An Unusual Case of Chronic Superior Mesenteric Vein Thrombosis

Introduction:Intestinal ischemia can be caused by any process that reduces intestinal blood flow. Mesenteric venous thrombosis (MVT) describes thrombosis of the superior or inferior mesenteric vein, and represents approximately 10 percent of all cases of acute mesenteric ischemia. The incidence of MVT has increased over the past 40 years, likely as a result of greater use of abdominal CT, and may present with acute abdominal pain or as an asymptomatic incidental finding on abdominal imaging. We present a rare and unusual case of MVT. Case presentation: A 42 year old female with decompensated alcoholic liver cirrhosis presented to the ED with severe RLQ pain associated with nausea and nonbloody emesis. She had a pulse of 130, BP of 102/47 and temperature of 102.5. Physical exam demonstrated a mildly distended abdomen with tenderness to palpation of the right upper and lower quadrants, and a negative fluid wave shift. Lactic acid on admission was 3.9. She was resuscitated with IV fluids and started on broad spectrum antibiotics. Blood cultures on admission grew E. coli. Lactic acid continued to rise despite fluid replacement and antibiotics, and her pain did not subside. A CT abdomen & pelvis with contrast was ordered for concern of acute appendicitis, and was notable for thickening of the terminal ileum with a normal caliber appendix. Her lactic acid peaked at 6.7, and concern arose for mesenteric ischemia. A CT angiography abdomen & pelvis was done revealing a chronic occlusion of the central superior mesenteric vein, with cavernous transformation. The patient’s lactic acid improved, and she remained hemodynamically well compensated despite no intervention pursued for her MVT after involving GI and IR. She was eventually discharged in stable condition. Discussion: Two large series demonstrated that chronic MVT accounts for 24% to 40% of total cases of MVT. Our patient had the rarer chronic MVT in the setting of suspected mesenteric ischemia, however, this was likely an incidental finding and was not the source of her pain. Our case highlights the importance of acknowledging the different presentations of MVT such that investigation and management is not confounded by the rarity of the pathology

Patient Safety Workshop: A Graduate Medical Education Interprofessional Simulation Half-Day

Introduction: As per the National Academy of Medicine, patient safety is considered indistinguishable from the delivery of quality health care, and is referred to as the foundation upon which all other aspects of quality care are built. Throughout the years, graduate medical education (GME) across the world has evolved to ensure the training of future medical professionals includes exposure to many of the elements that compose patient safety, such as implementing root cause analysis, systems thinking, and disclosing adverse events. University of Texas Rio Grande Valley (UTRGV) is the sponsoring institution for 19 GME programs across different specialties. As part of the orientation for their respective residencies, the GME office designed a workshop to introduce patient safety concepts and skills. We conducted a quality improvement project to assess the workshop and identify strengths and areas for improvement. Methods: The GME Office, with chief residents, program leaders and pharmacy faculty, developed and delivered a multidisciplinary simulation workshop involving internal medicine, family medicine, general surgery, psychiatry, and pharmacy residents spanning 4 hours during resident orientation period June 21-23, 2022. We created groups of 4-6 learners with mixed disciplines. Interventions focused on: (1) root cause analysis; (2) disclosure of patient safety events; (3) identifying patient safety hazards in the inpatient setting; (4) interdisciplinary communication skills. The workshop will include the use of small-group discussion, mannequins, reflection and role modeling. Participants will complete an anonymous pre and post survey to determine the effect of the workshop and seek improvements in GME at UTRGV. Discussion: Patient safety training and education of health care professionals have not kept pace with advances in patient safety or workforce requirements. Internal and national surveys show that residencies struggle to meet competencies in patient safety, quality improvement, and accountability as required by the ACGME. This inaugural UTRGV GME Office patient safety interprofessional simulation workshop attempts to address and enhance the knowledge and confidence surrounding patient safety concepts. Results will include and pre and post survey evaluations of the workshop and identify next steps

Quality Improvement Project to Increase Hepatitis C Virus Screening for Ambulatory GME Internal Medicine Clinic Patients

Background: In 2020, CDC established new guideline expanding Hepatitis C virus (HCV) screening to all adults aged 18 to 79 years. Our QI project objective is to enhance HCV screening amongst the UTRGV-DHR IM department by establishing suitable reminders and educational sessions. Methods: We reviewed HCV screening status of all adult patients 18 to 79 years old from June 1st 2020 to December 1st 2020. We then provided one lecture on the new screening recommendation from CDC 2020 guideline. We also encouraged residents to educate patients on the importance of HCV screening, and to identify and overcome barriers against screening. We then measured HCV screening performed from March 1st 2021 to May 1st 2021. The primary objective is to increase HCV screening in the ambulatory setting by 50%. Results: Among 843 patients from June 1st 2020 to December 1st 2020, 219 patients were screened for HCV (26%). The results from March 1st 2021 to May 1st 2021 was 190 out 548 patients (35%). The difference was significant with p-value of 0.0005 using Chi-square statistical analysis. Conclusions: Even though we did not achieve our primary objective, HCV screening performance in our clinic had increased significantly from 26% to 35%. With this positive result, we will continue to enhance awareness among the residents by implementing didactic lectures to support evidence –based medicine practice about HCV screening. It is also important to identify the drawbacks of HCV screening including stress on patients and their family, future costs and side-effects of further testing and treatments

Enhancing appropriate statin therapy in Type 2 Diabetic patients aged between 40-75 years at Graduate Medical Education (GME) Internal Medicine clinic

Background: The prevalence of type 2 diabetes mellitus (T2DM) is significantly higher in Rio Grande Valley than the rest of the United States. T2DM patients have an elevated risk of Atherosclerotic cardiovascular disease (ASCVD), and clinical trials have demonstrated the beneficial effects of statin therapy on ASCVD. A quality-improvement project was implemented in the GME Internal Medicine (IM) Clinic at Doctors Hospital at Renaissance to improve statin therapy appropriateness. Methods: T2DM patients aged 40-75 were selected from the GME IM Clinic visits from July 2021 to October 2021 for baseline data and from January 2022 to April 2022 after implementing our interventions, which included education of the new practice guidelines of statin therapy in T2DM to the internal medicine residents, as well as development of a clinical decision support tool designed to assess the indication and intensity of statin therapy. Exclusion criteria included patients without T2DM, ages above 75/below 40 years of age, and missing information for ASCVD risk stratification. Statin appropriateness was determined according to the American Diabetes Association standards in diabetes management. Results: The number of patients in the four months after the exclusions pre-intervention and post-intervention were 153 and 207, respectively. Overall, 71.9% (n=110) of the patients pre-intervention were receiving an appropriate statin therapy; the number increased to 80% (n=166) post-intervention (p = 0.003), considered statistically significant using t-test analysis. Of the total patients (N=43) with inappropriate statin therapy, 37% (n=16) had inadequate dose, and 63% (n=27) were not receiving any statin in the pre-intervention cohort. This percentage of inadequate statin dose and no statin therapy decreased to 65% (n=27) and 35% (n=14), respectively post-intervention. Conclusion: Appropriate statin therapy has been shown to reduce all-cause mortality by 19% in T2DM. Appropriateness of statin therapy was increased by 10%, and more than 50% reduction of patients without receiving any statin therapy, after our intervention. Effective implementation of new guidelines regarding risk stratification and prevention of ASCVD in T2DM age 40-75 years of age may be challenging. Barriers such as physicians\u27 adoption and knowledge regarding new guidelines can be overcome with appropriate tools and education, such as those implemented in our project