Encephalopathy Tango: When Beta-Lactam Antibiotics Waltz with GABA Receptor

Beta-lactam antibiotics are a class of drugs that are widely used to treat a variety of infections. They are generally well-tolerated, but they can cause a variety of side effects, including allergic reactions, acute interstitial nephritis (AIN) and neurotoxicity. We present a patient who developed neurotoxicity after being treated with cephalosporin and carbapenem antibiotics. A 76-year-old female was admitted to the hospital with osteomyelitis of the right foot. She was initially treated with cefepime and daptomycin. She was discharged and then began to experience delirium with visual hallucinations and acute kidney injury. After common causes of confusion were excluded, the patient was believed to have cefepime-related neurotoxicity. She was switched to ertapenem and the delirium was resolved. A few days later Ertapenem was then changed to meropenem based on pseudomonas found in culture. The patient again started to develop delirium after starting the meropenem, and the cause was believed to be meropenem-related neurotoxicity. Her confusion resolved after switching antibiotics to piperacillin-tazobactam. Beta-lactam antibiotics are associated with neurotoxicity, and risk is increased with the geriatric population, female sex, and neurological and kidney diseases. Both Cefepime and Meropenem can cause neurotoxicity and delirium. The mechanism of neurotoxicity is believed to be due to Gamma-aminobutyric acid (GABA) antagonism; Carbapenem binds to GABA receptors while Cefepime decreases GABA release from nerve terminals. Important steps in treating antibiotic-associated neurotoxicity are the withdrawal of the offending drug, use of benzodiazepine, and intermittent dialysis if no response is observed after discontinuation of the offending medication

Quality Improvement Project to increase pneumococcal vaccination rates in adults with inflammatory bowel diseases (IBD) being treated with immunosuppressants.

Abstract Patients with inflammatory bowel diseases (IBD) are at an increased risk of pneumonia, and using immunosuppressive medications further increases this risk. Hospitalized patients with IBD have a significantly higher mortality rate from infections with pneumonia being one of them. The American College of Gastroenterology recommends pneumococcal vaccination for all IBD patients as a part of preventative care for IBD patients. However, compliance rates of pneumococcal vaccination in IBD patients have been very low. Quality improvement projects in this regard have been successful at demonstrating increased immunization rates. Our quality improvement project was aimed at increasing pneumococcal vaccination rates in these adult IBD patients by establishing a process to identify eligible patients in primary care clinics. Methods: A total of 95 adult patients (under age 65) with IBD who were treated with immunosuppressants and had clinic visits in 2 primary care clinics (one internal medicine residents’ continuity clinic, and one primary care clinic without residents) from January 2010 to December 2020 were screened for their eligibility for pneumococcal vaccination and immunosuppressed status. Eligible patients were contacted via phone to schedule a clinic visit to receive pneumococcal vaccinations and reasons for refusal were documented. All the physicians, physician assistants, and nursing staff were informed of the project, and the plan was set up to identify yearly champions in each clinic whose patients are up to date with their pneumococcal vaccinations to ensure the project\u27s sustainability. Data were collected and analyzed using descriptive statistics. Fisher’s exact test compared patients with updated pneumococcal vaccination to those not up to date. McNemar’s exact test compared the before and after vaccination status. Results: A total of 95 patients (28 patients with ulcerative colitis and 67 patients with Crohn’s disease) treated with immunosuppressant medications were evaluated and only 10 patients (10%) were up to date with pneumococcal vaccination. 56 patients (58%) had not started pneumococcal vaccinations and were due to receive PCV 13 and 29 patients (30%) were due for PPSV 23. After the intervention, 32 patients (33.6%) had received pneumococcal vaccination at 6 months follow-up. 16 patients (16%) refused to get pneumococcal vaccination until after the consultation with their primary gastroenterologists and had not received the immunization at 6 months follow-up. The compliance rate of pneumococcal vaccinations was increased by 23% (p Conclusion: Patients with inflammatory bowel disease are at risk for vaccine-preventable illnesses, and pneumococcal vaccination rates are consistently low in this patient population. A simple primary care clinic-based intervention described in our project significantly improved the pneumococcal vaccination rate

