Routine Use of Prescription Adderall Leading to Non-cardiogenic Pulmonary Edema and Respiratory Failure.

A 47-year-old female with attention-deficit/hyperactivity disorder on prescription Adderall presented to the hospital with worsening dyspnea for the one-month duration. She was admitted to the medical intensive care unit with respiratory failure requiring non-invasive positive pressure ventilation. Cardiac catheterization confirmed the diagnosis of non-cardiogenic pulmonary edema. With the discontinuation of Adderall, use of BiPAP, and aggressive diuresis with loop diuretics, there was evidence of symptomatic, laboratory, and radiological improvement. Her symptoms were attributed to Adderall use as a diagnosis of exclusion. To our knowledge, this paper reports the first case of Adderall-induced non-cardiogenic pulmonary edema leading to respiratory failure. Although case reports of abuse or overdose of other stimulants such as amphetamine and cocaine leading to a plethora of cardiac and pulmonary complications such as acute respiratory distress syndrome (ARDS), cardiogenic pulmonary edema, and non-cardiogenic pulmonary edema exist, there are no reports that using Adderall at routine prescription doses can lead to these problems.

Impact of Structured and Scheduled Family Meetings on Satisfaction in Patients Admitted to Hospitalist Service.

Effective communication is key to patient satisfaction. Family meetings been shown to be effective in other settings such as critical care and palliative medicine. We evaluated the impact of scheduled and structured family meetings on patients admitted to the hospitalist service in terms of satisfaction with care delivery. More patients in the intervention group reported better understanding of their diagnosis, treatment plan, medications, and discharge plan. Based on these results, we advocate for structured and scheduled family meetings to be implemented as a communication tool for selected patients on the hospital medicine service to improve patient experience and satisfaction.

Sex Differences in Ischemic Stroke Readmission Rates and Subsequent Outcomes After Coronary Artery Bypass Graft Surgery.

BACKGROUND AND PURPOSE: Prior studies examining sex-related risk of readmission for ischemic stroke (IS) after coronary artery bypass grafting (CABG) did not adjust for preoperative comorbidities and used small study samples that were single-center or otherwise poorly generalizable. We assessed risk of readmission for IS after CABG for females compared to males in a nationwide sample. METHODS: The 2013 Nationwide Readmissions Database contains data on 49% of all U.S. hospitalizations. We used population weighting to determine national estimates. Using all follow-up data up to 1 year after discharge from CABG hospitalization, we estimated Kaplan-Meier cumulative risk of IS, stratified by sex, using the log-rank test for significance. We created Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (CI) for IS readmission, with sex as the main independent variable. We ran unadjusted models and models adjusted for age, vascular risk factors, estimated severity of illness and risk of mortality, hospital characteristics, and income quartile of patient's zip code. RESULTS: An estimated 53,270 females and 147,396 males survived index CABG admission in 2013. There was a consistently elevated cumulative risk of readmission for IS after CABG for females versus males (log-rank p-value = 0.0014). In the unadjusted Cox model, the HR of IS in females vs. males was 1.35 (95% CI 1.12-1.62, p = 0.0015). The elevated risk for females remained after adjusting for severity of illness (1.30 [1.08-1.56], p = 0.0056) and risk of mortality (1.28 [1.07-1.54], p = 0.0086). This elevated risk persisted after adjusting for multiple vascular risk factors, hospital characteristics, and income quartile of patient's zip code (1.23 [1.02-1.48], p = 0.03). CONCLUSIONS: We found a 23% increased risk of readmission for IS up to 1 year after CABG for females compared to males in a fully adjusted model utilizing a large, contemporary, nationwide database. Further research would clarify mechanisms of this increased risk among women.

Unilateral nipple discharge in a man without a palpable mass diagnosed as breast cancer.

