Enhancing the rates of advance directive documentation to improve the quality of patient care

Introduction Advance Directives (AD) allow patients to maintain autonomy during incapacitation. Patients and their caregivers benefit from these documents in times of crisis. Overcoming barriers to AD completion and documentation can improve patient care quality. Methods A retrospective chart review was performed initially, after consolidation of the electronic health record (EHR) and after alteration of the EHR, to evaluate the availability of a patient’s medical power of attorney (MPOA), living will (LW), and code status. Results Baseline documentation of MPOA (7.33%), LW (6.00%), and code status (5.33%) within the outpatient EHR was low. After 2 cycles, this improved to 13.10%, 13.10%, and 36.55%, respectively. Improvement in code status documentation was statistically significant (p=\u3c0.00001). Conclusion Altering the EHR can improve the rates of AD documentation. Further interventions in the EHR should include easily accessible documents and address other barriers, including educating both patients and providers

Alpha-Gal Allergy: a new threat to Appalachia

Abstract Alpha-gal allergy, or mammalian meat allergy, is described as the development of IgE antibodies to the oligosaccharide galactose-a-1,3-galactose following a bite from the tick species Amblyomma americanum (Lone Star tick) or Dermacentor variabillis (Wood tick). Dermatologic or gastrointestinal symptoms are usually delayed by four to six hours after exposure, making the diagnosis difficult. Due to the use of mammalian proteins in many common medications, surgical equipment and prosthesis, unexpected reactions can occur. In the United States, this pathology is predominately seen in the southeast, but has been associated with other tick species on every continent except Antarctica. As the habitat for Amblyomma and Dermacentor continues to move further north due to changing patterns in deer population and weather, incidence of alpha-gal syndrome has increased in the states outside its normal southeastern locale, especially in people with occupations and hobbies that require time outdoors in wooded areas

Velamentous Cord: A Dangerous Case Complicated by a Rural Population

A velamentous cord insertion occurs when the umbilical cord’s Wharton jelly fails to reach the placenta, due to early placental atrophy around the insertion site, leaving a segment of unprotected vessels running through the thin membranes of the amniotic sac. This area of weakness exposes a threat to the well-being of the fetus through acute hemorrhage and both acute and chronic restriction of nutrition. With advances in technology, resolution capabilities of ultrasounds allow for antenatal diagnosis, when previously this was impossible. With this knowledge, considerations for screening and management of this pathology are essential when dealing with a rural population that has barriers to accessing health care

Succenturiate Placental Lobe Abruption: a placental pathology complicating a dangerous delivery

The development of a placenta is a complex process that occurs without a clinically significant issue in most pregnancies. At times, however, the process develops in a way that isolates an island of placental tissue away from the main body, connected only by unprotected vasculature within the amniotic membranes. The vessels of this succenturiate lobe of the placenta are vulnerable both to compression or laceration, threatening the antepartum period with poor weight gain or the peripartum period with fetal distress, hemorrhage or retained products of conception. A majority of the time, this pathology is undiagnosed until recognized innocuously following delivery of the placenta. A placental abruption is a premature separation of the placenta from the uterus that can result in painful bleeding and fetal distress. This increased distress of mother or baby from continued blood loss usually necessitates delivery either vaginally, if stability is maintained, or by cesarean if it isn’t. The amount of distress correlates to where and how much of the placenta is affected. While succenturiate lobes of the placenta and placental abruptions are not routinely associated with each other, the abruption of only the succenturiate lobe of the placenta in this instance minimized the severity to the fetus, by allowing the main body of the placenta to remain intact. As the bleeding coagulated at the lobe, maternal well-being was maintained allowing enough time to complete a vaginal delivery

Pigmentary and Other Dermatologic Manifestations of Minocycline: a reminder of adverse effects

The applications of the tetracycline class of antibiotics extends beyond their antimicrobial activity to anti-inflammatory, immunosuppressive and neuroprotective applications making it a commonly used class of medication. Minocycline, a second generation tetracycline, has inherent characteristics that improve absorption and distribution. These benefits promote even more wide spread use. This familiarity of usage breeds prescriptive complacency toward the dermatologic complications including hyperpigmentation. The following case explores these adverse manifestations of Minocycline use

Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) in a Patient with Diabetes: a primary care perspective

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a recurrent and progressive disease that causes proximal, symmetrical extremity weakness. The disease is diagnosed using clinical features, electrophysiologic testing, albumino-cytological disassociation in the cerebrospinal fluid, and sural nerve plexus biopsy. However, because of the low sensitivity of diagnostic criteria and other similar neuropathies, including diabetic polyneuropathy (DPN), accurate diagnosis is difficult. Differentiating between these diseases is especially important as CIDP’s changes are reversible and DPN’s are not. Making this differentiation allows for symptomatic improvement in a patient’s quality of life that would not be achieved otherwise. Early recognition and treatment, with modalities including corticosteroids, plasmapheresis, and IVIG, demonstrate improvement in a majority of patients. Primary care physicians (PCP) encounter patients with diabetes daily. It is important for PCPs to have a level of familiarity with CIDP to best care for those patients

Diabetic Muscle Infarction: A Rare End-Organ Vascular Complication of Diabetes

Diabetic muscle infarction (DMI) is a rare microvascular complication of spontaneous ischemic necrosis of skeletal muscle in patients with poorly controlled diabetes. We herein describe the case of a 26-year-old woman with a history of type I diabetes and accompanying diabetic microvascular complications of neuropathy, nephropathy and retinopathy, who presented with sudden onset of swelling and sharp pain in her bilateral thighs. T2-weighted MRI imaging revealed subcutaneous edema and sub-fascial, hyper-intense enhancement of proximal thigh musculature. DMI has a relatively non-specific clinical presentation; therefore, physician awareness is key for early diagnosis, as aggressive management has been associated with poor patient outcomes. With poor long-term prognosis and high reoccurrence, DMI acts as an indicator of vascular end-organ damage