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Co-Author(s): Clay Bretz, Mason Mills, Temple D. West, Paul F. Aravich
Compassionate care can be the difference for those undergoing a crisis. I became interested in pursuing involvement in EVMS Compassionate Crisis Care to provide a helpful community resource for caring for vulnerable individuals in dire situations, when every minute counts.
Introduction: Many nursing home residents have neurocognitive disorders accompanied by behavioral changes. An increasingly larger share of Hispanic Medicare-insured residents admitted to nursing homes have Alzheimer’s disease and related dementias compared with African American and Caucasian beneficiaries. Nearly 60% of Hispanic adults have struggled to communicate with healthcare providers due to language barriers. We developed the EVMS Compassionate Crisis Care video series with Spanish language subtitles to improve the quality of behavioral care in nursing homes. Methods: EVMS Compassionate Crisis Care is a YouTube video series developed through partnership with the EVMS Standardized Patient Program; VPM Media Corporation in Richmond, VA; and a Statewide Steering Committee of experts. The video series targets specific populations: leadership, law enforcement, certified nursing assistants, emergency medical service and the Virginia Medical Reserve Corps. Spanish language subtitles were composed to facilitate accessibility among Spanish-speaking individuals. YouTube analytics were examined to assess key metrics. Results: The EVMS Compassionate Crisis Care for Leadership, Law Enforcement, Certified Nursing Assistants, Emergency Medical Service, and Virginia Medical Reserve Corps, have 72, 334, 33,000, 2,700, and 8,000 views, respectively. Watch times lasted nearly the entire duration of each of the videos. Spanish language subtitles were employed by users in each population. Conclusion: EVMS Compassionate Crisis Care can help individuals learn how to better care for patients during emergencies. Spanish-speaking certified nursing assistants and first responders handling Spanish-speaking nursing home residents with challenging behaviors may especially benefit from viewing Spanish language subtitles to bridge the language barrier and applying demonstrated interaction techniques.
As a PGY 1 who just started my residency, I have already encountered many patients diagnosed with cellulitis. I have also noticed that recurrence of cellulitis is quite common as well. I am curious how cellulitis can be prevented and if cellulitis lead into other types of infections.
Hand infections are commonly seen in primary care offices and can range from superficial to deep infections, causing the primary care physician to need to carefully consider their management. Recurrence of a hand infection, while not greatly uncommon due to the nature of the hand’s anatomy and common contact with pathogens through daily activity, can occur even after successful treatment. This is an interesting case of multiple different types of hand infections in a healthy 30-year-old female, over a 9-year span, with no other risk factors except for a previous medical history of cellulitis. This case illustrates the need for consideration of preventive measures and further evaluation for less common risk factors of hand infections. Recurrent cellulitis in general is not well-studied when it comes to preventative measures, but there has been some work done in recent years identifying new considerations for risk factors we can look for in patients even with an initial episode of cellulitis. When it comes specifically to hand cellulitis and other infections, more exploration is needed to identify patients at risk and to employ strategies to mitigate that risk.
Co-Author(s): Timothy Yu, MD
I became interested in pursuing this project after completing my residency training in a rural setting where resources were limited. Point of care ultrasound can be a quick, accessible and effective tool to diagnose conditions that would otherwise require a more expensive and timelier workup. I believe this in return, can lead to better outcomes for most patient populations.
Introduction: This case involves a 34-year-old female with a complex medical history including cystic fibrosis, diabetes mellitus, pancreatic islet cell transplantation, and Ehlers-Danlos syndrome with a right Mediport venous catheter. The patient presented with a 3-week history of right neck and shoulder pain following physical exertion (tango dancing). Case Presentation: On physical examination, the patient exhibited significant discrepancy in arm circumference, with the right upper arm measuring 3 cm larger than the left. Initial imaging consisting of a shoulder X-ray, was unremarkable. However, point-of-care ultrasound performed in the outpatient setting revealed a thrombus in the right internal jugular vein, prompting referral to the emergency department for further evaluation. Diagnosis and Treatment: A comprehensive doppler ultrasound confirmed the presence of an internal jugular vein thrombus. After reassuring evaluation of the Mediport device, the patient was placed on anticoagulation therapy with Eliquis. She experienced a resolution of symptoms with no further related complications. Discussion: This case highlights the importance and effectiveness of point-of-care ultrasound in identifying venous thromboembolism in an outpatient setting, particularly in patients with complex medical histories and indwelling catheters. Early detection and intervention, including anticoagulation and Mediport management, were crucial in preventing further complications. Conclusion: Point-of-care ultrasound can serve as an invaluable tool in the rapid diagnosis and management of thrombotic events in outpatient settings, reducing the need for more invasive procedures and facilitating timely treatment.
Co-Author(s): Dr. Syed Atif, Dr. Musaddiq Waheed, Dr. Abdul Waheed, Dr. Erum Azhar
Realizing that having consultants for capacity delay discharge and there are assessment tools readily available to test capacity that can have patient possibly be discharged earlier.
