Hospital Internal Medicine Research Articles

Donning and Doffing

In this narrative medicine essay an internal medicine hospitalist explores what the new diagnosis of breast cancer means for her professional identity and considers how the COVID-19 pandemic facilitates the hiding of serious illness but also complicates disclosing the news to colleagues and friends.

C19TM: A nurse practitioner and physician assistant-led telemonitoring initiative ensures timely transfer of critically ill coronavirus disease 2019 patients.

The coronavirus disease 2019 (COVID-19) pandemic has required swift implementation of innovative practices in health care across the globe. We describe a nurse practitioner (NP) and physician assistant (PA)-led initiative to implement telemonitoring (TM) of noncritical patients with COVID-19 by critical care NPs and PAs (C19TM) for early detection of decompensation and early transfer to the intensive care unit (ICU). Every hospitalized patient with suspected or confirmed COVID-19 received an initial telemedicine consult with a critical care NP or PA. Patients were subsequently monitored via electronic health record once every 12-hour shift for the following indicators: oxygen modality and flow, increase in oxygen requirements, sustained tachypnea, and hemodynamic instability. If signs of decompensation were noted, the NP/PA would remotely reassess the patient, provide recommendations to the hospital internal medicine team, and transfer the patient to the ICU. The primary goal was to avoid cardiopulmonary deterioration requiring aerosol-generating procedures outside of the ICU. Over 65 days, 113 patients (86 suspected and 27 confirmed) were enrolled in C19TM. As a result, there were 13 transfers to the ICU, none of which required an aerosol-generating procedure outside of the ICU.

Hospitalization and Post-hospitalization Outcomes Among Teaching Internal Medicine, Employed Hospitalist, and Locum Tenens Hospitalist Services in a Tertiary Center: a Prospective Cohort Study.

BackgroundThere are no prospective studies comparing hospitalization and post-hospitalization outcomes between teaching internal medicine services and non-teaching hospitalists, and no prospective studies comparing these outcomes between locum and employed hospitalists.ObjectiveTo compare the length of stay, hospital costs readmission rate, and mortality rate in patients treated by teaching internal medicine services vs. hospitalists and among patients treated by locum vs. employed hospitalists.DesignProspective cohort study. Propensity score was used to obtain weighted estimates.SettingReferral center.PatientsAll patients 18 years and older admitted to internal medicine services.InterventionTreatment by teaching internal medicine services vs. hospitalists. Treatment by locum hospitalists vs. employed hospitalists.Main MeasuresPrimary outcome was adjusted length of stay and secondary outcomes included hospital cost, inpatient mortality, 30-day all-cause readmission, and 30-day mortality.Key ResultsA total of 1273 patients were admitted in the study period. The mean patient age was 61 ± 19 years, and the sample was 52% females. Teaching internal medicine physicians admitted 526 patients and non-teaching hospitalists admitted 747 patients. Being seen exclusively by teaching internal medicine physicians comports with a shorter adjusted hospital stay by 0.6 days (95% CI − 1.07 to − 0.22, P = .003) compared to non-teaching hospitalists. Adjusted length of stay was 1 day shorter in patients seen exclusively by locums compared to patients seen exclusively by employed services (95% CI − 1.6 to − 0.43, P < .001) with an adjusted average hospital cost saving of 1339 dollars (95% CI − 2037 to − 642, P < .001). There was no statistically significant difference in other outcomes.ConclusionsTeaching internal medicine services care was associated with a shorter stay but not with increased costs, readmission, or mortality compared to non-teaching services. In contrary to the “expected,” patients treated by locums had shorter stays and decreased hospital costs but no increase in readmissions or mortality.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06578-4.

Gender-Based Discrimination and Sexual Harassment Among Academic Internal Medicine Hospitalists.

