Medicine and Health Sciences Commons^™

A Case Of Disseminated Nocardia Beijingensis In An Immunocompetent Patient, Manifesting As Subcutaneous And Cns Nocardiosis., Scott Cathcart, Patricia Stogsdill, Rebecca Bell

Journal of Maine Medical Center

Introduction

Nocardiosis is an uncommon infection, typically encountered in immunocompromised patients. With only 5 cases reported thus far in the United States, we present a case of disseminated Nocardia beijingensis in an immunocompetent patient, involving the lung, subcutaneous tissue, and CNS.

Clinical Findings

A 60-year-old immunocompetent male with no significant medical history presents to our institution after a complicated medical course, beginning with vague respiratory complaints. Initial work-up revealed a large right upper lung mass of unclear etiology. A month later he had a syncopal episode followed by the development of focal neurologic deficits.

Main Diagnoses, Therapeutics Interventions, and Outcomes …

Multifocal Bone Pain, Recurrent Fevers And Anemia In A 15-Year-Old, Anna M. Martens, Catherine Ezzio, Amanda Goddard, Leah Mallory

Journal of Maine Medical Center

Introduction: Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disorder that primarily affects children with recurrent episodes of sterile osteomyelitis in one or more bones. Patients usually present with recurrent bone pain, though it is often a diagnosis of exclusion with most patients undergoing extensive work-up to arrive at a diagnosis.

Clinical Findings: This 15-year-old female presented with months of progressive multifocal bone pain, 22-pound weight loss and recurrent fevers. Work-up as an outpatient included a positive screening assay and IgM Western blot Panel positive for Lyme disease, treated with a 28-day course doxycycline without resolution of the symptoms, …

Is Rocky Mountain Spotted Fever Transmitted In Maine?, Eric J. Ray

Journal of Maine Medical Center

Introduction:

Tickborne disease occurs worldwide with recent recognition of changes in tick vector distributions. Rocky Mountain Spotted Fever (RMSF) is already widespread across the United States; however, it is being monitored for introduction to non-endemic areas.

Clinical Findings:

A 65-year-old male with a history of psoriatic arthritis on adalimumab and local tick exposures but no known recent bites presented to the emergency department with fevers, myalgias, arthralgias, and a maculopapular rash of unclear etiology. Initial testing showed transaminitis, worsened chronic thrombocytopenia, and slight neutropenia with absolute neutrophil count 2,330 (reference value: 2,400-7,600 cells per µL); however, he was stable …

Ruptured Splenic Hemangioma Presenting As Small Bowel Obstruction: A Case Report, Haya S. Raef, Karin L. Cole Md

Journal of Maine Medical Center

Introduction: Splenic hemangioma is a rare vascular tumor of the spleen. Typically asymptomatic, these lesions can present with rupture and hemoperitoneum. Clinical Findings: We report the case of a patient with no previous abdominal surgery that presented with symptoms and imaging consistent with small bowel obstruction (SBO), and an incidental finding of a splenic lesion. Main diagnoses, therapeutic interventions, and outcomes: At diagnostic laparoscopy, a ruptured splenic hemangioma was identified, with obstructive ileus due to hemoperitoneum. The patient subsequently underwent splenectomy to prevent recurrent bleeding. Conclusions: Splenic hemangiomas are rare vascular neoplasms of the spleen, which can be complicated by …

Evaluation Of Pharmacist- Or Nurse-Driven Long-Acting Insulin Titration Protocol In Adult Primary Care Patients With Type 2 Diabetes, Ruth Manzi, Corinn Martineau, Carmine Laporta, Mary Muca, Samantha Marrier, Donald Medd, Jennifer Aronson

Journal of Maine Medical Center

INTRODUCTION

Studies have supported protocolized insulin titration to optimize insulin therapy. We implemented a long acting insulin titration (LAIT) protocol in a primary care setting to aid patients achieve optimal control of their diabetes. The purpose of the study was to evaluate the performance of the LAIT protocol.

METHODS

This retrospective analysis included patients ≥18 years with type 2 diabetes (T2D) and a hemoglobin A1c (A1C) >8% who were managed as outpatients at clinics within our health care system. We collected demographic and clinical data before and after a patient’s enrollment in the LAIT protocol. Our primary outcome measure was …

A Primer On Cognitive Errors Illustrated Through The Lens Of A Neurosurgical Practice, Jeffrey Evan Florman, Lisa Almeder, Robert Trowbridge

Journal of Maine Medical Center

Problem Statement:

Diagnostic error is often attributed to cognitive errors, including biased thinking patterns, rather than knowledge or data limitations, and education on cognitive bias deserves review in all spheres of practice.

