United States

Background 
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is a delayed type IV hypersensitivity reaction. It is an exfoliative mucocutaneous disease often caused by antibiotics or antiepileptics. Etiology of this disease is thought to be due to drug-specific CD8+ cytotoxic lymphocytes. These lymphocytes exocytose perforin and granzyme B, creating channels in the cell membrane &amp; activating caspases, leading to apoptosis. Exact pathophysiological mechanisms are still speculative, but it is thought to be due to the interaction/binding of drug-associated antigens with MHC type I or cellular peptide, inducing the formation of an immunogenic compound. 

Case Presentation
A 74-year-old female was initially admitted for severe sepsis secondary to CAUTI and pyelonephritis with metabolic encephalopathy. She started piperacillin-tazobactam at this time. Four days later, she developed a maculopapular rash on her abdomen that spread diffusely and progressed to blisters involving the face, back, and bilateral upper and lower extremities, covering &gt;30% of her body. Piperacillin-tazobactam was discontinued at this time and meropenem was initiated for pyelonephritis treatment. Therabond treatment was initiated along with fluids and electrolyte replacement. She completed pyelonephritis treatment with meropenem, and later levaquin. Her skin lesions continued to heal with conservative management. After two weeks, she was deemed suitable to discharge to an assisted living facility with daily Aquaphor dressing changes. 

Discussion
Among antibiotics, SJS/TEN is most commonly reported with aminopenicillins, sulfonamides and quinolones. Severe hypersensitivity reactions are reported less frequently with carboxypenicillins and ureidopenicillins; however, SJS/TEN and erythema multiforme have been reported with ticarcillin treatment. Aminopenicillins and ureidopenicillins share a similar biochemical structure; similar properties among antibiotics could cause a similar reaction. Piperacillin-tazobactam induced linear IgA bullous dermatosis (LABD) has been reported to present as SJS/TEN and was on the differential. On biopsy, LABD is a regenerating process compared to the degenerative nature of SJS/TEN. Atypical causes of SJS/TEN were ruled out: negative IgM for mycoplasma pneumoniae and negative ANA for potential autoimmune causes. Biopsies of the rash were taken and showed lymphocytic interface dermatitis and necrotic/degenerative keratinocytes, as well as epidermal blistering &amp; sloughing. These findings, along with the patient’s history, were consistent with SJS/TEN.

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Piperacillin-tazobactam induced toxic epidermal necrolysis

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Background 
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is a delayed type IV hypersensitivity reaction. It is an exfoliative mucocutaneous disease often caused by antibiotics or antiepileptics. Etiology of this disease is thought to be due to drug-specific CD8+ cytotoxic lymphocytes. These lymphocytes exocytose perforin and granzyme B, creating channels in the cell membrane & activating caspases, leading to apoptosis. Exact pathophysiological mechanisms are still speculative, but it is thought to be due to the interaction/binding of drug-associated antigens with MHC type I or cellular peptide, inducing the formation of an immunogenic compound. 

Case Presentation
A 74-year-old female was initially admitted for severe sepsis secondary to CAUTI and pyelonephritis with metabolic encephalopathy. She started piperacillin-tazobactam at this time. Four days later, she developed a maculopapular rash on her abdomen that spread diffusely and progressed to blisters involving the face, back, and bilateral upper and lower extremities, covering >30% of her body. Piperacillin-tazobactam was discontinued at this time and meropenem was initiated for pyelonephritis treatment. Therabond treatment was initiated along with fluids and electrolyte replacement. She completed pyelonephritis treatment with meropenem, and later levaquin. Her skin lesions continued to heal with conservative management. After two weeks, she was deemed suitable to discharge to an assisted living facility with daily Aquaphor dressing changes. 

