Tough Decisions During the COVID 19 Pandemic: A Frail Latino Patient

The pandemic of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had overwhelmed the healthcare system worldwide with multiple ethical dilemmas. Several tools have been used to assess risk factors in these patients. One of them, the Clinical Frailty scale, has shown good correlation between the patient functional status and hospital stay with overall mortality. We present a case were the Clinical Frailty Scale was used to assess patient management and goals of care

End of Life Decision-Making Challenges in a Latino Patient with COVID-19: Facing Barriers

COVID-19 pandemic brought difficult scenarios that patients and families are facing about end- of-life decisions. This exposed some weak areas in the healthcare system where we can continue improve in reducing disparities and emphasizing advance care planning from a primary level of care. We present a case of challenges in end-of-life decision-making in a Latino patient

Factor V Leiden and its Association with Vascular Disease and Treatment in a Latino patient

Introduction: Factor V Leiden (FVL) is the most common hereditary thrombophilia, and a single amino acid mutation renders Factor V resistant to inactivation by Activated Protein C resulting in a prothrombotic state. The association between FVL and vascular disease has been reported and debated. We present a case of a patient with FVL and its repercussion on medical treatment. Case Description: A 64-year old Hispanic man with a past medical history of coronary artery bypass grafting, Type 2 diabetes mellitus, hypertension and severe peripheral vascular disease with history of left above the knee amputation presented to the emergency department with severe, sharp right upper back pain that radiated to his chest for one day. It was not associated with fever, shortness of breath, or palpitations. He reported taking apixaban for the last three years however he was unsure of the indication. He denied smoking, prolonged inactivity or travel. Vital signs included a temperature of 97.7o F, heart rate of 97 bpm, respiratory rate of 17 breaths/min, blood pressure of 140/86 mmHg, and BMI of 28. Physical exam was remarkable for right paraspinal tenderness of the upper back upon palpation. Coagulation profile showed PT 15.8, INR 1.33, PTT 37.0. Patient was at moderate risk for a pulmonary embolism (PE) using the Wells’ Score. A PE was noted on CT angiography and bilateral non-occlusive proximal deep vein thromboses (DVTs) of the right deep femoral vein, the left common and superficial femoral veins were found on venous doppler. The cardiac echocardiography showed no evidence of right heart strain and troponins were negative. He was initially started on a heparin drip and two liters of oxygen nasal cannula in the emergency room and was transitioned to enoxaparin after admission. On genetic analysis, it was found that the patient was heterozygous for the FVL (R506Q) variant in the Factor V gene. Protein C and Protein S levels were normal. Given failed anticoagulation therapy, an IVC filter was placed. Apixaban was changed to rivaroxaban and the patient was discharged home with close follow up. Conclusion: Our patient with an extensive history of CAD and PAD was found to be heterozygous for FVL after presenting with a PE and bilateral DVTs despite anticoagulation. The EINSTEIN EXT trial found that there was an 82% relative risk reduction in recurrent DVT in patients who received rivaroxaban compared to placebo and acetylsalicylic acid. The AMPLIFY-EXT trial found a 64% relative risk reduction for recurrent VTE in patients who received apixaban compared to placebo. Previous studies have shown that FVL is associated with increased severity of CAD and PAD however the pathophysiology is unclear. It has been hypothesized that long-term anticoagulation may prevent severe progression of PAD and CAD in patients with FVL however it is unknown whether anticoagulation would have prevented progression of vascular disease in our patient. In patients with CAD and PAD with venous thromboembolism despite anticoagulation, screening for FVL may be warranted for appropriate anticoagulation management

An Unusual Case of Campylobacter jejuni Gastroenteritis Presenting with Acute Reversible Encephalopathy in an Immunocompetent Host

Campylobacter jejuni gastroenteritis is the most frequent organism associated with acute infectious diarrhea worldwide. (e clinical presentation involves fever, diarrhea, rigors, and myalgias. Other extraintestinal symptoms that have been described involve delirium and other neurological complications, and the most well-known is Guillain-Barr´e, where there is cross-reactivity between the gastrointestinal tract and the brain. Despite previously described multiple neurological complications, there is a lack of clinical data on the association of Campylobacter-related gastroenteritis with acute encephalopathy in immunocompetent patients. (e type of population, immunocompetent stage, and unfamiliarity with the clinical presentation makes this a challenging diagnosis for clinicians. We report a case of Campylobacter gastroenteritis associated with acute encephalopathy in an immunocompetent patient

Metabolic control in patients with type 2 diabetes mellitus in a public hospital in Peru: a cross-sectional study in a low-middle income country