Gender-based discrimination and sexual harassment, both implicit and overt, have been reported in academic medicine. This study examines experiences of academic hospitalists regarding gender-based discrimination and sexual harassment. A survey was distributed to Internal Medicine hospitalists at university-based academic institutions in the United States. Questions assessed experiences regarding gender-based discrimination and sexual harassment in their interactions with patients, as well as with other healthcare providers (HCPs). Eighteen institutions participated in the survey, resulting in 336 individual responses. Female hospitalists more frequently reported inappropriate touch, sexual remarks, gestures, and suggestive looks by patients compared with male peers both over their careers (P < .001) and in the last 30 days (P < .001). Similarly, females more frequently reported being referred to with inappropriate terms of endearment (eg, "dear," "honey," "sweetheart") by patients both over their careers (P < .001) and in the last 30 days (P < .001). Almost 100% of females reported being mistaken by patients for nonphysician HCPs over their careers, compared with 29% of males (P < .001) (76% vs 10%, in the last 30 days; P < .001). Similarly, females more frequently reported sexual harassment over their careers (P < .05) and being mistaken for nonphysician HCPs by colleagues both over their careers (P < .001) and in the last 30 days (P < .001). Females rated their sense of respect both by patients (P < .001) and colleagues (P < .001) lower than males (P < .001). More females than males reported that gender negatively impacted their career opportunities (P < .001). This survey demonstrates that gender-based discrimination and sexual harassment are commonly encountered by academic hospitalists, with a significantly higher number of females reporting these experiences.

A Taxonomic Review of Patient Complaints in Adult Hospital Medicine.

Previous studies show that patient complaints can identify gaps in quality of care, but it is difficult to identify trends without categorization. We conducted a review of complaints relating to admissions on hospital internal medicine (HIM) services over a 26-month period. Data were collected on person characteristics and key features of the complaint. The complaints were also categorized into a previously published taxonomy. Seventy-six unsolicited complaints were identified, (3.5 per 1000 hospital admissions). Complaints were more likely on resident services. The mean duration between encounter and complaint was 18 days, and it took an average of 12 days to resolve the complaint. Most patients (59%) had a complaint in the Relationship domain. Thirty-nine percent of complaints mentioned a specific clinician. When a clinician was mentioned, complaints regarding communication and humaneness predominated (68%). The results indicate that the efforts to reduce patient complaints in HIM should focus on the Relationships domain.

Behavioral drivers and observation of face covering use during the COVID-19 pandemic among outpatients and visitors at a tertiary hospital in Thailand.

BACKGROUND:Use of face covering may help prevent COVID-19 transmission. However, there is a lack of data on behavioral drivers of face covering use and compliance to mandatory face covering policy at health facilities. This study aimed to describe behavioral drivers and observed face covering use among outpatients and visitors at a tertiary hospital in Southern Thailand during the COVID-19 pandemic.MATERIALS AND METHODS:We conducted a hospital-based, cross-sectional study in June 2020. We developed, pilot-tested and finalized an interview questionnaire in Thai. We also developed a structured observation questionnaire. Two trained enumerators recruited outpatients and visitors at the hospital's internal medicine outpatient department (OPD), surgery OPD, and the pharmacy using the convenience sampling. Another enumerator conducted structured observation of face covering use among outpatients and visitors when interviews were not taking place. We analyzed the data using the descriptive statistics.RESULTS:A total of 206 persons that our interview enumerators approached agreed to participate (n = 206; response rate = 62.4%). Nearly all participants stated that the use of face covering was beneficial in preventing COVID-19 infection from others and preventing others from being infected (94.0% and 98.0%, respectively). Common barriers included inconvenience in breathing and speaking (19.7%) and pain at the ears (9.6%). Structured observation of 408 outpatients and visitors showed that nearly everyone (>99%) had a face covering on their person, most of whom (94.6%) covered both their nose and mouth.CONCLUSION:We found near-universal perceived benefits and compliance, but variations in perceived barriers, cues, and social norms for the use of face coverings. The findings of this study can inform future intervention programs on face covering use promotion.

THE EFFECT OF DIABETES SYMPTOMS ON QUALITY OF LIFE IN INDIVIDUALS WITH TYPE 2 DIABETES.

