult hospitalized patients who experienced a RR over one year (January 2020 to December 2020) at a tertiary care academic medical center. We used an objective scoring system to establish disease severity at the time of the event. We then compared disease severity and outcomes for patients who are primary language Spanish (PLS) and primary language English (PLE) using both univariable and multivariable analyses. RESULTS: Of 1133 patients, 42 identified as PLS and 1091 as PLE. In multivariable analyses, PLS patients had significantly higher disease severity scores, as measured by deterioration index score (8.2, p = 0.021) at the time of their rapid responses. PLS patients also had 18.5% increase in length of stay (LOS) after RRs and this disparity was not mitigated when controlling for disease severity at the time of RRs. PLS was not a significant predictor for hospital mortality after RRs. CONCLUSIONS: Our study found that PLS patients had increased disease severity at the time of RRs and increased LOS after RRs. However, the disparity in LOS was not mitigated when controlling for disease severity at the time of RRs. These findings suggest that language barriers may cause both delays in activation of RR systems, as well as the care provided during and after RRs.

Building High-Performance Team Dynamics for Rapid Response Events in a US Tertiary Hospital: A Quality Improvement Model for Sustainable Process Change.

Hospital rapid response systems are designed to reduce unmet patient needs and prevent clinical deterioration. Rapid response teams are the principal component of a rapid response system and require teamwork to function optimally; poor communication among team members can result in substandard patient care. The authors describe a process for developing and implementing standardized communication and a teamwork structure for rapid response events (RREs) at a large academic hospital. The multidisciplinary team developed a project charter and key driver diagram, developed a "communication bundle," used quality improvement methodology, monitored adherence to the changes, and reported these data to key stakeholders on a weekly basis. By project end, the team met the goal of having 70% or more of adult RREs include the use of the "communication bundle." The balancing measure demonstrated that the introduction of a formalized communication framework did not significantly increase the duration of RREs.

Comparative outcomes between COVID-19 and influenza patients placed on veno-venous extracorporeal membrane oxygenation for severe ARDS.

BACKGROUND: ECMO is an established supportive adjunct for patients with severe, refractory ARDS from viral pneumonia. However, the exact role and timing of ECMO for COVID-19 patients remains unclear. METHODS: We conducted a retrospective comparison of the first 32 patients with COVID-19-associated ARDS to the last 28 patients with influenza-associated ARDS placed on V-V ECMO. We compared patient factors between the two cohorts and used survival analysis to compare the hazard of mortality over sixty days post-cannulation. RESULTS: COVID-19 patients were older (mean 47.8 vs. 41.2 years, p = 0.033), had more ventilator days before cannulation (mean 4.5 vs. 1.5 days, p < 0.001). Crude in-hospital mortality was significantly higher in the COVID-19 cohort at 65.6% (n = 21/32) versus 36.3% (n = 11/28, p = 0.041). The adjusted hazard ratio over sixty days for COVID-19 patients was 2.81 (95% CI 1.07, 7.35) after adjusting for age, race, ECMO-associated organ failure, and Charlson Comorbidity Index. CONCLUSION: ECMO has a role in severe ARDS associated with COVID-19 but providers should carefully weigh patient factors when utilizing this scarce resource in favor of influenza pneumonia.

Time to Cannulation after ICU Admission Increases Mortality for Patients Requiring Veno-venous ECMO for COVID-19 Associated Acute Respiratory Distress Syndrome.

OBJECTIVE: COVID-19 can cause ARDS that is rapidly progressive, severe, and refractory to conventional therapies. ECMO can be used as a supportive therapy to improve outcomes but evidence-based guidelines have not been defined. SUMMARY BACKGROUND DATA: Initial mortality rates associated with ECMO for ARDS in COVID-19 were high, leading some to believe that there was no role for ECMO in this viral illness. With more experience, outcomes have improved. The ideal candidate, timing of cannulation, and best postcannulation management strategy, however, has not yet been defined. METHODS: We conducted a retrospective review from April 1 to July 31, 2020 of the first 25 patients with COVID-19 associated ARDS placed on V-V ECMO at our institution. We analyzed the differences between survivors to hospital discharge and those who died. Modified Poisson regression was used to model adjusted risk factors for mortality. RESULTS: Forty-four patients (11/25) survived to hospital discharge. Survivors were significantly younger (40.5 years vs 53.1 years; P < 0.001) with no differences between cohorts in mean body mass index, diabetes, or PaO2:-FiO2 at cannulation. Survivors had shorter duration from symptom onset to cannulation (12.5 days vs 19.9 days, P = 0.028) and shorter duration of intensive care unit (ICU) length of stay before cannulation (5.6 days vs 11.7 days, P = 0.045). Each day from ICU admission to cannulation increased the adjusted risk of death by 4% and each year increase in age increased the adjusted risk 6%. CONCLUSIONS: ECMO has a role in severe, refractory ARDS associated with COVID-19. Increasing age and time from ICU admission were risk factors for mortality and should be considered in patient selection. Further studies are needed to define best practices for V-V ECMO use in COVID-19.

