This case report describes the recurrence of diabetic ketoacidosis (DKA) leading to hypertriglyceridemia-induced pancreatitis. Hypertriglyceridemia is present in 2–5% of patients with diabetic ketoacidosis. Hypertriglyceridemiainduced pancreatitis occurs in up to 4% of patients with diabetic ketoacidosis and is a well-reported complication. This is the first case report to the author’s knowledge, where the same patient had two separate episodes of acute pancreatitis that have been attributed to diabetic ketoacidosis and resultant severe hypertriglyceridemia, etiology determined to be medication non-compliance. DKA and acute pancreatitis can co-exist, and hypertriglyceridemia has been the predominant pathogenetic link between the two conditions. We also describe the pathophysiology and treatment of hyper-triglyceridemia-induced pancreatitis in diabetic ketoacidosis.

No abstract

No abstract

Background and aimThe Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) has become a standardised instrument to measure hospitalised patients’ perception of care. Our hospital’s HCAHPS scores for the ‘communication with doctors’ domain in medical service were suboptimal when compared with peer groups in December 2020. Our goal was to improve performance in the ‘communication with doctors’ domain to at least 50% from baseline over a 6-month period.InterventionOrientation of house staff, nurses and attendings on the Acknowledge, Introduce, Duration, Explain, Thank you (AIDET) approach. Implementation of the afternoon rounds (with documentation) along with the morning rounds to summarise the plan and discuss updates throughout the day to enhance doctor–patient communication.Data analysisHCAHPS domain scores for ‘communication with doctors’ with each subcategory were tracked monthly as well as the number of PM notes written as a measure of afternoon rounds.Results‘Communication with doctor’ domain improved from 8% percentile rank in December to as high as 78%. ‘Doctors treat you with courtesy/respect’ improved from 24% percentile rank in December to as high as 90%. ‘Doctors listen carefully to you’ improved from 13% percentile rank in December to as high as 88%. ‘Doctors explain in a way you understand’ improved from 2% percentile rank in December to as high as 72%.ConclusionsOur results suggest that HCAHPS scores in the ‘communication with doctors’ domain can be improved when employing the AIDET approach with each patient encounter and the addition of afternoon rounds. Sustainability is vital to the success of these interventions, as we observed in our results that there is a direct proportional correlation with the number of afternoon rounds performed with higher scores.

Introduction: Adenocarcinoma (NSCLC) is the most common primary lung cancer in the United States, making up 30% of all lung cancers and accounting for nearly 25% of all cancer mortality. Lung cancer metastasis occurs in many organs, including the adrenal glands, bone, lymph nodes, brain and liver. More commonly associated with small cell lung carcinoma, metastasis of non-small cell lung carcinoma to the stomach and small bowel have been rarely reported, many of which were found incidentally or during autopsy. We present a case of a patient with NSCLC who developed metastasis to the duodenum almost four months after diagnosis. Case Description/Methods: The patient is a 43 year old female with a medical history of NSCLC and recent pulmonary embolism treated with eliquis presented with intermittent episodes of hematemesis and hemoptysis for three weeks. She described medium sized blood clots during episodic coughing and vomiting. On exam, she was afebrile, BP was 187/78, pulse 140, RR 26, and SpO2 94% on room air. She was ill appearing exhibiting epigastric tenderness without guarding. Lab studies revealed a Hg of 9.3, ALK 296, AST 67, ALT 56 and an elevated lactic acid at 4.4. All other lab tests were normal. Two large bore IVs were placed, initiated PPI, type and screened. Eliquis was stopped and the patient was transferred to the ICU for further monitoring. An EGD revealed a 2.5 cm fungating mass in the first portion of the duodenum, which did not require cauterization or clipping. Pathology reported a malignant mass and cells consistent with metastatic carcinoma from the lung primary. After discussing the pathology results with the patient, a decision was made to discontinue anticoagulation as the risk of bleeding outweigh the risk of pulmonary embolism (Figure). Discussion: Common primary tumors that metastasize to the duodenum are renal cell carcinoma, melanoma, breast cancer and small cell carcinoma of the lung. Metastasis to the small intestine may be indolent and a challenge to diagnosis given vague symptoms like nausea, vomiting, abdominal pain and lack of overt bleeding, which can lead to a delay in endoscopy and diagnosis. In this case, anticoagulation likely exacerbated bleeding resulting in a need for an EGD. Duodenal metastasis is a grim prognosis with a survival rate less than 12 months. The case displays that distant metastasis from a primary malignancy can present with vague gastrointestinal symptoms and should not be discarded in certain clinical settings.[3399] Figure 1. 2.5 cm fungating mass in the first portion of the duodenum.