This study aimed to investigate the effect of symptoms of diabetes on the quality of life of individuals with Type 2 diabetes. The study used a cross-sectional design. No sampling procedure was employed in the study; instead, 410 individuals presenting to the Balikesir Atatürk City Hospital Endocrinology and Internal Medicine Polyclinics between December 2016 and July 2017, diagnosed with Type 2 diabetes, and meeting the inclusion criteria were enrolled in the study sample. The study data were collected with a "Socio-demographic Characteristics Questionnaire", the "Diabetes Symptom Checklist", and the "SF-36 Quality of Life Questionnaire". The participants obtained the highest mean scores from the hyperglycemia subscale of the Diabetes Symptoms Checklist (3.35±0.60) and the mental health subscale of the SF-36 Quality of Life Questionnaire (50.65±8.10). The hypoglycemia, cardiology, psychology, and neurology variables included in the model were statistically significant and predicted 35% of the mental subscale score of the SF 36 questionnaire. SF 36 physical subscale score increased as the hypoglycemia, cardiology, psychology, and neurology scores decreased (p<0.05). The participants obtained high scores from the hyperglycemia subscale of the diabetes symptom checklist and mental health subscale of the quality of life questionnaire. Diabetes symptoms were found to affect the quality of life of individuals with diabetes.

Lung Cancer Patients, At High Risk for Admission Due to Pneumonia, Did Not Require Hospitalization for COVID-19 at Creighton University Medical Center-Bergan Mercy in 2020

Background: Patients with lung cancer are at high risk for hospitalizations and death, although causes for admission in these patients are elusive. Also, the hospitalizations rates of patients with lung cancer in the COVID-19 pandemic are unclear. Methods: The objectives of this study are to evaluate causes for admission in lung cancer patients and to follow this group into 2020 to see if COVID-19 was a contributor to their hospitalizations. The design is a cohort, retrospective chart review. Participants were patients with an established diagnosis of lung cancer, pursing treatment, ages 19-89 at Creighton University Medical Center- Bergan Mercy (CUMC-B) Hospital Internal Medicine Department from January 1, 2019 through December 31, 2020. Measurements include basic demographics as well as causes for admission and COVID-19 status. Results and Discussion: Out of 37 patients, selected from 311 candidates, there were 47 causes for admission. Of total admissions from this cohort in 2019, 16.88% were due to pneumonia, 11% with acute respiratory failure with hypoxia. The top 14 causes for admission were responsible for 71.4% of the admissions of lung cancer patients in 2019. Of the surviving patients from 2019 into 2020, 1 had confirmed COVID-19. None were hospitalized for COVID-19 within this cohort. Although there were not COVID-19 related hospitalizations in this cohort, the percentage of overall people who died increased (10 deaths out of 37 (27%) from Jan 1, 2019-Feb 29, 2020 in comparison to 13 deaths out of 26 (50%) after March 1, 2020). Conclusion: Despite pneumonia being a leading cause for hospitalization in patients with lung cancer, nobody in this cohort was admitted with COVID-19. Although sample size is a limiting factor in this study, further investigation is warranted into why lung cancer patients in this cohort appear to have a steady or increased death rate, but did not contract COVID-19t.

Anterior Mitral Valve Orifice in a Dog

The patient was admitted to OndokuzMay&#305s University Animal Hospital Internal Medicine outpatient clinic with complaints of epileptic seizures and hypothyroidism. A description of the patient’s owner is available in the history information. There was no physician information. Bradycardia was found in the electrocardiography of the patient. 2-D, M-Mode, PW, CW and Color doppler examinations were performed. Left-ventricular hypokinetic and mitral and tricuspidal valve movements were observed with limited M-Mode imaging. Anterior mitral orifice of 2 mm width was detected on septal mitral valve by PW doppler and color doppler. With this orifice, the presence of regurgitant jet, which covers LA at a rate of 1/3 and was 3.2 m/sec, together with mitral regurgitation (0.5 m/sec.), was demonstrated. PISA calculations; VFR (mL/s), ERO (mm2) and RVol (mL/pulse) values were calculated as if there were mitral regurgitation and data were obtained for mild-moderate mitral regurgitation. Therefore, no operative treatment of the orifice was recommended. Mitral valve orifice is a rare pathology and this is the first report in canine veterinary practice with degenerative mitral valve disorder. We aimed to underline the possibility of mitral orifice development in degenerative mitral valve disorders, known to present with vegetations and varying degrees of prolapsus, conventionally.