Title: Reducing In-Patient Hospital Avoidable Days/Delays (ADs) Due to Decision-Making Capacity Assessment by Implementing the U-CARe Assessment Tool with A Multifaceted Intervention. Introduction: Avoidable Days (ADs) are known contributors of financial loss for many hospitals. We aimed to determine if implementing a multifaceted intervention with a UCARe Assessment would reduce the ADs due to a Decision-Making Capacity. Methods: This QI project was conducted at a community hospital in Lebanon, Pennsylvania from June 2022 to July 2023. We aimed to reduce ADs by addressing delays in decision-making capacity assessments. A cross-sectional survey identified patients lacking decision-making capacity as major contributors to increased ADs. A multifaceted intervention was implemented, focusing on educating providers to use the U-CARe assessment instead of relying solely on psychiatry consultations. Daily multidisciplinary rounds (MDRs) were utilized to track and communicate the use of the tool, with added focus on identifying stable patients awaiting capacity assessments for discharge. Results were analyzed using Statistical Process Control (SPC) charts. Results: The analysis of data showed an interesting trend with a significant reduction in ADs from 208 to 162 per thousand patient days during the initial intervention phase. However, in Phase 1, the ADs unexpectedly increased to 534 due to a change in hospital leadership. In Phase 3, after engaging the new leadership, the ADs decreased again to 261 per thousand patient days. Conclusion: A multifaceted intervention can be used to reduce the ADs due to capacity assessment by engaging stakeholders and utilizing a standard assessment tool and process.
Co-Author(s): Timothy Yu, MD
As a primary care sports medicine fellow, I am interested in exploring lesser known diagnoses for common musculoskeletal complaints in the primary care clinic. This care was particularly interesting as it also presents a minimally invasive treatment plan that is highly effective and avoids possible escalation of care to specialists and surgeons.
Background: Low back pain is one of the leading causes of morbidity in the United States, with a lifetime prevalence of nearly 84% of the population. It is the most common musculoskeletal complaint in family medicine, accounting for 5% of all primary care visits. Additionally, up to 85% of low back pain has non-specific or heterogeneous etiology, making management difficult. Case: This case presents an athletic 49-year-old male with chronic low back pain unresponsive to conservative treatments, including physical therapy, medications, and activity modifications. Lumbar imaging showed only mild degenerative changes, insufficient to explain the patient’s symptoms. Physical examination revealed tenderness over the iliac crest and reproduction of pain with palpation, consistent with cluneal neuralgia. The patient subsequently underwent a cluneal nerve block, which resulted in complete resolution of his pain, including at 3 month follow up. Discussion: Cluneal neuralgia arises from entrapment or irritation of the cluneal nerves, branches of the sciatic nerve that provide sensory innervation to the area overlying the iliac crest, buttock, and upper thigh. The superior and middle cluneal nerves are particularly vulnerable to compression as they traverse the thoracolumbar fascia and pass over the iliac crest. Entrapment at this junction can lead to localized neuropathic pain, often mistaken as muscular or discogenic. In cases of persistent low back pain with minimal radiographic findings, this diagnosis should be considered. By recognizing this etiology in primary care and sports medicine settings, clinicians can provide targeted treatments that may prevent unnecessary imaging, referrals, or surgical interventions.
Co-Author(s): Junpei Tarashi, MS2; Brooke Ford, MS2
As an aspiring family physician, I love the way that primary care allows for relationship-based preventative care in a way that has been shown to improve the health of communities as a whole. However, the unfortunate reality is that there simply are not enough primary care physicians in the United States to meet the patient need. As such, I am interested in understanding ways to better support the field of primary care, especially as relates to the workforce shortage. This project in particular appealed to me as a way to better understand what patients value in healthcare in order to create practices and policies that support that.
Background: In the United States, there is a shortage of primary care physicians and an increasing number of adults who report they do not have a usual source of care. Objective: This study sought to investigate what patients value in their health care, including where and why they seek care, as well as what they expect from it. Methods: A secondary analysis of free responses from an existing dataset collected as part of a national survey during the COVID-19 pandemic was conducted using an emergent coding process. Potential respondents were recruited through SurveyMonkey audience, resulting in 1440 respondents with purposeful variation in sample demographics matching US census data regarding the spread of gender, age, income, and rurality. Results Among respondents, 71% went to primary care first, making it the clear first choice for general concerns. When asked what they expected from care, 14.2% noted some degree of emotional or social support from their clinicians. 16.7% noted familiarity as a primary determinant of where they sought care, while 14.2% noted trust in the provider, and 16.7% noted financial considerations. This means that overall, the percentage of respondents who noted relational factors as primary to determining where they went for care (30.9%) was almost double the percentage who noted financial concerns as their primary determinant (16.7%). Conclusion: With respondents showing a value for relational elements of primary care, our results re-emphasize the need to support and improve growth of the ever decreasing primary care workforce.
