Macrophage activation syndrome in MDA5 antibody-positive dermatomyositis and COVID-19 infection

Background Macrophage activation syndrome (MAS) is a rare multiorgan system disorder that may present as a fatal complication of underlying rheumatological disease, including dermatomyositis. Case presentation Here, we report the case of a 65-year-old Caucasian female with a history of psoriasis and a recent diagnosis of Coronavirus disease 2019 (COVID-19) who presented with progressive generalized weakness, joint pains, an erythematous rash, shortness of breath, and weight loss. She was ultimately diagnosed with biopsy-confirmed melanoma differentiation-associated protein 5 (MDA5)-positive dermatomyositis complicated by MAS, requiring intravenous immunoglobulin and high-dose methylprednisolone. Conclusions This report serves as a clinical reminder of the rare, yet clinically relevant association between MDA5-positive dermatomyositis and MAS, as well as highlights the potential contribution of other immune system activating diseases, such as COVID-19, associated with a cytokine storm and hyperinflammatory state.

Antibiomania: a case report of clarithromycin and amoxicillin-clavulanic acid induced manic episodes separately

Background Antibiomania is a rare but recognized side effect with yet unclear definite pathogenesis although multiple hypotheses have been proposed. The novelty of this case is the suspected pharmacodynamic drug-drug interaction between clarithromycin and amoxicillin-clavulanic acid. Case presentation We present the occurrence of a brief manic episode concerning a 50-year-old man with no psychiatric history, first started on amoxicillin-clavulanic acid therapy and then switched to clarithromycin for left basal pneumonia. Shortly after the antibiotic prescription, he presented psychiatric symptomatology (logorrhea, elevated mood, irritability, increase in physical activity and delusions). The antibiotic was stopped and the patient received lorazepam (2.5 mg p.o.) to treat psychomotor agitation. Approximately 12 h after clarithromycin cessation, amelioration was already observed, supporting the diagnosis of a clarithromycin-induced manic episode. Amoxicillin-clavulanic acid was then reintroduced because of the pneumonia and psychiatric symptoms reemerged. This second antibiotic was also stopped, and 1 week later, the patient was symptom-free. Conclusion The emergence of psychiatric side effects related to antibiotherapy, which is a common treatment, can greatly impact a patient’s quality of life. Early recognition and intervention could substantially influence the administered medical care and recovery. Moreover, given the widespread use of antibiotics including in combination, we thought our case report might be clinically useful as a clinical reminder relevant to the use of antibiotic combinations.

The Hepatic Innovation Team Collaborative: A Successful Population-Based Approach to Hepatocellular Carcinoma Surveillance

After implementing a successful hepatitis C elimination program, the Veterans Health Administration’s (VHA) Hepatic Innovation Team (HIT) Collaborative pivoted to focus on improving cirrhosis care. This national program developed teams of providers across the country and engaged them in using systems redesign methods and population health approaches to improve care. The HIT Collaborative developed an Advanced Liver Disease (ALD) Dashboard to identify Veterans with cirrhosis who were due for surveillance for hepatocellular carcinoma (HCC) and other liver care, promoted the use of an HCC Clinical Reminder in the electronic health record, and provided training and networking opportunities. This evaluation aimed to describe the VHA’s approach to improving cirrhosis care and identify the facility factors and HIT activities associated with HCC surveillance rates, using a quasi-experimental design. Across all VHA facilities, as the HIT focused on cirrhosis between 2018–2019, HCC surveillance rates increased from 46% (IQR 37–53%) to 51% (IQR 42–60%, p < 0.001). The median HCC surveillance rate was 57% in facilities with high ALD Dashboard utilization compared with 45% in facilities with lower utilization (p < 0.001) and 58% in facilities using the HCC Clinical Reminder compared with 47% in facilities not using this tool (p < 0.001) in FY19. Increased use of the ALD Dashboard and adoption of the HCC Clinical Reminder were independently, significantly associated with HCC surveillance rates in multivariate models, controlling for other facility characteristics. In conclusion, the VHA’s HIT Collaborative is a national healthcare initiative associated with significant improvement in HCC surveillance rates.