Evaluation of malnutrition risk of inpatients in a research and training hospital: A cross-sectional study.

Malnutrition is one of the most important factors affecting the prognosis of inpatients. The aim of this study is to determine the malnutrition risk of hospitalized patients and to examine the relationship between the presence of malnutrition and other parameters. The study included 162 inpatients over the age of 25 who were staying in the hospital's internal medicine service for 7 days or more and who volunteered to participate in the study. A demographic-information questionnaire, consisting of 5 sections, a 24-h food recall record, NRS-2002, NRI and Beck Depression Inventory was given to patients during bedside interviews. After obtaining the necessary permission, the anthropometric measurements and biochemical parameter values of the patients were taken from their files. All statistical analyzes were performed by researchers with the SPSS package program. Of 162 patients (48.8% female, 51.2% male), 24.7% were at risk for malnutrition according to NRS-2002 and 66.7% of the patients were not depressive, based on the Beck Depression Inventory scale. The malnutrition risk was higher (60.0%) in patients who had been hospitalized for more than 15 days (p=0.010). The majority of those with malnutrition had no problems preventing them from eating (32.5%), were found to be not depressive (52.5%) and were in the normal range of body mass index (57.5%) (p=0.002, p=0.034, p=0.001; respectively). Nutrient intake was lower in patients with a higher malnutrition risk, but the difference was insignificant (p>0.05). Albumin levels (p=0.028) and total protein levels (p=0.015) were significantly lower in patients who were at risk of malnutrition. While overweight patients showed higher levels of serum albumin (p<0.001), CRP levels were found to be lower in overweight patients (p<0.001). It was found that the majority of patients with malnutrition were in the normal range for BMI. Nutritional intake and biochemical parameters should be followed closely in patients who are at risk of malnutrition. Depression can be a cause for insufficient nutrition and should be evaluated, particularly in patients whose length of hospital stay is greater than 7 days.

Évaluation de l’implantation d’un processus de dé-prescription des inhibiteurs de la pompe à protons (IPP) à l’aide d’un algorithme au sein d’un service de médecine interne

IntroductionThe prescription of proton pump inhibitors (PPIs) seems excessive. Taken over the long term, PPIs can cause serious side effects. It therefore turns out to be justified to suspend treatments whose expected benefit seems too low compared to the risks involved : it is deprescription. The objective of this study is to assess a process for the deprescription of PPIs in a hospital internal medicine department. MethodAfter collegial deliberation, an algorithm for assisting in the deprescription of PPIs was validated. If necessary, the PPI was phased out over 1 month. A telephone follow-up at 1, 2 and 3 months was carried out in order to assess the maintenance of deprescription and the occurrence of digestive symptoms. The evaluation criteria were the rate of deprescription and the rate of maintenance of deprescription at 3 months following reports from patients, their caregivers or a family member. Results105 patients with a mean age of 72 years were included over a period of 21 weeks, and in 31 cases (29%), deprescription was performed. After 3 months of follow-up, there was 71% maintenance of deprescription. Three patients were lost to follow-up and 6 patients resumed PPI. ConclusionThe approach undertaken resulted in the suspension of PPI intake in almost 3 out of 10 cases. This result was maintained at least three months for a large majority of patients. It will be interesting to continue this process and extend the monitoring over longer periods, in order to ensure that PPI de-prescription is maintained in the long term.

Effect of medicines management versus standard care on readmissions in multimorbid patients: a randomised controlled trial

ObjectiveTo investigate the effect of pharmacist-led medicines management in multimorbid, hospitalised patients on long-term hospital readmissions and survival.DesignParallel-group, randomised controlled trial.SettingRecruitment from an internal medicine hospital ward in Oslo, Norway....

Improving Physical Activity in Adults Admitted to a Hospital With Interventions Developed and Implemented Through Cocreation: Protocol for a Pre-Post Embedded Mixed Methods Study.