Pulmonary Perfusion Scan Mimicking Hepatobiliary Scintigraphy in a Patient With an Uncommon Manifestation of Granulomatosis With Polyangiitis.

A 36-year-old man with known granulomatosis with polyangiitis underwent quantitative ventilation-perfusion pulmonary scintigraphy as part of an initial evaluation for lung transplant candidacy. Radiotracer uptake on the perfusion study has the appearance of the hepatic silhouette, drawing initial concern that there may have been a misadministration of Tc with a hepatobiliary agent. Comparison CT reveals extensive cystic bronchiectasis, parenchymal destruction, and volume loss involving the entire left lung and basal portions of the right lung, with the residual portions of functional lung parenchyma conforming to a shape similar to the liver.

Variability of CT Attenuation Measurements in Virtual Unenhanced Images Generated Using Multimaterial Decomposition from Fast Kilovoltage-switching Dual-energy CT.

RATIONALE AND OBJECTIVES: To compare Hounsfield unit (HU) data obtained from true-unenhanced (TUE) and virtual-unenhanced (VUE) imaging obtained with a fast kv-switching dual-energy computed tomography (CT) scanner using multimaterial decomposition algorithm. MATERIALS AND METHODS: In this Institutional Review Board-approved, Health Insurance Portability and Accountability Act-compliant, retrospective cohort study, CT scans of 19 patients undergoing multiphasic renal protocol abdominal CT on a fast kv-switching dual-energy CT scanner were reviewed. CT numbers were measured on the matched TUE and VUE generated using a multimaterial decomposition algorithm with selective iodine suppression, and postcontrast images at predefined locations in seven organs. Six hundred sixty regions of interest were placed at 132 locations. Agreement was assessed with paired t test, Pearson's correlation, and Bland-Altman analysis. RESULTS: Mean TUE and VUE measurements were not significantly different in the corticomedullary (P = 0.25) or nephrographic (P = 0.10) phases. There was a strong correlation between TUE and VUE CT numbers (corticomedullary: r = 0.90, nephrographic: r = 0.90, each P < 0.001). Discrepancies ≥5 HU occurred 46 times (35%, 46 of 132) in the corticomedullary phase and 44 times (33%, 44 of 132) in the nephrographic phase. Discrepancies ≥10 HU occurred in 7% (9 of 132 in both corticomedullary and nephrographic phases). Interphase, intrasubject VUE CT numbers were strongly correlated (r = 0.93, P < 0.001), but discrepancies ≥5 HU (22% [29 of 132]) and ≥10 HU (2% [3 of 132]) occurred. There was no significant correlation between the true postcontrast CT number and the magnitude of VUE-TUE discrepancy (r = -0.04, P = 0.6). CONCLUSION: CT numbers on VUE images generated from fast kv-switching dual-energy CT scans strongly correlate with TUE CT numbers on a population basis, but commonly vary 5-9 HU on a per-patient basis.

Alcoholic liver disease presents at advanced stage and progresses faster compared to non-alcoholic fatty liver diseas.