Discussion
Among antibiotics, SJS/TEN is most commonly reported with aminopenicillins, sulfonamides and quinolones. Severe hypersensitivity reactions are reported less frequently with carboxypenicillins and ureidopenicillins; however, SJS/TEN and erythema multiforme have been reported with ticarcillin treatment. Aminopenicillins and ureidopenicillins share a similar biochemical structure; similar properties among antibiotics could cause a similar reaction. Piperacillin-tazobactam induced linear IgA bullous dermatosis (LABD) has been reported to present as SJS/TEN and was on the differential. On biopsy, LABD is a regenerating process compared to the degenerative nature of SJS/TEN. Atypical causes of SJS/TEN were ruled out: negative IgM for mycoplasma pneumoniae and negative ANA for potential autoimmune causes. Biopsies of the rash were taken and showed lymphocytic interface dermatitis and necrotic/degenerative keratinocytes, as well as epidermal blistering & sloughing. These findings, along with the patient’s history, were consistent with SJS/TEN.

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Introduction
COVID19 infection can manifest as a broad spectrum of phenotypes ranging from asymptomatic cases to pneumonia, acute respiratory distress syndrome and death. It has been reported that elderly and immunosuppressed individuals are more prone to the severe manifestations of COVID19. Here we report a case of COVID19 infection in a person with Brutton’s agammaglobulinemia. 

Case presentation
A 41-year-old male with a past medical history of Bruton agammaglobulinemia on chronic IVIg therapy and bronchiectasis secondary to repeated respiratory infections and chronic obstructive pulmonary disease presented to our intensive care unit as a transfer from an outside hospital in hypoxic respiratory failure. The patient reported a subjective fever, dry cough, and lightheadedness, and on admission to the ICU, was found to be SARS-CoV-2 positive. On the physical exam, we saw a cachectic male with dampened breath sounds bilaterally with no audible wheezes or rhonchi. He was satting at 50% on room air in the field and had visibly increased work of breathing. The patient’s IgG and IgM were tested on ICU day 2 and were negative for a humoral response against SARS-CoV-2 despite being fully vaccinated. IVIG was initiated, and the patient received respiratory support from HFNC to BiPAP. After becoming stable, he was transferred to the hospital floor, where he continued to experience shortness of breath. He was placed on BiPAP, and sputum cultures were obtained. Sputum cultures grew gram-positive cocci in pairs, chains, and clusters and scant gram-positive rods, which were all presumed to be normal respiratory flora. Streptococcus pneumonia and Legionella pneumophila urine antigen tests were both negative. 
Labs showed elevated inflammatory markers with concurrent mixed radiological findings such as bilateral patchy ground-glass suggestive of COVID infection with features of bronchiectasis/ pneumonia exacerbation. In the pretext of immunosuppression with risk of non-clearance of infection, the patient was started on broad-spectrum antibiotics- ceftin, ceftriaxone, piperacillin/tazobactam, along with dexamethasone, tiotropium bromide, albuterol, fluconazole furoate/vilanterol. 
The patient was shifted back and forth in ICU and general medical floor due to unstable oxygen saturation with respiratory distress. Due to the progression in lung opacities, he was started on Meropenem for 14 days. Recent antibody workup showed a mild surge in COVID IgG (0.28) but was insufficient to mount appropriate IgG antibodies to SARS-CoV-2. He was finally shifted to the floor on AirVo with 40L O2/min. He was gradually weaned off of oxygen to 4L O2/min via NC within a week, showing a remarkable recovery in the background of chronically marked immunosuppression. 

Conclusion
T cell response is important for immune protection for the virus and it has been reported that the number of cytotoxic T cells expressing activation markers such as HLA-DR and CD38 increases during infection. Like in our case, since a patient with Brutton’s agammaglobulinemia could recover from the infection shows that human immune system could use multiple paths to counteract viral infection and a normal T cell immunity can be sufficient to curb the infection.


