Hepatopulmonary syndrome in a 22 year old gentleman with liver cirrhosis

Background: Hepatopulmonary syndrome is a severe complication of end-stage liver disease characterized by triad of liver disease, intrapulmonary vascular dilatation, and arterial hypoxemia. Although the pathogenesis is not completely understood, pulmonary vascular dilatation occurs due to imbalance between vasodilators and vasoconstrictors. Liver injury is thought to increase endothelin production and cause bacterial translocation, causing increased nitric oxide production, causing vasodilation of pulmonary vasculature. History and physical examination are important in leading the physician to the correct diagnosis as the majority of these patients present with non-specific clinical manifestations and imaging. Identification of specific physical exam findings is important in not missing key features of a patient’s physical exam which will give you direction to a diagnosis of hepatopulmonary syndrome. Case Presentation: We are presenting a 22-year-old hispanic male with past medical history of nonalcoholic steatohepatitis-related liver cirrhosis with evidence of portal hypertensive gastropathy with esophageal varices who presented with intermittent dyspnea and desaturation. Physical exam did not have overt signs of volume overload and was positive for platypnea and orthodeoxia. ABG revealed hypoxemia with PaO2 of 66 and orthodeoxia. Diagnosis of hepatopulmonary syndrome was confirmed with contrast Echo ordered which revealed normal ejection fraction and showed R to L shunting by agitated saline contrast. The patient was managed with medical and oxygen therapy. He was discharged home on oxygen therapy as he improved. Patient evaluated by a hepatologist outpatient and placed on the liver transplant list. Discussion: Hepatopulmonary syndrome can often be missed due to its nonspecific presentation. Dyspnea is its most common presenting symptom. However, being aware of other presenting symptoms are key to diagnosis; such as platypnea and orthodeoxia, as present in our case. Obtaining Echo with contrast is important as it will confirm the presence of an intrapulmonary shunt. Differentiating an intracardiac shunt vs intrapulmonary shunt is important. With an intracardiac shunt, contrast appears in the left heart within three heart beats after injection, however, with an intrapulmonary shunt, contrast appears in the left heart after three beats as in our patient. Once diagnosed, oxygen therapy is recommended. Liver transplantation is the only effective therapy

Takotsubo Cardiomyopathy, presentation as a cardiac arrest in a 67 year old female with depression and anxiety history

Background: Takotsubo cardiomyopathy also known as broken heart syndrome or stress induced cardiomyopathy is a sudden transient reversible dramatic left ventricular apical akinesis mimicking acute coronary syndrome, making it a diagnostic challenge. Most common mechanism for Taktosubo is stress induced catecholamine release causing sympathetic activation leading to microvascular dysfunction or direct toxicity. Mayo Clinic Criteria for making diagnosis at the time of presentation requires 1) transient hypokinesis, dyskinesis, or akinesis of the LV midsegments with or without apical involvement, and a stressful trigger is often but not always present. 2) absence of obstructive coronary disease or angiographic evidence of acute plaque rupture 3) new ECG abnormalities (either ST segment elevation and or T wave inversion) 4) absence of pheochromocytoma or myocarditis. Case presentation: A sixty-seven year old Hispanic woman with past medical history of depression and anxiety, presented to emergency department with generalized body weakness, chronic severe lower back pain. In emergency department, patient experienced cardiac arrest with return of spontaneous circulation achieved in 5 mins, was intubated for airway protection. Electrocardiogram showed sinus tachycardia with elevated cardiac troponins. Echocardiogram revealed large area of akinesis involving mid anteroseptal, lateral wall, inferoapical; severe left ventricular dysfunction with ejection fraction 30-35%. She was found to have pulmonary edema and was started on vasopressors, heparin drip, and aggressive diuresis for cardiogenic shock. Imaging negative. Eventually she was able to be weaned off vasopressor support and extubated. Her repeat echo three days later revealed improved left ventricular systolic function with ejection fraction of 45-50%. Patient underwent left heart catheterization which demonstrated no significant obstructive coronary disease. Patient improved clinically and was discharged to a skilled nursing facility for rehabilitation on beta blocker and angiotensin receptor blocker. Discussion: The exact etiology of our patient’s arrest remains unknown. Early suspicion and use of Mayo clinic criteria at time of presentation is important especially in patients with a history of psychiatric disorders as there is a high rate of recurrence and complications reported among them. Our patient has a history of anxiety and depression, which can be considered precipitating factors predisposing the patient to a stress induced cardiomyopathy

