ENRICH Week 2021

Kaizen-Education is a software developed at University of Alabama at Birmingham (UAB). This app has been used for educational purposes in the School of Nursing, School of Medicine, and Internal Medicine Residency Program at UAB. To this point, it has not been used outside of UAB. Novel, low burden education techniques was important to identify given evolving educational needs during the COVID pandemic. Hypothesis: We hypothesized that we could leverage social media to recruit learners to a gamification-infused ID knowledge competition, and entice them to explore additional online educational resources.

Methods: We created the ID Fellows Cup, a knowledge-based trivia competition, to engage Infectious Diseases fellows. The game was crafted via Kaizen-Education, a software platform developed at UAB that uses gamification to engage learners. Multiple choice questions including figures and/or text are presented to learners, followed by detailed teaching explanations. 60 questions emphasizing high-yield concepts were delivered over4 weeks. Questions were written by fellows and reviewed by faculty at three programs. Elements of gamification (virtual rewards, leaderboards, etc.) were included to enhance engagement. Recruitment strategies included Twitter, program director emails, and peer-to-peer. We measured game statistics and participation. Learners were invited to complete a post-game survey about their experience.

Results: We had broad geographic reach including 42 fellowship programs. Most fellows matriculated in 2019 or 2020;the number of US ID fellows equaled 17% of those completing ID in training exam. Recruitment sources included 44% co-fellow, 42% Twitter, and 15% Program Director. Through 20 days with questions, we had 155 daily average users. Overall, fellows answered 11,419 total questions, representing 89% of all released questions. Of 103 responses to post-game survey (table 1) 97% would participate again and all felt the game was a good use of their time. Over 80% of participants reported some engagement with linked resources included in the answer explanations. In general, 78% felt engagement with online resources increased subsequent to participating in the game, including learning about at least one new online.

Lauren Nicholas Herrera <nherrera@uabmc.edu>

University of Alabama At Birmingham, Division of Infectious Diseases

Background Boot camp style courses are often utilized at the beginning of training programs to increase trainee knowledge, skills, and confidence. These activities are limited by faculty and trainee time and cost of materials for simulation. Our anesthesiology residency program developed a boot camp course for PGY-3 residents to provide training prior to their transition to senior trauma call role, facilitated by faculty and senior trainees. Objective: The objective of our boot camp was to increase knowledge, skills, and self-confidence prior to assuming this role mid-training. Methods The two-session senior trauma boot camp was developed for residents and delivered in December 2019, just prior to their assuming the role of senior trauma call resident. Sessions focused on induction and airway management in unstable patients, indications for fiberoptic intubations, management of the operating room schedule, and provided hands-on practice with equipment utilized on call. Results Sixteen of 19 (84%) and 16 of 17 (94%) participants completed the survey on day one and two, respectively. Statistically significant increases in self-reported confidence were found on all 12 retrospective pre/post-test questions. All participants strongly agreed/agreed that sessions were useful in developing their knowledge and would improve their clinical performance. Conclusions Although traditionally offered at the beginning of training programs, our results show that boot camps can be effective at any point during training to increase confidence and perceived knowledge and clinical skills. Future studies should include follow-up assessment of knowledge after transition into the role to document effect on knowledge and skill acquisition.

Michelle D. Tubinis

University of Alabama at Birmingham

School of Medicine, Department of Anesthesiology and Perioperative Medicine

Background: Rapid Cycle Deliberate Practice (RCDP) is an increasingly popular simulation technique that allows learners to achieve mastery of skills through repetition, feedback, and increasing difficulty. This manuscript describes the implementation and assessment of RCDP in an anesthesia residency curriculum.

