The Impact of a Paracentesis Clinic on Internal Medicine Resident Procedural Competency.

Background: Competency in paracentesis is an important procedural skill for health care practitioners caring for patients with decompensated cirrhosis. It is estimated that 97,577 paracentesis procedures were performed between 2010 and 2012 across 120 academic medical centers and 290 affiliated hospitals. Methods: Due to limitations of resources at the Central Texas Veterans Affairs Hospital, a paracentesis clinic was created to give patients improved access to this procedure which is staffed by a supervising physician and internal medicine residents. We evaluated resident competency via survey and change in the number of paracentesis procedures performed with the utilization of this clinic. Results: Thirty-three residents completed the survey. The total mean number of paracentesis sessions participated in was 4.8. It was found that during training, 79% met conditional independence in performing this procedure with a high level of comfort by rotating through this clinic. It was also found that the number of procedures performed by internal medicine residents significantly increased with the addition of this clinic. Conclusions: A dedicated paracentesis clinic with internal medicine resident involvement can increase resident paracentesis procedural independence, the number of procedures available and performed, and procedural comfort level by the end of training.

Close outpatient follow-up associated with reduced readmission rates in patients with inflammatory bowel disease.

Background: Few studies have shown the effects of prompt outpatient follow-up in relation to reducing readmission rates in patients hospitalized with inflammatory bowel disease (IBD). Our study evaluated whether postdischarge follow-up was associated with fewer IBD-related readmissions. Methods: This single-center retrospective study included 477 patients with Crohn's disease (CD) or ulcerative colitis (UC) who were readmitted to our tertiary care hospital from January 1, 2016, to June 1, 2022. Rehospitalization admissions were defined as admissions that occurred within 90 days after discharge date. We used a chi-square or Fisher's exact test to test for bivariate comparisons to determine if there was an association in patients readmitted for IBD and primary care or gastroenterology follow-up at 1, 2, 3, and 4 weeks versus no follow-up. Results: In UC patients, there were 118 admissions from 2016 to 2022; 36/118 (31%) and 41/118 (34.7%) of the patients were readmitted at 30 days and 90 days, respectively. In the CD group, there were 101 (36.73%) readmissions among 277 patients, with 174 nonreadmissions (63.27%). Conclusions: Gastroenterology follow-up within 1 month was associated with reduced rates of admission in both groups (P < 0.05). This study highlights the importance of close gastroenterology follow-up for IBD-related hospitalizations.

Gastrointestinal Bleeding Caused by Large Intestine Amyloidosis.

Background: Amyloidosis is a rare disorder caused by abnormal folding of proteins, leading to the dysfunction of normal tissues. Amyloid deposition can affect several organs, but deposition in the large intestine is rare. Case Presentation: A 79-year-old man presented with gastrointestinal bleeding and nonspecific symptoms of weight loss, dry heaves, dysphagia, and weakness. The patient underwent esophagogastroduodenoscopy and colonoscopy and a biopsy confirmed the diagnosis of intestinal amyloidosis. Conclusions: This case report highlights the importance of a strong differential when working up gastrointestinal bleeding that includes amyloidosis. Early identification and multidisciplinary involvement are crucial for management and tailored care to each patient's needs.

Cholecystitis: A Rare Presentation for Diffuse Eosinophilic Granulomatosis With Polyangiitis.

Eosinophilic granulomatosis with polyangiitis is a rare disorder of small- to medium-sized vessel vasculitis that can affect a multitude of organ systems. It typically presents as asthma, with 50% of cases having some gastrointestinal involvement, but involvement of the gallbladder is very rare. We present a unique case report of a patient who presented for nonspecific symptoms, ultimately leading to a cholecystectomy, which officially histologically diagnosed them with eosinophilic granulomatosis with polyangiitis.

Nightmare on CIL Street: A Simulation Series to Increase Confidence and Skill in Responding to Clinical Emergencies.

Background: The Central Texas Veterans Health Care System (CTVHCS) in Temple, a 189-bed teaching hospital, recently opened its Center for Innovation and Learning for simulation-based learning. CTVHCS built a rapid response simulation curriculum to improve preparedness for internal medicine residents, medical students, and physician assistant students that exploits newly developed medical education technology. Observations: The Center for Innovation and Learning curriculum was created based on the most common rapid response calls received over the previous 3 years. Cardiac, respiratory, and neurological simulations were implemented. Learners approach each scenario as if they were on night service alone without specialist help. Learners must identify tachyarrhythmia, impending respiratory failure, and a patient with encephalopathy requiring transfer. Conclusions: Sixteen learners were surveyed before the simulation and after addressing each educational objective was completed and showed improvement. Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation.

Leptin Enhances Hepatic Fibrosis and Inflammation in a Mouse Model of Cholestasis.