Improving colon cancer screening/referrals based on current guidelines in an underserved area outpatient clinic.

Background: In 2021 in the US there was an estimated 1.8 million new cases of cancer and 600,000 cancer death, that means 5200 new cases per day and 1670 deaths. CRC is the 4th most common cancer diagnosed among adults and the 2ndleading cause of death from cancer. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool- based test or a structural (visual) examination, depending on patient preference and test availability. Screening with any one of multiple options is associated with a significant reduction in CRC. Objectives: The primary objective was to show that the intervention of choice leads to an improvement of percentage of the appropriate colorectal screening significantly. We also, wanted to educate residents and improve awareness of current guidelines for CRC screening. Methods: We designed a prospective, interventional study and compared the percentage of patients screened or referred for screening older than 45 years old, before and after the intervention over a six-month period. Inclusion criteria were all Hispanic and non-Hispanic, at the age of 45 to 75 seeing in the clinic from January 1st, 2021, to July 1st, 2021.The initial and primary intervention was as ground round about Colorectal cancer screening on 08/25/21. The secondary intervention were informative flyers at the dictation and conference room at the clinic about FOBTx3, FIT and Colonoscopy options for screening. The expected duration of project was a year. Results: Pre intervention, the percentage of patients screened were about 50.09%, after our intervention the percentage increased to 60.49% with a p value of 0.0006

Implementation of a Quality Improvement Project for Medical Reconciliation: Outcomes in a Primary Care Residency Clinic

Background: Medication reconciliation is the process of creating the most accurate list of medications a patient is taking and comparing it against the physician’s admission, and discharge orders. It is an effective intervention to prevent drug-related events which are the leading cause of medical errors. Medical reconciliation training promotes patient safety and is imperative for a better transition of care. Methods: We implemented a quality improvement project to promote awareness of medication reconciliation. We aimed to increase compliance of medication to 80% in 3 months and maintain it through March 2021. Our interventions consisted in reminders to prompt residents to perform medication reconciliation. As an independent reviewer, our clinic manager shared a monthly metric reports for the number of missed medication reconciliations. Results: Prior to our intervention, our percentage of medication reconciliation was 62% (August 2020). Following our intervention, the compliance increased to 82% in November 2020 and, in December, it peaked at 90%. At the end of our intervention, medication reconciliation plateaued at 85% (April 2021). Conclusions: Our quality improvement project increased resident and staff awareness of medication reconciliation. We maintained medication reconciliation above 80% from January 2021 to March 2021. In addition, we identified barriers in the process that were not recognized before including issues related with equipment, workflow and environment. Our intervention allowed for accountability because residents were monthly informed about their own performance. Our initiative allowed for development and self-improvement during training which, ultimately, might result in less medical errors

Participant Satisfaction and Investigator Assessment of Collagenase Clostridium Histolyticum Injection as a Nonsurgical Intralesional Treatment Option for Plantar Fibromatosis

