American journal of hospital medicine, volume 5, issue 2 (2021 April-June)
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Item Mandating vaccination -- is it justified?(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2021-04) Fleming, David A."The answer is yes…and no. It depends... Personal and Public Obligations: Freedom from oppression, the right to choose, and self-determination are bedrock values upon which our country was founded. They are also central building blocks of patient autonomy that physicians are obligated to respect. But rights of autonomy are not without limits. As members of society, we are governed by rules and laws created to control behavior and protect all members, especially the most vulnerable. We live with an understanding that our freedoms must be proportionately tempered if there is a possibility that others could be harmed by the choices we make (or do not make) daily. The recent pandemic has created an environment of fear and we have found ourselves in an existential crisis as a society. In response to the surge of critically ill patients and growing scarcity of resources, many health care systems have been forced to shift guidance of their practices from primarily patient-centric to an ethics of public health, where the greatest good can be provided to the greatest number. In some areas, rationing of critical care resources and altered standards of care have been necessary to treat and save as many as possible, knowing all cannot be saved. In addition, public health officials have encouraged or required face masks, distancing, and social avoidance proportional to the severity of situation and risk in each locale.Item Rothman Index as a predictor of 30-day hospital readmission(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2021-04) Thal, Karissa A.; Adelman, Alan M.Introduction: The Centers for Medicare and Medicaid services financially penalize hospitals for elevated 30-day readmission rates. Identifying patients at high risk for short-term readmission would allow health systems to strategically allocate resources to this vulnerable population. The objective of this study was to determine whether there was a difference in mean Rothman Index value for patients readmitted to the hospital within 30 days of index stay versus patients not readmitted in order to evaluate the Rothman Index's utility as a predictive tool. Materials and Methods: Data from 100 subjects from a single academic medical center, with a balanced number of readmit (n=50, mean age 68.9 years, 54% female) and non-readmits (n=50, 46% female, mean age 70.9 years), was collected. Results: Non-readmits demonstrated significantly higher mean Rothman Index values (70.94 [plus or minus] 1.3) compared to patients readmitted within 30 days (mean Rothman Index of 61.68 [plus or minus] 1.6) at (P[less than] .001; 95% CI, 5.10 to 13.41). Age (95% CI, -0.052 to 0.006; P= .12), gender (95% CI, -0.949 to 0.948; P= .99) and primary discharge diagnosis from index stay (P= 0.31) were not predictive of readmission; only the Rothman Index was (95% CI, -0.136 to -0.039; P[less than].001).The coefficient of the Rothman Index was -0.088, indicating that for each 1 point increase in Rothman Index, a patient's odds of readmission within 30 days declined by 8.8% (95% CI, -0.136 to -0.039; P[less than] .001). Conclusions: The Rothman Index can be utilized as a predictive tool to identify patients at high risk of unplanned 30-day hospital readmission, thereby allowing health systems to strategically allocate outside hospital resources.Item Duodenal dieulafoy's lesion(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2021-04) Mikhael, Mary; Tahan, Veysel; Daglilar, EbubekirCase: A 92-year-old female presented to hospital with one week history of black tarry stools that was associated with generalized weakness and fatigue. She denied dizziness, hematemesis, hematochezia, or abdominal pain. She had medical history of myelodysplastic syndrome, gastro-esophageal reflux disease, and hypertension. On admission, she was hemodynamically stable, her physical exam was unremarkable. Initial Hgb was noted to be 5.7 g/dL with baseline Hgb of 9.0 g/dL. Her chemistry was notable for elevated BUN of 40 mg/dL and creatinine of 1.0 mg/dL. Her INR and platelet counts were normal. She was given intravenous proton pump inhibitor and two units of packed red blood cells. Following initial medical treatment, an urgent upper endoscopy was performed, which demonstrated an actively spurting visible vessel in duodenal sweep with normal surrounding mucosa consistent with Dieulafoy's lesion (DL) (Figure 1). A complete hemostasis was achieved with dual therapy of sub-mucosal epinephrine injection, followed by deployment of seven hemoclips (Figure 2). Post-procedure Hgb remained stable at 8.5 g/dL and subsequently, she was discharged home after 3-days of hospital stayItem Disseminated cysticercosis(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2021-04) Assefa, Mahilet; Nada, Ayman; Bran, Andres; Rojas-Moreno, ChristianCase presentation: A 49-year-old male refugee from Uganda with a history significant only for hypothyroidism and hypertension presented to the neurology clinic with an eight-year history of seizures. He has not had a seizure for almost two years while on phenobarbital and phenytoin. He denied any history of parasitic infections or any kind of anti-parasitic treatment in the past. He did not have any headache, fever, nausea, or vomiting but reported intermittent episodes of dizziness. Findings on neurological and general physical examination were normal. Laboratory findings were notable for peripheral eosinophilia and thrombocytopenia present for a few months, which resolved in subsequent evaluations. Human immunodeficiency virus 1/2 Antigen/Antibody (HIV 1/2 Ag/Ab) screen was negative. T1-weighted magnetic resonance imaging (MRI) of his brain showed rim-enhancing cystic lesions in the left frontal and right occipital lobes, left parietal, left temporalis muscle, and left trapezius muscle. The parenchymal lesions were partially calcified. Cysticercosis serum antibody immunoglobulin G (IgG) was negative. Confirmatory immunoblot antibody testing offered by the Center for Disease Control and Prevention (CDC) was positive, supporting the diagnosis of disseminated cysticercosis.