A 69-year-old man without a family history of breast cancer presented to his primary care physician with a 1-year history of clear, unilateral nipple discharge (ND) without an associated palpable breast mass. His laboratory findings were significant for hyperprolactinaemia at 28 ng/mL. Diagnostic work up including mammography, ultrasound and core needle biopsy ultimately revealed a ductal carcinoma in situ and a rare papillary variant of invasive ductal carcinoma. The patient was referred to a multidisciplinary oncology team and underwent a right total mastectomy followed by adjuvant hormonal therapy. The patient made a good postoperative recovery and remains without evidence of recurrence 6 months from surgery. Male breast cancer is rare, but its incidence is increasing. Male breast cancer presenting as ND without a palpable mass is uncommon. Early recognition of breast symptoms in men can lead to earlier diagnoses and improved outcomes.

Transaminitis is an indicator of mortality in patients with COVID-19: A retrospective cohort study.

BACKGROUND: Since its discovery in Wuhan, China in December of 2019, the novel coronavirus has progressed to become one of the worst pandemics seen in the last 100 years. Recently, there has been an increased interest in the hepatic manifestations of coronavirus disease 19 (COVID-19). AIM: To describe the demographic and clinical characteristics of COVID-19 positive patients and study the association between transaminitis and all-cause mortality. METHODS: This is a descriptive retrospective cohort study of 130 consecutive patients with a positive COVID PCR test admitted between March 16, 2020 to May 14, 2020 at a tertiary care University-based medical center. The Wilcoxon-rank sum test and paired t-test were used for comparing non-parametric and parametric continuous variables respectively and a multivariable logistic regression models to study the association between transaminitis and mortality using SAS version 9.4 (SAS Institute, Cary, NC, United States). RESULTS: Out of the 130 patients, 73 (56%) patients were found to have transaminitis and 57 (44%) did not. When compared to patients without transaminitis, the transaminitis group was found to have a higher median body mass index (30.2 kg/m2 vs 27.3 kg/m2, P = 0.04). In the multivariate analysis those with transaminitis were found to have 3.4 times higher odds of dying as compared to those without transaminitis adjusting for gender, the Age-adjusted Charlson Comorbidity Index and admission to the intensive care unit (P = 0.03). CONCLUSION: Our study showed that transaminitis on admission was associated with severe clinical outcomes such as admission to the intensive care unit, need for mechanical ventilation, and mortality.

The Converging Pathologies of Obstructive Sleep Apnea and Atrial Arrhythmias.

Obstructive sleep apnea (OSA) is highly prevalent in the United States (US). Along with epidemic rates of obesity, the rate of OSA cases is also on the rise. OSA is associated with multiple chronic health conditions, including hypertension, diabetes, stroke, myocardial ischemia, and heart rhythm disturbances. OSA is commonly treated with continuous positive airway pressure (CPAP) therapy. Several reports indicate that effective treatment of OSA can reduce the risk of cardiovascular diseases, including cardiac arrhythmias, especially atrial fibrillation (AF). CPAP therapy helps to maintain sinus rhythm after interventions such as electrical cardioversion and catheter ablation in patients with AF. However, more data is required to establish a relationship between OSA and other atrial arrhythmias as well to evaluate the effect of CPAP. This review will compile the latest evidence on the pathophysiology, management, and treatment of atrial arrhythmias associated with OSA.

Manganese Neurotoxicity as a Complication of Chronic Total Parenteral Nutrition.

