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Standing adjacent Poster 391 in a loud, crowded meeting hall, Monika Wells, MD, MPH, a resident in internal medicine at Virginia Mason Medical Center in Seattle, chatted with a colleague. A few feet away, a group of doctors and healthcare professionals huddled dramatically, just barely out of earshot.
The fate of Dr. Wells’ scientific abstract hung in the balance.
Her study, a look at scheduling the start and stop times of hospitalist shifts around expected demand to reduce costs and patient wait times, was a short-list finalist in the Innovations category of HM16’s annual Research, Innovation, and Clinical Vignettes scientific abstract competition. With her work done—she had already made presentations to first a pair of semifinalist judges and then to a herd of all 10 of the category judges—Dr. Wells looked remarkably calm as she waited for the announcement of the winners.
Either way, she said, the competition had been an invigorating, exciting experience.
“I’m a doctor, so I like to compete,” she half-joked. “It definitely has been motivating.”
RIV ribbons this year were handed out to seven winners in four categories. The competition garnered 914 abstracts accepted for presentation.
Dr. Wells ended up being one of them. She was named Innovations’ trainee winner. In her study, researchers found that analyzing the flow of admissions and redistributing hospitalists to better conform to that flow reduced patient wait times and costs as well as improved the subjective experience of hospitalists even as volume increased.
The overall winner in the Innovations category also went to a trainee, Baely Crockett, PharmD, a resident at Eskenazi Health in Indianapolis. Her study looked at a pharmacist-managed rivaroxaban clinic for the treatment of venous thromboembolism (VTE). It was the first time, as far as the judges knew, that an award had gone to a pharmacist.
Dr. Crockett’s abstract showed that patients diagnosed in the ED with low-risk VTE are given a prescription scheduled to be seen in the follow-up clinic within two to five days, at which point the pharmacist sees the patients and reviews their case with them and determines treatment duration.
Dr. Crockett said the pharmacists involved are especially suitable for the role not only because of their expertise in the medication and the handling of time-consuming co-pay issues and other concerns but also because they shadowed ED physicians for six months to get training and experience.
“We’re able to fill in gaps that are true challenges to the patient’s success in finishing therapy,” she said.
One of the Innovations judges, Michael Craig, MD, MPH, FHM, associate professor of medicine at the University of North Carolina in Chapel Hill, said the research hit on an area of growing interest.
“The movement toward outpatient treatment of VTE is a pretty big topic that lots of people are working on,” he said. “It’s very relevant. The whole idea of having a pharmacist-driven intervention is unique; nobody had thought of or heard of before.”
The winner in the Research category was Vineet Chopra, MD, MSc, FHM, assistant professor at the University of Michigan in Ann Arbor, whose work set out to quantify how to prevent bloodstream infection and blood clots from the use of peripherally inserted central catheters, or PICC lines. Researchers created a simulation model, based on data from the literature, looking at what would happen to a hospital if the use of certain types of PICCs was increased while use of other types was decreased—the rationale being that PICCs with just one channel, or port, have a lower risk of infection or blood clots than those with multiple ports.
It is a risk that is often unrecognized, and PICC lines with multiple ports are often ordered as a just-in-case measure in the event that the first port gets clogged.
Chopra and colleagues found that, at the average hospital, about 75% of all PICCs used tend to be multichannel and 25% single-channel. They found every 5% increase in single-channel PICC use could prevent almost 1.5 infections per 1,000 patients, and 0.5 blood clots, with a corresponding cost savings of $13,000 per event. That can add up to hundreds of thousands of dollars a year at large hospitals.
And those calculations, Dr. Chopra noted, do not include penalties for infections or the financial effects of having those results publicly reported. Researchers are now creating an online tool— at improvepicc.com—that will allow users to calculate their own costs and potential savings.
“The hope of this is that it will give hospital administrators and hospital leadership and quality officers the momentum, perhaps, to overcome the inertia of not thinking actively,” said Dr. Chopra, who notched his first win after 10 years of participating in the RIV competition. “I think we don’t think actively about the choices we make when it comes to these devices.”
In the Clinical Vignettes category, winner Molly Kantor, MD, assistant clinical professor at the University of California, San Diego, recounted the case of a sickle-cell disease patient whose diagnosis, and hence treatment, was delayed and who ultimately died. She outlined a series of missteps, including taking at face-value a patient-reported past medical disease, which turned out to be wrong; making certain diagnoses based on lab tests and stopping there; and anchoring on the original diagnosis when the thought process was later reevaluated.
Dr. Kantor said the case is a caution flag to hospitalists, reinforcing the need for “a broad differential diagnosis.”
“[Make] sure that the data fits together and that you’re not using just one isolated piece of information to cinch everything, including the past medical history or a certain lab test, when the whole picture doesn’t quite fit together,” she said. “Looking back at this case, it’s pretty clear that the puzzle pieces probably weren’t quite fitting together, but there was enough that the easier thing to do was to make the diagnosis and move on.”
In the Pediatric Clinical Vignettes category, winner Jennifer Ladd, MD, a resident at Duke University, won for a study of a vexing case of a 2-year-old who was irritable and stalled on developmental milestones. At the hospital, the thought was that it could likely be a recurrence of herpes simplex (HSV) encephalitis, but the spinal fluid showed no signs of that and the acyclovir, which nearly always works for the disorder, was having no effect and the symptoms worsened.
The key in the case, said Alyssa Stephany, MD, then assistant professor at Duke University and now section chief of pediatric hospital medicine at Children’s Hospital of Wisconsin, who presented the case in Dr. Ladd’s absence, was that the team reopened the diagnosis and didn’t get ensnared in cognitive bias. A biopsy ultimately showed HSV in the brain tissue; it was a case of recurrence, despite signs to the contrary. Foscarnet was used to effectively treat the child; it is unknown why acyclovir didn’t work in this case.
“It kind of brings to the surface that that’s what a hospitalist is—a hospitalist is that person who sits and thinks, and really thinks, about the patient and doesn’t just do their rote work of input and output of a patient through the hospital system,” Dr. Stephany said. “When you get a case like this, it makes you take pause.”
The trainee winner in the Research category was N. Lance Downing, MD, of Stanford University School of Medicine, for work on an EHR-based severe sepsis alert. The trainee winner in Clinical Vignettes was Bhakti Shah, MD, of North Shore-LIJ Health System, now Northwell Health, on a rare case of autoimmune NMDA receptor encephalitis. TH
Thomas R. Collins is a freelance writer in South Florida.