Methods: Researchers describe the comparison of RCDP with traditional instructional methods for anesthesiology residents' application of Emergency Cardiovascular Care (ECC) and communication principles in a simulated environment. Residents (n = 21) were randomly assigned to either Traditional or RCDP education groups, with each resident attending 2 days of bootcamp. On their first day, the Traditional group received a lecture, then participated in a group, immersive simulation with reflective debriefing. The RCDP group received education through an RCDP simulation session. On their second bootcamp day, all participants individually engaged in an immersive simulation, then completed the "Satisfaction and Self-Confidence in Learning" survey. Application of ECC and communication principles during the simulation was scored by a blinded reviewer through video review. Participants ended the bootcamp by ranking the experiences they found most valuable.

Results: No significant differences were found in the different group members' individual performances during the immersive simulation, nor in the experiences they deemed most valuable. However, the Traditional education group reported higher levels of satisfaction and self-confidence in learning in 5 areas (p = 0.004-0.04).

Conclusions: Regardless of RCDP or Traditional education grouping, anesthesia residents demonstrated no difference in ECC skill level or perceived value of interventions. However, members of the Traditional education group reported higher levels of satisfaction and self-confidence in numerous areas. Additional RCDP opportunities in the anesthesia residency program should be considered prior to excluding it as an educational method in our program.

Keywords: Anesthesiology residents; Medical education; Rapid cycle deliberate practice; Simulation.

Erin Blanchard

University of Alabama Birmingham

Department of Anesthesiology and Perioperative Medicine; UAB Clinical Simulation/Office of Interprofessional Simulation for Innovative Clinical Practice

Purpose: To explore how school and specialty characteristics impact the match location of US senior medical students.

Method: The authors collected student match data between 2018-2020 from US allopathic medical schools and calculated match distance between medical school and residency training. Ordinal logistic regression correlated school and specialty characteristics with match distance.

Results: 26,102 medical students, representing 66 medical schools from 28 states, matched in 23 specialties. 59% of students were from public institutions, and 27% of schools ranked in the top 40 of research funding. The match space was higher for students graduating from private institutions (OR 1.14; 95% CI, 1.06 to 1.22), matching into more competitive specialties (OR 1.07; 95% CI, 1 to 1.14). The match space was lower for students graduating from top NIH-funded institutions (OR 0.89; 95% CI, 0.85 to 0.94), and from schools with higher percentage of in-state matriculants (OR 0.75; 95% CI, 0.72 to 0.77).

Conclusions: School characteristics such as region, public/private designation, NIH funding, and percentage of in-state students were associated with an impact on residency match geography. Matching into more competitive specialties also showed a marginal increase in match distance. These findings suggest that a student’s choice of specialty and medical school may impact subsequent geographic placement for residency training. The impact of geography should be considered by students and residency programs alike.

Ammar Hasnie

University of Alabama in Birmingham

Background: Medical students decide on which specialty to pursue based on interests, prior experiences, geographic preferences, and other factors including specialty competitiveness, yet how competitiveness is operationalized is not well defined.

Aim: To examine how residency matching specialty characteristics correlate with each other and explore which specialties are more competitive.

Methods: Design: Cross-sectional. Participants/setting: US residency specialties. Inclusion: US allopathic medical schools with publicly available match data of individual students, 2018-2020. Exclusions: Combined residencies, interventional radiology, oral and maxillofacial surgery, child psychiatry, non-residency fellowships, or Canadian residencies. Specialty data: US senior applicants per position, US senior fill rate, number of post-graduate year (PGY) positions available, salary, number of programs, applicants (total, US), applicants/position, mean Steps 1 and 2, % AOA, % from top 40 NIH funding school, scholarship (mean abstracts, presentations, publications), and US Sr Fill Rate from 2020 National Resident Matching Program(NRMP) data of all matched applicants by specialty. Analysis: Spearman rho correlation, factor analysis.

Results: Of the 155 US medical schools, 66 displayed match data of 26,102 students matching into 23 specialties. Among the 23 included specialties, 10/14 variables had correlation coefficients of 0.8-0.9 (all p<0.001).