BackgroundAdmission to a hospital is often related with hospital-associated disabilities. Improving physical activity during hospitalization is considered effective to counteract hospital-associated disabilities, whereas many studies report on very low physical activity levels. Gradually developing and implementing interventions in cocreation with patients and health care professionals rather than implementing predefined interventions may be more effective in creating sustainable changes in everyday clinical practice. However, no studies have reported on the use of cocreation in the development and implementation of interventions aimed at improving physical activity.ObjectiveThis protocol presents a study that aims to investigate if interventions, which will be developed and implemented in cocreation, improve physical activity among patients in surgery, internal medicine, and cardiology hospital wards. The secondary aims are to investigate effectiveness in terms of the reduction in the time patients spend in bed, the length of hospital stay, and the proportion of patients going home after discharge.MethodsThe Better By Moving study takes place for 12 months at the following five different wards of a university hospital: two gastrointestinal and oncology surgery wards, one internal medicine hematology ward, one internal medicine infectious diseases ward, and one cardiology ward. The step-by-step implementation model of Grol and Wensing is used, and all interventions are developed and implemented in cocreation with health care professionals and patients. Outcome evaluation is performed across the different hospital wards and for each hospital ward individually. The primary outcome is the amount of physical activity in minutes assessed with the Physical Activity Monitor AM400 accelerometer in two individual groups of patients (preimplementation [n=110], and 13 months after the start of the implementation [n=110]). The secondary outcomes are time spent in bed measured using behavioral mapping protocols, and length of stay and discharge destination assessed using organizational data. A process evaluation using semistructured interviews and surveys is adopted to evaluate the implementation, mechanisms of impact, context, and perceived barriers and enablers.ResultsThis study is ongoing. The first participant was enrolled in January 2018. The last outcome evaluation and process evaluation are planned for May and June 2020, respectively. Results are expected in April 2021.ConclusionsThis study will provide information about the effectiveness of developing and implementing interventions in cocreation with regard to improving physical activity in different subgroups of hospitalized patients in a university hospital. By following step-by-step implementation and by performing process evaluation, we will identify the barriers and enablers for implementation and describe the effect of new interventions on improving physical activity among hospitalized patients.Trial RegistrationNetherlands Trial Register NL8480; https://www.trialregister.nl/trial/8480International Registered Report Identifier (IRRID)DERR1-10.2196/19000

Psychological wellness of internal medicine hospitalists during the COVID-19 pandemic

ABSTRACT Background Patients with COVID-19 infection requiring in-hospital care are frequently managed by Internal Medicine hospitalists, comprised of physicians, nurse practitioners and physician assistants. There is sparse information on the psychological impact of the COVID-19 pandemic on Internal Medicine hospitalists. Methods We surveyed Internal Medicine hospitalists at Mayo Clinic sites in four states (Arizona, Florida, Minnesota, and Wisconsin). We collected demographic information, and used Patient-Reported Outcomes Measurement Information System (PROMIS®) measures to assess global well-being, anxiety, social isolation, and emotional support. Descriptive statistics were used to compare responses between two periods: prior to the pandemic (before March 15th, 2020), and during the pandemic (March 15 through 30 April 2020). The survey was conducted from May 4–25, 2020. Results Of 295 Internal Medicine hospitalists, 154 (52%) responded. Fifty-six percent were women (n = 85/154) and 54% were physicians (n = 84/154). Most hospitalists (75%; n = 115/154) reported concerns about contracting COVID-19 infection at work, and 5% (n = 8/154) reported changing where they lived during the pandemic. Most hospitalists (73%; n = 112/154) reported relying primarily on institutional resources for COVID-19 information. During the pandemic, the percentage of participants with excellent or very good global well-being decreased (90% prior to pandemic vs. 53% during pandemic), with increases in mean anxiety (–4.88 [95% confidence interval, – 5.61 to – 4.16]; P<.001) and social isolation (–3.91[95% confidence interval, – 4.68 to – 3.13]; P<.001). During the same period, there was a small decrease in mean emotional support (1.46 [95% confidence interval, 0.83 to 2.09]; P<.001). Conclusion During the COVID-19 pandemic, Internal Medicine hospitalists reported lower global well-being, higher anxiety and social isolation, and a small decrease in emotional support. These results provide a framework to develop programs to support hospitalists and potentially mitigate long-term psychological sequelae including burnout.

