Internal Medicine Commons^™

A Rare Cause Of Pneumoperitoneum, Robert Zusman, George Michael, Anna E. Augustin, My Myers, Dudith Pierre-Victor

West Florida Division GME Research Day 2020

Pneumoperitoneum is most commonly associated with a perforated viscus. When free air is seen on imaging, the most common course of action is an emergent exploratory laparotomy. However, pneumoperitoneum may not always be indicative of a perforated bowel. In the case described below, we will discuss a patient who developed acute peritonitis and pneumoperitoneum after undergoing chest compressions during cardiopulmonary resuscitation (CPR) and positive pressure mechanical ventilation.

The Β3-Adrenergic Receptor Agonist Mirabegron Improves Glucose Homeostasis In Obese Humans, Brian S. Finlin, Hasiyet Memetimin, Beibei Zhu, Amy L. Confides, Hemendra J. Vekaria, Riham H. El Khouli, Zachary R. Johnson, Philip M. Westgate, Jianzhong Chen, Andrew J. Morris, Patrick G. Sullivan, Esther E. Dupont-Versteegden, Philip A. Kern

Internal Medicine Faculty Publications

BACKGROUND. Beige adipose tissue is associated with improved glucose homeostasis in mice. Adipose tissue contains β3-adrenergic receptors (β3-ARs), and this study was intended to determine whether the treatment of obese, insulin-resistant humans with the β3-AR agonist mirabegron, which stimulates beige adipose formation in subcutaneous white adipose tissue (SC WAT), would induce other beneficial changes in fat and muscle and improve metabolic homeostasis.

METHODS. Before and after β3-AR agonist treatment, oral glucose tolerance tests and euglycemic clamps were performed, and histochemical analysis and gene expression profiling were performed on fat and muscle biopsies. PET-CT scans quantified brown adipose tissue volume and …

Provider-Led Intervention For Overweight Or Obese African American Women Ages 18-65 With A Bmi 25 Kg/ M₂, Tonya A. Harvey

Evidence-Based Practice Project Reports

Overweight and obese African American women tend to suffer most from the impacts of diseases, health disparities, disabilities, and decreased qualities of life (Sutton et al., 2016). Most weight loss programs are not culturally specific, despite the benefits of dietary changes and increased physical activity for all groups. The purpose of this EBP project was to implement a provider-led program including lifestyle, dietary, and activity components to decrease weight, BMI, waist circumference and blood pressure in African American women. The Iowa Model of Evidence-Based Practice to promote quality care was used to guide the EBP project, aimed to address obesity …

The Implementation Of Diabetic Foot Care Into Primary Care, Shelby D. Strong

Evidence-Based Practice Project Reports

Diabetes mellitus (DM) is one of the most common metabolic diseases worldwide. It can lead to complications in many parts of the body and can increase overall risk of dying prematurely (World Health Organization (WHO), 2016). Diabetic peripheral neuropathy (DPN) in the feet is one of the most frequent complications of DM (Wang et al., 2017). Other lower extremity complications which can occur as a result of diabetic foot complication (DFC) includes peripheral artery disease (PAD), infection, ulcer and amputation. One of the obstacles for preventing (DFC) is the lack of examinations of the feet in clinical practice (Feitosa et …

A Protocol To Increase Referral Rates To Diabetic Education, David M. Rokser

Evidence-Based Practice Project Reports

In 2015, approximately 30.3 million Americans, including 10.5% of the population of Minnesota, had been diagnosed with diabetes mellitus (American Diabetes Association, 2019). Increased risk of diabetic complications including neuropathy, retinopathy, nephropathy, cardiovascular disease, and chronic wounds has been associated with an elevated hemoglobin A1C (HgA1C). Formal diabetic education has been shown to be a cost-effective intervention to reduce HgA1C. The Office of Disease Prevention and Health Promotion published an objective within HealthyPeople 2020 that seeks to increase the percentage of diabetics receiving formal diabetic education in the United States from 46.9% of adults to 58.4%. The purpose of this …