Co-Author(s): Marisa Riley, MD; David. M. Milgraum, MD
I became interested in pursuing this research after encountering patients in primary care settings who were struggling with atopic dermatitis management. While dupilumab provided relief for many, I noticed that some patients, particularly those with skin of color, developed unexpected skin reactions that were underrecognized and often led to premature discontinuation of a highly effective treatment. This gap in awareness motivated me to investigate the presentations and management of dupilumab-associated HND, aiming to improve early recognition and care strategies to help patients maintain treatment continuity.
Dupilumab, a monoclonal antibody targeting the interleukin-4 receptor alpha, has transformed the management of moderate-to-severe atopic dermatitis. While it offers substantial relief for many patients, emerging reports have identified an adverse effect not highlighted in initial clinical trials: erythematous eruptions on the head and neck. We present a case series of an uncommon entity, dupilumab-associated erythema, in a population where it is underrecognized and undertreated. In these patients, dupilumab-associated erythema have a broad range of presentations, which may be severe as in our first case or subtle as in our second patient. Delineating this entity from pre-existing atopic dermatitis is more difficult due to co-existing features such as dyspigmentation and lichenification in skin of color. Characteristics that distinguish this condition include presentation after dupilumab initiation, burning sensation, and seborrheic distribution. Duplimab-associated erythema can lead to the early discontinuation of dupilumab, underscoring the importance of prompt recognition in primary care settings and appropriate management to prevent treatment interruption.
Co-Author(s): Hannah DePoy, DO
There is high morbidity and mortality associated with opioid use disorder. Our clinic previously did not have formal education on MOUD; therefore, there are not many providers who routinely prescribe MOUD. We aim to increase provider awareness and knowledge surrounding the diagnosis and management of opioid use disorder within our clinic.
Introduction: Opioid use disorder is a treatable, chronic disease. Medications for opioid use disorder (MOUD) are effective at treating opioid use disorder and reducing morbidity and mortality. There is currently only sparse research on provider comfort and knowledge surrounding MOUD initiation and management. Identified barriers to using MOUD in clinic may include perceived logistical challenges, lack of experience and training, and the need for more consistent, accurate prescribing information. Objective: We aim to assess the effect of an organized MOUD curriculum on FM provider comfort prescribing MOUD by comparing three residency classes: one before a formal MOUD curriculum was implemented (class of 2023), one with an abbreviated MOUD curriculum (class of 2024), and one with a full MOUD curriculum (class of 2025). Methods: Surveys will be given to FFP residents from the classes of 2023, 2024, and 2025 after receiving varying amounts of an MOUD curriculum. The full educational curriculum consists of 4-5 hours given by a faculty member experienced in teaching MOUD. The abbreviated MOUD curriculum is approximately 2 hours. The educational curriculum will consist of general information on OUD, mechanisms for OUD screening, discussion of available medication treatment options, and an informational template to be incorporated into the electronic medical record that can be used during patient visits. Data will be stratified and compared across the three residency classes. Results: The surveys are being sent to the residency classes this upcoming week, as the Class of 2025 just finished the MOUD curriculum this past week. Preliminary results will be in within the next 2 weeks.
I became interested in pursuing the case report, “Surviving the Storm: Navigating Complicated UTI, Septic Shock, Multi-Organ Failure,” due to a profound interest in critical care medicine and the complexities of managing severe infections. The multidisciplinary approach required to treat conditions like septic shock and multi-organ failure showcases the collaboration and depth of knowledge necessary in modern healthcare. Additionally, the challenge of diagnosing and treating complicated urinary tract infections, especially in atypical patient populations such as males, underscores the importance of thorough investigation and comprehensive medical intervention. This case represents the intricacies and the impact of critical care, making it a compelling and educational pursuit.
The case report, titled “Surviving the Storm: Navigating Complicated UTI, Septic Shock, Multi-Organ Failure,” details a 41-year-old male with no significant PMH who experienced nausea, vomiting, diarrhea, and fatigue for a week. Unable to eat or drink for 3-4 days, he visited urgent care and received doxycycline for a presumed upper respiratory infection. Upon admission to the Emergency Department, the patient had hypotension (BP 56/26), and was treated with intravenous fluids, Levophed, Vancomycin, and Zosyn. Lab results showed elevated lactate, severe renal impairment (creatinine 8.25, BUN 92), liver dysfunction (ALT 535, AST 3840), and metabolic acidosis (pH 7.16). Imaging (CXR and CT of the chest, abdomen, and pelvis) showed no acute findings. In the hospital, the patient was admitted to the Intensive Care Unit (ICU) due to septic shock, requiring vasopressors, broad-spectrum antibiotics, and dialysis for acute kidney injury (creatinine 7.74). He also had anemia, thrombocytopenia, and liver failure, managed by critical care, nephrology, infectious disease, and hematology/oncology teams. Despite extensive workup, there was no fever, leukocytosis, or clear infection source. A urine culture was positive for Enterococcus faecalis, suggesting a urinary tract infection (UTI) as the likely sepsis source. The patient’s condition improved with multidisciplinary treatment, leading to discharge with outpatient dialysis follow-up. Importance: UTI in males is considered complicated and can lead to septic shock and multi-organ dysfunction, necessitating prompt, comprehensive medical intervention.