Leptin is an adipokine with roles in food intake and energy metabolism through its actions on neurons in the hypothalamus. The role of leptin in obesity and cardiovascular disorders is well documented. However, its influence on liver conditions such as cholestasis is poorly understood. The effects of exogenous leptin and leptin-neutralizing antibody on biliary hyperplasia, hepatic fibrosis, and inflammation in the multidrug resistance protein 2 knockout (Mdr2KO) mouse model of cholestasis were assessed by quantifying markers specific for cholangiocytes, activated hepatic stellate cells (HSCs), and cytokines. Serum and hepatic leptin were increased in Mdr2KO mice compared with FVB/NJ (FVBN) controls, and exogenous leptin enhanced biliary hyperplasia and liver fibrosis in Mdr2KO and FVBN mice. Leptin administration increased hepatic expression of C-C motif chemokine ligand 2 and IL-6 in Mdr2KO mice. In contrast, leptin-neutralizing antibody reduced intrahepatic bile duct mass and decreased HSC activation in Mdr2KO mice compared with FVBN controls. Sex-related differences were noted, with female Mdr2KO mice having more leptin than males. In cholangiocytes and LX2 cells in vitro, leptin increased phosphorylated Akt and stimulated cell proliferation. Leptin receptor siRNA and inhibitors of Akt phosphorylation impaired leptin-induced cell proliferation and proinflammatory cytokines. The current data suggest that leptin is abnormally increased in cholestatic mice, and excess leptin increases ductular reaction, hepatic fibrosis, and inflammation via leptin receptor-mediated phosphorylation of Akt in cholangiocytes and HSCs.

An international multicenter study of early intravenous fluid administration and outcome in acute pancreatitis.

AIMS: Early aggressive fluid resuscitation in acute pancreatitis is frequently recommended but its benefits remain unproven. The aim of this study was to determine the outcomes associated with early fluid volume administration in the emergency room (FVER) in patients with acute pancreatitis. METHODS: A four-center retrospective cohort study of 1010 patients with acute pancreatitis was conducted. FVER was defined as any fluid administered from the time of arrival to the emergency room to 4 h after diagnosis of acute pancreatitis, and was divided into tertiles: nonaggressive (<500 ml), moderate (500 to 1000 ml), and aggressive (>1000 ml). RESULTS: Two hundred sixty-nine (26.6%), 427 (42.3%), and 314 (31.1%) patients received nonaggressive, moderate, and aggressive FVER respectively. Compared with the nonaggressive fluid group, the moderate group was associated with lower rates of local complications in univariable analysis, and interventions, both in univariable and multivariable analysis (adjusted odds ratio (95% confidence interval): 0.37 (0.14-0.98)). The aggressive resuscitation group was associated with a significantly lower need for interventions, both in univariable and multivariable analysis (adjusted odds ratio 0.21 (0.05-0.84)). Increasing fluid administration categories were associated with decreasing hospital stay in univariable analysis. CONCLUSIONS: Early moderate to aggressive FVER was associated with lower need for invasive interventions.

Clinical Significance of Nonsustained Ventricular Tachycardia on Routine Monitoring of Pacemaker Patients.

BACKGROUND: Permanent pacemakers (PPMs) are capable of recording tachyarrhythmic events including nonsustained ventricular tachycardia (NSVT), though the clinical significance of NSVT on routine PPM evaluation is unknown. Our goals: assess the prevalence of NSVT on routine PPM follow-up and survival of PPM patients with NSVT, without NSVT, and with ventricular high rate (VHR) episodes of undefined origin. METHODS: A single-center retrospective, cohort study was performed on patients implanted with PPMs capable of recording NSVT, defined as ≥5 consecutive ventricular beats at ≥170/minutes lasting <30 seconds. Patients were categorized: (1) no NSVT; (2) NSVT; or (3) VHR episodes of uncertain etiology. The primary endpoint was all-cause mortality within 6 months of last follow-up. RESULTS: Note that in 1,125 enrollees (51.8% male, age 74.2 ± 15.5 years, ejection fraction 57.0 ± 9.0%), 742 (66%) had no NSVT, 223 had NSVT (20%), and 160 (14%) had VHR. There were no differences in ejection fraction, diabetes, hypertension, coronary disease, prior myocardial infarction, baseline creatinine, QRS duration, prevalence of left bundle branch block, or ß-blocker use among groups. "No NSVT" patients were older (P = 0.013), NSVT patients had more males (P = 0.012); atrial fibrillation and digoxin use were more prevalent in VHR patients (P < 0.01). During median follow-up of 2.8 years there were 93 deaths within 6 months of last follow-up with no differences in survival among groups (log rank P = 0.47). Age, ejection fraction at time of implant, and ß-blocker use were independent predictors of survival. CONCLUSION: NSVT detected on routine PPM follow-up in this patient population with a preserved ejection fraction is not associated with long-term mortality.