BACKGROUND AND OBJECTIVE: Steatohepatitis is a common cause of liver disease due to alcohol (ALD) or non-alcoholic fatty liver disease (NAFLD). We performed this study to compare natural history of ALD and NAFLD. MATERIAL AND METHODS: Retrospective analysis of ALD or NAFLD patients managed at our center (2007-2011). ALD diagnosed by excluding other liver diseases (except HCV) and alcohol abuse of > 40 g/d in women and > 60 g/d in men for > 5 years. NAFLD diagnosed by excluding other liver diseases and a history of alcohol use of < 10 g/d. Cirrhosis was diagnosed using biopsy for uncertain clinical diagnosis. RESULTS: Compared to patients with NAFLD (n = 365; mean age 50 yrs; 43% males; 53% diabetic), ALD patients (n = 206; mean age 51 yrs; 68% males; 24% diabetic) presented more often with cirrhosis or complications(46vs. 12%; P< 0.0001) with a higher MELD score (13 ± 7 vs. 8 ± 8; P<0.0001). On logistic regression, ALD diagnosis was associated with presence of cirrhosis by over 4-fold (4.1 [1.8-9.1]) even after excluding 23 patients with concomitant HCV. Over median follow up of about 3 and 4 yrs among ALD and NAFLD patients respectively, ALD patients more frequently developed cirrhosis or its complications including HCC with worse transplant free survival (90 vs. 95%; P = 0.038). CONCLUSIONS: Compared to NAFLD, ALD patients present at an advanced stage of liver disease with a faster progression on follow-up. Prospective multicenter studies are needed to identify potential barriers to early referral of ALD patients as basis for development of strategies to improve outcome of patients with ALD.

Diabetes Mellitus Predicts Occurrence of Cirrhosis and Hepatocellular Cancer in Alcoholic Liver and Non-alcoholic Fatty Liver Diseases.

BACKGROUND AND AIMS: Alcohol abuse and nonalcoholic fatty liver disease (NAFLD) are common causes of liver disease. Diabetes mellitus (DM) is a common comorbidity among NAFLD patients. We performed this study with the specific aim to examine the impact of DM on progression of alcoholic liver disease (ALD) liver and NAFLD. METHODS: Medical charts of 480 patients with ALD or NAFLD (2004-2011) managed at a tertiary center were retrospectively reviewed. NAFLD was diagnosed based on exclusion of other causes of liver disease and alcohol use of <10 g/d. ALD was diagnosed based on alcohol use of >40 g/d in women or >60 g/d in men for >5 years. RESULTS: Of 480 patients (307 NAFLD), 200 diabetics differed from nondiabetics for: age (52±11 vs. 49±11 years; p=0.004); male gender (48% vs. 57%; p=0.03); metabolic syndrome (49% vs. 30%; p=0.0002); NAFLD (80% vs. 56%; p<0.0001); cirrhosis (70% vs. 59%; p=0.005); and hepatocellular carcinoma (HCC; 8% vs. 3%; p=0.009). Over a 3 year median follow-up period, diabetics relative to nondiabetics had a higher probability to develop cirrhosis (60% vs. 41%; p=0.022) and HCC (27% vs. 10%; p=0.045). There was a trend for increased development of hepatic encephalopathy in diabetics compared to nondiabetics (55% vs. 39%; p=0.053), and there was no difference between the two groups in survival or other liver disease complications. CONCLUSIONS: DM increased risk for cirrhosis and HCC among patients with ALD and NAFLD. Prospective studies with longer follow-up periods are needed to examine the impact of DM on survival and the role of aggressive HCC screening in diabetic cirrhotics.

Autoimmune Markers Do Not Impact Clinical Presentation or Natural History of Steatohepatitis-Related Liver Disease.

BACKGROUND AND AIM: Autoimmune (AI) markers are reported in patients with steatohepatitis-related liver disease. However, their clinical significance is unclear. METHODS: Charts of patients due to alcoholic liver disease (ALD) or nonalcoholic fatty liver disease (NAFLD) were stratified for antinuclear antigen (ANA > 1:80), antismooth muscle antibody (ASMA > 1:40), or antimitochondrial antibody (AMA > 1:20). Study outcomes were patient survival and complications of liver disease. RESULTS: Of 607 patients (401 NAFLD), information about AI markers was available for 398 (mean age 50 ± 15 year; 52% males; median body mass index (BMI) 38; 44% diabetic; 62% nonalcoholic steatohepatitis (NASH) as type of steatohepatitis; median MELD score 9). A total of 78 (19.6%) patients were positive for AI markers without differences for ALD versus NAFLD, cirrhosis versus no cirrhosis, and NASH versus no NASH. There were no differences for age, gender, BMI, cirrhosis at presentation, MELD score, endoscopic findings, and histology based on AI markers. Serum ALT was higher among patients with AI markers (65 ± 46 vs. 59 ± 66 IU/l; P = 0.048). Data remained unchanged on analyzing NAFLD patients. None of the 11 ANA-positive patients (1:640 in 4) showed findings of AI hepatitis. Biopsy in three AMA-positive patients showed mild bile duct damage in one patient. On median follow-up of about 3 years, there were no differences in liver disease outcomes (ascites, encephalopathy, variceal bleeding), hepatocellular carcinoma, transplantation, and survival. CONCLUSIONS: Autoimmune markers are frequently present in steatohepatitis-related liver disease patients. Their presence is an epiphenomenon without histological changes of autoimmune hepatitis. Further, their presence does not impact clinical presentation and follow-up outcomes.