Factor 1 explained 58% of the variance (Eigenvalue 8.2) and comprised of US senior fill rate, salary, Step 1, Step 2, % AOA, % from top 40 NIH funding school, and scholarship. Factor 2 explained 17% of the variance (Eigenvalue 2.3) and comprised of number of PGY-1 positions available, number of programs, applicants (total), and applicants (US). Factor 3 explained 10% of the variance (Eigenvalue 1.5) and comprised of US senior applicants per position and applicants/position. The internal consistencies were excellent (Factor 1, Cronbach’s alpha =0.94; Factor 2, Cronbach’s alpha = 0.97) – Table.

Based on the ranking of the predictive value for Factor 1, the top 5 most competitive specialties were Plastic Surgery, Neurosurgery, Dermatology, Orthopedic Surgery, and ENT.

Conclusions: Residency matching specialty characteristics are highly correlated to each other and fall within one main construct representing academic achievement, salary potential, and program preference. Supply-demand mismatch appears less influential in the residency match process.

Ammar Hasnie

University of Alabama in Birmingham

Cover Page Primary Presenter: Name: Connie Shao School: Medicine Department: Surgery Academic Rank: General Surgery Resident Email: shaocc@uab.edu

Other authors: Name: Grace Kennedy School: Medicine Academic Rank: Medical Student Email: gracek@uab.edu

Name: Courtney Rentas School: Medicine Academic Rank: Medical Student Email: cmrentas@uab.edu

Name: Herbert Chen School: Medicine Department: Surgery Division: Breast and Endocrine Academic Rank: Professor Email: hchen@uabmc.edu

Name: Jessica Fazendin School: Medicine Department: Surgery Division: Breast and Endocrine Academic Rank: Assistant Professor Email: jmfazendin@uabmc.edu

  Leadership development among junior surgery residents: communication and perception at different levels of training Shao C, Kennedy G, Rentas C, Chen H, Fazendin J BACKGROUND: Leadership is necessary for effective healthcare teams, particularly for surgeons. However, surgical leadership is rarely formally assessed, particularly for junior trainees. HYPOTHESES/AIM: We aimed to establish themes of communication, self-perception, and external perception under stress among junior surgical residents at a single institution. METHODS: The Data Dome Inc.(datadome.com) DiSC personality assessment was administered 2018-2020 to residents at an academic General Surgery training program in Alabama. Resident demographics were recorded and themes from de-identified reports were analyzed by year (PGY-1, PGY-2) using JMP 14 Pro. RESULTS: Of the residents surveyed(n=54), half(48.2%) responded: 17 PGY-1(65.4%), 7 PGY-2(26.9%). Respondent demographics reflected the training program(57.7% White, 73% female). Mean age at assessment was not significantly different between PGY-1(27.7) and PGY-2(29.9, p=0.27). PGY-1 communication was most frequently described as ‘accomplished best by well-defined avenues’(n=9) with ‘duties and responsibilities of others who will be involved explained’(n=9) in ‘friendly terms’(n=9). PGY-2 communication involved ‘deal with people’(n=6), ‘strong feelings about a particular problem’(n=5), and ‘good at giving verbal and nonverbal feedback’(n=4). Self-perception of PGY-1’s was ‘charming’(n=6), ‘considerate’(n=6), and ‘dependable’(n=6); PGY-2’s were ‘charming’(n=6), ‘enthusiastic’(n=6), and ‘inspiring’(n=6). Under stress, PGY-1 external perception was ‘detached’(n=6), ‘insensitive’(n=6), and ‘poor listener’(n=6); PGY-2’s were ‘overly confident’(n=4), ‘poor listener’(n=4), and ‘self-promoter’(n=4). CONCLUSION: Communication style, self-perception, and external perception under stress vary by training level. Clear expectations and approachable communication are important for PGY-1’s, interpersonal feedback for PGY-2’s. Under ideal conditions, junior residents self-perceive as naturally engaging. Under stress, PGY-1’s seem distracted/uninvolved, PGY-2’s arrogant. Understanding stress responses can help trainees adapt to become more effective leaders.

