Joseph Chiovaro

So many options, where do we start? An overview of the care transitions literature.

BACKGROUND Health systems are faced with a large array of transitional care interventions and patient populations to whom such activities might apply. PURPOSE To summarize the health and utilization effects of transitional care interventions, and to identify common themes about intervention types, patient populations, or settings that modify these effects. DATA SOURCES PubMed and Cochrane Database of Systematic Reviews (January 1950-May 2014), reference lists, and technical advisors. STUDY SELECTION Systematic reviews of transitional care interventions that reported hospital readmission as an outcome. DATA EXTRACTION We extracted transitional care procedures, patient populations, settings, readmissions, and health outcomes. We identified commonalities and compiled a narrative synthesis of emerging themes. DATA SYNTHESIS Among 10 reviews of mixed patient populations, there was consistent evidence that enhanced discharge planning and hospital-at-home interventions reduced readmissions. Among 7 reviews in specific patient populations, transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations. In general, interventions that reduced readmission addressed multiple aspects of the care transition, extended beyond hospital stay, and had the flexibility to accommodate individual patient needs. There was insufficient evidence on how caregiver involvement, transition to sites other than home, staffing, patient selection practices, or care settings modified intervention effects. CONCLUSIONS Successful interventions are comprehensive, extend beyond hospital stay, and have the flexibility to respond to individual patient needs. The strength of evidence should be considered low because of heterogeneity in the interventions studied, patient populations, clinical settings, and implementation strategies.

Cat Got Your Spleen? Hepatosplenic Bartonella Infection

PRESENTATION The patient’s collection of pets offered a key clue to the source of his vague symptoms. A 63-year-old goat herder presented after three weeks of recurrent intermittent fevers and fatigue. He also reported a 22-pound unintentional weight loss and mild headaches and arthralgias. He had no myalgias, rashes, lymphadenopathy, abdominal pain, conjunctivitis, or seizures. His past medical history was notable only for latent tuberculosis, which had been treated 30 years earlier with a 9-month course of isoniazid. He owned numerous dogs and semi-domesticated cats. During the previous year, his menagerie had included at least 18 kittens, but he did not recall any recent animal bites or scratches.

Renal failure with a large bladder calculus related to a foreign body: a case report

We encountered a patient with renal failure in the setting of long‐standing difficulty urinating, which he previously treated with intermittent self‐catheterizations. Imaging showed a large urinary calculus in the bladder. This case illustrates the importance of taking a detailed history and the dramatic long‐term effects of bladder calculi.

Capsule Commentary on Blumenthal et al., Using a Self-Reported Global Health Measure to Identify Patients at High Risk for Future Healthcare Utilization

U nderstanding which patients are at high risk for future emergency department (ED) visits and hospitalization has long been a goal of both healthcare systems and practicing clinicians. Identification of the highest-risk cohort, in particular, has been a target of interest, as these patients account for a disproportionate amount of healthcare expenditure. Efforts do to this have largely focused on the use of administrative data, though more recent studies suggest the addition of patientreported outcome measures (PROMs) may better capture changes in health status. This retrospective cohort study by Blumenthal et al. investigated the association between patient-reported health scores collected at routine primary care visits and healthcare utilization. After adjustment for confounders, patients with the lowest reported physical health scores were found to have higher rates of subsequent hospitalization. Conversely, mental health scores were not found to be predictive of hospitalization, and neither physical nor mental health scores were associated with the risk for ED visits. The addition of physical health scores to administrative data led to a modest increase in sensitivity for detecting patients with the highest healthcare utilization (from 36 to 44%). This research builds on previous studies showing PROMs to be associated with future healthcare expenditures, readmission rates, and mortality. Despite these correlations, most models lack the ability to accurately predict future healthcare use. Low sensitivity is particularly problematic. The implication is that those who report low physical health scores are likely to be high users of healthcare, but not all high users of healthcare will report low physical health scores. Perhaps it is the second group that is of most interest and not easily identified by current methodology. In fact, the low sensitivity of most risk prediction models raises the question of whether they add significantly to clinician gestalt. Nevertheless, routine collection of PROMs is a relatively simple intervention, and understanding its contribution to risk prediction models is important. Given the interest in focused interventions in high-risk populations, it makes sense to use every tool at our disposal to identify the patients who might benefit the most.

Urinothorax: A Rare Case of Pleural Effusion

A 71-year-old male presented with two weeks of nausea, vomiting, abdominal pain, and difficulty urinating. He denied shortness of breath or chest pain. Vital signs were normal. Laboratory tests were notable for a potassium of 7 mmol/l, BUN 176 mg/dl, and creatinine 17.6 mg/dl. A CT scan of his abdomen demonstrated a profoundly distended bladder with bilateral hydronephrosis and left calyceal rupture (Fig. 1). A chest x-ray revealed a large left-sided pleural effusion (Fig. 2). A Foley catheter was placed and drained 3.7 liters of urine, after which the patient’s laboratory tests rapidly normalized. Urinothorax was suspected, and follow-up imaging was arranged. On repeat CT 6 weeks later, the effusion had resolved. Urinothorax, or urine in the pleural space, is a rarely reported complication of bilateral urinary obstruction or trauma to the urinary tract. There are fewer than 100 reported cases in the literature, although it may be underdiagnosed because of low clinical suspicion. Patients typically have only minor respiratory symptoms and are often diagnosed clinically, with an effusion that improves after the obstruction or urinary tract injury has resolved. If performed, thoracentesis reveals a transudative fluid that smells of urine with a low pH (<7.3) and a fluid/serum creatinine ratio >1.

The Electrocardiogram Following Dynamic Cardiomyoplasty

A 66-year-old man with ischemic cardiomyopathy status post-dynamic cardiomyoplasty in 1994 and revision 2 months prior to admission presented with increasing erythema around the site of his muscle stimulator. An ultrasound of the stimulator pocket showed no fluid collection, and the patient was started on intravenous antibiotics. The ECG revealed artifactual spikes from the latissimus dorsi muscle (LDM) stimulated to contract in synchrony with cardiac systole: typical changes following dynamic cardiomyoplasty (Fig. 1). Cardiomyoplasty is a surgical treatment for end-stage heart failure that is an alternative to heart transplant, whereby the LDM is pedunculated and wrapped around the heart (Fig. 2). This wrap is then Bconditioned^ by electrical stimulation to reduce fatigability, transforming the fast-twitch skeletal muscle into slow-twitch fibers similar to cardiac muscle. Dynamic cardiomyoplasty was hypothesized to improve systolic function via augmented contraction and to reduce remodeling by a girdling effect of the wrap, with most clinical benefit arising from the latter. The procedure fell out of favor in the USA, primarily due to (a) improvement in ejection fraction but neutral effect on invasive hemodynamics, (b) lack of longtermmortality improvement and (c) Medtronic withdrawal of their cardiomyostimulators in the late 1990s, leaving surgeons without an FDA-approved device.

Exhausting the Differential

In this series, a clinician extemporaneously discusses the diagnostic approach (regular text) to sequentially presented clinical information (bold). Additional commentary on the diagnostic reasoning process (italic) is interspersed throughout the discussion.