Pain and Frailty in Hospitalized Older Adults.

IntroductionPain and frailty are prevalent conditions in the older population. Many chronic diseases are likely involved in their origin, and both have a negative impact on quality of life. However, few studies have analysed their association.MethodsIn light of this knowledge gap, 3577 acutely hospitalized patients 65 years or older enrolled in the REPOSI register, an Italian network of internal medicine and geriatric hospital wards, were assessed to calculate the frailty index (FI). The impact of pain and some of its characteristics on the degree of frailty was evaluated using an ordinal logistic regression model after adjusting for age and gender.ResultsThe prevalence of pain was 24.7%, and among patients with pain, 42.9% was regarded as chronic pain. Chronic pain was associated with severe frailty (OR = 1.69, 95% CI 1.38–2.07). Somatic pain (OR = 1.59, 95% CI 1.23–2.07) and widespread pain (OR = 1.60, 95% CI 0.93–2.78) were associated with frailty. Osteoarthritis was the most common cause of chronic pain, diagnosed in 157 patients (33.5%). Polymyalgia, rheumatoid arthritis and other musculoskeletal diseases causing chronic pain were associated with a lower degree of frailty than osteoarthritis (OR = 0.49, 95%CI 0.28–0.85).ConclusionsChronic and somatic pain negatively affect the degree of frailty. The duration and type of pain, as well as the underlying diseases associated with chronic pain, should be evaluated to improve the hospital management of frail older people.Electronic Supplementary MaterialThe online version of this article (10.1007/s40122-020-00202-3) contains supplementary material, which is available to authorized users.

Quality of Life and Utility Values for Cost-Effectiveness Modeling in Japanese Patients with Type2 Diabetes.

IntroductionReliable quality of life (QoL) measures and utility values are needed for patients with type 2 diabetes mellitus (T2DM) with a variety of comorbid conditions to help facilitate cost-effectiveness modeling. This study aimed to evaluate the Diabetes Treatment-Related Quality of Life (DTR-QOL) and EuroQol 5-dimension 5-level (EQ-5D-5L) questionnaires in patients with T2DM with and without diabetes complications and comorbidities in Japan.MethodsThis was an observational survey study involving 1000 patients with T2DM, at least 20 years old, receiving treatment at Nara University Hospital or Takamura Internal Medicine Clinic in Japan. Patients completed the DTR-QOL and EQ-5D-5L questionnaires and clinicians completed an accompanying case report form. The DTR-QOL and EQ-5D-5L are scored on a scale of 0–100 and 0–1, with 100 and 1 representing the best possible scores, respectively.ResultsOut of 1000 recruited patients, 978 were included in the final analysis. Patients reported an average EQ-5D-5L value of 0.92 ± 0.11. Utility values corresponded to the degree of severity of health conditions while few differences were observed when stratified by the HbA1c 7% threshold, age, or BMI level, nor did the values correspond to the degree of clinical risk factors. Patients reported an average total DTR-QOL score of 79.26 ± 13.26. The DTR-QOL was sensitive to detect differences in patients with T2DM with a variety of complications and comorbidities, risk factors, and treatments.ConclusionThis is the largest study to report QOL values for patients with diabetes in Japan and the first to include a variety of comorbid diabetic conditions. These findings may be useful for cost-effectiveness modeling of patients with T2DM in Japan.