Response to COVID-19 in a Patient with Bruton Agammaglobulinemia: Humoral immunity may not be necessary to overcome COVID-19 infection

TB or not TB?
An uncommon presentation of a common disease

BACKGROUND:
● Tuberculous dactylitis accounts for 4-8% of skeletal tuberculosis. It is relatively
common in children aged 1-6 years and adults aged 20-50 years. It is rare in
children over 10 years old. It is 3x more common in men than women.
● The usual presenting feature is painless swelling of fingers. A single digit, usually
middle or index finger, is involved. The proximal phalanx is most often involved. Toe
involvement is less common. Multiple sites are involved in 25% to 30% of cases.
Joint involvement may/may not be present. Fistulas and sinuses occur in neglected
cases.

CASE PRESENTATION:
The patient, a 20 year old female with 8 months of amenorrhea, was admitted to the
hospital with chief complaints of multiple episodes of vomiting and streaky hematemesis
since 1 day.
The patient also had gradually progressive painful swelling of the left index finger since
1 month, associated with low grade fever.
No history of:
-similar episodes in the past
-past medical and surgical illness
-tuberculosis or tuberculosis contact
-trauma/unknown bite over hand
Examination
General Examination:
-Pallor
-Hyperpigmented knuckles
-Angular cheilitis
-Multiple enlarged cervical lymph nodes
Local examination: Erythematous, painful swelling of the left index finger with full ROM.
Investigations:
Hb: 8.2 gm%
ESR,CRP: Elevated
Left hand X-ray: suspicious for osteomyelitis
Local USG: s/o index finger tenosynovitis with local abscess
Management
Surgical drainage f/b gene Xpert and culture sensitivity which revealed Mycobacterium
tuberculosis.
Lymph node FNAC confirmed necrotic cervical lymphadenopathy, s/o MTb.
Rx: Antituberculous regimen
Final Diagnosis
Tuberculous dactylitis and tuberculous cervical lymphadenopathy.

DISCUSSION:
Tuberculous dactylitis is an uncommon form of extra-pulmonary tuberculosis involving
the small bones of the hand or the foot. Tuberculous dactylitis is quite uncommon
beyond 6 years of age after the formation of the epiphyseal centers.
The bones of the hands are more affected than the bones of the feet, manifesting as
soft tissue swelling and periostitis.
Thus, in order to diagnose this condition in adults, eliciting a detailed history and
entertaining a high index of suspicion is extremely important, as a delay in
diagnosis can have serious consequences for the patient.

TB or not TB? An uncommon presentation of tuberculous dactylitis

Authors:
Xavier C Cortez, Emily Finlayson, Susan Smith, Catherine Lau, Ralph Gonzales, Thomas Chi, Harnoor Jolly

Background:
Prolonged length of stay (LOS) after surgery has been shown to worsen patient recovery and utilize health system resources unnecessarily. Logistical and social support barriers to optimizing surgical care have been under-examined. The primary objective of this study was to implement a social needs screening tool amongst patients undergoing surgery and measure its impact on LOS and total direct cost.

Methods:
This was a single institution prospective cohort study where staff members utilized a social needs screening tool for patients undergoing surgery in seven surgical departments (Plastics, Vascular, Neurosurgery, OHNS, Ophthalmology, Orthopedics, Urology) from July 1, 2020 to June 30, 2021. Patient ability to obtain mandatory COVID testing, transportation to and from the hospital for surgery, availability of a post-operative caregiver, and current mood were queried during screening. Referral to Social Work Services was conducted if the patient reported a resource deficiency. LOS and total direct cost were collected for each encounter and compared to a control cohort of patients from the same departments from January 1, 2019 to February 28, 2020 that did not undergo social needs screening.

Results:
3284 patients were screen-eligible and were compared to 3360 control encounters. 190 patients screened positive and were provided social work support. There were no significant differences in age, gender, and race between the screened and control cohorts. Screen-positive patients were more likely to have government insurance as their primary payor (p<0.05). Median and average LOS was lower in the intervention (1, 2.67 days) compared to the control cohort (2, 3.58 days). Median and average direct cost was lower in the intervention ($11,661; $20,406) compared to the control ($18,193; $30,084) cohort.

