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Introduction: Many internal medicine residents struggle to prepare for both the ITE and board test. Most existing resources are simply test question banks that are not linked to existing supporting literature from which they can study. Additionally, program directors are unable to track how much time residents are spending or performing on test preparation. We looked to evaluate the benefit of using this online platform to augment our pulmonary didactics and track time and performance on the pulmonary module and ITE pulmonary section. Method: During the month-long live didactic sessions, residents had free access to the pulmonology NEJM K+ platform. A platform-generated post-test was administered with new questions covering the same key elements, including the level of confidence meta-metric. An anonymous feedback survey was collected to assess the residents’ feelings regarding using the NEJM Knowledge+ platform as compared to other prep resources. Results: 44 of 52 residents completed the pre-test. 51/52 completed the month-long didactic sessions and the post-test. Residents’ score improvement from % correct pre-test (M = 46.90, SD = 15.31) to % correct post-test (M = 76.29, SD = 18.49) correlated with levels of mastery (t = 9.60, df = 41, p

We have completed volume 9 of the Journal of Community Hospital Internal Medicine Perspectives â€" JCHIMP. In this perspective piece we discuss the many achievements of our journal, including our impact factor, the diversity of institutions publishing, our editorial board, and the importance of our reviewers.

Inpatient early mobility initiatives are effective therapeutic interventions for improving patient outcomes and decreasing use of hospital resources among adult ICU and general medicine patients. To establish and demonstrate guidelines for early patient ambulation, we developed and implemented a novel multidisciplinary mobility bundle utilizing the JH-HLM (Johns Hopkins Highest Level of Mobility) scale for mobility classification, on a single adult general medicine unit of a community hospital. Our results show that patients admitted to the unit after implementation of the mobility bundle had improved mobility scores, reduced rates of 30-day hospital readmission, and a shortened length of hospital stay. This study emphasizes the importance of measuring mobility using a systematic method, easing workflow among unit practitioners, and allowing mobility initiatives to be jointly driven by nursing, physical therapy, and physicians.

The pandemic outbreak of COVID-19 challenges medical care systems all around the world. We here describe our experiences during the treatment of COVID-19 patients (n = 42) treated from 2 March 2020 to 16 April 2020 at a German district hospital. Forty-two COVID-19 patients were hospitalized and five patients developed a severe disease, requiring intensive care. Overall, 11 out of 42 hospitalized patients died. COVID-19 caused lymphocytopenia, as well as increased d-dimer, c-reactive protein and creatine kinase, and lactate dehydrogenase levels. These changes were mostly pronounced in patients that developed a severe disease course. Radiologic findings included ground-glass opacity, bilateral/multilobular involvement, consolidation, and posterior involvement. We compared COVID-19 patients to an average population of ‘non-COVID’ patients. Interestingly, no laboratory or radiologic finding was specific for COVID-19 when standing alone, as comorbidities of ‘non-COVID’ patients certainly can mimic similar results. In common praxis, the diagnosis of COVID-19 is based on a positive PCR result. However, a false-negative result causes problems for the workflow of an entire hospital. In our clinic, the consequences of a false assumption of SARS-CoV-2 negativity in four cases had dramatic consequences, as contact persons had to be quarantined. To avoid this, a comprehensive view of lab-results, radiology, clinical symptoms and comorbidities is necessary for the correct diagnosis or exclusion of COVID-19.

Background: Sacubitril/valsartan has been incorporated into guidelines based on the results of the PARADIGM-HF trial, which demonstrated reduced mortality in stable patients with heart failure with reduced ejection fraction (HFrEF). Sacubitril/valsartan is recommended in addition to other HF therapies in place of an angiotensin-converting-enzyme inhibitor or angiotensin-receptor-blocker. Objectives: To evaluate the safety and tolerability of sacubitril/valsartan initiation in a community hospital. Design/methods: This single-center, retrospective review evaluated patients that received ≥24 hours of sacubitril/valsartan therapy August 2015-March 2018. The primary outcome included the incidence of hypotensive events during hospitalization. Secondary outcomes included: incidence of inpatient acute kidney injury (AKI) and hyperkalemia, rates of inpatient discontinuation, and change in ejection fraction (EF) ≥30 days after initiation. Results: Of the 59 patients included, 21 (35.6%) experienced a hypotensive event. A total of 6 patients (10.2%) discontinued therapy while inpatient, which was more likely in patients that developed AKI (n = 3; p = 0.005) or those who experienced a hypotensive event (n = 5; p = 0.018). There was a significant difference in mean EF from baseline to ≥ 30 days post-initiation (24.8% vs. 33.2%; p = 0.018). Conclusion: Careful patient selection and monitoring for hypotension, AKI, and hyperkalemia can help increase successful outcomes and improve patient safety.

Background: Several studies have demonstrated a patient preference for physicians wearing a white coat associated with improved patient satisfaction. There are few studies on physicians’ perceptions of attire mainly done in the outpatient and surgical specialties. Objective: Assess non-surgical physicians’ perception of attire in the hospital and to identify if any difference in the choice of attire amongst generation X and millennial physicians. Methods: We surveyed 86 physicians in the hospital with six sets of pictures of commonly worn physician attires in the hospital setting with a two-part questionnaire. Key Results: Formal attire with a white coat was found to be most favored, followed by formal without a white coat. Casual attire without a white coat was the least preferred across the surveyed attributes. The results were similar in generation X and millennial physicians. Only 49% concordance was observed with what physicians preferred and what they wore. Conclusion: Our study showed that physicians felt wearing a white coat was the best to convey specific attributes like honesty, confidence, professionalism, among others, similar to prior studies done in patients. However, less than half of the physicians surveyed themselves followed the preferred attire.