Reduced Length of Stay Using Clinical Decision Support Tool (ASAP) for Empiric Antibiotic Selection

Background: Empiric antibiotic selection is challenging and requires knowledge of the local antibiogram, national guidelines and patient-specific factors, such as drug allergy and recent antibiotic exposure. Clinical decision support for empiric antibiotic selection has the potential to improve adherence to guidelines and improve patient outcomes. Methods: At NorthShore University HealthSystem, a 4-hospital, 789 bed system, an automated point-of-care decision support tool referred to as Antimicrobial Stewardship Assistance Program (ASAP) was created for empiric antibiotic selection for 4 infectious syndromes: pneumonia, skin and soft-tissue infections, urinary tract infection, and intra-abdominal infection. The tool input data from the electronic health record, which can be modified by any user. Using an algorithm created with electronic health record data, antibiogram data, and national guidelines, the tool produces an antibiotic recommendation that can be ordered via a link to order entry. If the tool identifies a patient with a high likelihood for a multidrug-resistant infection, a consultation by an infectious diseases specialist is recommended. Utilization of the tool and associated outcomes were evaluated from July 2018 to May 2019. Results: The ASAP tool was executed by 140 unique, noninfectious diseases providers 790 times. The tool was utilized most often for pneumonia (194 tool uses), followed by urinary tract infection (166 tool uses). The most common provider type to use the tool was an internal medicine hospitalist. The tool increased adherence to the recommended antibiotic regimen for each condition. Antibiotic appropriateness was assessed by an infectious diseases physician. Antibiotics were considered appropriate when they were similar to the antibiotic regimen recommended by the ASAP. Inappropriate antibiotics were classified as broad or narrow. When antibiotic coverage was appropriate, hospital length of stay was statistically significantly shorter (4.8 days vs 6.8 days for broad antibiotics vs 7.4 days for narrow antibiotics; P &lt; .01). No significant differences were identified in mortality or readmission. Conclusions: A clinical decision support tool in the electronic health record can improve adherence to recommended empiric antibiotic therapy. Use of appropriate antibiotics recommended by such a tool can reduce hospital length of stay.Funding: NoneDisclosures: None

THROMBOTIC MICROANGIOPATHY: A RARE SEQUELAE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thrombotic microangiopathy (TMA) is characterized by many etiologies, however it is not often described as a complication of Endoscopic Retrograde Cholangiopancreatography (ERCP). Failure to identify the relationship between TMA and ERCP may result in delay of diagnosis and poor patient outcomes. We present a case of a young healthy female who developed TMA after ERCP. CASE PRESENTATION: A 26-year-old woman presented to the hospital with complaints of abdominal pain, nausea and vomiting. An abdominal CT scan showed cholelithiasis and choledocholithiasis and the patient was scheduled for ERCP. She tolerated the procedure well with no immediate complications. However, a day after procedure, labs showed elevated serum lipase and amylase levels with renewed abdominal pain. Two days after ERCP she developed fever, severe thrombocytopenia, anemia and acute kidney injury (AKI) evidenced by elevated serum creatinine. A preliminary diagnosis of thrombotic thrombocytopenic purpura (TMA) was considered. Plasma exchange therapy with platelet transfusion and high dose steroids was initiated. She also received multiple packed red cell transfusion for severe anemia. ADAMTS13 antibody testing returned low at 53% with negative anti-ADAMTS13 IgG. After 7 daily sessions of plasma exchange platelets improved, AKI and anemia resolved, and the patient was discharged from the hospital. DISCUSSION: Literature review shows only about 4 cases of ERCP induced TMA. A well-known complication of ERCP is pancreatitis and a rare unfortunate sequela of this is TMA. There is a known correlation between TMA and pancreatitis, though the mechanism by which this occurs is still not well understood. Endothelial damage, cytokine release and platelet activation are thought to be the pathophysiological links between these two conditions (1). Cytokines cause release of ultra-large von-Willebrand factor (VWf) molecules that attach to activated platelets promoting aggregation, clumping and thrombus formation. There is concomitant reduction in serum ADAMTS13, which would normally cleave the ultra-large VWf, due to pancreatic enzyme degradation. CONCLUSIONS: This case illustrates how complicated the diagnosis of TMA can be, but also points out how clinical judgment is imperative to prompt early treatment and increase favorable outcomes. TMA caused by ERCP is rare, but recognizing this link is important for immediate initiation of life saving treatment. Reference #1: 1. Malik, F., Ali, N., Ahsan, I., Ghani, A. R., & Fidler, C. (2016). Eculizumab refractory thrombotic thrombocytopenic purpura secondary to post-endoscopic retrograde cholangiopancreatography pancreatitis in a patient. Journal of community hospital internal medicine perspectives, 6(6), 32310. DISCLOSURES: No relevant relationships by Kitson Deane, source=Web Response No relevant relationships by Abidemi Idowu, source=Web Response

