Dietary Sodium Intake: Perceptions of an Urban Heart Failure Population

Background: Dietary sodium restriction is a mainstay of disease management and self-care in heart failure (HF). Heart failure education programs that include recommendations on limiting sodium intake are fairly variable across centers and populations. A clear assessment is lacking on efficacy of such programs in enhancing levels of patient understanding regarding recommendations on sodium intake and knowledge of sodium content in commonly consumed food items. This pilot study was designed to assess the knowledge pertaining to sodium-restricted diets in underserved, at-risk patients with chronic, stable HF at an urban, academic center. Methods: Adult English-speaking patients with either stable, chronic HF reduced ejection fraction (HFREF) or HF preserved ejection fraction (HFPEF) were included. Baseline characteristics such as demographics, knowledge of HF self-care including understanding of sodium intake and related health implications were collected. Subsequently, a pictorial survey was administered that asked participants to categorize food items into high-, medium- or low-sodium based on the FDA-recommended daily sodium intake of 2.4g. Unordered Pearson chi-square tests were performed for differences between each group. Results: A total of 24 participants (mean age 57.3, 58.3% male, 75% HFREF) participated in the survey. Seventy-five percent of participants had a high-school or equivalent level education and 25% had an advanced degree. Participants were able to accurately categorize foods into high-, moderate-, or low-sodium categories 74%, 36% and 63% of the time, respectively (respective 95% confidence intervals 0.69-0.79, 0.29-0.43, 0.56-0.63). These percentages differed significantly from each other (p Conclusions: Understanding of dietary sodium intake varies significantly among HF patients. Despite intensive HF education, patients were not able to accurately identify sodium content in appropriate categories. Further research is needed on barriers to understanding of dietary education and its effect on outcomes

Use of Macros for Improvement of Speed and Quality: Ensuring Accurate and Timely Patient Documentation

This study hopes to increase the speed and quality of resident documentation at GW Hospital by expanding the use of macros at George Washington University Hospital’s general cardiology service. The project will focus on medical residents who are rotating on the Gold Team service (general cardiology service). A baseline survey was recently administered to query residents regarding time spent on writing comprehensive discharge instruction sheets for patients, self-assessed quality of discharge instructions written, and baseline use of macros templates. Macros templates for discharge instructions for the most common Gold Team diagnoses (heart failure exacerbation, non-cardiac chest pain, myocardial infarction, and syncope) will be composed by the study investigators under guidance and approval from cardiology attendings. The principle investigators will also compare discharge instructions before and after the intervention by randomly selecting 4 discharges per each of 8 Gold Team residents at baseline, and 4 discharges per each of 8 Gold Team residents during the intervention period. The instructions will be graded using a standard discharge grading form that is currently used in the Department of Medicine discharge clinic for rotating residents and has been validated in the literature. Each discharge instruction sheet will be graded by both investigators, and discrepancies will be resolved by discussion to consensus

The Rarest of Rare: Unlikely Presentation of Dermatofibrosarcoma Protuberans

A 31-year-old female presented to the emergency department following witnessed syncope. At the time of admission, she reported that she had a “small mass” on the left thigh that was previously excised in 2006 only to return two years later. Over the last three to four weeks, she noted rapid expansion, with associated discomfort, bleeding, and even functional impairment due to its size. On exam, the patient was febrile to 101F, sinus tachycardia to the 120s, and hypotensive 90/55 mmHg. Initial labs were noteworthy for leukocytosis of 15k as well as low hemoglobin and hematocrit of 7.2 g/dL and 24 respectively. The physical exam highlighted a 13cm x 16cm x 7cm, necrotic, ulcerating mass on the left hip. MRI imaging revealed a 13 cm x 13 cm heterogeneously enhancing mass along the left hip and thigh, indicating rapid progression from the 7.5 cm x 6 cm mass seen on a 2015 MRI. Management for acute blood loss included crystalloid and colloid products and initiation of broad spectrum antibiotic for a superimposed soft tissue infection. Histopathology highlighted a storiform pattern of monotonous, slender highly atypical, spindle shaped cells with focal regions of fibrosarcomatous change that demonstrated a fascicular, herringbone pattern of growth, consistent with Dermatofibrosarcoma protuberans. The patient underwent wide resection and flap reconstruction without adjunctive radio or chemotherapy per her preference. Dermatofibrosarcoma protuberans is a rare soft tissue tumor that arises from the dermis and accounts for approximately 2 percent of all soft tissue sarcomas and less than 0.1 percent of all malignancies. The infiltrative soft tissue tumor is locally aggressive and has an increased probability to recur or metastasize if not resected with disease free margins. While rare to be evaluated and diagnosed in the outpatient setting, it is even more uncommon to have syncope as the presenting complaint for a soft tissue tumor. At the time of presentation, the size, associated functional impairment and resulting hemodynamic instability required immediate medical intervention and subsequent surgical treatment, highlighting this case as an extreme example of this tumor’s aggressive nature