Conclusion:
The implementation of a social needs screening tool to proactively address logistical barriers to care reduces LOS and total direct cost for surgical patients, optimizing comprehensive healthcare delivery.

A social needs screening tool facilitates reduced length of stay and total encounter cost for surgical patients

Background
More than 90% of patient facing health literature is written at a readability level above the recommended sixth grade cutoff, resulting in patient confusion, worse health outcomes, and preventable hospital readmissions. Our aim was to leverage natural language processing (NLP) and artificial intelligence (AI) to improve the readability of hospital discharge instructions, which previous studies show can reduce readmissions by up to 50%.

Methods
We analyzed discharge instructions for adults hospitalized for heart failure, determined by discharge summary designation, at the Hershey Medical Center from 2016 to 2021 (n=18,615). Discharge instructions were collected from medical records. Readability scores were calculated using the SMOG index. Discharge instructions were manually rewritten via a standardized process to improve readability, such as eliminating long sentences and exchanging complex terms with lay terms. Afterward, readability scores were re-calculated. The original and rewritten instructions were then processed via AI-based machine learning.

Results
From 80 discharge instructions, the average SMOG reading level was 10.6 ± 0.2 for the original discharge instructions, 9.4 ± 0.2 for rewritten instructions, and 9.3 ± 0.2 for AI-simplified instructions. In 26% of instances, the algorithm made appropriate improvements to the readability level (improved by 1.3 ± 0.3 grade levels).

Conclusion
Our NLP system learns meaningful phrase-level simplifications from human-simplified discharge instructions.

Artificial Intelligence Tool to Improve the Readability of Discharge Instructions for Heart Failure

Out-of-hospital sudden cardiac arrest (OHCA) kills over 350,000 Americans annually with a survival rate of only 9%. OHCA outcomes improve with bystander CPR and early use of an AED, however, less than one-fourth of the population feels confident in performing CPR, and only one-third feels confident after CPR education. We conducted a survey study aimed at better understand bystander perceptions of CPR and potential barriers towards performing CPR. 24-question surveys were distributed at community CPR classes in May 2022 prior to participant training. Surveys were given in both English and Nepali to explore differences among the refugee population. In addition to basic demographics, participants were surveyed about their knowledge, perceptions, and barriers towards bystander CPR. 86 participated with ages ranging from 13-82 (mean 44.6) with 55 (64%) identifying as female. 50 (66.6%) completed at least 2 years of college. Nepalese respondents were significantly less likely to call 911 or performing CPR due to law enforcement concerns, immigration status and language barrier. English respondents were more concerned with "doing something wrong." Fears over calling 911 were significantly less common than performing bystander CPR (50.5% vs 87.8%). English respondents placed significantly more importance on a patient's or families wishes when deciding when to initiate CPR, while Nepalese were more likely to consider a person's occupation or role in society. Identifying barriers provides avenues for increased public awareness and more inclusive discussion during CPR training events. 

Barriers to Bystander CPR and AED Intervention

Background: Hospitals across the country have worked to reduce readmission rates, but the efficacy of such interventions is challenging to interpret due to the disjointed nature of programs as well as heterogeneous patient populations and healthcare systems. This project aims to describe the current landscape of data on transitions of care and assess for opportunities to optimize such transitions in a large, multi-hospital health system.

Methods: To understand current best practices, we conducted two interviews of large hospital systems and a PubMed literature review of transitions of care from the inpatient setting to the home, with a focus on medically complex and vulnerable populations. Of the 320 articles reviewed, 93 were selected for analysis. This was followed by 17 internal stakeholder interviews at five Johns Hopkins Medicine affiliated hospitals. The results of the literature review and external interviews were compared to programs at Johns Hopkins affiliated hospitals and synthesized into recommendations as a process map that delineated a risk-based discharge algorithm.