Background: Thrombophilia tests are often ordered unnecessarily and/or inappropriately, with significant impact on healthcare costs, hospital resources, time, and potential harm to the patient. Objective: To identify the incidence of unnecessary and inappropriate thrombophilia testing in a community hospital setting. Methods: We retrospectively reviewed electronic medical records for patients who underwent inpatient thrombophilia testing at The Brooklyn Hospital Center from 1/1/2018 to 12/31/2018. The indications, and details of the tests, and associated costs were recorded. Results: A total of 62 patients were included (mean age 45.8, 67.7% female). In 57/62 (91.9%) patients, tests were ordered in the acute phase of thrombosis. At the time the tests were ordered, 29/62 (46.8%) patients were on anticoagulation. Positive results were found in 21/62 (53.2%) patients, but was repeated in only 1/21 (4.7%) patient. Results for 51/62 (82%) patients were obtained after discharge. The hematology-oncology service was consulted in 5/62 (8.1%) cases and recommended testing in only 1 (1.6%) patient. Only 1 (1.6%) patient had both an appropriate indication and appropriate testing. Costs for the 273 total tests were $26,400. Conclusion: Thrombophilia tests were often ordered inappropriately and unnecessarily. We recommend testing only for patients with inpatient status under recommendation from the hematology-oncology service.

Background: Although the prevalence of overweight and obesity (OW/OB) has increased in the last three decades, studies show that these conditions are sub-optimally documented by physicians. Health information technology tools have varying effects on improving documentation of OW/OB but often have to be complemented with other interventions to be effective. Objective: Upon identifying low rates of documentation of diagnoses of overweight and obesity by resident and attending physicians, despite the use of an electronic health record (EHR) with automated BMI calculations, we performed a quality improvement (QI) project to improve documentation of these diagnoses for patients in our community hospital primary care clinic. Methods: The EHR was reviewed to determine documentation rates by resident and attending physicians between 1 March 2018 and 31 September 2018. We collected pre-intervention data, developed interventions, and implemented tests of change using Plan-Do-Study-Act (PDSA) cycles to improve documentation of OW/OB. Results: Documentation of overweight and obesity diagnoses increased from a baseline of 46% to 79% over a 20-week period after initiation of our project. Conclusion: We demonstrate the successful implementation of resident-led, multi-faceted interventions in a team-based QI project to optimize documentation of OW/OB in the EHR.

The use of bedside ultrasound over the past few decades has created a new wave of options for visualizing pathological processes allowing for faster and better detection of disease. We aimed to evaluate the reliability of focused cardiac ultrasound (FCU) performed by first-year internal medicine residents at a community hospital after a short period of training. They received a two-hour lecture and initially performed a supervised FCU followed by ten unsupervised/independent FCUs each. The four parameters that were assessed were left systolic ventricular function, right systolic ventricular function, presence of pericardial effusion, and presence of IVC dilation. Interpretation and analysis of ultrasound images were then carried out by both the residents and an attending physician with expertise in FCU analysis and interpretation. Cohen’s Kappa values were obtained comparing the results found by the interns versus the attending. Our findings indicate that more training is required for reliable analysis of FCU by first-year medical residents. Our results also emphasize the need to carefully evaluate the medical residents’ FCU skills after the training.

Hypernatremia affects up to 9% of critically ill patients upon hospital admission, especially in elderly patients with thirst impairment. However, hypernatremia is not entirely explained by fluid imbalance. Recent studies suggest that sodium is an important enhancer of the immune system, raising the question of whether inflammatory states such as sepsis may contribute to hypernatremia. Although sepsis patients with hypernatremia face a greater mortality rate, there is a lack of studies examining a potential association between hypernatremia and sepsis. Motivated by the frequent concurrence of hypernatremia and sepsis observed at an eastern Pennsylvanian community hospital, the current study was conducted to evaluate whether hypernatremia on admission may serve as a potential surrogate marker for sepsis. The medical records of 153 patients with hypernatremia on admission (serum sodium > 145mEq/L) were retrospectively analyzed. The mean age of patients was 81.1. Sepsis was observed in 77.1% of patients, of which 86.2% had dementia. This study demonstrated a positive correlation between hypernatremia on admission and the presence of sepsis. We suggest that the existence of hypernatremia should prompt clinicians to further investigate for sources of infection, especially in the elderly and patients with dementia.

Background: Peer review by resident physicians, a standard evaluation technique, has rarely been studied for potential biases related to demographic and cultural characteristics of trainees. Objective: The study sought to determine whether peer evaluations were favorably biased toward trainees of similar background. Methods: This observational study was conducted in the Internal Medicine residency of a large, metropolitan, community hospital, and included all 91 Internal Medicine residents who had entered the program from 1 July 2009 thru 30 June 2017. Of 3,445 Peer Evaluation Forms (PEF)s offered, 2,922 (84%) were completed and studied. Multivariate statistical analysis was completed. The primary dependent variable was the Peer Evaluation Score (PES). Independent variables included age, gender, race, birth country and country of medical school training. Confounding variables included United States Medical Licensing Examination (USMLE) and In-Training Examination (ITE) scores, and the American Board of Internal Medicine (ABIM) yearly assessment. Results: Confounding factors accounted for most of the variation. Among the independent variables, only age difference and medical school country were statistically associated with PES. Race and Gender were not significant. Conclusions: Peer evaluations were not significantly biased by race or gender similarities and only minimally biased by age and medical school country similarities.