Pseudohyperkalaemia in essential thrombocytosis: an important clinical reminder

Summary An 82-year-old female was admitted to a general hospital due to progressive bilateral lower limb weakness. A T8–T9 extramedullary meningioma was diagnosed by MRI, and the patient was referred for excision of the tumour. During the patient’s admission, she was noted to have persistent hyperkalaemia which was refractory to treatment. Following a review by an endocrinology team, a diagnosis of pseudohyperkalaemia secondary to thrombocytosis was made. This case demonstrates the importance of promptly identifying patients who are susceptible to pseudohyperkalaemia, in order to prevent its potentially serious consequences. Learning points Pseudohyperkalaemia should be considered in patients with unexplained or asymptomatic hyperkalaemia. It should also be considered in those patients who are resistant to the classical treatment of hyperkalaemia. A diagnosis of pseudohyperkalaemia is considered when there is a difference of >0.4 mmol/L of potassium between serum and plasma potassium in the absence of symptoms and ECG changes. In patients who are presenting with consistently elevated serum potassium levels, it may be beneficial to take venous blood gas and/ or plasma potassium levels to rule out pseudohyperkalaemia. Pseudohyperkalaemia may subject patients to iatrogenic hypokalaemia which can be potentially fatal. Pseudohyperkalaemia can occur secondary to thrombocytosis, red cell haemolysis due to improper blood letting techniques, leukaemia and lymphoma.

ANCA-negative microscopic polyangiitis with diffuse alveolar hemorrhage masquerading as congestive heart failure

Background Microscopic polyangiitis (MPA) is a subtype of anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), involving small and medium sized vessels, often affecting the kidneys and lungs. Anti-neutrophil cytoplasmic antibody (ANCA) is detected in up to 90% of cases of MPA and its detection helps guide diagnosis, however cases of ANCA-negative MPA have been reported, hence definitive diagnosis relies on tissue biopsy. Case report A 23-year-old man was evaluated for dyspnea and pleuritic chest pain, and found to have bilateral intra-alveolar opacities and hilar adenopathy. Diagnostic work up revealed positive anti-nuclear antibodies (ANA) and negative ANCA, which in the setting of a non-classical presentation, delayed diagnosis and appropriate treatment. Due to persistent symptoms and a high suspicion for autoimmune disease with pulmonary-renal syndrome, he underwent lung biopsy which revealed intra-alveolar hemorrhage and capillaritis indicative of microscopic polyangiitis (MPA). Surprisingly, kidney biopsy was not typical of classic MPA, but revealed less common features. Due to therapeutic noncompliance he was readmitted multiple times thereafter with rare complications of MPA such as acute pancreatitis and hemorrhagic pericardial effusion with tamponade. Conclusion This case serves as an important clinical reminder to consider AAV even in those with negative ANCA serologies and a high suspicion for pulmonary-renal syndrome. It also demonstrates the high morbidity in cases of diagnostic delay and inadequate treatment.

Closing the gap in health care disparities by improving the rate of lung cancer screening in an intercity hospital.

195 Background: The National Lung Cancer Screening Trial showed reduced lung cancer mortality with low-dose computed tomography (LDCT) screening. Although LDCT is generally covered by private and government insurance, the rate of LDCT screening has been reported to be very low (2-3%) in previous studies. One of the main barriers in adequate screening was assessment of smoking history to identify eligible populations. Purpose: To increase the rate of lung cancer screening in Medstar Washington Hospital Center Internal Medicine (WHCIM) clinics from a baseline rate of 2.88% by 50% over a 3-month period. Methods: Retrospective baseline data was collected over a 2-week period 01/06/2020–01/17/2020 from patients visits at WHCIM to assess the rate of lung cancer screening. A session was held with physicians and nursing staff to find the barriers in identifying eligible patients for lung cancer screening and to create a fishbone diagram. The first plan-do-study act cycle (PDSA) was initiated from 02/24/2020–03/13/2020 where we piloted a clinical reminder in the form of a print-out filled out by the medical assistants at check in and then given to physicians. The form included the patient's age and simple smoking questionnaire according to the lung cancer screening guidelines. Data was collected during this time period which included documentation of patient’s smoking history, lung cancer screening eligibility and referral to LDCT. Results: By retrospective analysis from the time period of 01/06/2020-01/17/2020 providers documented a smoking history in only 16% of patients seen and only 2.88% of all patients seen over the age of 55 were referred for lung cancer screening. Post intervention for the time period of 02/24/2020-03/13/2020 increased the amount of documented smoking history by providers to 26% and number of patients sent for lung cancer screening to 6.0%. Of patients who met the criteria for lung cancer screening, prior to the intervention only 42% of patients were referred. However, after the clinical reminder has been initiated, 86% of patients who did meet the criteria were sent for screening. Conclusions: The clinical reminder has increased documentation of smoking history by 62% and lung cancer screening for those who meet the criteria according to the guidelines by a relative increase of 105%. We are currently working on PDSA cycle 2 to incorporate education materials in the encounter room and PDSA cycle 3 to incorporate this clinical reminder into the electronic medical record and to implement hospital wide.