Point-Of-Care Reminders To Prompt Provider Adherence With Diabetes Care Guidelines For Adults, Eric E. Spohn

Evidence-Based Practice Project Reports

Diabetes is a complex, chronic illness, and a leading cause of morbidity and mortality (ODPHP, 2019). Gaps in diabetes care exist between clinical guidelines and interventions provided in the clinical setting (ADA, 2015; Chauhan et al., 2017; Renders et al., 2001; Worswick et al., 2013). Improved diabetes management strategies and interventions among healthcare providers are essential to close the quality gap. The purpose of this evidenced-based practice (EBP) project was to prompt providers to adhere to diabetes care guidelines using a paper point-of-care reminder over a 12-week period. Provider performance rates covering four specific guidelines were measured: HbA1c, microalbuminuria, diabetic …

Dietary Fat And Sugar Differentially Affect Β-Adrenergic Stimulation Of Cardiac Erk And Akt Pathways In C57bl/6 Male Mice Subjected To High-Calorie Feeding, Sadia Ashraf, Gizem Yilmaz, Xu Chen, Romain Harmancey

Faculty, Staff and Student Publications

BACKGROUND: High dietary fat and sugar promote cardiac hypertrophy independently from an increase in blood pressure. The respective contribution that each macronutrient exerts on cardiac growth signaling pathways remains unclear.

OBJECTIVE: The goal of this study was to investigate the mechanisms by which high amounts of dietary fat and sugar affect cardiac growth regulatory pathways.

METHODS: Male C57BL/6 mice (9 wk old; n = 20/group) were fed a standard rodent diet (STD; kcal% protein-fat-carbohydrate, 29-17-54), a high-fat diet (HFD; 20-60-20), a high-fat and high-sugar Western diet (WD; 20-45-35), a high-sugar diet with mixed carbohydrates (HCD; 20-10-70), or a high-sucrose diet …

Unique Case Of Anca-Negative Pauci-Immune Necrotizing Glomerulonephritis With Diffuse Alveolar Hemorrhage, Potentially Associated With Midostaurin, Jonathan D Pankow, Guillaume Richard-Carpentier, Naval G Daver, William F Glass, Jaya Kala

Faculty, Staff and Student Publications

We present a 61-year-old male with FLT3-mutated acute myeloid leukemia treated with midostaurin who developed acute kidney injury requiring hemodialysis and pulmonary renal syndrome. Antibodies to proteinase-3, myeloperoxidase, and glomerular basement membrane were negative. Renal biopsy confirmed acute pauci-immune focal necrotizing glomerulonephritis (GN) with fibrin crescents indicating rapidly progressing glomerulonephritis. He improved with pulse methylprednisolone, intravenous cyclophosphamide, and plasma exchange with resolution of hemoptysis. This case highlights the importance of prompt renal biopsy to guide early initiation of life-saving therapies. To our knowledge, this is the first reported case of ANCA-negative pauci-immune necrotizing GN likely secondary to midostaurin.

A Call For Grounding Implicit Bias Training In Clinical And Translational Frameworks, Nao Hagiwara, Frederick W. Kron, Mark W. Scerbo, Ginger S. Watson

Psychology Faculty Publications

Since the publication of Unequal Treatment in 2003,¹ the number of studies investigating the implicit bias of health-care providers and its troubling consequences has increased exponentially. Bias can occur in all three psychological components: affects (ie, prejudice), cognition (ie, stereotypes), and behaviour (ie, discrimination). Implicit bias refers to prejudicial attitudes towards and stereotypical beliefs about a particular social group or members therein. These prejudicial attitudes and stereotypical beliefs are activated spontaneously and effortlessly, which often result in discriminatory behaviours.² This definition is consistent with how implicit bias is defined in psychology³ and in literature on health disparities. …

Dietary Fat And Sugar Differentially Affect Β-Adrenergic Stimulation Of Cardiac Erk And Akt Pathways In C57bl/6 Male Mice Subjected To High-Calorie Feeding, Sadia Ashraf, Gizem Yilmaz, Xu Chen, Romain Harmancey

Faculty, Staff and Student Publications

BACKGROUND: High dietary fat and sugar promote cardiac hypertrophy independently from an increase in blood pressure. The respective contribution that each macronutrient exerts on cardiac growth signaling pathways remains unclear.

