8 research outputs found

    Gout: A missed diagnosis in the elderly

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    Spotting a zebra by its stripes

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    Covert cryptococcal meningitis in a patient with systemic lupus erythematous

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    BACKGROUND: Cryptococcal meningitis is a rare but well-recognized illness with a high mortality rate in immunosuppressed patients with systemic lupus erythematosus (SLE). The diagnosis of cryptococcal meningitis in these patients can be challenging, especially in the emergency department (ED), as the clinical presentation may be non-specific, which can lead to delayed treatment. OBJECTIVE: To recognize risk factors associated with the development of cryptococcal meningitis infection in patients with SLE and to provide an update on the clinical presentation, prognosis, and therapeutic options. CASE REPORT: A 21-year-old man with SLE presented with a 4-day history of headache, fever, nausea, and vomiting after being discharged from the ED 1 day before this visit, after lumbar puncture showed normal values. One week before, he had completed 7-day pulse therapy with intravenous cyclophosphamide and intravenous methylprednisone for lupus nephritis. The patient was febrile, but the remainder of the examination was normal. Laboratory data showed lymphopenia. Given his immunocompromised state, a cryptococcal antigen was added to cerebrospinal fluid (CSF) sent from the prior ED visit and was positive at a titer of 1:8. The patient was treated with amphotericin B and 5-flucytosine for 6 weeks. Ten months later the patient remained free of infection. CONCLUSION: Normal neurological and CSF examination do not exclude cryptococcal meningitis in immunocompromised patients with SLE. India ink or, preferably, latex agglutination test and CSF fungal culture are recommended. A high level of suspicion is the key in the diagnosis of cryptococcal meningitis and will help avoid delays in treatment. Copyright © 2012 Elsevier Inc. All rights reserved

    Geographical assignment of hospitalists in an urban teaching hospital: feasibility and impact on efficiency and provider satisfaction

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    OBJECTIVE: To evaluate whether implementation of a geographic model of assigning hospitalists is feasible and sustainable in a large hospitalist program and assess its impact on provider satisfaction, perceived efficiency and patient outcomes. METHODS: Pre (3 months) - post (12 months) intervention study conducted from June 2014 through September 2015 at a tertiary care medical center with a large hospitalist program caring for patients scattered in 4 buildings and 16 floors. Hospitalists were assigned to a particular nursing unit (geographic assignment) with a goal of having over 80% of their assigned patients located on their assigned unit. Satisfaction and perceived efficiency were assessed through a survey administered before and after the intervention. RESULTS: Geographic assignment percentage increased from an average of 60% in the pre-intervention period to 93% post-intervention. The number of hospitalists covering a 32 bed unit decreased from 8-10 pre to 2-3 post-intervention. A majority of physicians (87%) thought that geography had a positive impact on the overall quality of care. Respondents reported that they felt that geography increased time spent with patient/caregivers to discuss plan of care (p \u3c 0.001); improved communication with nurses (p = 0.0009); and increased sense of teamwork with nurses/case managers (p \u3c 0.001). Mean length of stay (4.54 vs 4.62 days), 30-day readmission rates (16.0% vs 16.6%) and patient satisfaction (79.9 vs 77.3) did not change significantly between the pre- and post-implementation period. The discharge before noon rate improved slightly (47.5% - 54.1%). CONCLUSIONS: Implementation of a unit-based model in a large hospitalist program is feasible and sustainable with appropriate planning and support. The geographical model of care increased provider satisfaction and perceived efficiency; it also facilitated the implementation of other key interventions such as interdisciplinary rounds
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