Background:

The cognitive biases of practitioners create an inherent fallibility in recognizing and treating medical conditions. Awareness of cognitive errors is valuable for mitigating risk of diagnostic error.

The impact of cognitive error is substantial in the management of neurosurgically relevant disease. Remarkably broad differential diagnoses often accompany neurologic symptoms. Both focal and non-focal symptoms lend themselves to diagnostic inertia that contributes to errors. Further, initial diagnostic direction …

Evaluation Of Geographic Disparities In Cervical Cancer Survival Across Maine, Kaylee Underkofler, Jason Lachance

Journal of Maine Medical Center

Introduction. National data exists suggesting the existence of geographic disparities in oncology care within the United States. It is unknown whether geographic disparities present a problem for women with gynecologic malignancies locally in Maine.

Methods. Data for each cervical cancer case diagnosed or treated under the MaineHealth system between 2007 and 2011 were acquired from the MaineHealth Network Registry. Average annual incidence and 5-year survival were calculated for each county in Maine and were mapped using geographic information systems (GIS) software. Next, cases were divided into 2 groups: those residing less than or equal to 60 miles from the sole …

Injection Drug Use And Care Charges For Infective Endocarditis, Verity N. Ramirez, Jenny L. Carwile, Kristina Rokas, Wendy Craig, Kinna Thakarar

Journal of Maine Medical Center

No abstract provided.

A Phantom Of The Past: Withdrawal From Meprobamate Presenting With Focal Seizures., Thomas M. Zink, John E. Erickson

Journal of Maine Medical Center

Introduction: Meprobamate (Miltown, Equinil) is a sedative-hypnotic medication that first gained popularity as an anxiolytic and later as a muscle relaxant. It is a major metabolite of the more commonly used muscle relaxant carisoprodol (Soma). In vitro and electroencephalogram studies demonstrated that meprobamate modulates gama-aminobutyric acid (GABA) receptors, similar to barbiturates. Withdrawal from meprobamate manifests in symptoms ranging from mild anxiety to severe autonomic instability and death. Meprobamate is rarely prescribed, but is still given to a small subset of elderly patients.

Clinical findings: In this case of meprobamate withdrawal, the patient initially displayed altered mental status and recurrent seizures …

Toxic Leukoencephalopathy Presenting As Agitation And Social Withdrawal In A Patient With Substance Use Disorder: A Case Report, Andrew R. Beauchesne, Brian F. King

Journal of Maine Medical Center

Introduction: Toxic leukoencephalopathy (TLE) is characterized by damage to myelin of cerebral white matter and is caused by a number of offending agents, including drugs of abuse. The clinical presentation of TLE is variable and not fully understood.

Clinical Findings: A 51-year-old male presented with pneumonia, parapneumonic effusion, and acute kidney injury. His medical course was complicated by neurobehavioral changes, including aggression and social withdrawal.

Diagnoses, interventions, and outcomes: The patient was diagnosed with acute toxic leukoencephalopathy based on diffuse subcortical T2-weighted-fluid-attenuated inversion recovery (T2/FLAIR) on brain MRI, bilateral frontal arrhythmic delta waves on encephalogram, and a …

Small Cell Lung Cancer Presenting With Personality Change, Brian F. King, Heidi Horstman, Katherine Rizzolo

Journal of Maine Medical Center

Introduction: Paraneoplastic limbic encephalitis is a syndrome characterized by autoimmune inflammation of the limbic system in the setting of underlying malignancy. The syndrome presents with acute to subacute neuropsychiatric clinical findings, often before the cancer diagnosis is known.

Clinical Findings: A 57-year-old woman with a 30 pack-year smoking history presented to Maine Medical Center after multiple generalized tonic-clonic seizures. Her family reported periodic odd behavior including confusion, disinhibition, and paranoia--all of which preceded her first seizure by two weeks.

Diagnoses, interventions, and outcomes: MRI brain showed T2/FLAIR signal hyperintensity of the right amygdala and hippocampus with sparing of the right …

Fresh Fruits And Vegetables Really Do Keep The Doctor Away: Symptomatic Vitamin Deficiency In A Middle Aged Man, Matthew J. Turnquist Md, Christina Holt Md, Msc

Journal of Maine Medical Center

Introduction

We present a clinical case of symptomatic vitamin deficiency typically seen only in resource limited environments or alcoholics, presenting in an adult male with frequent oral intake, but limited diet of prepared foods, as well as co-occurring pernicious anemia.