Physician and Patient Moves in the Hospital Do Not Move Patient Satisfaction: A Single-Center Retrospective Analysis

Background. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey for measuring patient\u27s experiences at US hospitals. There is a shift towards geographically assigning patients and physicians. However, its impact on patient satisfaction scores has not been studied. Objective: Examine the correlation between patient experience and overall hospital rating with the number of physicians seen and the number of times the patient was moved during a hospitalization. Methods: A retrospective observational study was performed using select HCAHPS & Press Ganey survey questions to assess physician satisfaction scores and overall hospital rating and recommendation scores. Results: There was no significant difference across the select survey questions based on the number of times a patient was moved or the hospitalists seen during a hospitalization on most questions. A higher case mix index was associated with an increased likelihood of receiving the highest rating for the hospital (OR 1.39,95% CI 1.03-1.88), p 0.03), and two other physician communication questions. An increase in the length of stay was associated with a lower likelihood of receiving the highest rating for similar physician communication questions (OR 0.91, 95% CI 0.83 to 0.99,p 0.04) Conclusions: The number of hospitalists seen by the patient and the number of times a patient is moved during a hospitalization is not associated with physicians related patient satisfaction scores, overall care received in the hospital, or if the patient would recommend the hospital to others

POCUS not a HOCUS

Point of care ultrasound Outline: Clinical cases Definition of POCUS History of POCUS POCUS in UME, GME, Hospitalist medicine and literature Competency, certification Future need

Multi-model hybrid ensemble weighted adaptive approach with decision level fusion for personalized affect recognition based on visual cues

In the domain of affective computing different emotional expressions play an important role. To convey the emotional state of human emotions, facial expressions or visual cues are used as an important and primary cue. The facial expressions convey humans affective state more convincingly than any other cues. With the advancement in the deep learning techniques, the convolutional neural network (CNN) can be used to automatically extract the features from the visual cues; however variable sized and biased datasets are a vital challenge to be dealt with as far as implementation of deep models is concerned. Also, the dataset used for training the model plays a significant role in the retrieved results. In this paper, we have proposed a multi-model hybrid ensemble weighted adaptive approach with decision level fusion for personalized affect recognition based on the visual cues. We have used a CNN and pre-trained ResNet-50 model for the transfer learning. VGGFace model’s weights are used to initialize weights of ResNet50 for fine-tuning the model. The proposed system shows significant improvement in test accuracy in affective state recognition compared to the singleton CNN model developed from scratch or transfer learned model. The proposed methodology is validated on The Karolinska Directed Emotional Faces (KDEF) dataset with 77.85% accuracy. The obtained results are promising compared to the existing state of the art methods

Cost of a learner in pediatric ED

Background: Experiential learning in a cornerstone of medical education, but impacts throughput, utilization of resources and patient outcomes. Objectives: Our study sought to determine the cost of a resident across various throughput, utilization, and patient outcome measures. Methods: This retrospective study was conducted in 2016 in the pediatric emergency department of an urban tertiary care hospital. . We compared various throughput, utilization and patient outcome measures between resident-covered and nonresident–covered patients. A subgroup analysis was performed based on complexity as determined by CPT codes. Results: 33,278 patient encounters occurred between 1 January 2016, and 31 December 2016. Of these, 8,434 (25.42%) were resident-covered patients. Across all encounters, throughput, utilization and patient experience measures were unfavorable for the resident covered group. In subgroup analysis based on complexity of patients, throughput measures were either unfavorable or there was a trend towards unfavorability across all complexities for the resident covered group. Overall utilization and patient outcome measures were unfavorable in low and moderate complexity patients for the resident covered group. In high complexity patients, most of the utilization and patient outcome measures were similar in both groups. Conclusion: Presence of a resident led to unfavorable increases in many throughput, utilization and outcome measures, a difference which disappeared in most cases with higher complexity patients. Therefore, the cost of a resident may actually decrease with increasing patient complexity

