Unique case of cocaine induced TMA and renal infarction mimicking atypical HUS

Introduction: Cocaine use has known association with fatal medical complications, including myocardial ischemia, cerebrovascular accident, and kidney injury secondary to ischemia, rhabdomyolisis, and malignant hypertension. However, cocaine induced Thrombotic microangiopathy (TMA) and renal infarction is a rare entity that has not been described in the literature except in few case reports. Case Presentation: A 24-year-old female with a past medical history of alcohol and cocaine abuse was admitted with alcoholic induced acute pancreatitis and acute anuric renal injury. She developed microangiopathic hemolytic anemia, thrombocytopenia, and neurologic symptoms including headache and blurry vision which were concerning for TMA versus atypical hemolytic uremic syndrome (HUS). Her labs showed creatinine 7 mg/dL with a baseline of 0.7–0.9 mg/Dl, thrombocytopenia (PLT 40), schistocytes on peripheral smear, a drop in hemoglobin (from 9 to 5.6 g/Dl), with elevated total bilirubin 3.2 g/dL and LDH 3400. She was started on plasma exchange and IV mehtylprednisone for presumptive diagnosis of Thrombotic thrombocytopenic purpura (TTP). ADAMTS13 level was 86 which is normal, therefore TTP was ruled out. Complement level was low shifting the diagnosis toward atypical HUS and the patient was started on Eculizumab. Further workup include immunologic work-up including ANA, CCP, RF, CRP, C3/ C4, myeloperoxidase AB, and proteinase-3 AB which were all unremarkable. Lupus anticoagulant was positive. Finally the patient underwent kidney biopsy once her platelet count improved and the final report showed evidence of ATN, ischemic necrosis, focal interstitial hemorrhage, and infarcts most likely due to cocaine induced TMA. Conclusion: Cocaine induced renal TMA should be suspected in patients with heavy use of cocaine who presents with a new onset Acute Kidney Injury. There is also emerging evidence that cocaine can activate complements and causes hypo-complementemia seen in our patient

Positive Impact on Patient Satisfaction and Caregiver Identification Using Team Facecards: A Quality Improvement Study

Background: Patients satisfaction is an increasingly important metric in measuring the quality of care that hospitals and physicians provide. It can be difficult for patients to remember their providers and their roles, all of which may potentially impact a patient’s overall satisfaction. Purpose: To see if giving facecards with pictures and names of caregivers and description of roles improved patient satisfaction and identification of care team members. Methods: Team facecards were designed and distributed to the patients during the interventional period of the study. Patients’ identification of team members, the role of each physician and overall satisfaction was measured using a longitudinal prospective survey. Patients in the control arm of the study took the same survey but did not receive team facecards. Results: A total of 192 patients completed the survey. They were divided into a control group (n = 96, 50%) and an interventional group (n = 96, 50%) during the period of the study (February 2016–August 2016). Patients who received the intervention were more likely to identify: their team attending (71 [74%] in the interventional group vs [34.4%] in the control group; P \u3c 0.001); team resident (40 [40.7%] in the interventional group vs 25 [26%] in the control group; P = 0.0222); team intern (42 [43.8%] in the interventional group vs 19 [19.8%] in the control group; P = 0.0004). Patients in the interventional group reported slightly higher level of satisfaction (72 [75%] reported level of satisfaction \u3e 9 on a scale of 1 to 10 in the interventional group vs 59 [61.5%] in the control group). Conclusion: Use of facecards improves patient identification of primary team members and roles; however, patients still lack enough knowledge of provider roles. Use of facecards showed a slight improvement on overall patient satisfaction