Clinical Findings

The patient presented with complaints of ascending paresthesia leading to near syncope, lower extremity edema and hyperpigmentation on his anterior legs bilaterally which had been present for years.

Diagnosis and interventions

He was found to have mixed B12, thiamine, and folate deficiency. These were attributed to a combination of nutritional deficiency due to a diet of exclusively cooked …

End-Of-Life Healthcare Use Of Medicare Patients With Melanoma Based On Patient Characteristics And Year Of Death, Rebecca N. Hutchinson, F. Lee Lucas, Kathleen Fairfield

Journal of Maine Medical Center

Background: Many cancer patients receive overly-intensive care at end-of-life (EOL), despite recognition that this is a marker of poor quality. There is limited knowledge about care received by patients dying with melanoma.

Objective: We characterized healthcare utilization during EOL and patient characteristics associated with variations in care. We also described how utilization changed over time.

Methods: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify 9099 melanoma patients aged 65+ at diagnosis between 2000 and 2009, who died by 12/31/2010. We included patients enrolled in Medicare part A and B six-months prior to diagnosis and not in managed …

Increasing Actual And Perceived Burden Of Tick-Borne Disease In Maine, Robert P. Smith Md Mph, Carol A. Mccarthy Md, Susan P. Elias Phd

Journal of Maine Medical Center

Introduction: The burden of tick-borne disease (TBD) in Maine has steadily increased since the first case of Lyme disease was reported in the late 1980s. The emergence of five different agents of TBD in Maine has been challenging and confusing for clinicians and the public.

Methods: We reviewed the ecology of emerging of tick -borne disease, then reviewed risk factors for tick bites and tick-borne disease in Maine. We then compared the burden of TBD versus community-acquired comparison infections in terms of hospitalizations, deaths, and media attention.

Results and Discussion: In Maine, risk of exposure to bites from the vector …

A Case Report Of Water Hemlock Poisoning, Blue Butterfield, Alicia Bond Md, Dan Meyer, Gary Diperna, Tamas Peredy Md

Journal of Maine Medical Center

Introduction: Water hemlock poisoning is an uncommon cause of seizures, gastrointestinal upset, and renal failure. This poisoning occurs infrequency and is likely to go unrecognized without a proper history and consideration in the differential diagnosis.

Clinical Findings: A 23-year-old male with an unremarkable past medical history presented to the emergency department after being found unresponsive at a farm where he was employed. He had several tonic-clonic seizures en route. Initial evaluation was unremarkable and included toxicology screening, lumbar puncture, and brain imaging.

Main diagnoses, therapeutics, interventions, and outcomes: The patient was treated with broad-spectrum antibiotics and antivirals with a suspected …

Signs Of Psychosis Leading To A Diagnosis Of Progressive Multifocal Leukoencephalopathy: A Case Report, Bryan L. Walker, Christina Holt Md, Msc

Journal of Maine Medical Center

Introduction: Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating process of the central nervous system that occurs in in the setting of severe immunocompromise. Patients with PML develop varying focal neurological deficits and mental status changes that have not been well-described previously.

Clinical findings: We present a patient who was found by security wandering the lobby of this hospital. He was oriented only to self and unable to state a reason for presentation. Medical records were limited and included a visit to an outside hospital that documented a past medical history of HIV infection. He exhibited multiple signs of psychosis …

Increased 18f-Fdg-Pet Uptake In Granulomatosis With Polyangiitis: Case Report And Review Of The Literature, Rama El-Yafawi, Patricia Cantlin, Thomas E. Van Der Kloot

Journal of Maine Medical Center

We present an unusual case of granulomatosis with polyangiitis (GPA), which initially presented as a large lung mass, without renal or other systemic features. The lung mass was most concerning for malignancy, and positron emission tomography (PET) further supported this concern, with intense uptake in the mass as well as in mediastinal and hilar lymph nodes. Biopsies however were non-diagnostic, and the patient developed acute kidney injury with active urinary sediment, leading to a definitive diagnosis of GPA. With supportive care and treatment directed at GPA, she was ultimately able to discontinue hemodialysis, and the lung mass resolved. This case …