Introduction: Novel Corona Virus Disease 19 has created unforeseen burden on health care. New York city is one of the epicenters of pandemic and here we explore physical, mental and social impact of COVID 19 on Resident Physicians (RP) working within the center of this epicenter. Methods: This is a single-center cross-sectional web-based survey involving RP of a community hospital in Brooklyn, New York. Questionnaire was formulated in online platform. We used a convenient sampling method. Univariate analysis was conducted and presented the distribution of qualitative responses as frequency and percentages. Result: COVID19 related symptoms were reported by 39.8% RP. COVID19 IgG and IgM antibodies, both negative were reported by 34.9%, while only 6% RPs were IgG antibody positive. Symptomatic RP tested for COVID19-PCR was positive in 42.42%. Self-isolation from family during the pandemic was reported by only 14.5%. Financial constraints, lack of accommodation, and emotional reasons were main reasons of not being able to self isolate. Being bothered by ‘Anxiety’ and ‘Nervousness’ were reported by 8.5% on ‘Almost every day’ while 46.3% reported on ‘several days in the two weeks duration’. ‘Uncontrollable worrying’, ‘Feeling down’, ‘Depressed,’ or ‘Hopeless’ was reported as ‘Not at all’ by 78.8% and 3.7% reported it to ‘occur nearly every day for the last two weeks’. Conclusion: Aftermath of fight against pandemic has left RP with significant physical, mental, and social impact. Appropriate stress management and safety interventions are urgently needed. Further studies are needed to explore the detailed impact of COIV19 on RP.

The outbreak related to SARS-CoV-2 or COVID-19 has been classified as a pandemic. Many healthcare institutions enacted policies to limit the spread within their facility. As hospitals begin to return to normal particularly with elective procedures, a common concern is how an organization should react in the event that healthcare workers test positive for COVID-19. When our organization had a cluster of positive inpatient healthcare workers, we elected to test all direct patient care healthcare workers. Through this process we learned two valuable lessons that have redefined our practice: 1) the recognition that aggressive contact tracing provides greater yield than testing everyone and 2) organizations must implement effective social distancing both within each department and how departments interact with each other to limit the scope of contract tracing.

With this issue, we complete volume 8 of the Journal of Community Hospital Internal Medicine Perspectives – JCHIMP. In this perspective piece we discuss the many achievements of our journal, including the journals our articles have been cited in, the increasing number of downloads, and the importance of our reviewers.

Objective: The objective of this study was to review the impact of an automatic email notification to infectious disease consultants. Design: Cases were identified from a community hospital system microbiology database by at least one positive blood culture. Records were reviewed both before (2013 and 2014) and after (2015 and 2016) the implementation of the automated email system (intervention). Prior to this policy, consultation with the infectious disease (ID) specialist was at the discretion of the primary team. Results: There were no significant differences in 30-day mortality between the two groups (18 vs 20%, p = 0.10). However, a trend of shorter hospital stays (12.2 vs 9.5 days, p = 0.03) and reduced 30 day readmissions (40% vs 19%, p = 0.03) was observed and antibiotics prescribed for complicated cases was more appropriate (57% vs 85%, p = 0.004). Conclusions: In this study population, the implementation of an automatic email generator to ID specialists was associated with a shorter hospital length of stay, less 30-day readmissions and more appropriate length of antibiotics prescribed in complicated cases of SAB. The authors recommend future studies replicating the methodology employed here with larger sample sizes before consideration of employing a similar automatic email ID consult generation at other health systems.

Introduction: Only 12% of Americans have proficient health literacy (HL). Patients hide this fact from others including physicians. This quality improvement (QI) project was developed to compare internal medicine (IM) resident physicians’ (RPs) ability to accurately predict patients with low HL and to improve IM-RPs’ understanding of low HL and its impact on patients. Aim statement: Over six-months, our aim was to increase the IM residents’ HL-knowledge by 30% as measured by an HL-Knowledge-Based-Survey. Methods: After IRB exemption, patients visiting the residency-clinic within a two-week period were screened for low HL with the REALM-R, a validated tool. Post-visit, IM-RPs were asked to predict their patients’ HL. A comparison of predicted-HL and measured-HL was made. IM-RPs were emailed an HL-Knowledge-Based-Survey (pre-education and post-education) to measure their background knowledge of HL. Education included HL-workshop, pre-clinic conference and lectures. Pre-education and post-education scores were compared. Results: HL-RPs’ prediction and patients’ REALM-R results were completed by 108 RP-patient pairs. IM-RPs correctly identified 5 of 40 patients who were at risk for low HL (sensitivity = 12.5%). They correctly identified 97.1% of 68 who were not at risk (specificity = 97.1%). Our residents’ knowledge pre-education and post-education did not improve – 58% (n = 18) vs 62% (n = 10). Conclusion: Our QI result verified that IM-RPs overestimate patients’ HL and do not understand the magnitude or consequences of low HL nor techniques to improve such patients’ understanding. This suggests an area for residency curricular development in order to improve patients’ ability to navigate the healthcare system successfully.