OBJECTIVE: The goal of this study was to investigate the mechanisms by which high amounts of dietary fat and sugar affect cardiac growth regulatory pathways.

METHODS: Male C57BL/6 mice (9 wk old; n = 20/group) were fed a standard rodent diet (STD; kcal% protein-fat-carbohydrate, 29-17-54), a high-fat diet (HFD; 20-60-20), a high-fat and high-sugar Western diet (WD; 20-45-35), a high-sugar diet with mixed carbohydrates (HCD; 20-10-70), or a high-sucrose diet …

When Treating Sick Joints Harms Lungs, Ixekizumab Induced Pleural Effusion, Rami Batarseh, Kyle Smith, Mohammed Al-Ourani, Amro K. Al-Astal

Marshall Journal of Medicine

Immunological therapies have provided a multitude of new and effective treatment strategies for various disease states. While monoclonal antibody therapy benefits many patients, side effects are widely variable. here we present a case of pleural effusion complicating psoriatic arthritis treatment.

Acute Disseminated Encephalomyelitis, Ashan Hatharasinghe, Hossein Akhondi, Don Pepito

HCA Healthcare Journal of Medicine

Introduction: Acute Disseminated Encephalomyelitis (ADEM) is a rare autoimmune demyelinating disorder of the central nervous system. Clinical manifestations include encephalopathy, motor deficits, ataxia, and meningeal signs. In most cases, ADEM is preceded by either vaccination or viral illness. Here, we present a case with neither of the two predisposing elements.

Discussion: A 28-year-old Hispanic female presenting with substance use and suicidal ideation was placed on an involuntary psychiatric hold, started on olanzapine and scheduled for a psychiatric facility transfer. The following day, she was noted to have neurological deficits when ambulating. Computed tomography of the brain showed a right frontal …

Unpainfully Sweet, Khoi Nguyen, Alex Schafir

Providence St. Vincent Internal Medicine 2020

Introduction: Sweet's syndrome (ss), or acute febrile neutrophilic dermatosis, is characterized by sudden onset of fever, leukocytosis and erythematous plaques or nodules infiltrated by neutrophils. There are three main clinical settings in which Sweet's syndrome has been described: The diagnosis of Sweet’s syndrome often has a temporal association with the discovery or relapse of cancer as reported in this case.

Case Report: A 64-year-old woman with recurrent breast cancer on targeted and hormonal therapy presented to the ED with acute onset of fever and diffuse non-tender body rash. Vitals suggested sepsis and she was treated with broad spectrum …

Addressing The Social Determinants Of Health In The Clinic Setting, Larissa Sharma, Man Tran

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: It is estimated that clinical care accounts for only 20% of health, while behaviors, physical environment, and social and economic factors determine the rest. The social determinants of health include the basic life needs of housing, food, transport, along with other factors that include employment, education, drug and alcohol use, dental and eye care, etc. Insecurity in these socioeconomic factors are expressed in chronic medical illness, mental health problems, substance use, all leading to high healthcare utilization. Healthcare costs and utilization decrease when when these needs are provided for. In a survey of 6,000 Providence patients, 50% expressed …

Lemierre’S Syndrome, Jennifer Nguyen, Tom Chau

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Lemierre’ssyndrome is a rare and potentially fatal complication of acute pharyngitis most commonly seen in healthy, young adults who present with neck pain and persistent, high-grade fever. It is caused by anaerobic gram-negative organisms, most often Fusobacteriumnecrophorum, spreading into the deep spaces of the neck. This leads to septic thrombophlebitis of the internal jugular vein (IJ) with septic emboli, most frequently to the lungs.

