A Case of Whipple's Disease With Concomitant Esophageal Candidiasis.

Whipple's Disease (WD) is a rare disease caused by the infection of Tropheryma whipplei. It can lead to immunosuppression and a multitude of effects on different organ systems, resulting in a constellation of seemingly unrelated findings. Although treatment may appear straightforward, T. whipplei can be difficult to eradicate. We present the case of a 36-year-old male with months of progressively worsening watery diarrhea, migratory arthralgias, and weight loss. He had undergone an extensive evaluation for rheumatologic, oncologic, and infectious disorders without positive findings. Esophagogastroduodenoscopy and colonoscopy revealed esophageal candidiasis, Helicobacter pylori infection, and foamy macrophages in the lamina propria of the duodenum and ileum with positive polymerase chain reaction for T. whipplei. There were no other risk factors for esophageal candidiasis. He received treatment for his esophageal candidiasis and H. pylori infection and was treated for WD with ceftriaxone for 2 weeks, followed by hydroxychloroquine and doxycycline for 1 year. Symptoms resolved after 3 months of therapy. One year later, repeat bidirectional endoscopy was performed. Biopsies were negative for T. whipplei, although there were persistent foamy macrophages. There have been previously reported cases of patients with WD with concomitant esophageal candidiasis, and this association implies a likely state of relative immunosuppression associated with WD, which is thought to be the result of impaired T helper cell 1 activity. This impairment likely contributes to the high rate of relapse. Having a low threshold for repeat evaluation is advisable for recurrent symptoms, but long-term surveillance strategies are not clearly defined.

Automation of the I-PASS Tool to Improve Transitions of Care.

INTRODUCTION: Errors in communication during handoffs are a significant source of medical error and put patients at risk. The I-PASS system was designed to systematically communicate information to the oncoming healthcare provider and has been shown to decrease the risk of communication errors. The objective of this observational quality improvement study was to determine whether the addition of a partially automated, electronic handoff tool would further decrease errors in communication during transitions of care for inpatient medical teams. METHODS: We created an electronic tool to incorporate user-generated patient information in the I-PASS format with automatically compiled data derived from the electronic medical record. Numbers of errors in the printed handoff document were recorded before and after intervention. RESULTS: The first implementation cycle demonstrated an absolute risk reduction for written errors of 45.6% (95% confidence interval [CI] 39.2-51.2%) and a number needed to treat (NNT) of three patients. The second cycle showed an absolute risk reduction of 53.3% (95% CI 39.8-63.9%; NNT 2). Aggregate data showed an absolute risk reduction of 46.6% (95% CI 41.0-51.7%, NNT 3). CONCLUSIONS: Improving the routine task of patient handoff through the thoughtful application of technology can yield benefits in terms of decreasing documentation errors and streamlining workflow before patient handoff.