2016 RIV Finalists, Winners
Research Category
WINNER:
Vineet Chopra, MD, MSc, FHM, LIMITING THE NUMBER OF LUMENS IN PERIPHERALLY INSERTED CENTRAL CATHETERS TO IMPROVE OUTCOMES AND REDUCE COST: A SIMULATION STUDY
TRAINEE WINNER:
N. Downing, MD, AN ELECTRONIC HEALTH RECORD-BASED SEVERE SEPSIS ALERT TO IMPROVE SEPSIS TREATMENT PERFORMANCE: RANDOMIZED EVALUATION
FINALISTS:
Waseem Khaliq, MD, MPH, PREVALENCE AND PREDICTORS OF NON-ADHERENCE TO BREAST CANCER SCREENING: PERSPECTIVE AND PREFERENCES OF HOSPITALIZED WOMEN
Dilli Poudel, MD, SYSTEMIC SCLEROSIS AS A RISK FACTOR OF ACUTE MYOCARDIAL INFARCTION: A US POPULATION BASED STUDY
Aiham Albaeni, MD, REGIONAL VARIATION IN RESOURCES UTILIZATION AND OUTCOMES FOLLOWING OUT-OF-HOSPITAL CARDIAC ARREST IN THE UNITED STATES
Poushali Bhattacharjee, MD, DETECTING SEPSIS: ARE TWO OPINIONS BETTER THAN ONE?
Vineet Chopra, MD, MSc, FHM, THE INFLUENCE OF RED BLOOD CELL TRANSFUSION ON VENOUS THROMBOEMBOLISM IN PATIENTS WITH PERIPHERALLY-INSERTED CENTRAL CATHETERS
Shaker Eid, MD, MBA, IMPACT OF HOSPITAL TEACHING STATUS ON OUT-OF-HOSPITAL CARDIAC ARREST OUTCOMES AND RESOURCE UTILIZATION IN THE UNITED STATES: 2000-2012
Tarun Jain, MD, CONTRAST-INDUCED NEPHROPATHY IN STEMI PATIENTS WITH AND WITHOUT CHRONIC KIDNEY DISEASE
Mona Beier, MD, CREATING A PATIENT SAFETY CULTURE ONE INCIDENT REPORT AT A TIME
Charles Pollack, MD, REINITIATION OF ANTITHROMBOTIC THERAPY AFTER EMERGENCY PROCEDURES OR AFTER AN EMERGENT BLEEDING EVENT: ADDITIONAL INTERIM EXPERIENCE FROM THE RE-VERSE AD TRIAL
Robert Boxer, MD, PhD, SAVING TIME: A TIME-MOTION ANALYSIS OF THE IMPACT OF REGIONALIZATION AND DAILY ADMITTING ON INTERN WORKFLOW
Kaleigh Evans, MD, THIRD TROPONIN ORDER OVERUSE IN THE SETTING OF CLINICAL STABILITY
David Paje, MD, SFHM, RISK OF VENOUS THROMBOEMBOLISM IN HOSPITALIZED PATIENTS WITH INFLAMMATORY BOWEL DISEASE
Rehan Qayyum, MD, COMPARISON OF TIME-TRENDS IN PATIENT SATISFACTION BETWEEN TEACHING AND NONTEACHING HOSPITAL
Joshua Rolnick, MD, VALIDATION OF TEST PERFORMANCE AND CLINICAL TIME ZERO FOR AN ELECTRONIC HEALTH RECORD-EMBEDDED SEVERE SEPSIS ALERT
Allison Louis, MD, BLIND SIDED: MISSING POOR VISUAL ACUITY AND DECREASED SELF-EFFICACY IN HOSPITALIZED PATIENTS WITH DIABETES
G. Randy Smith, MD, MS, SFHM, ASSOCIATION OF HOSPITAL ADMISSION SERVICE STRUCTURE WITH EARLY TRANSFER TO CRITICAL CARE, HOSPITAL READMISSION, AND LENGTH OF STAY
Kathleene Wooldridge, MD, R-VA-MARQUIS: IMPLEMENTING BEST PRACTICES IN MEDICATION RECONCILIATION FOR RURAL VETERANS
INNOVATION CATEGORY
WINNER:
Baely Crockett, PharmD, NOVEL PHARMACIST-MANAGED RIVAROXABAN CLINIC FOR OUTPATIENT TREATMENT OF VENOUS THROMBOEMBOLISM
TRAINEE WINNER:
Monika Wells, MD, MPH, DESIGNING HOSPITALIST SHIFTS AROUND ADMISSION DEMAND REDUCES PATIENT WAIT TIMES AND COST
FINALISTS:
Jessica Dong, WHO MOVED MY EHR CHEESE? A NEW APPROACH TO CURATING AND INDIVIDUALIZING COMMUNICATIONS TO PHYSICIANS ABOUT EHR SOFTWARE UPDATES
Stephanie Rennke, MD, MED REC: A SKILLS-BASED CURRICULUM ON MEDICATION SAFETY AND MEDICATION RECONCILIATION FOR MEDICAL STUDENTS
Jens Langsjoen, MD, DEVELOPING AN INPATIENT DELIRIUM PREVENTION PROTOCOL
Mark Goldin, MD, BUILDING PARALLEL CO-MANAGEMENT SERVICES IN A LARGE ACADEMIC HOSPITALIST GROUP
Brian Lichtenstein, MD, IMPROVING RISK-ADJUSTED OUTCOME MEASURES WITH PHYSICIAN-ORIENTED DOCUMENTATION INTERVENTIONS
Matthew Cerasale, MD, REAL-TIME PADUA: AN AUTOMATED EHR INTEGRATED VENOUS THROMBOEMBOLISM RISK ASSESSMENT TOOL
Franziska Jovin, MD, MMM, FHM, IMPLEMENTATION OF A PAY-FOR-PERFOMANCE STRUCTURE FOR HOSPITALIST-LED QUALITY IMPROVEMENT PROJECTS
Arpit Khandelwal, MD, MANAGING CHALLENGING PATIENTS: FROM CONFLICT TO TEACHING OPPORTUNITY
Justin Lotfi, MD, MAKING IT SIMPLE - PROCESS IMPROVEMENT FOR OUTSIDE MEDICAL RECORDS
David McCollum, MD, FIXING WHAT IS BROKEN: QUALITY IMPROVEMENT IN THE CRITICAL LAB VALUE PROCESS
Nidhi Rohatgi, MD, MS, A NOVEL MD-RN COLLABORATIVE PROTOCOL TO PREVENT AND MANAGE ACUTE DELIRIUM IN INPATIENT WARDS
Lesley Schmaltz, MD, UNNECESSARY TRANSFUSIONS: HOSPITAL MEDICINE LEADING INSTITUTION-WIDE CHANGE
Anuj Dalal, MD, FHM, IMPLEMENTATION OF A PATIENT-CENTERED ‘MICROBLOG' MESSAGING PLATFORM TO IMPROVE CARE TEAM COMMUNICATION
Willard Ellis, MD, PhD, FHM, INTENSIVE FOLLOW UP AFTER PALLIATIVE CARE CONSULTATIONS TO REDUCE READMISSIONS
Lakshmi Swaminathan, MD, MHSA, FHM, USING “MAGIC” TO FACILITATE APPROPRIATE PICC USE: RESULTS OF IMPLEMENTATION OF A PICC APPROPRIATENESS ASSESSMENT TOOL
Charles Coffey, MD, MSc, FHM, IMPLEMENTING GUIDELINE-BASED INDICATIONS FOR CARDIAC MONITORING AT CEDARS-SINAI MEDICAL CENTER