Background: Population-based studies are the gold standard to understand the burden of different diseases, plan health care policy and resource allocation, and provide an accurate estimate of disease several disease indices including mortality. However, population-based studies are difficult to undertake in a resource-limited situation where no robust data bases and disease registries are available. Therefore, hospital-based cohorts may be used to inform about the community health. Objectives: We sought to study the pattern of disease causing admission, hospital stay, and outcomes of medical admissions to King Abdullah Hospital in Bisha in order to inform clinicians, public health professionals, and policymakers about the current status of diseases within the community in Bisha. Methods:This is a cross-sectional study including all adult patients aged above 18 years who were admitted to King Abdullah Hospital in Bisha, Assir region, to medical services including general internal medicine, general cardiology, nephrology, gastroenterology, rheumatology, and neurology during the study period between 1 June 2015 and 31 May 2016. Common causes of hospital admission, outcomes of hospitalization, and length of stay were estimated and the data were presented as frequency and percentage for categorical valve and mean and standard deviation for continuous variables. Results: Cardiovascular diseases including stroke are considered the leading cause of hospital admission in a teaching community hospital in Bisha, Assir region. Diabetes mellitus and hypertension are prevalent comorbidities among hospitalized patients. Majority of admitted patients have improved and discharged home (83.3%). However, 6.7% were transferred to another facility, 4.1% have left against medical advice, and 5.9% died. Conclusion: Health-related data bases and disease registries are urgently needed to precisely estimate the burden of cardiovascular disease in Assir region in Saudi Arabia. Lifestyle changes, healthy diet, aggressive management of hypertension and diabetes within the community, and allocating necessary resources are urgently to combat the growing burden of cardiovascular disease.

Background: Insomnia is common in hospitalized patients. However, no study has examined new onset of insomnia in patients without a prior history of insomnia. Objectives: Incidence of new onset of insomnia in inpatients, associated factors and resolution rate after 2 weeks. Method: This is a prospective observational study conducted at a community hospital. We used the Insomnia Severity Index questionnaire to screen for insomnia in all patients located in the general medical floors from day 3 to day 5 of their hospital stay. We excluded patients with a prior insomnia history. Results: Out of the 205 patients who met the inclusion criteria, 75 patients (36%) reported insomnia. Severe insomnia was present in 3% of patients. Difficulty in maintaining sleep is the most common symptom. Frequent staff disruptions due to blood draws and vital signs checks were reported by 68% as the cause of insomnia, followed by illness associated causes (64%) and sleep disruption due to noise and or brightness (23%). Patients with insomnia had more awakenings due to noise, brightness, and staff interruptions than those without insomnia (1.35 times vs. 0.9 times, p = 0.027). Patients with respiratory symptoms, cardiac monitoring, oxygen use, private rooms, and no sedative use did not have a higher insomnia risk. Patients with insomnia had significant lower satisfaction scores than patients without insomnia (4.53 vs. 4.05, p = 0.001) but did not have a different length of stay (6.18 vs. 6.19, p = 0.97). In 31% of patients with insomnia who were able to be contacted two weeks after discharge, 75% of them had insomnia resolution. Conclusion: New onset of insomnia occurred in 36% of hospitalized patients. Most common causes are staff disruption and disease symptoms. It was usually short-term and could decrease patients’ satisfaction score.

Objectives: Neuroimaging is contributing to the rising costs of dizziness evaluation. This study examined the rate of central neurological causes of dizziness, relevant clinical predictors, and the costs and diagnostic yields of neuroimaging in dizziness assessment. Methods: We retrospectively reviewed the records of 521 adult patients who visited the hospital during a 12-month period with dizziness as the chief complaint. Clinical findings were analyzed using Fisher’s exact test to determine how they correlated with central neurological causes of dizziness identified by neuroimaging. Costs and diagnostic yields of neuroimaging were calculated. Results: Of the 521 patients, 1.5% had dizziness produced by central neurological causes. Gait abnormalities, limb ataxia, diabetes mellitus, and the existence of multiple neurological findings predicted central causes. Cases were associated with gait abnormalities, limb ataxia, diabetes mellitus, and the existence of multiple neurological findings . Brain computed tomography (CT) and magnetic resonance imaging (MRI) were performed in 42% and 9.5% of the examined cases, respectively, with diagnostic yields of 3.6% and 12%, respectively. Nine cases of dizziness were diagnosed from 269 brain scans, costing $607 914. Conclusion: Clinical evaluation can predict the presence of central neurological causes of dizziness, whereas neuroimaging is a costly and low-yield approach. Guidelines are needed for physicians, regarding the appropriateness of ordering neuroimaging studies. Abbreviations: OR: odds ratio; CI: confidence interval; ED: emergency department; CT: computed tomography; MRI: magnetic resonance imaging; HINTS: Head impulse, Nystagmus, Test of skew

Aim: To evaluate the prevalence and longitudinal changes of prolonged QTc in DM patients admitted to our community hospital, and to determine, if any, its correlation with changes of left ventricular ejection fraction (LVEF). Methods: A retrospective chart review of patients with Type 1 (T1DM) and Type 2 (T2DM) with at least two admissions during a four-year period was performed to identify QTc interval, and LVEF, as measured on transthoracic echocardiogram. Changes in QTc and LVEF between patient hospital admissions were compared. Results: A prolonged QTc interval was found in 66.7% (n = 24) of type 1 and 51.3% (n = 154) type 2 diabetic patients. The QTc interval is progressively increased in both type 1 and type 2 diabetes during follow-up, although it did not reach statistical significance. A total of 62% patients (23 out 37 patients) had a reduction of LVEF during follow-up. Conclusion and Discussion: High prevalence of QTc prolongation was confirmed in hospitalized patients with in both T1DM and T2DM. Significant reduction of LVEF correlated with QTc prolongation over a mean of 17.3 months in T2DM patients, and may have implications for interventions. Abbreviations CHF: Congestive heart failure LVEF: Left ventricular ejection fraction