Serotonin syndrome due to duloxetine and tramadol use in an older patient

This case report describes a 92-year old woman presenting with acute confusion and agitation. She was initially diagnosed as having a hyperactive delirium. However, based on the presence of additional and evolving features of twitchiness, reduced coordination, palpitations and headaches, the diagnosis was re-evaluated. The clinical presentation was subsequently recognised as being that of the serotonin syndrome. In this instance, the serotonin syndrome was judged to have arisen from the concurrent use of duloxetine and tramadol. Duloxetine is an antidepressant with serotonergic properties. Tramadol is an analgesic agent with weak opiate agonist receptor effects, and also exerts reuptake inhibition of noradrenaline and serotonin. The patient’s polypharmacy was reviewed, and alongside other general supportive care measures, her symptoms and signs resolved within 48 hours. This report serves as a clinical reminder on the potential pitfalls of polypharmacy in older patients. Delirium is a common presentation in older patients, and on occasions, clearly establishing the underlying causes or risk factors may prove challenging or even elusive. The report prompts clinicians to bear in mind that the presentation and diagnosis of the serotonin syndrome requires a high index of suspicion, and that patients may present atypically. In support of pharmacovigilance reporting, two scales of causality assessment are employed in this case review. The application of these systems exemplifies their potential in promoting and enhancing objectivity when clinicians report suspected adverse drug reactions (ADRs) noted in routine clinical practice.

A behavioral economic intervention to increase psychiatrist adherence to tobacco treatment guidelines: a provider-randomized study protocol

BackgroundPeople with a psychiatric diagnosis smoke at high rates, yet are rarely treated for tobacco use. Health care systems often use a ‘no treatment’ default for tobacco, such that providers must actively choose (opt-in) to treat their patients who express interest in quitting. Default bias theory suggests that opt-in systems may reinforce the status quo to not treat tobacco use in psychiatry. We aim to conduct a pilot study testing an opt-out system for implementing a 3A’s (ask, advise, assist) tobacco treatment model in outpatient psychiatry.MethodsWe will use a mixed-methods, cluster-randomized study design. We will implement a tobacco use clinical reminder for outpatient psychiatrists at the VA New York Harbor Healthcare System. Psychiatrists (N = 20) will be randomized 1:1 to one of two groups: (1) Opt-In Treatment Approach: Psychiatrists will receive a reminder that encourages them to offer cessation medications and referral to cessation counseling; or (2) Opt-Out Treatment Approach: Psychiatrists will receive a clinical reminder that includes a standing cessation medication order and a referral to cessation counseling that will automatically generate unless the provider cancels. Prior to implementation of the reminders, we will hold a 1-hour training on tobacco treatment for psychiatrists in both arms. We will use VA administrative data to calculate the study’s primary outcomes: 1) the percent of smokers prescribed a cessation medication and 2) the percent of smokers referred to counseling. During the intervention period, we will also conduct post-visit surveys with a cluster sample of 400 patients (20 per psychiatrist) to assess psychiatrist fidelity to the 3 A’s approach and patient perceptions of the opt-out system. At six months, we will survey the clustered patient sample again to evaluate the study’s secondary outcomes: 1) patient use of cessation treatment in the prior 6 months and 2) self-reported 7-day abstinence at 6 months. At the end of the intervention period, we will conduct semi-structured interviews with 12-14 psychiatrists asking about their perceptions of the opt-out approach. DiscussionThis study will produce important data on the potential of opt-out systems to overcome barriers in implementing tobacco use treatment in outpatient psychiatry.