Erik Hoyer, MD, USE OF A HOSPITALIST CLINICAL COMMUNITY TO FACILITATE DISSEMINATION OF AN EARLY MOBILITY QUALITY IMPROVEMENT PROGRAM
Elizabeth Stewart, MD, A MULTIDISCIPLINARY APPROACH TO HIGH VALUE CARDIAC BIOMARKER
CLINICAL VIGNETTES CATEGORY
WINNER (ADULT):
Molly Kantor, MD, THE TIP OF THE ICEBERG: A RARE CAUSE OF ACUTE LIVER FAILURE
WINNER (PEDIATRIC):
Jennifer Ladd, MD, MORE THAN JUST THE “TERRIBLE TWOS”: A CASE OF RESISTANT HSV ENCEPHALITIS
TRAINEE WINNER:
Bhakti Shah, MD, UNMASKING THE TERATOMA
FINALISTS:
Weijen Chang, MD, SFHM, UNCOILING A PROBLEMATIC TICKLE IN THE THROAT
Kenton Dover, MD, KEEPING AN EYE OUT FOR THE DIAGNOSIS
Stephanie Royer, MD, THE YOUNGEST REPORTED CASE OF EOSINOPHILIC CHOLANGITIS
Oluremi Ajala, MD, ANGINA OF ABDOMINAL ORIGIN
Asana Anderson, MBBS, A PARATHYROID CRISIS BURIED IN A SEPTIC OTOMASTOIDITIS
Kyle Bennett, DO, BULLS-EYE MARKS THE SPOT: LYME CARDITIS PRESENTING AS RASH AND PRESYNCOPE
John Biebelhausen, MD, MBA, CROSSFIT CATASTROPHE: CHEST PAIN IN A HEALTHY YOUNG WOMAN
Xuan Gao, MD, A CASE OF THE UNSEEN: KLEBSIELLA PNEUMONIA PYOGENIC LIVER ABSCESS WITH PNEUMONIA AND SEPTIC ENDOPHTHALMITIS IN A NON-ASIAN U.S. RESIDENT
Sana Grover, MBBS, 'ABSTINENT AND INTOXICATED'. A RARE CASE OF AUTO-BREWERY SYNDROME
Andrew Hawrylak, MD, WHEN IT'S NOT AN ALLERGIC REACTION: AN UNUSUAL CASE OF ECTHYEMA GANGRENOSUM ASSOCIATED WITH PROTEUS BACTEREMIA
Rasheen Imtiaz, MD, LACTIC ACIDOSIS IN ASTHMA
Jessie King, MD, PhD, THE SMOKING WOMAN
Bradley Manning, MD, A SUPER-ANTIGEN-MEDIATED MIMIC OF ACUTE APPENDICITIS
Hiroki Matsuura, IMPAIRED CONSCIOUSNESS WITH INDOLENT BREAST MASS
Niharika Singh, MD, LOWER EXTREMITY NECROTIZING FASCIITIS: AN UNUSUAL PRESENTATION OF PERFORATED SIGMOID DIVERTICULITIS
Vivan Tran, DO, PUTTING THE PEE IN PREGNANCY: A CASE OF GESTATIONAL DIABETES INSIPIDUS YOU DON'T WANT TO MISS
Kristen Welch, THE MYSTERIOUS DANCE: A RARE CASE OF DELAYED ONSET DIABETIC STRIATOPATHY
Standing adjacent Poster 391 in a loud, crowded meeting hall, Monika Wells, MD, MPH, a resident in internal medicine at Virginia Mason Medical Center in Seattle, chatted with a colleague. A few feet away, a group of doctors and healthcare professionals huddled dramatically, just barely out of earshot.
The fate of Dr. Wells’ scientific abstract hung in the balance.
Her study, a look at scheduling the start and stop times of hospitalist shifts around expected demand to reduce costs and patient wait times, was a short-list finalist in the Innovations category of HM16’s annual Research, Innovation, and Clinical Vignettes scientific abstract competition. With her work done—she had already made presentations to first a pair of semifinalist judges and then to a herd of all 10 of the category judges—Dr. Wells looked remarkably calm as she waited for the announcement of the winners.
Either way, she said, the competition had been an invigorating, exciting experience.
“I’m a doctor, so I like to compete,” she half-joked. “It definitely has been motivating.”
RIV ribbons this year were handed out to seven winners in four categories. The competition garnered 914 abstracts accepted for presentation.
Dr. Wells ended up being one of them. She was named Innovations’ trainee winner. In her study, researchers found that analyzing the flow of admissions and redistributing hospitalists to better conform to that flow reduced patient wait times and costs as well as improved the subjective experience of hospitalists even as volume increased.
The overall winner in the Innovations category also went to a trainee, Baely Crockett, PharmD, a resident at Eskenazi Health in Indianapolis. Her study looked at a pharmacist-managed rivaroxaban clinic for the treatment of venous thromboembolism (VTE). It was the first time, as far as the judges knew, that an award had gone to a pharmacist.
Dr. Crockett’s abstract showed that patients diagnosed in the ED with low-risk VTE are given a prescription scheduled to be seen in the follow-up clinic within two to five days, at which point the pharmacist sees the patients and reviews their case with them and determines treatment duration.
Dr. Crockett said the pharmacists involved are especially suitable for the role not only because of their expertise in the medication and the handling of time-consuming co-pay issues and other concerns but also because they shadowed ED physicians for six months to get training and experience.
“We’re able to fill in gaps that are true challenges to the patient’s success in finishing therapy,” she said.