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: Currently, there is no safe and efficacious injectable therapy for symptomatic plantar fibromatosis (PFi) that addresses its pathophysiology. Patients with PFi nodules experience symptoms that reduce quality of life, causing functional disability leading to severe impairment in some patients. Collagenase clostridium histolyticum (CCH) is approved for Dupuytren’s and Peyronie’s disease treatment, which are both fibroproliferative disorders that may coexist in patients with PFi. This first study of CCH treatment for PFi evaluated participant satisfaction and investigator assessment of improvement. Methods: Participants were randomly allocated (1:1:1) in this Phase 1, multicenter study to receive 0.6, 1.2, or 2.25 mg/mL CCH. All participants underwent the initial treatment period (ITP) and received 1–2 intralesional injections per nodule on Day 1 with follow-up assessments at specified intervals. Participants with palpable treated nodules could enter the retreatment period (RP) and receive additional CCH doses (at 2.25 mg/mL), with follow-up at specified intervals. Assessments included the Subject Satisfaction with Treatment Rating Scale (+2: very satisfied; to -2: very dissatisfied), and the Investigator Assessment of Improvement Scale (+3: very much improvement; to -3: very much worse). Results: After ITP, ≥75% of participants reported “very” or “quite” satisfied across all treatment groups, with 2.25 mg/mL group reporting 100% satisfaction. For ≥72.7% of nodules, participants reported satisfaction with outcome. Investigators reported improvement (“minimal”, “much”, or “very much”) in ≥75% of participants and ≥80% of treated nodules. After RP, 63.6% of participants reported treatment satisfaction; participants were satisfied with 66.7% of treated nodules, indicating continued improvement from the ITP. Almost all participants (90.9%) were deemed by investigators to have shown improvement, with 86.7% of treated nodules being assessed as having improvement. Conclusion: CCH-treated PFi participants were satisfied with their improvement; physicians assessed improvement in >90% of participants. Results indicate CCH as a potential nonsurgical intralesional option for PFi treatment

Efficacy of Collagenase Clostridium Histolyticum Injection, a Potential Nonsurgical Intralesional Treatment Option for Plantar Fibromatosis: A Randomized, Open-Label, Dose-Ranging Study

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: Plantar fibromatosis (PFi) is characterized by collagen-containing nodules on the foot along the plantar fascia that can cause pain and functional disability. Current treatments focus on symptom relief, which may become ineffective, or surgery, which can have lengthy recovery times. Collagenase clostridium histolyticum (CCH) is approved for Dupuytren’s and Peyronie’s disease treatment, which are both fibroproliferative disorders that may coexist in patients with PFi. This dose-ranging study assessed the efficacy and safety of CCH treatment of PFi. Methods: In this Phase 1, multicenter study, participants were randomly allocated (1:1:1) to receive 0.6, 1.2, or 2.25 mg/mL CCH. All participants underwent the initial treatment period (ITP) and received 1–2 intralesional injections per nodule on Day 1 with 5 follow-up assessments. Participants with palpable treated nodules could receive additional CCH doses (at 2.25 mg/mL; retreatment period, RP), with follow-up at specified intervals. Assessments included a 5-scale measure of nodule hardness (0 [nonpalpable] to 4 [hard]), and the Foot Function Index-Short Form23 (FFI-SF23) reported as a composite score (0 – 100) of 3 subscale scores (disability, difficulty, and pain subscales). Results: After ITP (n=24), 100% (8/8) of participants receiving 2.25 mg/mL CCH showed improvement in nodule hardness, compared with 87.5% (7/8) and 75% (6/8) of participants receiving 1.2 and 0.6 mg/mL, respectively. FFI-SF23 also showed a negative change from baseline across treatment groups, indicating improvement. Participants that received 2.25 mg/mL reported the largest percent improvement (-83.7%). After RP (n=11), 81.8% (9/11) of participants showed improvement in nodular hardness and an FFI-SF23 score change of -9.3%, indicating further improvement from baseline after ITP. CCH had a consistent safety profile in ITP/RP. Conclusion: CCH caused dose-dependent improvement of nodule hardness after treatment, with 2.25 mg/mL utilized for nodule retreatment; FFI-SF23 scores correlated with this finding, indicating CCH may be a potential nonsurgical intralesional option for PFi treatment