Results: Our literature review revealed six major interventions: 1) medication reconciliation; 2) phone calls; 3) home visits; 4) care navigation; 5) post-discharge clinics; and 6) telemedicine. Notably, single-center studies demonstrated that the post-discharge clinic showed efficacy in reducing 30- and 90-day hospital readmissions and healthcare utilization. However, there was mixed evidence for all other interventions. Stakeholder interviews revealed differing approaches to these interventions. Within the five Johns Hopkins Medicine affiliated hospitals, all offered medication reconciliation, phone calls, home visits, and care navigation. All but one offered telemedicine and only two hospitals had post discharge clinics. Lastly, the structuring and management of each of these services varied across the five hospitals.

Conclusion: Transitions of care programs are heterogeneous, define interventions differently, address distinct patient needs, and lack clear options for scaling up. Even within the Johns Hopkins affiliated hospitals, there were varying programs designed to achieve the same goals. Thus, we need a standardization of programs and research methods to better understand transitions of care and allow for the application of these programs to diverse healthcare systems and contexts.

Best Practices: A Health System’s Experience with Inpatient to Outpatient Transitions of Care

Objective
Food insecurity (FI) is a prevalent health-related social risk that can be exacerbated by pediatric hospitalization. Community-based food supports can mitigate FI; however, little is known about rates of food support knowledge, use, and need among caregivers of hospitalized children. We quantified patterns of food support knowledge, use, and need among parents of hospitalized children and analyzed the relationship between food support use and need and food security. We hypothesized that knowledge and use of food supports would be positively associated with food security.

Methods
We performed a cross-sectional analysis of parents (N = 639) of children admitted to an urban academic hospital from 2020-2022. We described self-reported food support knowledge, use, and need by food security status and examined for bivariate associations. We then analyzed the odds of being food secure by use and need of food supports.

Results
Among marginally food secure/food insecure participants (53%), 27% and 46% reported no knowledge and use of food supports, respectively, while 55% reported needing food support. Food support knowledge was positively associated with food security (P = 0.02). Participants reporting use of food supports were more likely to be food secure than those who reported no use of food supports but indicated a need for them (aOR: 1.99, 95% CI: 1.05-3.76). 

Conclusion
Parents of hospitalized children exhibit a high prevalence of FI and food support need but limited knowledge and use of food supports. A hospital-based strategy that enhances knowledge and use of community-based food supports may help mitigate FI.


Do Parents of Hospitalized Children Experiencing Food Insecurity Know About and Use Community-Based Food Supports?

Background
Roughly 1 in 8 people in South Carolina lacks health insurance. Those without insurance are at a higher risk of skin cancers due to lack of preventative screening. Student-run clinics play an important role in bridging the gap and providing preventative care to those who otherwise may not have access. The CARES Medical Clinic is a student-run free clinic for uninsured patients affiliated with the Medical University of South Carolina. During monthly dermatology clinic staffed by university faculty, patients receive comprehensive dermatologic care, including procedures such as cryotherapy and biopsies. The objective of this study is to characterize the financial value of dermatology clinics for uninsured patients seeking care from a student-run free clinic.
Methods
This is a single-site retrospective chart review of patients who attended Dermatology Night from December 2019 -May 2022. A cost analysis was performed using Medicare reimbursement payments to quantify the value of the care provided.
Results
Patients seen by a dermatologist were identified for chart review. Patient ages ranged from 19 to 73 years, with median age 43. 54.7% identified as female. A procedure was indicated for 27 patients; of those, 20 received the appropriate procedure. Overall costs saved for patients were $7807.82, or $433.77 per night
Conclusion
Access and affordability of dermatologic care are limited and vary across health systems. It is our hope that the results demonstrate the value of dermatologic care for underserved patients in community clinics.

Economic Value of Dermatology Clinic at a Student-Run Free Medical Clinic

Background
We surmised the COVID-19 pandemic and associated lockdown measures may have had a gender-based disparate impact on researchers due to “second-shift” responsibilities. Consequently, women may have been temporarily distracted from publishing first-author research, which proxies for academic productivity.