Cost of a learner in pediatric ED

: Experiential learning in a cornerstone of medical education, but impacts throughput, utilization of resources and patient outcomes. : Our study sought to determine the cost of a resident across various throughput, utilization, and patient outcome measures. : This retrospective study was conducted in 2016 in the pediatric emergency department of an urban tertiary care hospital. . We compared various throughput, utilization and patient outcome measures between resident-covered and nonresident-covered patients. A subgroup analysis was performed based on complexity as determined by CPT codes. : 33,278 patient encounters occurred between 1 January 2016, and 31 December 2016. Of these, 8,434 (25.42%) were resident-covered patients. Across all encounters, throughput, utilization and patient experience measures were unfavorable for the resident covered group. In subgroup analysis based on complexity of patients, throughput measures were either unfavorable or there was a trend towards unfavorability across all complexities for the resident covered group. Overall utilization and patient outcome measures were unfavorable in low and moderate complexity patients for the resident covered group. In high complexity patients, most of the utilization and patient outcome measures were similar in both groups. : Presence of a resident led to unfavorable increases in many throughput, utilization and outcome measures, a difference which disappeared in most cases with higher complexity patients. Therefore, the cost of a resident may actually decrease with increasing patient complexity

Menetrier Disease

Menetrier disease is a rare disorder that is characterized by giant mucosal folds in the proximal part of the stomach, diminished acid secretion, and a protein-losing state with hypoalbuminemia. Other names for Menetrier disease are hypoproteinemic hypertrophic gastropathy and giant hypertrophic gastritis. This condition is common in middle-aged men. The age group affected is generally between 30 years to 60 years. It is less commonly described in females and children. In adults, the condition is often progressive. The etiopathogenesis of Menetrier disease is not entirely understood. It affects mainly the proximal part of the stomach (body and fundus) and spares the distal portion (antrum)

Preparing Internal Medicine Trainees for Independent Practice: A Pilot Simulation Program on Emotional Intelligence

Introduction: Emotional intelligence (EI) is the ability to monitor emotions and use this knowledge to guide one’s thinking and actions. EI shapes the physician’s bedside manner and leads to a better doctor-patient relationship. Higher physician EI is inversely proportional to feelings of burnout and increases resiliency to the stresses of the profession. Given the increasing levels of physician burnout, there has been a call to incorporate the development of emotional intelligence into medical education. However, little guidance exists on best practices in incorporating EI training into graduate medical education. Purpose/Aim: Utilization of EI simulation as a pedagogical instrument to increase physician skillset in four key areas of EI: self-awareness, self-management, social awareness, and relationship management. Methods: Post-Graduate Year 3 residents from two internal medicine residencies were divided by residency and first year Cardiology fellows received either a pre-posttest utilizing the Emotional Intelligence Appraisal Tool (EIAT) © separated by 5 months with no educational intervention or an EI-focused simulation curriculum between the pre and post-tests. EIAT data was collated and compared across the study groups. Results: There were a total of 33 participants in the study (32 residents, 1 fellow) between September, 2019 – February, 2020. Participants in the control group were younger (mean 29.4 years, P=0.011) and less experienced than the participants in the intervention group (mean 4.25 years, P=0.026). Of the participants, there were more males (54.5%). The intervention group had significantly better overall social competence and awareness, (P=0.004), and relationship management (P=0.005) scores. There was a trend towards significance for the overall emotional quotient score in the interventional group. Conclusions: Simulation was a useful pedagogical instrument to enhance EI acumen in resident education. Time and experience alone offered no benefit

QoS Based Framework for Effective Web Services in Cloud Computing

Enhancements in technology always follow Consumer requirements. Consumer requires best of service with least possible mismatch and on time. Numerous applications available today are based on Web Services and Cloud Computing. Recently, there exist many Web Services with similar functional characteristics. Choosing “a-right ” Service from group of similar Web Service is a complicated task for Service Consumer. In that case, Service Consumer can discover the required Web Service using non functional attributes of the Web Services such as QoS. Proposed layered architecture and Web Service-Cloud, i.e. WS-Cloud computing Framework synthesizes the non functional attributes that includes reliability, availability, response time, latency etc. The Service Consumer is projected to provide the QoS requirements as part of Service discovery query. This framework will discover and filter the Web Services form the cloud and rank them according to Service Consumer preferences to facilitate Service on time