PNPLA3 Gene Polymorphism Is Associated With Predisposition to and Severity of Alcoholic Liver Disease.

OBJECTIVES: The genetic polymorphism with an isoleucine-to-methionine substitution at position 148 (rs738409 C>G) in the patatin-like phospholipase domain protein 3 (PNPLA3) gene confers risk of steatosis. PNPLA3 polymorphism is shown to be associated with alcoholic liver disease (ALD). We performed a systematic review and meta-analysis to examine association of this genetic polymorphism with ALD spectrum and its severity. METHODS: Medline, Embase, and Cochrane Library were searched for studies on association of PNPLA3 polymorphism and ALD spectrum: alcoholic fatty liver (AFL), alcoholic liver injury (ALI), alcoholic cirrhosis (AC), and hepatocellular carcinoma (HCC). Pooled data are reported as odds ratio (OR) with 95% confidence interval. Heterogeneity was assessed using the I(2) statistics and publication bias using Egger's test and Begg and Mazumdar's test. Individual participant data obtained from five studies were used for subgroup analyses. RESULTS: Among 10 studies included in this pooled analysis, compared with controls, OR for rs738409 CG and GG among ALI patients was 1.45 (1.24-1.69) and 2.22 (1.50-3.28), respectively, compared with CC. Respective OR among AC patients was 2.09 (1.79-2.44) and 3.37 (2.49-4.58) and among AC patients with HCC was 2.87 (1.61-5.10) and 12.41 (6.99-22.03). Data for AFL were inconsistent. Among ALD patients, OR of CG and GG genotypes was 2.62 (1.73-3.97) and 8.45 (2.52-28.37), respectively, for AC compared with fatty liver (FL) patients. Similar OR for AC compared with ALI was 1.98 (1.24-3.17) and 3.86 (1.18-12.60). The OR for CG and GG genotypes among AC patients for HCC occurrence was 1.43 (0.76-2.72) and 2.81 (1.57-5.01), respectively. Individual participant data analysis showed age to predispose to AC among ALI patients. CONCLUSIONS: PNPLA3 genetic polymorphism (rs738409 C>G) is associated with increased risk for the entire spectrum of ALD among drinkers including ALI, AC, and HCC. Studies are needed to clarify association of PNPLA3 polymorphism and steatosis in alcoholics. PNPLA3 gene may potentially be a therapeutic target in ALD.

Use of a covered stent modification to produce a transcatheter valve: laboratory and animal testing.

Stent-based transcatheter valves continue to require large sheaths inappropriate for deployment in children. Low-profile covered stent valves (CSVs) were constructed by removing triangular sections from two sides of partially expanded Palmaz P308 stents before covering the stents with 0.1 mm polytetrafluoroethylene. Valves were carefully crimped onto balloon catheters and deployed in a pulsatile flow loop. With fixed afterload and pump output, flow, degree of stenosis, effect on pulse pressure, and ease of deployment were determined for each valve. In vivo transcatheter feasibility studies were then performed by disabling the aortic valve of two 25-kg pigs, and deploying transcatheter CSVs into their descending aorta. All transcatheter valves deployed consistently via sheaths three French sizes larger than the recommended sheath for their balloon and none created significant obstruction. With the bicuspid and supravalvar CSVs, the flow was 64% and 79% (respectively) of a commercially available valve. Angiograms revealed excellent acute CSV function after deployment with only mild regurgitation and without significant obstruction to systolic flow. Although long-term testing is required, a modified CSV design may have utility in low-profile pediatric transcatheter valve replacement.