Community hospitals with limited resources struggle to engage physicians in Quality improvement initiatives. We introduced Quality Improvement (QI) curriculum for residents in response to ACGME requirements and surveyed the residents understanding of QI and their involvement in QI projects before and after the introduction of the curriculum. The current article describes our experiences with the process, the challenges and possible solutions to have a successful resident led QI initiative in a community hospital. Methods: A formal QI curriculum was introduced in the Department of Internal Medicine from September to October 2015 using the Model for Improvement from Institute for Health care Improvement (IHI). Learners were expected to read the online modules, discuss in small group sessions and later encouraged to draft their QI projects using the Charter form and PDSA form available on the HI website. Online surveys were conducted a week prior and 3 months after completion of the curriculum Results: 80% (100/117) of residents completed the pre-curriculum survey and 52% (61/117) completed the survey post curriculum. 96.7% of residents report that physicians should lead QI projects and training rather than the hospital administrators. Residents had 20% increase in understanding and confidence in leading quality improvement projects post curriculum once initiated. Most Residents (72%) feel QI should be taught during residency. Active involvement of residents with interest was seen after the initiation of Open School Institute of health improvement (IHI) curriculum as compared to Institutional led QI’s. The resident interventions, pitfalls with change processes with an example of PDSA cycle are discussed. Conclusion: A Dedicated QI curriculum is necessary to prepare the physicians deliver quality care in an increasing complex health care delivery system. The strength of the curriculum is the ease of understanding the material, easily available to all, and can be easily replicated in a Community Hospital program with limited resources. Participation in QI by residents may promote constructive competitiveness among related hospitals in public system to improve delivery of safe care. Abbreviations: ACGME: Accreditation Council for Graduate Medical Education; IHI: Institute of Healthcare Improvement; PDSA: Plan-Do-Study-Act; PGY: QI: Quality improvement

Background : Takotsubo cardiomyopathy (TTC) is characterized by reversible left ventricular dysfunction, frequently precipitated by a stressful event. Despite the favorable course and good long-term prognosis, a variety of complications may occur in the acute phase of the disease. The aim of this study was to evaluate the in-hospital and long-term outcomes of a cohort of TTC patients. Methods : Fifty-five patients (mean age 68.1±12 years) were prospectively followed for a mean of 69.6±32.2 months (64,635 days). In-hospital (death, heart failure, arrhythmias) and long-term events (death and recurrences) were recorded. Results : Patients were predominantly women (87.3%) who experienced a recent stressful event (emotional or physical) and were admitted to hospital for chest pain. Eleven patients (20%) had a diagnosis of depressive disorder, and arterial hypertension was the most frequent cardiovascular risk factor. The ECG revealed ST-segment elevation in 43.6% of patients. At angiography, seven cases (12.7%) had at least one significant (≥50%) coronary artery stenosis and four patients (7.3%) had myocardial bridging of the left anterior descending artery. During hospitalization, three patients died (one from cardiac causes) and cardiovascular complications occurred in 12 patients. During follow-up, five patients died (none from cardiac causes), six patients had recurrences within the first year. Two patients had two recurrences: one after 114 days, triggered by an asthma attack as the first event, and the other after 1,850 days. Conclusions : In TTC patients, in-hospital and long-term mortality is primarily due to non-cardiovascular causes. Recurrences are not infrequent and coronary artery disease is not an uncommon finding. Keywords: coronary artery disease; follow-up study; recurrence; Takotsubo cardiomyopathy (Published: 6 July 2016) Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6 : 31082 - http://dx.doi.org/10.3402/jchimp.v6.31082

Background : Screening adult patients for obesity and offering appropriate counseling and treatment for weight loss is recommended. However, many healthcare providers feel ill-equipped to address this topic. Objective : We examined whether didactic presentations lead to increased obesity documentation and counseling among internal medicine (IM) residents. Methods : We reviewed medical records of patients seen at the IM Resident Continuity Clinic during April 2015. Residents were provided feedback at two didactic presentations during May 2015. To examine the effect of this intervention, we repeated medical record review during June 2015. For both reviews, we abstracted patient-specific (i.e., age, body mass index [BMI], race, sex, and number of comorbid diagnoses) and resident-specific (i.e., sex and training level) data as well as evidence of obesity documentation and counseling. We used logistic regression models to examine the effect of intervention on obesity documentation and counseling, adjusting for patient- and resident-specific variables. Results : Of the 278 patients with BMI≥30 kg/m 2 , 139 were seen before and 139 after the intervention. Intervention had no effect on obesity documentation or counseling with or without adjustment for confounding variables (both P >0.05). In adjusted post-hoc analyses, each additional comorbidity increased the odds of obesity documentation by 8% (OR=1.08; 95% CI=1.05–1.11; P

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is an organism causing significant mortality and morbidity with nosocomial infections. Ceftaroline is a new cephalosporin antibiotic that has activity against MRSA. In the USA, this antibiotic has not been approved for use in pneumonia caused by MRSA. Objectives: To review the use of ceftaroline in MRSA pneumonia in a US hospital and evaluate its clinical success. Methods: A retrospective study was conducted in an urban community hospital assessing the use of ceftaroline for MRSA pneumonia. Results: The clinical success was comparable to the currently approved treatment for MRSA pneumonia. Conclusion: The results of our study showed a favorable result for the treatment of MRSA pneumonia. Well-designed studies need to be performed for further validation of these results.