One of the Innovations judges, Michael Craig, MD, MPH, FHM, associate professor of medicine at the University of North Carolina in Chapel Hill, said the research hit on an area of growing interest.
“The movement toward outpatient treatment of VTE is a pretty big topic that lots of people are working on,” he said. “It’s very relevant. The whole idea of having a pharmacist-driven intervention is unique; nobody had thought of or heard of before.”
The winner in the Research category was Vineet Chopra, MD, MSc, FHM, assistant professor at the University of Michigan in Ann Arbor, whose work set out to quantify how to prevent bloodstream infection and blood clots from the use of peripherally inserted central catheters, or PICC lines. Researchers created a simulation model, based on data from the literature, looking at what would happen to a hospital if the use of certain types of PICCs was increased while use of other types was decreased—the rationale being that PICCs with just one channel, or port, have a lower risk of infection or blood clots than those with multiple ports.
It is a risk that is often unrecognized, and PICC lines with multiple ports are often ordered as a just-in-case measure in the event that the first port gets clogged.
Chopra and colleagues found that, at the average hospital, about 75% of all PICCs used tend to be multichannel and 25% single-channel. They found every 5% increase in single-channel PICC use could prevent almost 1.5 infections per 1,000 patients, and 0.5 blood clots, with a corresponding cost savings of $13,000 per event. That can add up to hundreds of thousands of dollars a year at large hospitals.
And those calculations, Dr. Chopra noted, do not include penalties for infections or the financial effects of having those results publicly reported. Researchers are now creating an online tool— at improvepicc.com—that will allow users to calculate their own costs and potential savings.
“The hope of this is that it will give hospital administrators and hospital leadership and quality officers the momentum, perhaps, to overcome the inertia of not thinking actively,” said Dr. Chopra, who notched his first win after 10 years of participating in the RIV competition. “I think we don’t think actively about the choices we make when it comes to these devices.”
In the Clinical Vignettes category, winner Molly Kantor, MD, assistant clinical professor at the University of California, San Diego, recounted the case of a sickle-cell disease patient whose diagnosis, and hence treatment, was delayed and who ultimately died. She outlined a series of missteps, including taking at face-value a patient-reported past medical disease, which turned out to be wrong; making certain diagnoses based on lab tests and stopping there; and anchoring on the original diagnosis when the thought process was later reevaluated.
Dr. Kantor said the case is a caution flag to hospitalists, reinforcing the need for “a broad differential diagnosis.”
“[Make] sure that the data fits together and that you’re not using just one isolated piece of information to cinch everything, including the past medical history or a certain lab test, when the whole picture doesn’t quite fit together,” she said. “Looking back at this case, it’s pretty clear that the puzzle pieces probably weren’t quite fitting together, but there was enough that the easier thing to do was to make the diagnosis and move on.”
In the Pediatric Clinical Vignettes category, winner Jennifer Ladd, MD, a resident at Duke University, won for a study of a vexing case of a 2-year-old who was irritable and stalled on developmental milestones. At the hospital, the thought was that it could likely be a recurrence of herpes simplex (HSV) encephalitis, but the spinal fluid showed no signs of that and the acyclovir, which nearly always works for the disorder, was having no effect and the symptoms worsened.
The key in the case, said Alyssa Stephany, MD, then assistant professor at Duke University and now section chief of pediatric hospital medicine at Children’s Hospital of Wisconsin, who presented the case in Dr. Ladd’s absence, was that the team reopened the diagnosis and didn’t get ensnared in cognitive bias. A biopsy ultimately showed HSV in the brain tissue; it was a case of recurrence, despite signs to the contrary. Foscarnet was used to effectively treat the child; it is unknown why acyclovir didn’t work in this case.
“It kind of brings to the surface that that’s what a hospitalist is—a hospitalist is that person who sits and thinks, and really thinks, about the patient and doesn’t just do their rote work of input and output of a patient through the hospital system,” Dr. Stephany said. “When you get a case like this, it makes you take pause.”
The trainee winner in the Research category was N. Lance Downing, MD, of Stanford University School of Medicine, for work on an EHR-based severe sepsis alert. The trainee winner in Clinical Vignettes was Bhakti Shah, MD, of North Shore-LIJ Health System, now Northwell Health, on a rare case of autoimmune NMDA receptor encephalitis. TH
Thomas R. Collins is a freelance writer in South Florida.
2016 RIV Finalists, Winners
Research Category
WINNER:
Vineet Chopra, MD, MSc, FHM, LIMITING THE NUMBER OF LUMENS IN PERIPHERALLY INSERTED CENTRAL CATHETERS TO IMPROVE OUTCOMES AND REDUCE COST: A SIMULATION STUDY
TRAINEE WINNER:
N. Downing, MD, AN ELECTRONIC HEALTH RECORD-BASED SEVERE SEPSIS ALERT TO IMPROVE SEPSIS TREATMENT PERFORMANCE: RANDOMIZED EVALUATION
FINALISTS:
Waseem Khaliq, MD, MPH, PREVALENCE AND PREDICTORS OF NON-ADHERENCE TO BREAST CANCER SCREENING: PERSPECTIVE AND PREFERENCES OF HOSPITALIZED WOMEN
Dilli Poudel, MD, SYSTEMIC SCLEROSIS AS A RISK FACTOR OF ACUTE MYOCARDIAL INFARCTION: A US POPULATION BASED STUDY
Aiham Albaeni, MD, REGIONAL VARIATION IN RESOURCES UTILIZATION AND OUTCOMES FOLLOWING OUT-OF-HOSPITAL CARDIAC ARREST IN THE UNITED STATES
Poushali Bhattacharjee, MD, DETECTING SEPSIS: ARE TWO OPINIONS BETTER THAN ONE?
