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Proceedings from the 2011 Annual Meeting of the American College of Physicians, Wisconsin Chapter

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Proceedings from the 2011 Annual Meeting of the American College of Physicians, Wisconsin Chapter PROCEEDINGS Proceedings from the 2011 Annual Meeting of the American College of Physicians, Wisconsin Chapter The Wisconsin Chapter of the American College of Physicians held its annual meeting in evaluate the temporal relationship between Wisconsin Dells, September 9-11, 2011. Internal medicine residents from each of Wisconsin’s 5 onset of atopic dermatitis (AD) and EE residency programs presented their research and/or unusual clinical experiences via posters diagnosis. and vignettes. Methods: A retrospective cohort study was conducted in a population-based cohort. PRESENTED POSTERS ger length of hospitalization (OR, 0.72, Esophageal biopsy reports from 1995- Effect of Hyperglycemia on Outcomes 95% CI, 0.54-0.96, P = 0.03). Forty-one 1997 and 2005-2007 were screened using in Acute Exacerbations of Chronic patients (19%) were readmitted to the SNOMED (Systematized Nomenclature Obstructive Pulmonary Disease hospital within 30 days of discharge from of Medicine) to identify patients with Narendranath Epperla, MD, Yusuf Kasirye, index hospitalization. Adjusting for previ- pathologic confirmed or suspected EE. MD, Melissa Simpson, PhD, Hong Liang, PhD, ous covariates and length of hospitalization, Histopathology reports in which EE could Chaitanya Mamillapalli, MD, Steven Yale, MD; BG was not associated with 30-day hospital not be excluded and those with features sug- Departments of Internal Medicine, Biostatistics, readmission (OR, 0.82, 95% CI, 0.54-1.22, and Clinical Research and Marshfield Clinic gestive of EE were reviewed. Cases of esoph- Research Foundation; Marshfield Clinic, P = 0.32). Nine patients (4%) died within agitis due to chemicals, drugs, infections, Marshfield, Wis 90 days of their index hospitalization. inflammation, and structural abnormalities Adjusting for previous covariates and read- Background: Hyperglycemia is associated (tumors, strictures, ulcers) were excluded. mission, decreased BG was associated with with adverse health outcomes independent A single pathologist blinded to clinical, increased odds of 90-day all-cause mortality of its associated metabolic disease states. endoscopic features, and histopathology (OR, 0.30, 95% CI, 0.11-0.86, P = 0.02). However, little evidence exists concerning diagnosis reviewed 373 tissue specimens. hyperglycemia and outcomes associated Conclusion: Decreased BG levels were asso- Medical records of confirmed EE cases were with acute exacerbations of chronic obstruc- ciated with a longer hospitalization and reviewed to determine associated atopic tive pulmonary disease (AECOPD). This 90-day all-cause mortality, suggesting that dermatitis based on American Academy of study examined blood glucose (BG) during BG during hospitalization may be indicative Dermatology (AAD) criteria, clinical pre- AECOPD hospitalization and clinical out- of overall health and therefore may be a use- sentation, macroscopic findings on endos- comes. We hypothesized that increased BG ful prognostic tool. Blood glucose response copy, and site of biopsy. is associated with worse clinical outcomes. (or lack thereof) in light of hyperglycemic Results: Twenty-seven cases of EE were agents (96% of cohort received corticoste- Methods: We retrospectively studied a cohort positively confirmed: 20 adults and 7 chil- roids during hospitalization) may be a proxy of 215 hospitalized patients (40 to 80 years dren. Median age at diagnosis was 32.1 for a patient’s overall physiological status. of age) with physician-validated AECOPD years. Though 9 patients had some features from January 1, 2004 to December 31, of AD, none met all the major criteria set Eosinophilic Esophagitis: An Escalating 2008. Inclusion criteria for this study were by AAD. There was a significant increase Epidemic? in the incidence rates of EE in the study a diagnosis of AECOPD at admission and Rajesh B Kethireddy, MD, Camille Torbey, MD, discharge, and BG obtained within 6 hours Jeffrey Resnick, MD; Departments of Internal population from 1995-1997 compared to of hospital presentation. Regression analyses Medicine-Pediatrics, Gastroenterology, and 2005-2007 (2.76 vs 13.6 cases per 100,000 accounting for repeated BG measurements Pathology; Marshfield Clinic, Marshfield, Wis person years). Similarly increased incidence during hospitalization were performed to Background: Eosinophilic Esophagitis (EE) rates were observed in both female (1.91 vs estimate the odds ratio (OR) for daily mean is a relatively “new” clinicopathological 11.4 cases per 100,000 person years) and BG and length of hospitalization, hospital entity characterized by chronic esophagitis male (4.37 vs 18.2 cases per 100,000 person readmission, and 