Manganese accumulation in the central nervous system creates clinical symptoms of cognitive dysfunction, behavioral changes, and movement disorders resembling Parkinson's disease. Radiographic features of this rare clinical entity include symmetric T1 hyperintensities in the bilateral globus pallidi, with corresponding hypointensities on T2-weighted images. Total parenteral nutrition (TPN) is an increasingly used potentially lifesaving therapy for patients who cannot tolerate enteral nutrition. However, when used over a period of several weeks to months, its associated risks and complications carry significant morbidity and mortality. One of the more rare complications of TPN use is manganese toxicity. We provided care for a 38-year-old female on chronic TPN who presented to the hospital with Parkinsonian features, confusion, falls, and lethargy. MRI brain showed T1 hyperintensities in the bilateral globus pallidi, which were attributed to manganese toxicity from chronic TPN use. Supporting evidence for this rare entity included decreased signal intensity in the bilateral globus pallidi on T2-weighted images and T1 hyperintensities in the substantia nigra. With antifungal treatment and permanent cessation of TPN, her mentation and neurological symptoms began to improve within a week. Repeat MRI brain performed one month after discontinuation of TPN revealed improvement of the T1 hyperintensities in the bilateral globus pallidi. Our objective in presenting this case is to highlight manganese neurotoxicity as a rare complication of TPN in a patient without known hepatic dysfunction and to emphasize the importance of routinely monitoring patients for the possible adverse effects of chronic TPN. Our case is among the handful of published cases in which a patient without known liver dysfunction, which is the primary organ responsible for manganese elimination from the body, developed manganese neurotoxicity.

Synchronous Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma and Metastatic Squamous Cell Carcinoma of the Cervix Involving the Coronary Arteries Leading to Acute Myocardial Infarction.

A 66-year-old woman presented to the hospital with a one-month history of shortness of breath, fatigue, and postmenopausal vaginal bleeding and a one-week history of chest pain. This case report discusses the rare synchronous occurrence of two different malignancies in the setting of non-ST segment elevation myocardial infarction and the relation between these unfortunate events. Besides the case presented in this report, there have been only 13 reported cases of synchronous chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) associated with metastatic squamous cell carcinoma. While it is well known that malignancy causes a hypercoagulable state, there are other mechanisms which may have contributed to the patient's myocardial ischemia including external vascular compression, tumor lysis syndrome, and anemia. This case report discusses the rarity of synchronous malignancies but the importance of understanding and consideration of cardiac events in this population.

Miller Fisher syndrome with bilateral vocal cord paralysis: a case report.

BACKGROUND: Miller Fisher syndrome is a variant of acute inflammatory demyelinating polyneuropathy classically characterized by ataxia, ophthalmoplegia, and areflexia. Miller Fisher syndrome can present with uncommon symptoms such as bulbar, facial, and somatic muscle palsies and micturition disturbance. CASE PRESENTATION: We describe the case of a 76-year-old white man with new-onset ataxia, stridor, areflexia, and upper and lower extremity weakness who required intubation at presentation. An initial work-up including imaging studies and serum tests was inconclusive. Eventually, neurophysiological testing and cerebrospinal fluid analysis suggested a diagnosis of Miller Fisher syndrome. Our patient responded to treatment with intravenous immunoglobulin and supportive therapy. CONCLUSION: The occurrence of acute or subacute descending paralysis with involvement of bulbar muscles and respiratory failure can often divert clinicians to a diagnosis of neuromuscular junction disorders (such as botulism or myasthenia gravis), vascular causes like stroke, or electrolyte and metabolic abnormalities. Early identification of Miller Fisher syndrome with appropriate testing is essential to prompt treatment and prevention of further, potentially fatal, deterioration.

Usefulness of a metronome to improve quality of chest compressions during cardiopulmonary resuscitation.

The objective of this study was to improve the quality of chest compressions after the introduction of a metronome during cardiopulmonary resuscitation (CPR). A retrospective analysis of Zoll® compression data of 219 in-hospital adult participants who received CPR from January 2017 to December 2018 was done. A metronome was introduced during chest compressions in January 2018, and the 2017 data served as the control. The main outcome measure compared the overall quality of chest compressions measured by the rate (100 to 120 compressions per minute), depth (2.0 to 2.4 inches), and mean release velocity (≥400 mm/sec) on chest recoil. Compared to control, the metronome group had a statistically significant improvement of the mean percent compression rate within 100 to 120 beats per minute: 28.16% vs. 71.14% (P < 0.001) and a statistically significant improvement of the mean percent compression depth within 2.0 to 2.4 inches: 29.35% vs. 34.84% (P = 0.03). However, there was no statistically significant improvement of mean percent release velocity ≥400 mm/second: 47.41% vs. 51.09% (P = 0.38). Our data suggest that an inexpensive and widely available intervention may improve the quality of CPR. We suggest that further research be conducted to measure patient clinical outcomes.