Background: Hospitalized patients with diabetes are at risk of complications and longer length of stay (LOS). Inpatient Diabetes Management Services (IDMS) are known to be beneficial; however, their impact on patient care measures in community, non-teaching hospitals, is unknown. Objectives: To evaluate whether co-managing patients with diabetes by the IDMS team reduces LOS and 30-day readmission rate (30DR). Methods: This retrospective quality improvement cohort study analyzed LOS and 30DR among patients with diabetes admitted to a community hospital. The IDMS medical team consisted of an endocrinologist, nurse practitioner, and diabetes educator. The comparison group consisted of hospitalized patients with diabetes under standard care of attending physicians (mostly internal medicine-trained hospitalists). The relationship between study groups and outcome variables was assessed using Generalized Estimating Equation models. Results: 4,654 patients with diabetes (70.8 ± 0.2 years old) were admitted between January 2016 and May 2017. The IDMS team co-managed 18.3% of patients, mostly with higher severity of illness scores (p

Background: Resident physicians are known to be infrequent reporters of patient safety events (PSE). Previous studies assessing barriers to resident PSE reporting have not considered possible cultural barriers faced by international medical graduates (IMG). This study aimed to assess the knowledge and attitudes of residents regarding PSE and possible barriers contributing to poor resident reporting. Methods: A cross sectional survey of all house staff undergoing post-graduate residency training at two independent community hospital based academic medical centers was conducted through an online questionnaire. Sample case vignettes were created to assess the residents’ ability to identify safety events and classify them as near miss, adverse events or sentinel events and decide whether they were reportable. Results: The Reporting of PSE increased significantly by year of residency training (p

Introduction: The aim of our study is to determine the clinical, biochemical, and imaging factors that affect the duration of hospital stay in patients admitted with normotensive acute pulmonary embolism. Methods: This was a single-center retrospective study conducted in a community hospital in New York metropolitan area for patients admitted from October 2015 to October 2017. Results: A total of 79 patients were included, the mean age was 55.76 (SD = 17.33), 29 cases were males (37%) and 50 cases were females (63%). Among all patients, 17 cases had short length of stay (LOS) (≤2 days) and 62 cases had long LOS (>2 days). There were statistically significant differences in age (p = .041), presence of lung disease (p = .036), number of comorbidities (p = .043), and pulmonary embolism severity index (PESI) scores (original and simplified; p = .002 and .001, respectively). Logistic regression analysis showed that PESI score significantly predicted long LOS (OR 1.067, 95% CI [1.001, 1.137], p = .048). Similarly, sPESI significantly predicted long LOS (OR 0.223, 95% CI [0.050, 0.999], p = .050). Both regression models were adjusted for age, lung disease, and number of comorbidities. Conclusion: Both original and simplified PESI scores were statistically significant predictors of duration of hospital stay. Patients with multiple comorbidities or with chronic lung disease were also likely to have prolonged hospital stay. None of the cardiac biomarkers affected the duration of hospital stay, neither did the presence of right ventricular dysfunction nor treatment modality.

Background : Sepsis is one of the leading causes of death in the United States and the most common cause of death among critically ill patients in non-coronary intensive care units. Previous studies have showed pulse pressure (PP) to be a predictor of fluid responsiveness in patients with sepsis. Additionally, previous studies have correlated PP to cardiovascular risk factors and increase in mortality in end-stage renal disease patients. Objectives : To determine the correlation between PP and mortality in patients with sepsis. Methods : A retrospective review was conducted on 5,003 patients admitted with the diagnosis of sepsis using ICD-9 codes during the time period from January 2010 to December 2014 at two community-based hospitals in central Pennsylvania. Results : Our study findings showed significant decrease in the mortality when the PP was greater than 70 mmHg of patients with sepsis ( p -value: 0.0003, odds ratio: 0.67, 95% confidence limit: 0.54–0.83). Conclusion : Based on our findings, we suggest that PP could be a valuable clinical tool in the early assessment of patients admitted with sepsis and could be used as a prognostic factor to assess and implement management therapy for the patients with sepsis. Keywords: sepsis; pulse pressure; septic shock; sepsis mortality; sepsis therapy (Published: 11 December 2015) Citation: Journal of Community Hospital Internal Medicine Perspectives 2015, 5 : 29426 - http://dx.doi.org/10.3402/jchimp.v5.29426

Type 1 diabetes mellitus (T1DM) is an autoimmune condition that results in low plasma insulin levels by destruction of beta cells of the pancreas. As part of the natural progression of this disease, some patients regain beta cell activity transiently. This period is often referred to as the ‘honeymoon period’ or remission of T1DM. During this period, patients manifest improved glycemic control with reduced or no use of insulin or anti-diabetic medications. The incidence rates of remission and duration of remission is extremely variable. Various factors seem to influence the remission rates and duration. These include but are not limited to C-peptide level, serum bicarbonate level at the time of diagnosis, duration of T1DM symptoms, haemoglobin A1C (HbA1C) levels at the time of diagnosis, sex, and age of the patient. Mechanism of remission is not clearly understood. Extensive research is ongoing in regard to the possible prevention and reversal of T1DM. However, most of the studies that showed positive results were small and uncontrolled. We present a 32-year-old newly diagnosed T1DM patient who presented with diabetic ketoacidosis (DKA) and HbA1C of 12.7%. She was on basal bolus insulin regimen for the first 4 months after diagnosis. Later, she stopped taking insulin and other anti-diabetic medications due to compliance and logistical issues. Eleven months after diagnosis, her HbA1C spontaneously improved to 5.6%. Currently (14 months after T1DM diagnosis), she is still in complete remission, not requiring insulin therapy. Keywords: Type 1 diabetes mellitus; honeymoon period; spontaneous complete remission; partial remission (Published: 19 October 2015) Citation: Journal of Community Hospital Internal Medicine Perspectives 2015, 5 : 28709 - http://dx.doi.org/10.3402/jchimp.v5.28709