Objective The objective of this study was to assess patients’ achievement of ADA (American Diabetes Association) guideline recommendations for glycosylated hemoglobin, lipid profile, and blood pressure in a type 2 diabetes mellitus (T2DM) outpatient clinic in a low-middle income country (LMIC) setting. Methods This is a descriptive cross-sectional study with 123 ambulatory T2DM patients who are being treated at a public hospital in Lima, Peru. Data was gathered via standardized interviews, clinical surveys, and anthropomorphic measurements for each patient. Blood samples were drawn in fasting state for measures of glucose, glycosylated hemoglobin (HbA1c), and lipid profile. Laboratory parameters and blood pressure were evaluated according to ADA recommendations. Results Of the 123 patients, 81 were women and the mean age was 61.8 years. Glycemic control was abnormal in 82 (68.33%) participants, and 45 (37.50%) were unable to control their blood pressure. Lipid profile was abnormal in 73 (60.83%) participants. Only nine (7.50%) participants fulfilled ADA recommendations for glycemic, blood pressure, and lipid control. Conclusions Amongst individuals with type 2 diabetes, there was poor attainment of the ADA recommendations (HbA1c, blood pressure and LDL-cholesterol) for ambulatory T2DM patients. Interventions are urgently needed in order to prevent long-term diabetic complications

Getting Ahead: A Resident Led Quality Improvement Project to Increase Diabetic Nephropathy Screening in an Underserved Hispanic-Predominant Population

Introduction: Diabetes is the leading cause of end-stage renal disease (ESRD) in the United States (US), with 37 million having chronic kidney disease. Despite national guidelines recommendations for diabetic nephropathy screening with urine albumin-to-creatinine ratio (UACR), less than 50% receive full screening. Our Internal Medicine residents led a quality improvement project to increase diabetic nephropathy screening rate with UACR in our resident clinic by 50% in one academic year. Methods: We conducted the resident-led quality improvement project from July 2021 to April 2022. We reviewed the electronic medical records (EMR) from our clinic pre-intervention July 2020 to June 2021 and compared this to post intervention July 2021 to March 2022 determining the nephropathy screening rates in patients with diabetes. Our interventions included resident education, pre and post surveys to test foundational knowledge, adding UACR in the affordable laboratory order form and establishing normal reference range of UACR in the EMR. Results: We collected 217 patients with diabetes, 27% were uninsured, 38% had Medicare/Medicaid and 90% identified as Hispanic. Comparing pre to post intervention, there was a significant change of 45 (20.7%) vs 71 (32.7%) patients screened for diabetic nephropathy with a UACR. The correct average score of knowledge-based questions was 82% on the pre survey, which increased to 88% in the post survey. Conclusion: Our study showed promising results on improving diabetic nephropathy screening. The comprehensive approach including resident education about diabetic nephropathy screening with UACR and more so facilitating the order set in the EMR were key to achieve this goal

A Resident Led Quality Improvement Project to Increase Diabetic Nephropathy Screening in an Underserved Hispanic-Predominant Population

Background: Diabetes is the leading cause of end-stage renal disease (ESRD) in the United States, with 37 million having chronic kidney disease. Unfortunately, despite guidelines recommendations from the American Diabetes Association and the Kidney Disease Improving Global Outcomes for diabetic nephropathy, screening with urine albumin-to-creatinine ratio (UACR) and annual estimated glomerular filtration rate (eGFR), there is still poor screening rates throughout the country. Our aim is to increase the screening for type 2 diabetic nephropathy in our GME Internal Medicine clinic. Methods: Our group of 10 Internal Medicine residents and 2 faculty advisors conducted this project from July 2021 to April 2022. We used the electronic medical record (EMR) to determine the screening rates in patients with diabetes using UACR. Our interventions included resident education, adding reference range of UACR in the EMR, highlighting abnormal results of UACR in the EMR, and including UACR in the low-cost wellness laboratory order form. We calculated the probability ratio and attributable probability of being screened after the intervention and used a pre and post survey to assess resident knowledge. Analysis was performed with Stata version 17.0. Results:We included 217 patients with diabetes from which90% identified as Hispanic. Comparing pre and post intervention, there was a significant change of 45 (20.7%) vs 71 (32.7%) patients screened for diabetic nephropathy with a UACR. The probability ratio for being screened before intervention was 1.6 (95%CI 1.2, 2.1; p=0.003). If screening only completed in the post-intervention period the probability ratio increased to 3.2 (95%CI 2.4, 4.3; p Conclusion: Through education, EMR optimization and updates to the low-cost lab order form, our resident-led quality improvement project increased screening for diabetic nephropathy from 20.7% to 32.7%which reached our goal of 50% increase. We found the resident-led QI project to be feasible and effective even in an underinsured and high-risk Hispanic population