Vineet Chopra, MD, MSc, FHM, THE INFLUENCE OF RED BLOOD CELL TRANSFUSION ON VENOUS THROMBOEMBOLISM IN PATIENTS WITH PERIPHERALLY-INSERTED CENTRAL CATHETERS
Shaker Eid, MD, MBA, IMPACT OF HOSPITAL TEACHING STATUS ON OUT-OF-HOSPITAL CARDIAC ARREST OUTCOMES AND RESOURCE UTILIZATION IN THE UNITED STATES: 2000-2012
Tarun Jain, MD, CONTRAST-INDUCED NEPHROPATHY IN STEMI PATIENTS WITH AND WITHOUT CHRONIC KIDNEY DISEASE
Mona Beier, MD, CREATING A PATIENT SAFETY CULTURE ONE INCIDENT REPORT AT A TIME
Charles Pollack, MD, REINITIATION OF ANTITHROMBOTIC THERAPY AFTER EMERGENCY PROCEDURES OR AFTER AN EMERGENT BLEEDING EVENT: ADDITIONAL INTERIM EXPERIENCE FROM THE RE-VERSE AD TRIAL
Robert Boxer, MD, PhD, SAVING TIME: A TIME-MOTION ANALYSIS OF THE IMPACT OF REGIONALIZATION AND DAILY ADMITTING ON INTERN WORKFLOW
Kaleigh Evans, MD, THIRD TROPONIN ORDER OVERUSE IN THE SETTING OF CLINICAL STABILITY
David Paje, MD, SFHM, RISK OF VENOUS THROMBOEMBOLISM IN HOSPITALIZED PATIENTS WITH INFLAMMATORY BOWEL DISEASE
Rehan Qayyum, MD, COMPARISON OF TIME-TRENDS IN PATIENT SATISFACTION BETWEEN TEACHING AND NONTEACHING HOSPITAL
Joshua Rolnick, MD, VALIDATION OF TEST PERFORMANCE AND CLINICAL TIME ZERO FOR AN ELECTRONIC HEALTH RECORD-EMBEDDED SEVERE SEPSIS ALERT
Allison Louis, MD, BLIND SIDED: MISSING POOR VISUAL ACUITY AND DECREASED SELF-EFFICACY IN HOSPITALIZED PATIENTS WITH DIABETES
G. Randy Smith, MD, MS, SFHM, ASSOCIATION OF HOSPITAL ADMISSION SERVICE STRUCTURE WITH EARLY TRANSFER TO CRITICAL CARE, HOSPITAL READMISSION, AND LENGTH OF STAY
Kathleene Wooldridge, MD, R-VA-MARQUIS: IMPLEMENTING BEST PRACTICES IN MEDICATION RECONCILIATION FOR RURAL VETERANS
INNOVATION CATEGORY
WINNER:
Baely Crockett, PharmD, NOVEL PHARMACIST-MANAGED RIVAROXABAN CLINIC FOR OUTPATIENT TREATMENT OF VENOUS THROMBOEMBOLISM
TRAINEE WINNER:
Monika Wells, MD, MPH, DESIGNING HOSPITALIST SHIFTS AROUND ADMISSION DEMAND REDUCES PATIENT WAIT TIMES AND COST
FINALISTS:
Jessica Dong, WHO MOVED MY EHR CHEESE? A NEW APPROACH TO CURATING AND INDIVIDUALIZING COMMUNICATIONS TO PHYSICIANS ABOUT EHR SOFTWARE UPDATES
Stephanie Rennke, MD, MED REC: A SKILLS-BASED CURRICULUM ON MEDICATION SAFETY AND MEDICATION RECONCILIATION FOR MEDICAL STUDENTS
Jens Langsjoen, MD, DEVELOPING AN INPATIENT DELIRIUM PREVENTION PROTOCOL
Mark Goldin, MD, BUILDING PARALLEL CO-MANAGEMENT SERVICES IN A LARGE ACADEMIC HOSPITALIST GROUP
Brian Lichtenstein, MD, IMPROVING RISK-ADJUSTED OUTCOME MEASURES WITH PHYSICIAN-ORIENTED DOCUMENTATION INTERVENTIONS
Matthew Cerasale, MD, REAL-TIME PADUA: AN AUTOMATED EHR INTEGRATED VENOUS THROMBOEMBOLISM RISK ASSESSMENT TOOL
Franziska Jovin, MD, MMM, FHM, IMPLEMENTATION OF A PAY-FOR-PERFOMANCE STRUCTURE FOR HOSPITALIST-LED QUALITY IMPROVEMENT PROJECTS
Arpit Khandelwal, MD, MANAGING CHALLENGING PATIENTS: FROM CONFLICT TO TEACHING OPPORTUNITY
Justin Lotfi, MD, MAKING IT SIMPLE - PROCESS IMPROVEMENT FOR OUTSIDE MEDICAL RECORDS
David McCollum, MD, FIXING WHAT IS BROKEN: QUALITY IMPROVEMENT IN THE CRITICAL LAB VALUE PROCESS
Nidhi Rohatgi, MD, MS, A NOVEL MD-RN COLLABORATIVE PROTOCOL TO PREVENT AND MANAGE ACUTE DELIRIUM IN INPATIENT WARDS
Lesley Schmaltz, MD, UNNECESSARY TRANSFUSIONS: HOSPITAL MEDICINE LEADING INSTITUTION-WIDE CHANGE
Anuj Dalal, MD, FHM, IMPLEMENTATION OF A PATIENT-CENTERED ‘MICROBLOG' MESSAGING PLATFORM TO IMPROVE CARE TEAM COMMUNICATION
Willard Ellis, MD, PhD, FHM, INTENSIVE FOLLOW UP AFTER PALLIATIVE CARE CONSULTATIONS TO REDUCE READMISSIONS
Lakshmi Swaminathan, MD, MHSA, FHM, USING “MAGIC” TO FACILITATE APPROPRIATE PICC USE: RESULTS OF IMPLEMENTATION OF A PICC APPROPRIATENESS ASSESSMENT TOOL
Charles Coffey, MD, MSc, FHM, IMPLEMENTING GUIDELINE-BASED INDICATIONS FOR CARDIAC MONITORING AT CEDARS-SINAI MEDICAL CENTER
Erik Hoyer, MD, USE OF A HOSPITALIST CLINICAL COMMUNITY TO FACILITATE DISSEMINATION OF AN EARLY MOBILITY QUALITY IMPROVEMENT PROGRAM
Elizabeth Stewart, MD, A MULTIDISCIPLINARY APPROACH TO HIGH VALUE CARDIAC BIOMARKER
CLINICAL VIGNETTES CATEGORY
WINNER (ADULT):
Molly Kantor, MD, THE TIP OF THE ICEBERG: A RARE CAUSE OF ACUTE LIVER FAILURE
WINNER (PEDIATRIC):
Jennifer Ladd, MD, MORE THAN JUST THE “TERRIBLE TWOS”: A CASE OF RESISTANT HSV ENCEPHALITIS
TRAINEE WINNER:
Bhakti Shah, MD, UNMASKING THE TERATOMA
FINALISTS:
Weijen Chang, MD, SFHM, UNCOILING A PROBLEMATIC TICKLE IN THE THROAT
Kenton Dover, MD, KEEPING AN EYE OUT FOR THE DIAGNOSIS
Stephanie Royer, MD, THE YOUNGEST REPORTED CASE OF EOSINOPHILIC CHOLANGITIS
Oluremi Ajala, MD, ANGINA OF ABDOMINAL ORIGIN
Asana Anderson, MBBS, A PARATHYROID CRISIS BURIED IN A SEPTIC OTOMASTOIDITIS
Kyle Bennett, DO, BULLS-EYE MARKS THE SPOT: LYME CARDITIS PRESENTING AS RASH AND PRESYNCOPE
John Biebelhausen, MD, MBA, CROSSFIT CATASTROPHE: CHEST PAIN IN A HEALTHY YOUNG WOMAN
Xuan Gao, MD, A CASE OF THE UNSEEN: KLEBSIELLA PNEUMONIA PYOGENIC LIVER ABSCESS WITH PNEUMONIA AND SEPTIC ENDOPHTHALMITIS IN A NON-ASIAN U.S. RESIDENT
Sana Grover, MBBS, 'ABSTINENT AND INTOXICATED'. A RARE CASE OF AUTO-BREWERY SYNDROME
Andrew Hawrylak, MD, WHEN IT'S NOT AN ALLERGIC REACTION: AN UNUSUAL CASE OF ECTHYEMA GANGRENOSUM ASSOCIATED WITH PROTEUS BACTEREMIA
Rasheen Imtiaz, MD, LACTIC ACIDOSIS IN ASTHMA
Jessie King, MD, PhD, THE SMOKING WOMAN
Bradley Manning, MD, A SUPER-ANTIGEN-MEDIATED MIMIC OF ACUTE APPENDICITIS
Hiroki Matsuura, IMPAIRED CONSCIOUSNESS WITH INDOLENT BREAST MASS
Niharika Singh, MD, LOWER EXTREMITY NECROTIZING FASCIITIS: AN UNUSUAL PRESENTATION OF PERFORATED SIGMOID DIVERTICULITIS
Vivan Tran, DO, PUTTING THE PEE IN PREGNANCY: A CASE OF GESTATIONAL DIABETES INSIPIDUS YOU DON'T WANT TO MISS