Methods
We selected high-impact journals (9 Pain Management and 5 Internal Medicine) for review, retrieved the summer issues from 2018 and 2019 (pre-COVID) and 2020 and 2021 (postCOVID), divided the articles into Original and Non-Original Research, separated the Pain journals into Interventional and Non-interventional and created a database listing the first authors of each publication. Two reviewers independently identified first-author gender based on personal and professional websites, social media, and authors’ institutions’ published information. A third reviewer settled inconsistencies.

Results
The total number of publications (Retrieved=1105; Analyzed=1064) in high-impact
interventional pain management journals increased year-over-year between 2018 and 2021. Between 2019 and 2020 in particular, the sum of male first-author publications increased 25.68% and the sum of female first-author publications decreased by 25.00%. This disparity was statistically significant (p=0.044). In 2020, the first year of the COVID pandemic, compared to the other years, a gender disparity occurred in the publication of unblinded non-original research (p=0.046). First-author gender did not impact blinded original research over the same time period. 

Conclusion
If the number of publications correlated with the number of women pain researchers, the differences should have remained relatively stable. However, the divergence between male and female first-authors became significant in summer 2019, prior to COVID. In 2018, perhaps in response to record-high fentanyl overdoses, the Drug Enforcement Agency (DEA) investigated more clinicians than ever before. Medicare revamped its audit process. Federal datasets suggest
both agencies target junior physicians with fewer resources to defend against recoupments. These providers are more likely to be women. The current process for DEA and Medicare investigations may have a deleterious and disparate impact on women in terms of clinical research and academic promotions as well as a negative impact on patient care, research advances in pain management, and the opioid epidemic overall. Our research suggests women face both implicit and overt biases when measuring academic productivity. Further research is needed.

Gender Disparities in High Impact Pain Management Publications Across the COVID Pandemic

Background: The COVID-19 pandemic significantly changed the undergraduate medical education (UME) NRMP application process (NAP). Changes included virtual interviews, the suspension or elimination of away rotations, elimination of COMLEX 2 PE/USMLE STEP 2 CS licensing exams, and increased online rotations. The purpose of this study was to survey medical students from two colleges of osteopathic medicine regarding the impact the pandemic had on their 2021-2022 application process in order to better understand challenges faced by students.

Methods: An IRB-approved 20 question survey was developed and distributed after the 2022 match via email and social media. Likert-scale questions with a range of 1-5 and a comment box were used to assess student experiences related to changes the pandemic had on their match process. Several areas were assessed, e.g., away rotations, virtual interviews, board requirement changes, advising, psychological well-being, etc. 

Results: 83 students from the Liberty University College of Osteopathic Medicine and the Kansas City University College of Osteopathic Medicine participated in the study. 94.81% matched in their first-choice specialty. The number of away rotations in matched specialties ranged from 1 to 9 (M=2.36, SD=0.91). Only 39.74% matched at an audition rotation site. 50.77% of students reported the suspension of the third board exam impacted their application process very highly. Approximately one-third of students rated both stress and anxiety as high impacts. 72.05% of participants sought feedback from students from the 2020-2021 NAP and 48.98% of participants found this feedback to be highly helpful. 

Conclusion: Changes in the 2021-2022 NAP due to COVID-19 positively and negatively impacted students. Student comments indicated that virtual interviews opened up more opportunities to interview and save money. Students also commented that due to the strain of the pandemic, they had less time with their attendings and that this could have negatively impacted their letters of recommendation. Overall, cancellation of the PE and CS was viewed positively. And many students sought out feedback from applicants of the 2020-2021 NAP to be better prepared to face the challenges of the continued pandemic. 


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Response to COVID-19 in a Patient with Bruton Agammaglobulinemia: Humoral immunity may not be necessary to overcome COVID-19 infection

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