Development of a real-time physician-patient communication data collection tool.

Objectives: To design a tool to assess and improve physician communication, provide physicians with personalised feedback in real time, and relate specific communication behaviours to patient experience measures. It was hypothesised that performance of fundamental communication behaviours would correlate with individual patient experience scores as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Design: Prospective observational study. Setting: Single-centre study at a mid-sized academic tertiary medical centre. Participants: Thirteen hospitalists across 305 patient interactions were assessed in this study. Participants were recruited from three geographically cohorted adult general medicine-teaching teams on two inpatient units. Participants with cognitive impairment or who were unable to speak English were excluded from the study. Main outcome measures: Frequency of performance of 10 fundamental communication behaviours. Results: The communication behaviours of 13 hospitalists were assessed by 305 surveys: 146 observations, 106 patient reports and 52 excluded interactions. During rounds, 50% of physicians introduced themselves, 40% explained their role, 44% introduced other members of the team, 59% addressed patients by name, 58% addressed friends/family, 59% attempted to be at eye level, 41% asked permission before performing a physical examination, 40% asked if patients had questions and 20% asked if patients understood the plan of care. Several variables correlated with higher HCAHPS scores; however, addressing patients by name (r=0.60482, p=0.0492) and introducing other members of the team (r=0.87239, p=0.0234) were statistically significant. Conclusion: This study highlights the importance of effective physician-patient communication and presents a unique data collection tool to assess and improve physician communication in real time. This tool can provide physicians with personalised feedback and relate specific communication behaviours to patient experience measures to provide high-quality care and improve the patient experience.

Sepsis: The evolution in definition, pathophysiology, and management.

There has been a significant evolution in the definition and management of sepsis over the last three decades. This is driven in part due to the advances made in our understanding of its pathophysiology. There is evidence to show that the manifestations of sepsis can no longer be attributed only to the infectious agent and the immune response it engenders, but also to significant alterations in coagulation, immunosuppression, and organ dysfunction. A revolutionary change in the way we manage sepsis has been the adoption of early goal-directed therapy. This involves the early identification of at-risk patients and prompt treatment with antibiotics, hemodynamic optimization, and appropriate supportive care. This has contributed significantly to the overall improved outcomes with sepsis. Investigation into clinically relevant biomarkers of sepsis are ongoing and have yet to yield effective results. Scoring systems such as the sequential organ failure assessment and Acute Physiology and Chronic Health Evaluation help risk-stratify patients with sepsis. Advances in precision medicine techniques and the development of targeted therapy directed at limiting the excesses of the inflammatory and coagulatory cascades offer potentially viable avenues for future research. This review summarizes the progress made in the diagnosis and management of sepsis over the past two decades and examines promising avenues for future research.

Reply to the Comment on: Subrat Khanal et al. The Repertoire of Adenovirus in Human Disease: The Innocuous to the Deadly. Biomedicines 2018, 6, 30.

We would like to thank Dr. Atkinson for his comments on our review article on the manifestations of adenoviral infections in humans. [...].

A pilot study to standardize and peer-review shift handoffs in an academic internal medicine residency program: The DOCFISH method.

