American journal of hospital medicine, volume 4, issue 2 (2020 April-June)
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Item Ring-enhancing Brain Lesions in a Patient with Advanced Human Immunodeficiency Virus from the Central United States of America(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2020-04) Shoemaker, D. Matthew; Schwetye, KatherineBackground: Histoplasmosis is an endemic fungus found worldwide. It most commonly causes pulmonary infections. In patients with defects in cellular immunity it can cause disseminated infections including central nervous system infections. Case presentation: We present a case of a 44-year-old with advanced human immunodeficiency virus who presented with neurologic complaints. Magnetic resonance imaging of the brain revealed ring-enhancing brain lesions. He underwent brain biopsy of one of the ring-enhancing lesions and histopathology revealed Histoplasma capsulatum. Conclusion: Ring-enhancing brain lesions due to endemic fungi in patients with advanced HIV are uncommon. Nonetheless, this should remain a diagnostic consideration in endemic areas.Item The Failing Right Ventricle : An Internist's Guide to the Diagnosis and Management of Pulmonary Hypertension(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2020-04) Miller, Aaron C.Pulmonary hypertension represents a complex and multifactorial disease with significant implications on patients' morbidity, mortality, and quality of life. The number of patients hospitalized with pulmonary hypertension is increasing. Elevated pulmonary artery pressures as estimated by transthoracic echocardiogram are most commonly associated with left heart disease; however, careful attention and screening must be performed to promptly identify patients who may benefit from pulmonary vasodilator treatment. Early recognition and diagnosis of pulmonary hypertension is very important, but it can be challenging due to the nonspecific nature of patient symptoms and clinical findings. Furthermore, transthoracic echocardiogram does not always accurately estimate pulmonary artery pressures. Other clinical assessment tools such as computed tomography (CT) angiography of the chest and brain-type natriuretic peptide (BNP) levels can be helpful. Pulmonary hypertension is ultimately defined hemodynamically as a mean pulmonary artery pressure >20 mmHg, which is measured by right heart catherization. Following diagnostic evaluation, management of pulmonary hypertension and right ventricular failure focuses on optimizing right ventricular preload, afterload and contractility. A goal-directed approach to therapy helps guide treatment, and it helps identify patients who need escalation of therapy when goals are not being met. A goal-oriented approach to management improves outcomes and delays progression of pulmonary hypertension.Item Incidental Portal Vein Aneurysm Found in a Patient with a Diaphragmatic Hernia and Evolving Gastric Volvulus(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2020-04) Kashanchi, Ashkan; Akivis, Yonatan; Scalzo, AnthonyRare and poorly described within the literature, a portal vein aneurysm (PVA) is defined as an abnormal vascular dilation of the portal vein exceeding 19 mm in patients with cirrhotic livers and 15 mm in patients with normal livers. Incidence has been estimated to be 0.06[percent] and fewer than 200 cases have been described in the literature1,4. We describe an incidental and asymptomatic PVA found in an 80-year-old Caucasian male presenting with evolving gastric volvulus in the context of a large diaphragmatic hernia. Computed tomography (CT) revealed displacement of abdominal contents and 37 mm aneurysm of the main portal vein (image 1,2). Because of the large size of our patients' malformation (37 mm), surgery was pursued in the form of aneurysmorrhaphy. There is a paucity of literature regarding the management of PVA - however the literature distinguishes between those with and without underlying portal hypertension. Notably, the patient was asymptomatic from this pathology and had no underlying portal hypertension. He was seen in an outpatient clinic two weeks after discharge and had fully recovered without any reported sequela or symptoms related to his vascular surgery.Item Perceptions Towards the Discharge Process in a Community Teaching Hospital(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2020-04) Yang, Ruifang; Khalili, Leila; Cheng, Zhi; Markic, Ana; Ayutanont, Napatkamon; Akhondi, HosseinBackground: Discharge process in the hospital is lengthy and with low efficiency, especially in teaching facilities. Our objective was to identify perceptions towards the current discharge process and possible ways to improve it in a community teaching hospital in Las Vegas, NV. Methods: Quality improvement with cross-sectional survey questionnaire. Participants: 200 hospital staff (total possible participants) who were involved in the discharge process. 149 (actual participants) completed the surveys (response rate of 75[percent]) which included multiple choices as well as open ended questions; 95 nurses, 43 residents, and 11 case managers. Results were analyzed using the Chi-Square test. Results: 44[percent] of respondents believed that the hospital discharge process is efficient while 56[percent] did not. Frequent delays in discharge process from hospital were estimated often by 57.7[percent]. Easiest placements were home health (51.7[percent]) followed by hospice (19.5[percent]). The most time-consuming placements were skilled nursing facility (43[percent]) followed by acute rehab (22.8[percent]). The preferred method of contact regarding discharge process differed among roles. 41[percent] of nurse respondents listed voice calls while 54.5 [percent] of case managers and 44[percent] of residents documented text messaging (P-value [less than] 0.001). While most (61 [percent]) believed that multidisciplinary rounds are of value, the percentage of those who preferred it, differed among roles. 69.4[percent] of nurses favored multidisciplinary round versus 4.2[percent] who did not. This was 54.5[percent] vs. 27.2[percent] for case managers and 44.1[percent] vs. 30.2[percent] for the residents (P-value = 0.002). Conclusion: Discharge process in teaching facilities is considered fragmented, inefficient and different groups of health care personnel perceive it differently.Item Troponin-Positive Chest Pain with Unobstructed Coronary Arteries(University of Missouri, Department of Medicine, Division of Hospital Medicine, 2020-04) Padkins, Mitchell; Issa, MeltiadyWe present a 29-year-old man who presented with crushing substernal chest pain with radiation to his jaw and associated diaphoresis. He was hemodynamically stable and electrocardiogram was unremarkable. Laboratory studies revealed initial high-sensitivity troponin of 1950 ng/L (reference: [less than]15 ng/L), 2-hour troponin 2165 ng/L, and 6-hour troponin 2413 ng/L. NT-pro-BNP was elevated at 1692 pg/mL (reference: [less than]51 pg/mL), and C-reactive protein was 50.9 mg/L (reference: [less than]8 mg/L). Transthoracic echocardiogram revealed an ejection fraction (EF) of 30[percent] with severe global left ventricular hypokinesia. Left heart catheterization revealed normal coronary arteries. Cardiac magnetic resonance imaging showed acute myocarditis. With aggressive diuresis and anti-inflammatory therapy for concomitant pericarditis, his symptoms improved. After one month of beta-blocker and angiotensin converting enzyme inhibitor therapy, his EF improved to 63[percent] with normal left ventricular function.