Background : Contrast-induced nephropathy (CIN) remains a leading cause of acute renal failure in hospitalized patients. N -Acetylcysteine has been studied previously for the prevention of CIN, resulting in mixed findings. Objective : The objective of this study was to determine the impact of N -acetylcysteine on the development of CIN in order to guide its use at community, teaching hospitals. Methods : Patients admitted between January 1 and December 31, 2011, receiving intravenous radiocontrast dye were included if they were compliant with two or more of the following conditions: baseline serum creatinine >1.2 mg/dL or estimated creatinine clearance

A 41-year-old female was brought to the ER after a presyncope and absence episode while riding a bike. She recalled no prodromi. Her physical and neurological examinations were unremarkable; past medical, family, substance, and travel history bland. She reported a constant tiredness, sporadic slight cephalgia, responsive to acetaminophen, and a recent syncope while jogging, resulting in a fall, circumstances of which she could not recall. Non-compaction cardiomyopathy is a type of cardiomyopathy that was first described 25 years ago. Its molecular genetic basis is not yet fully clear, and the same is true of its diagnosis, treatment, and prognosis. Further study of these matters is needed. Keywords: non-compaction cardiomyopathy; orthostase; presyncope; syncope; trabeculations; cardiac MRI (Published: 15 June 2015) Citation: Journal of Community Hospital Internal Medicine Perspectives 2015, 5 : 27699 - http://dx.doi.org/10.3402/jchimp.v5.27699

A formal high value, cost-conscious care (HVCCC) curriculum was implemented at a community hospital-based university-affiliated residency program starting January 1, 2014, based on the recommendations of the American Board of Internal Medicine’s (ABIM) Choosing Wisely campaign. The program included a competition requiring each resident to write a HVCCC case based on an actual patient experience. Residents completed a questionnaire assessing their understanding of HVCCC near the end of the program. Residents subsequently reviewed two actual cases that had vividly described unexpected adverse outcomes (‘anecdotal’ cases). Postexposure data were collected and the results were analyzed. Keywords: high value; cost-conscious care; defensive medicine; anecdotes (Published: 15 June 2015) Citation: Journal of Community Hospital Internal Medicine Perspectives 2015, 5 : 27089 - http://dx.doi.org/10.3402/jchimp.v5.27089

Background and objective : Severe adverse events such as cardiac arrest and death are often heralded by abnormal vital signs hours before the event. This necessitates an organized track and trigger approach of early recognition and response to subtle changes in a patient's condition. The Modified Early Warning System (MEWS) is one of such systems that use temperature, blood pressure, pulse, respiratory rate, and level of consciousness with each progressive higher score triggering an action. Root cause analysis for mortalities in our institute has led to the implementation of MEWS in an effort to improve patient outcomes. Here we discuss our experience and the impact of MEWS implementation on patient care at our community academic hospital. Methods : MEWS was implemented in a protocolized manner in June 2013. The following data were collected from non-ICU wards on a monthly basis from January 2010 to June 2014: 1) number of rapid response teams (RRTs) per 100 patient-days (100PD); 2) number of cardiopulmonary arrests ‘Code Blue’ per 100PD; and 3) result of each RRT and Code Blue (RRT progressed to Code Blue, higher level of care, ICU transfer, etc.). Overall inpatient mortality data were also analyzed. Results : Since the implementation of MEWS, the number of RRT has increased from 0.24 per 100PD in 2011 to 0.38 per 100PD in 2013, and 0.48 per 100PD in 2014. The percentage of RRTs that progressed to Code Blue, an indicator of poor outcome of RRT, has been decreasing. In contrast, the numbers of Code Blue in non-ICU floors has been progressively decreasing from 0.05 per 100PD in 2011 to 0.02 per 100PD in 2013 and 2014. These improved clinical outcomes are associated with a decline of overall inpatient mortality rate from 2.3% in 2011 to 1.5% in 2013 and 1.2% in 2014. Conclusions : Implementation of MEWS in our institute has led to higher rapid response system utilization but lower cardiopulmonary arrest events; this is associated with a lower mortality rate, and improved patient safety and clinical outcomes. We recommend the widespread use of MEWS to improve patient outcomes. Keywords: Modified Early Warning System; mortality; rapid response system; patient safety (Published: 1 April 2015) Citation: Journal of Community Hospital Internal Medicine Perspectives 2015, 5 : 26716 - http://dx.doi.org/10.3402/jchimp.v5.26716