Kristen Welch, THE MYSTERIOUS DANCE: A RARE CASE OF DELAYED ONSET DIABETIC STRIATOPATHY
Standing adjacent Poster 391 in a loud, crowded meeting hall, Monika Wells, MD, MPH, a resident in internal medicine at Virginia Mason Medical Center in Seattle, chatted with a colleague. A few feet away, a group of doctors and healthcare professionals huddled dramatically, just barely out of earshot.
The fate of Dr. Wells’ scientific abstract hung in the balance.
Her study, a look at scheduling the start and stop times of hospitalist shifts around expected demand to reduce costs and patient wait times, was a short-list finalist in the Innovations category of HM16’s annual Research, Innovation, and Clinical Vignettes scientific abstract competition. With her work done—she had already made presentations to first a pair of semifinalist judges and then to a herd of all 10 of the category judges—Dr. Wells looked remarkably calm as she waited for the announcement of the winners.
Either way, she said, the competition had been an invigorating, exciting experience.
“I’m a doctor, so I like to compete,” she half-joked. “It definitely has been motivating.”
RIV ribbons this year were handed out to seven winners in four categories. The competition garnered 914 abstracts accepted for presentation.
Dr. Wells ended up being one of them. She was named Innovations’ trainee winner. In her study, researchers found that analyzing the flow of admissions and redistributing hospitalists to better conform to that flow reduced patient wait times and costs as well as improved the subjective experience of hospitalists even as volume increased.
The overall winner in the Innovations category also went to a trainee, Baely Crockett, PharmD, a resident at Eskenazi Health in Indianapolis. Her study looked at a pharmacist-managed rivaroxaban clinic for the treatment of venous thromboembolism (VTE). It was the first time, as far as the judges knew, that an award had gone to a pharmacist.
Dr. Crockett’s abstract showed that patients diagnosed in the ED with low-risk VTE are given a prescription scheduled to be seen in the follow-up clinic within two to five days, at which point the pharmacist sees the patients and reviews their case with them and determines treatment duration.
Dr. Crockett said the pharmacists involved are especially suitable for the role not only because of their expertise in the medication and the handling of time-consuming co-pay issues and other concerns but also because they shadowed ED physicians for six months to get training and experience.
“We’re able to fill in gaps that are true challenges to the patient’s success in finishing therapy,” she said.
One of the Innovations judges, Michael Craig, MD, MPH, FHM, associate professor of medicine at the University of North Carolina in Chapel Hill, said the research hit on an area of growing interest.
“The movement toward outpatient treatment of VTE is a pretty big topic that lots of people are working on,” he said. “It’s very relevant. The whole idea of having a pharmacist-driven intervention is unique; nobody had thought of or heard of before.”
The winner in the Research category was Vineet Chopra, MD, MSc, FHM, assistant professor at the University of Michigan in Ann Arbor, whose work set out to quantify how to prevent bloodstream infection and blood clots from the use of peripherally inserted central catheters, or PICC lines. Researchers created a simulation model, based on data from the literature, looking at what would happen to a hospital if the use of certain types of PICCs was increased while use of other types was decreased—the rationale being that PICCs with just one channel, or port, have a lower risk of infection or blood clots than those with multiple ports.
It is a risk that is often unrecognized, and PICC lines with multiple ports are often ordered as a just-in-case measure in the event that the first port gets clogged.
Chopra and colleagues found that, at the average hospital, about 75% of all PICCs used tend to be multichannel and 25% single-channel. They found every 5% increase in single-channel PICC use could prevent almost 1.5 infections per 1,000 patients, and 0.5 blood clots, with a corresponding cost savings of $13,000 per event. That can add up to hundreds of thousands of dollars a year at large hospitals.
And those calculations, Dr. Chopra noted, do not include penalties for infections or the financial effects of having those results publicly reported. Researchers are now creating an online tool— at improvepicc.com—that will allow users to calculate their own costs and potential savings.
“The hope of this is that it will give hospital administrators and hospital leadership and quality officers the momentum, perhaps, to overcome the inertia of not thinking actively,” said Dr. Chopra, who notched his first win after 10 years of participating in the RIV competition. “I think we don’t think actively about the choices we make when it comes to these devices.”
In the Clinical Vignettes category, winner Molly Kantor, MD, assistant clinical professor at the University of California, San Diego, recounted the case of a sickle-cell disease patient whose diagnosis, and hence treatment, was delayed and who ultimately died. She outlined a series of missteps, including taking at face-value a patient-reported past medical disease, which turned out to be wrong; making certain diagnoses based on lab tests and stopping there; and anchoring on the original diagnosis when the thought process was later reevaluated.