90-day all-cause mortality. and dense eosinophilia of the esophageal years) populations. Results: Mean length of hospitalization mucosa. We sought to determine the inci- Conclusions: Given the stability of demo- was 3 days. Adjusting for age and diabe- dence of EE, observe the incidence trends graphic conditions and health care access, tes, decreased BG was associated with lon- between 1995-1997 and 2005-2007, and our study demonstrates an increase in 72 WMJ • APRIL 2012 incidence of EE from 1995 to 2007 in a mean change in Ha1c after approximately critical decision points in patient care, and population-based cohort that cannot be 6 months (n=44) was -1.32±1.66 with doctor-patient communication. attributed to misclassification or misdiag- a P value of <0.001 (95% CI, -1.82 to Conclusions: Nearly 70% of house staff nosis. There was no significant association -0.81); mean change in BMI at 6 months identified at least 1 time in the preceding between atopic dermatitis and EE. These was 0.67±2.42 (P = 0.082) and 1.55±5.39 2 weeks that they wanted to exceed current findings suggest that EE may be more com- (P = 0.021) at the latest date. duty hours. The majority involved provid- mon than previously realized. Identifying Conclusion: U-500 may improve glycemic ing continuity for an acutely ill patient; factors that contribute to this increased risk control, both in the short term and long however, the doctor-patient relationship, should be subject to further investigations. term for those patients in whom glycemic humanistic attention to patients, and control is not achieved with U-100 insulin. workload also were commonly cited. We Long-term Glycemic Control in There does appear to be a small increase in conclude that after July 1, situations will Diabetes Mellitus Patients Started on BMI in the long term. One needs to take routinely arise during which house staff U-500 Regular Insulin this into account when deciding whether will want to stay beyond duty hours, and Rachel McKenney, MD, Mary Frohnauer, MD, Jacob Gundrum, MS; Gundersen Lutheran or not to use U-500. However, this alone this may occur more frequently than antici- Medical Foundation, La Crosse, Wis should not deter a clinician from consider- pated by the ACGME. ing the use of U-500. Background: Glycemic control in types Resident-Driven Quality Improvement 1 and 2 diabetes mellitus has become Working Beyond the Duty Hour Rules Pinky Patel, Karrie Martin, Zouyan Lu; Medical more challenging with the rising obesity Sarah J. Nickoloff, Kathlyn E. Fletcher; Medical College of Wisconsin, Milwaukee, Wis epidemic. In patients who require insu- College of Wisconsin, Milwaukee, Wis Background: There are more than 51,000 lin doses exceeding 200 units/day, using Background: The Accreditation Council for deaths in the United States each year from U-100 regular insulin may not provide Graduate Medical Education (ACGME) colorectal cancer (CRC) and more than adequate glycemic control because of either recently announced new guidelines that 500,000 patients receiving treatment for poorly absorbed subcutaneous depositions will allow occasional exceptions to the duty end-stage renal disease. Early diagnosis or unreliable absorption patterns. hour rules in very limited circumstances. and prevention of both CRC and chronic Methods: This study’s purpose was to test This study assessed the frequency and cir- kidney disease (CKD) leads to better out- the hypothesis that switching from U-100 cumstances in which house staff might use comes for patients, making these optimal regular insulin to U-500 regular insulin these exceptions. areas of concentration for quality improve- improves long-term glycemic control in Methods: We conducted a cross-sectional ment (QI) initiatives. Using the Wisconsin diabetic patients who have not attained gly- survey study of internal medicine house Collaborative for Healthcare Quality cemic control. A retrospective review was staff at a single academic tertiary care hospi- (WCHQ) as a guide for the development conducted for these patients with U-500 tal. The anonymous survey asked about the and measurement of residents’ QI interven- begin dates between January 2005 and 2 prior weeks of ward service and whether tions, the Internal Medicine residency pro- December 2010. participants would have used the antici- gram at the Medical College of Wisconsin The primary measure of long-term gly- pated exceptions, if allowed. Participants (MCW) formulated academic, year-long cemic control is a long-term reduction in also were asked to provide brief descrip- projects to improve outcomes in both CRC hemoglobin A1C (Ha1c). This is defined tions of situations. screening and health markers in CKD. at a time point greater than 8 months Results: Fifty-nine percent of the surveys Methods: For the CRC project, chart post U-500 initiation and ending either were returned. Interns and residents
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