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of disability and death worldwide. COPD exacerbation is usually treated with antibiotics, systemic corticosteroids, and inhaled bronchodilators. We present a case of recurrent COPD exacerbation that was treated repeatedly with standard therapy. Dynamic expiratory computed tomography of the chest was done, which revealed concomitant tracheomalacia. COPD and tracheomalacia may coexist during recurrent exacerbations of COPD, and delayed diagnosis can be associated with severe comorbidities. Ordering the appropriate imaging may aid in the correct diagnosis and facilitate appropriate management. Keywords: chronic obstructive lung disease; tracheomalacia; dynamic computed tomography; bronchoscopy; pulmonary function tests (Published: 15 December 2016) Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6 : 33540 - http://dx.doi.org/10.3402/jchimp.v6.33540

No abstract available! (Published: 25 November 2014) Citation: Journal of Community Hospital Internal Medicine Perspectives 2014, 4 : 26425 - http://dx.doi.org/10.3402/jchimp.v4.26425

Background : Transfer of clinic patients from graduating residents to interns or junior residents occurs every year, affecting large numbers of patients. Breaches in care continuity may occur, with potential for risk to patient safety. Several guidelines have been developed for implementing standardized inpatient sign-outs, but no specific guidelines exist for outpatient handover. Methods : Residents in primary care programs – internal medicine, family medicine, and pediatrics – at a US academic medical center were invited to participate in an online survey. The invitation was extended approximately 2 years after electronic medical record (EMR) rollout began at the institution. Results : Of 71 eligible residents, 22 (31%) responded to the survey. Of these, 18 felt that handover of ambulatory patients was at least moderately important – but only one affirmed the existence of a system for handover. IM residents perceived that they had the highest proportion of high-risk patients ( p =0.042); transition-of-care letters were more important to IM residents than other respondents ( p =0.041). Conclusion : There is room for improvement in resident acknowledgement of handover processes in continuity clinics. In this study, IM residents attached greater importance to a specific handover tool than other primary care residents. Thus, the different primary care specialties may need to have different handover tools available to them within a shared EMR system. Keywords: post graduate year; internal medicine; residents; ambulatory care; graduate medical education; patient handoff (Published: 25 November 2014) Citation: Journal of Community Hospital Internal Medicine Perspectives 2014, 4 : 25087 - http://dx.doi.org/10.3402/jchimp.v4.25087

Laparoscopic adjustable gastric banding (LAGB) is an increasingly common therapeutic option in the management of obesity and certain obesity-related comorbid conditions. As it gains popularity for its advantages of being minimally invasive and reversible, clinicians should be aware of growing evidence of esophageal and pulmonary complications, which may be irreversible and associated with long-term morbidity. We report a case of esophageal and pulmonary complications in a patient with successful weight loss after lap-band surgery necessitating its removal. Keywords : Morbid obesity; obesity surgery; laparoscopic adjustable gastric banding; aspiration pneumonia (Published: 31 July 2014) Citation : Journal of Community Hospital Internal Medicine Perspectives 2014, 4 : 24461 - http://dx.doi.org/10.3402/jchimp.v4.24461

Objective : The objective of this paper was to propose an algorithm for approaching hypertensive hemodialysis patients admitted to the hospital for hypertensive urgency. Methods : A literature search was conducted using PubMed (Medline). Articles selected were limited to humans and the English language. Results : We identified eight management modalities including: short-daily and nocturnal dialysis, sodium restriction, sodium profiling, antihypertensive medications, sympathetic denervation, bilateral nephrectomy, and bioimpedance spectroscopy. The benefits and drawbacks of each were investigated and discussed before implementation into the algorithm. Discussion : The algorithm presented suggests a linear approach to patient care, but treatment modalities may not be mutually exclusive, and additional factors, such as patient compliance and individual health status, should be taken into account to provide patients with optimum care. Keywords : hypertension; hemodialysis; algorithm; sodium dialysate; anti-hypertensive medication (Published: 31 July 2014) Citation : Journal of Community Hospital Internal Medicine Perspectives 2014, 4 : 24055 - http://dx.doi.org/10.3402/jchimp.v4.24055

Background : In current state of practice, disease severity assessment for Clostridium difficile infection (CDI) lacks consensus between different organizations. In the latest guidelines for management of CDI, authors have proposed a new disease severity classification. This classification has been derived from expert opinion and includes previously reported patient related factors that predict unfavorable outcome in CDI. Objective : To evaluate the performance of new disease severity classification to predict CDI-related colectomy or in-patient deaths. Methods : This observational study was performed at a 300-bed community hospital catering to a suburban population. All the adult patients discharged during October 2005 through September 2012 and diagnosed with CDI were included in the study. Cases of CDI were identified using the billing database. Demographic and clinical characteristics of CDI cases were extracted from medical chart reviews performed by two physician researchers. Cases were classified as mild-to-moderate, severe, or severe and complicated CDI. Major outcomes measured were in-patient deaths and colectomy attributed to CDI. For risk stratification, each variable of severe and complicated CDI was counted. Results : In total, 59,897 patients were discharged from our hospital during the study period; 894 of them were diagnosed with CDI. Mean age of CDI cases was 74 years (standard deviation 15 years), 345 (39%) were male, and median length of hospital stay was 7 days (interquartile range 4–13). One hundred ninety-one patients (21%) were classified as mild-to-moderate, 93 patients (10%) as severe, and 610 patients (68%) as severe and complicated. In total, 14 patients underwent colectomy for CDI and 53 patients expired. In 35 of these patients, the cause of death was thought to be CDI. The combined outcome (CDI-related colectomy and/or death in hospital) occurred in 47 patients. None of the patients in mild-to-moderate disease or severe disease had combined outcome. On severe and complicated cases, as the score increased, rate of combined outcome increased significantly ( z −12.7, p