Dr. Kantor said the case is a caution flag to hospitalists, reinforcing the need for “a broad differential diagnosis.”
“[Make] sure that the data fits together and that you’re not using just one isolated piece of information to cinch everything, including the past medical history or a certain lab test, when the whole picture doesn’t quite fit together,” she said. “Looking back at this case, it’s pretty clear that the puzzle pieces probably weren’t quite fitting together, but there was enough that the easier thing to do was to make the diagnosis and move on.”
In the Pediatric Clinical Vignettes category, winner Jennifer Ladd, MD, a resident at Duke University, won for a study of a vexing case of a 2-year-old who was irritable and stalled on developmental milestones. At the hospital, the thought was that it could likely be a recurrence of herpes simplex (HSV) encephalitis, but the spinal fluid showed no signs of that and the acyclovir, which nearly always works for the disorder, was having no effect and the symptoms worsened.
The key in the case, said Alyssa Stephany, MD, then assistant professor at Duke University and now section chief of pediatric hospital medicine at Children’s Hospital of Wisconsin, who presented the case in Dr. Ladd’s absence, was that the team reopened the diagnosis and didn’t get ensnared in cognitive bias. A biopsy ultimately showed HSV in the brain tissue; it was a case of recurrence, despite signs to the contrary. Foscarnet was used to effectively treat the child; it is unknown why acyclovir didn’t work in this case.
“It kind of brings to the surface that that’s what a hospitalist is—a hospitalist is that person who sits and thinks, and really thinks, about the patient and doesn’t just do their rote work of input and output of a patient through the hospital system,” Dr. Stephany said. “When you get a case like this, it makes you take pause.”
The trainee winner in the Research category was N. Lance Downing, MD, of Stanford University School of Medicine, for work on an EHR-based severe sepsis alert. The trainee winner in Clinical Vignettes was Bhakti Shah, MD, of North Shore-LIJ Health System, now Northwell Health, on a rare case of autoimmune NMDA receptor encephalitis. TH
Thomas R. Collins is a freelance writer in South Florida.
2016 RIV Finalists, Winners
Research Category
WINNER:
Vineet Chopra, MD, MSc, FHM, LIMITING THE NUMBER OF LUMENS IN PERIPHERALLY INSERTED CENTRAL CATHETERS TO IMPROVE OUTCOMES AND REDUCE COST: A SIMULATION STUDY
TRAINEE WINNER:
N. Downing, MD, AN ELECTRONIC HEALTH RECORD-BASED SEVERE SEPSIS ALERT TO IMPROVE SEPSIS TREATMENT PERFORMANCE: RANDOMIZED EVALUATION
FINALISTS:
Waseem Khaliq, MD, MPH, PREVALENCE AND PREDICTORS OF NON-ADHERENCE TO BREAST CANCER SCREENING: PERSPECTIVE AND PREFERENCES OF HOSPITALIZED WOMEN
Dilli Poudel, MD, SYSTEMIC SCLEROSIS AS A RISK FACTOR OF ACUTE MYOCARDIAL INFARCTION: A US POPULATION BASED STUDY
Aiham Albaeni, MD, REGIONAL VARIATION IN RESOURCES UTILIZATION AND OUTCOMES FOLLOWING OUT-OF-HOSPITAL CARDIAC ARREST IN THE UNITED STATES
Poushali Bhattacharjee, MD, DETECTING SEPSIS: ARE TWO OPINIONS BETTER THAN ONE?
Vineet Chopra, MD, MSc, FHM, THE INFLUENCE OF RED BLOOD CELL TRANSFUSION ON VENOUS THROMBOEMBOLISM IN PATIENTS WITH PERIPHERALLY-INSERTED CENTRAL CATHETERS
Shaker Eid, MD, MBA, IMPACT OF HOSPITAL TEACHING STATUS ON OUT-OF-HOSPITAL CARDIAC ARREST OUTCOMES AND RESOURCE UTILIZATION IN THE UNITED STATES: 2000-2012
Tarun Jain, MD, CONTRAST-INDUCED NEPHROPATHY IN STEMI PATIENTS WITH AND WITHOUT CHRONIC KIDNEY DISEASE
Mona Beier, MD, CREATING A PATIENT SAFETY CULTURE ONE INCIDENT REPORT AT A TIME
Charles Pollack, MD, REINITIATION OF ANTITHROMBOTIC THERAPY AFTER EMERGENCY PROCEDURES OR AFTER AN EMERGENT BLEEDING EVENT: ADDITIONAL INTERIM EXPERIENCE FROM THE RE-VERSE AD TRIAL
Robert Boxer, MD, PhD, SAVING TIME: A TIME-MOTION ANALYSIS OF THE IMPACT OF REGIONALIZATION AND DAILY ADMITTING ON INTERN WORKFLOW
Kaleigh Evans, MD, THIRD TROPONIN ORDER OVERUSE IN THE SETTING OF CLINICAL STABILITY
David Paje, MD, SFHM, RISK OF VENOUS THROMBOEMBOLISM IN HOSPITALIZED PATIENTS WITH INFLAMMATORY BOWEL DISEASE
Rehan Qayyum, MD, COMPARISON OF TIME-TRENDS IN PATIENT SATISFACTION BETWEEN TEACHING AND NONTEACHING HOSPITAL
Joshua Rolnick, MD, VALIDATION OF TEST PERFORMANCE AND CLINICAL TIME ZERO FOR AN ELECTRONIC HEALTH RECORD-EMBEDDED SEVERE SEPSIS ALERT