Bringing Upstairs Care Downstairs; Integration Of Rehabilitation Medicine, Care Management, And The Hospital Elder Life Program (Help) Into An Emergency Department., Robert Anderson, Molly Anderson, Rhonda Babine, Farid Feghali, Elizabeth Dunstan, Matthew Glazer, Susan Horton, Stephanie O'Brien, Elizabeth Pontius, David Smith, Megan Viens, Heather Williams

Journal of Maine Medical Center

Introduction: Services such as physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), social work (SW), care management, and elder life specialists have long been an established part of care for patients admitted to Maine Medical Center (MMC) but not for patients in the Emergency Department (ED). Methods and Results: Driven in part by changes in Medicare reimbursement models, care management established a presence in the Emergency Department (ED) in 2003 with a focus on care planning and cost avoidance. In recent years PT, OT, SLP, SW, and the Hospital Elder Life Program (HELP) have increased their ED involvement substantially. …

Using Physician Champions To Extend The Reach Of The Let’S Go! 5-2-1-0 Obesity Prevention Program In Clinical Practice, Michael Dedekian, Jackie Vine, Jonathan Fanburg, Naomi Anderson Schucker, Victoria Rogers

Journal of Maine Medical Center

ABSTRACT

Introduction: There is limited evidence for large scale interventions to address childhood obesity. Let’s Go! is a Maine-based obesity prevention program that deploys a consistent message across multiple community settings to encourage children and families to make healthy choices. This report describes implementation of Let's Go! in primary care offices.

Methods: Consideration for physician champion recruitment included previous involvement with Let’s Go! and ensuring statewide geographic coverage. Champions received standardized training and became local leaders in obesity prevention and treatment. 13 champions engaged 99 practices at baseline; 71 practices were engaged all 4 years (2012-2015). Data were analyzed on …

Pediatric Interfacility Transfers – Association Of Pre-Transfer Vital Signs With Length Of Stay At A Tertiary Care Center, Sarah Bunting, Leah Mallory, Logan Murray

Journal of Maine Medical Center

Objective: Determine which abnormal pre-transfer vital signs predict longer length of stay (LOS) for pediatric patients transferred to a tertiary care center.

Patients and Methods: A retrospective study of all patients transferred between Aug 2016 and Jan 2017 to Maine Medical Center’s pediatric inpatient units, PICU, and Emergency Department with pediatric consult. Charts were examined for pre-transfer vital signs and diagnosis. The primary outcome of interest was LOS. Vital signs were determined to be normal or abnormal using the 2015 PALS Guidelines.

Results: Two hundred thirty-six pediatric patients were included. Median LOS was 42.5 hours; median age was 68.0 months. …

Physician Gender Impact On Obesity Care In The Academic Ambulatory Setting, Peggy R. Cyr Md, Christina Holt Md, Msc, Amy Haskins Phd, Karyn King Md, Robert Post Md, Derjung M. Tarn, Arch Mainous Phd

Journal of Maine Medical Center

BACKGROUND & OBJECTIVE: The purpose of this study was to assess a nationally representative sample of academic family physicians to determine whether personal physician characteristics are associated with attitudes towards and care of overweight and/or obese patients.

METHODS: Questions pertaining to physician’s interactions with overweight and obese patients was administered as the 2012 Council of Academic Family Medicine Educational Research Alliance (CERA) survey to academic family physicians. We analyzed self-reported demographic responses physicians gave with the main outcome the association between self-reported likelihood of engaging in weight loss discussions with overweight or obese patients and physicians’ personal characteristics …

Changing The Surgical Residency: A Mixed-Methods Study Of Residents’ And Faculty Experiences One Year After Implementation, Sarah B. Cairo, Wendy Craig, Caitlin Gutheil, Paul K. J. Han, Kristiina Hyrkas, Lynda Macken, Jim Whiting

Journal of Maine Medical Center

Objective: To evaluate a reformed surgical residency curriculum aimed at addressing emerging practice models, enhancing residents’ educational experience, and improving the quality/continuity of patient care by reducing the service size and enhancing attending-resident interactions.

Methods: A mixed-methods study of the surgical training program following curriculum reform including: 1) focus group and individual qualitative interviews with residents, attendings, nurses, and advanced practice providers to explore stakeholder perspectives on curriculum reform, 2) time study of surgical resident activities, and 3) quantitative assessment of surgical case logs.

Results: Qualitative interviews demonstrated disparate knowledge and attitudes regarding the goals of the curriculum with emergence …