With increased oversight of residency work hours, there has been an increase in shift handoffs, which are prone to medical errors. To date, there are no evidence-based recommendations on essential elements of shift handoffs. We implemented a standardized shift-handoff rubric at an academic medicine residency program. Compliance, resident/faculty perceptions, and surrogate markers of patient safety were measured.Shift-handoff documents were collected January-February 2016 (control) April-June 2016 (intervention). Signouts were scored based on inclusion of seven elements: Daily events, Overnight events, Code status, Follow up tasks, If/then statements, 'sick or stable' and History present illness. The mnemonic 'DOCFISH' was taught in a grand-rounds forum then embedded into a shift-handoff tool within our electronic health record (EHR). Senior residents were assigned to supervise/provide feedback on shift handoffs from April-June 2016. Faculty and resident perceptions regarding quality of shift handoffs was measured by the annual ACGME (Accreditation Council Graduate Medical Education) program survey.Patient safety was measured by number of rapid-response teams (RRT) initiated for unstable vital signs. Handoffs were 74% complete in intervention group and 60% in control group (p < .0001). Median DOCFISH features present in patients that required RRT was 3 of 7 whereas, total post-intervention group had 5 of 7 (p < .001). 'Daily events' and 'follow -up tasks' were less frequent in patients that required RRT (20%, 67% respectively, p < .001).Academic medical centers can implement standardized shift handoffs by embedding high-yield information in an EHR with peer-review. Information during shift changes that may have significant improvement on patient safety includes: 'daily events' and 'follow -up tasks.'

Extensive Cutaneous Scalp Angiosarcoma.

Angiosarcoma is a cancer that is derived from endothelial cells that line blood vessels and lymphatic channels. Cutaneous angiosarcoma can appear anywhere on the skin and the clinical presentation is highly variable. Most cases appear on the scalp and face de novo. Our case describes a 91-year-old female with cutaneous scalp angiosarcoma. Our case serves to remind physicians that an abnormal skin finding in older adults should raise their index of suspicion for angiosarcoma and an early biopsy should be performed.

The Repertoire of Adenovirus in Human Disease: The Innocuous to the Deadly.

Adenoviridae is a family of double-stranded DNA viruses that are a significant cause of upper respiratory tract infections in children and adults. Less commonly, the adenovirus family can cause a variety of gastrointestinal, ophthalmologic, genitourinary, and neurologic diseases. Most adenovirus infections are self-limited in the immunocompetent host and are treated with supportive measures. Fatal infections can occur in immunocompromised patients and less frequently in the healthy. Adenoviral vectors are being studied for novel biomedical applications including gene therapy and immunization. In this review we will focus on the spectrum of adenoviral infections in humans.

A Successful Pharmacist-Based Quality Initiative to Reduce Inappropriate Stress Ulcer Prophylaxis Use in an Academic Medical Intensive Care Unit.

Stress ulcer prophylaxis (SUP) is often inappropriately utilized, particularly in critically ill patients. The objective of this study is to find an effective way of reducing inappropriate SUP use in an academic medical intensive care unit (ICU). Medical ICU patients receiving SUP were identified over a 1-month period, and their charts were reviewed to determine whether American Society of Health-System Pharmacists guidelines were followed. Inappropriate usage was calculated as inappropriate patient-days and converted to incidence per 100 patient-days. Two interventions were implemented: (1) Pharmacists reviewed indications for SUP on each patient during daily team rounds and daily medication reconciliation and (2) residents rotating on ICU services were educated on a bimonthly basis. Postintervention data were obtained in a similar fashion. Prior to intervention, the incidence of inappropriate SUP usage was calculated to be 26.75 per 100 patient-days (n = 1099 total patient-days). Total cost attributable to the inappropriate use was $2433. Post intervention, we were able to decrease the inappropriate incidence of SUP usage to 7.14 per 100 patient-days (n = 1149 total patient-days). In addition, total cost of inappropriate use was reduced to $239.80. Our study highlights an effective multidisciplinary approach to reduce the inappropriate use of SUP in an academic medical ICU. We were able to reduce the incidence of inappropriate use of SUP by 73.31% ( P < .001). Furthermore, we were able to decrease the costs by approximately $2200/month.