Utility of Alpha-Fetoprotein-L3 and Golgi Protein 73 for Diagnosis of Hepatocellular Carcinoma

Background: Hepatocellular carcinoma (HCC) is amongst the most common malignant tumors that carries a poor prognosis. Clinically, alpha-fetoprotein (AFP) is the most extensively used serum biomarker for diagnosing HCC. Objectives: The current study was conducted to explore the diagnostic value of serum levels of alpha-fetoprotein-L3 (AFP-L3) and Golgi protein 73 (GP73) regarding HCC, and to determine the diagnostic accuracy of these biomarkers when used individually as well as in combination with AFP. Methodology: Blood samples were collected from 50 patients with HCV-related cirrhosis (25 subjects with HCC and 25 without HCC) recruited from the outpatient clinics of the Specialized Internal Medicine Hospital, Mansoura University, Egypt. Serum concentrations of AFP-L3 and GP73 were evaluated using enzyme-linked immunosorbent assay (ELISA). Diagnostic performance of AFP-L3 and GP73 was determined by receiver operating characteristic (ROC) curve analysis. Results: Overall, the median serum level of AFP-L3 was higher in the HCC group compared to the cirrhotic group (p=0.05). Moreover, a statistically-significant difference was observed between the median serum value of GP73 in HCC patients compared to those with cirrhosis (p &lt; 0.001). The ROC curve analysis showed that the area under the ROC curve (AUROC) values for AFP, AFP-L3 and GP73 were 0.88, 0.67 and 0.83, respectively. Of the 3 biomarkers, GP73 demonstrated the highest sensitivity (88%). The AUROC for AFP and AFP-L3 combination was 0.85, whereas that for AFP and GP73 was 0.90. Conclusion: Our findings indicate that GP73 is more sensitive than AFP and AFP-L3 in diagnosing HCC. Furthermore, the combined determination of GP73 and AFP could improve the diagnostic ability of HCC.

Presepsin and Resistin as Diagnostic Markers for Bacterial Infection in Patients with Decompensated Cirrhosis

Background and study aim: Bacterial infections mess up prognosis of cirrhotic patients. Presepsin and resistin are favorable infection markers that can help in diagnosis of such condition. This study aimed to assess performance of presepsin and resistin in diagnosis of infection compared with C reactive protein (CRP) and procalcitonin (PCT) among patients with decompensated cirrhosis. Patients and Methods: Two hundred and thirteen patients with decompensated cirrhosis admitted to Internal Medicine hospital, Zagazig University, were included in this study. All patients underwent history taking, thorough clinical examination and laboratory investigations including measuring CRP, PCT, presepsin and resistin. Results: About 47% of patients have infections. Presepsin and resistin were significantly higher among patients with infection and positively correlated with Model for End-stage Liver Disease score (MELD), Child-pough score (CPS), CRP and PCT. Presepsin cutoff≥1205 pg/ml could predict infection at sensitivity 83.8%, specificity 93% and accuracy 88.7%. Resistin cutoff≥21 ng/ml could predict infection at sensitivity 64.6%, specificity 68.4% and accuracy 66.7%. Adding CRP to PCT or presepsin increased sensitivity to 99%, specificity 73.7%, and accuracy 85.4%. Adding presepsin to PCT or resistin increased sensitivity to 94.9%. Yet combined presepsin and PCT had higher specificity than combined presepsin and resistin. Conclusion: Presepsin has comparable diagnostic performances to CRP and PCT for bacterial infection in decompensated cirrhosis while resistin has poor sensitivity and specificity. Adding presepsin to CRP yields the same diagnostic performance as combined CRP and PCT. So, combining any of them to CRP helps to early diagnose bacterial infection in those patients