CASE REPORT: A healthy 18-year-old woman presented to the hospital with five days of fever, rigors, sore throat, and left neck pain. She appeared relatively non-toxic but was febrile to 105.6℉ and in septic shock. …

Pulmonary Nocardiosisin An Immunocompetenthost, Leah Grant, Laura Loertscher, Jennifer Marfori

Providence St. Vincent Internal Medicine 2020

Introduction: • Nocardia is known to cause severe pulmonary or disseminated infection in immunocompromised patients, but can cause infection in immunocompetent patients. Providers should consider Nocardiosis in immunocompetent patients with prolonged and unexplained respiratory failure. • The preferred therapy for pulmonary Nocardiosis is a sulfa antibiotic for 3-6 months. Toxicity from prolonged use of alternative agents presents a therapeutic challenge in those with sulfa allergy.

Case Report: • An 85 year-old woman with a history of paroxysmal atrial fibrillation and heart failure with preserved EF presented to her primary care provider with 1 week of cough and progressive dyspnea. Chest …

Catastrophic Antiphospholipid Syndrome, Gabriel Hocum, Jeff Youker

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: Catastrophic Antiphospholipid Syndrome (CAPS) is a rare and extreme manifestation of Antiphospholipid Syndrome (APS) that features widespread thrombotic disease affecting multiple small vessels in a short time frame. CAPS affects only 0.8% of APS patients, but when it occurs it is has a mortality rate of approximately 50%.

CASE REPORT: A 50 year old female with SLE and APS presented with 1 month of cough and fatigue and 2 days of severe confusion after missing doses of rivaroxaban. In the ED she was intubated for airway protection and transferred to the ICU. Her evaluation revealed multi-organ failure with extensive …

Not Just Kids –A Case Of Adult Iga Vasculitis, Heidi Reich, Jeff Youker

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: IgA vasculitis, formerly known as HenlochSchonleinPurpura, is generally recognized as the most common form of systemic vasculitis in children, with 90% of cases occurring in the pediatric age group. However, the remaining 10% are noted in adult populations, and often has poorer long term outcomes if not identified and treated quickly. IgAVis commonly associated with streptococcal infections, although additional triggers such as drug ingestions, insect bites, and vaccinations have been described. Symptoms can include palpable purpura, acute abdominal pain, arthralgias, and hematuria. Recognizing the constellation of signs and symptoms is key for expediting appropriate therapy, which may reduce long …

Delirium: Delirious Elders, Implementing Reduction Interventions Using Mobility, Michael Silvas, Joe Miller, Shelley Sanders

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: This quality improvement project involved hiring, training, and managing 3 Delirium Mobility Aids to implement a non-pharmacologic delirium prevention bundle package, including early mobility, on hospitalized patients age >65.

Background: Delirium affects 20-30% of older hospitalized patients [1]. Patients with delirium have double the mortality rate [3], which increases with delirium duration [4]. Delirium worsens long term cognitive functioning [9,10,11,12]. Hospital costs increase by $2,500 per patient, totaling $6,900,000,000 in Medicare expenditures [7]. A single delirium episode increases total yearly costs by ~$64,421 [2]. Research suggests the best treatment is non-pharmacologic multicomponent interventions [6], and those with most …

Battling The Stigma: Hiv Screening In Resident Primary Care Clinic, Garrett Spencer, Laura Loertscher, Shelley Sanders

Providence St. Vincent Internal Medicine 2020

INTRODUCTION: HIV affects ~1.2 million in the US, with 25% unaware of their statusand annual incidence of 50,000. Early detection and treatment reduces risk of AIDS-related deaths and transmission. Both the CDC and the US Preventative Service Task Force recommend routine HIV screening. The Providence Medical Group at St Vincent (PMG-STV) resident clinic has no routine screening protocol. • 24% (757/3139) of all clinic patients have ever been screened. • Of active clinic patients seen quarterly, 5% are offered screening with only 3% completing screening. We implemented and measured a clinic-wide HIV screening protocol leveraging existing clinic workflows. We aimed …