Allison Louis, MD, BLIND SIDED: MISSING POOR VISUAL ACUITY AND DECREASED SELF-EFFICACY IN HOSPITALIZED PATIENTS WITH DIABETES
G. Randy Smith, MD, MS, SFHM, ASSOCIATION OF HOSPITAL ADMISSION SERVICE STRUCTURE WITH EARLY TRANSFER TO CRITICAL CARE, HOSPITAL READMISSION, AND LENGTH OF STAY
Kathleene Wooldridge, MD, R-VA-MARQUIS: IMPLEMENTING BEST PRACTICES IN MEDICATION RECONCILIATION FOR RURAL VETERANS
INNOVATION CATEGORY
WINNER:
Baely Crockett, PharmD, NOVEL PHARMACIST-MANAGED RIVAROXABAN CLINIC FOR OUTPATIENT TREATMENT OF VENOUS THROMBOEMBOLISM
TRAINEE WINNER:
Monika Wells, MD, MPH, DESIGNING HOSPITALIST SHIFTS AROUND ADMISSION DEMAND REDUCES PATIENT WAIT TIMES AND COST
FINALISTS:
Jessica Dong, WHO MOVED MY EHR CHEESE? A NEW APPROACH TO CURATING AND INDIVIDUALIZING COMMUNICATIONS TO PHYSICIANS ABOUT EHR SOFTWARE UPDATES
Stephanie Rennke, MD, MED REC: A SKILLS-BASED CURRICULUM ON MEDICATION SAFETY AND MEDICATION RECONCILIATION FOR MEDICAL STUDENTS
Jens Langsjoen, MD, DEVELOPING AN INPATIENT DELIRIUM PREVENTION PROTOCOL
Mark Goldin, MD, BUILDING PARALLEL CO-MANAGEMENT SERVICES IN A LARGE ACADEMIC HOSPITALIST GROUP
Brian Lichtenstein, MD, IMPROVING RISK-ADJUSTED OUTCOME MEASURES WITH PHYSICIAN-ORIENTED DOCUMENTATION INTERVENTIONS
Matthew Cerasale, MD, REAL-TIME PADUA: AN AUTOMATED EHR INTEGRATED VENOUS THROMBOEMBOLISM RISK ASSESSMENT TOOL
Franziska Jovin, MD, MMM, FHM, IMPLEMENTATION OF A PAY-FOR-PERFOMANCE STRUCTURE FOR HOSPITALIST-LED QUALITY IMPROVEMENT PROJECTS
Arpit Khandelwal, MD, MANAGING CHALLENGING PATIENTS: FROM CONFLICT TO TEACHING OPPORTUNITY
Justin Lotfi, MD, MAKING IT SIMPLE - PROCESS IMPROVEMENT FOR OUTSIDE MEDICAL RECORDS
David McCollum, MD, FIXING WHAT IS BROKEN: QUALITY IMPROVEMENT IN THE CRITICAL LAB VALUE PROCESS
Nidhi Rohatgi, MD, MS, A NOVEL MD-RN COLLABORATIVE PROTOCOL TO PREVENT AND MANAGE ACUTE DELIRIUM IN INPATIENT WARDS
Lesley Schmaltz, MD, UNNECESSARY TRANSFUSIONS: HOSPITAL MEDICINE LEADING INSTITUTION-WIDE CHANGE
Anuj Dalal, MD, FHM, IMPLEMENTATION OF A PATIENT-CENTERED ‘MICROBLOG' MESSAGING PLATFORM TO IMPROVE CARE TEAM COMMUNICATION
Willard Ellis, MD, PhD, FHM, INTENSIVE FOLLOW UP AFTER PALLIATIVE CARE CONSULTATIONS TO REDUCE READMISSIONS
Lakshmi Swaminathan, MD, MHSA, FHM, USING “MAGIC” TO FACILITATE APPROPRIATE PICC USE: RESULTS OF IMPLEMENTATION OF A PICC APPROPRIATENESS ASSESSMENT TOOL
Charles Coffey, MD, MSc, FHM, IMPLEMENTING GUIDELINE-BASED INDICATIONS FOR CARDIAC MONITORING AT CEDARS-SINAI MEDICAL CENTER
Erik Hoyer, MD, USE OF A HOSPITALIST CLINICAL COMMUNITY TO FACILITATE DISSEMINATION OF AN EARLY MOBILITY QUALITY IMPROVEMENT PROGRAM
Elizabeth Stewart, MD, A MULTIDISCIPLINARY APPROACH TO HIGH VALUE CARDIAC BIOMARKER
CLINICAL VIGNETTES CATEGORY
WINNER (ADULT):
Molly Kantor, MD, THE TIP OF THE ICEBERG: A RARE CAUSE OF ACUTE LIVER FAILURE
WINNER (PEDIATRIC):
Jennifer Ladd, MD, MORE THAN JUST THE “TERRIBLE TWOS”: A CASE OF RESISTANT HSV ENCEPHALITIS
TRAINEE WINNER:
Bhakti Shah, MD, UNMASKING THE TERATOMA
FINALISTS:
Weijen Chang, MD, SFHM, UNCOILING A PROBLEMATIC TICKLE IN THE THROAT
Kenton Dover, MD, KEEPING AN EYE OUT FOR THE DIAGNOSIS
Stephanie Royer, MD, THE YOUNGEST REPORTED CASE OF EOSINOPHILIC CHOLANGITIS
Oluremi Ajala, MD, ANGINA OF ABDOMINAL ORIGIN
Asana Anderson, MBBS, A PARATHYROID CRISIS BURIED IN A SEPTIC OTOMASTOIDITIS
Kyle Bennett, DO, BULLS-EYE MARKS THE SPOT: LYME CARDITIS PRESENTING AS RASH AND PRESYNCOPE
John Biebelhausen, MD, MBA, CROSSFIT CATASTROPHE: CHEST PAIN IN A HEALTHY YOUNG WOMAN
Xuan Gao, MD, A CASE OF THE UNSEEN: KLEBSIELLA PNEUMONIA PYOGENIC LIVER ABSCESS WITH PNEUMONIA AND SEPTIC ENDOPHTHALMITIS IN A NON-ASIAN U.S. RESIDENT
Sana Grover, MBBS, 'ABSTINENT AND INTOXICATED'. A RARE CASE OF AUTO-BREWERY SYNDROME
Andrew Hawrylak, MD, WHEN IT'S NOT AN ALLERGIC REACTION: AN UNUSUAL CASE OF ECTHYEMA GANGRENOSUM ASSOCIATED WITH PROTEUS BACTEREMIA
Rasheen Imtiaz, MD, LACTIC ACIDOSIS IN ASTHMA
Jessie King, MD, PhD, THE SMOKING WOMAN
Bradley Manning, MD, A SUPER-ANTIGEN-MEDIATED MIMIC OF ACUTE APPENDICITIS
Hiroki Matsuura, IMPAIRED CONSCIOUSNESS WITH INDOLENT BREAST MASS
Niharika Singh, MD, LOWER EXTREMITY NECROTIZING FASCIITIS: AN UNUSUAL PRESENTATION OF PERFORATED SIGMOID DIVERTICULITIS
Vivan Tran, DO, PUTTING THE PEE IN PREGNANCY: A CASE OF GESTATIONAL DIABETES INSIPIDUS YOU DON'T WANT TO MISS
Kristen Welch, THE MYSTERIOUS DANCE: A RARE CASE OF DELAYED ONSET DIABETIC STRIATOPATHY