Connie Shao

University of Alabama at Birmingham

ABSTRACT Background: Even if Enhanced recovery protocols (ERP) were introduced more than 20 years ago, and their benefits are widely accepted and published, studies have demonstrated a lack of adherence to guidelines and protocols. As a result, patients experience a delay in recovery after surgery. Aim: ERP have the potential to streamline care and improve short-term outcomes for surgical patients. However, for patients undergoing modern iterations of complex abdominal wall reconstruction (AWR), little literature exists on the effectiveness of these protocols. Methods: In this retrospective study we reviewed our institutional experience with complex AWR over a 2-year period both before and after implementation of our ERP in May 2019 (January 2018-February 2020). Patients undergoing primarily minimally invasive complex AWR who were compliant with 11 elements of our ERP (N=46) were compared to patients who did not meet these criteria (N=86). Baseline patient characteristics and patient outcomes including hospital length of stay, narcotic usage, and readmissions were compared across groups. Finally, our modern cohort of patients was compared to a historical cohort of primarily open AWR patients. Multivariable regression modelling was also performed. Results: Most patients were female (60.6%), white (77.3%) with ASA class 3 (71.2%) and BMI average BMI 31.7. Median hernia width was 6cm (IQR 5-9) and length was 10 (IQR 7-15). Fifty-three percent of all cases were performed robotically, and 47.0% of cases required transversus abdominus release. Median length of stay for the overall cohort was 3 days (IQR 1-4). Morbidity and mortality rates were 22.6% and 0.7%. ERP patients were less likely to have a complication (8.7% vs. 30.2%, p=0.005), had a significantly lower median length of stay (1 days vs. 3 days, p<0.001), and receive fewer morphine equivalents (31 vs. 45, p=0.005). ERP patients had a trend towards lower rates of readmissions (6.5% vs. 11.8%, p=0.3). In a multivariate analysis, ERP was independently associated with decreased length of stay and decreased narcotic usage, but not complications or readmissions. Conclusion: A modern cohort of patients undergoing complex abdominal wall reconstruction within an ERP experience a decreased post-operative length of stay and require fewer morphine equivalents during their hospitalization compared to their non-ERP counterparts. ERPs are effective in patients undergoing complex abdominal wall reconstruction and can provide benefits for both patients and hospitals.

Dasiel Bellidode Luna

UAB School of Medicine/ Department of Surgery

Prevalence of HCV in Sexual Assault Survivors Presenting to a SANE Clinic: A Descriptive Analysis Erin Ward, Nicholas Carlisle, JD, Ebony Williams, MBA, MA, CHES, Sonya Heath, MD Lauren Walter, MD Introduction: Over two million Americans are living with chronic Hepatitis C (HCV); however, as many as 75% may not be aware that they are infected, resulting in subsequent disease progression and transmission. While previous epidemiologic research has demonstrated that Survivors of Sexual Assault (SAS) may be at disproportionate risk for exposure to HCV, HCV screening in SAS is not addressed in current CDC post-sexual assault testing recommendations. We sought to identify the prevalence of HCV among a SAS cohort along with associated basic demographics. Methods: Universal, opt-out HCV antibody screening and RNA confirmatory testing was provided for all SAS at a Sexual Assault Nurse Examiner (SANE) clinic in Birmingham, Alabama, beginning in April, 2020. In February 2021, a retrospective chart review was conducted inclusive of SAS seen from April, 2020, through December, 2020, to assess number of HCV screens performed, proportion of HCV positive screens, and associated available demographics. Descriptive statistical and Chi-square analyses were performed. Results: Of 226 SAS who presented to the SANE clinic in an 8-month period, 189 (83.6%) were screened for HCV; 16 (8.5%) of those tested were HCV positive. This is significantly higher than state (<1.0%) and national (1.0%) HCV incidence rates (p <.0001). No significant testing rate differences were noted with regards to race, gender, or age. Male SAS were more likely to screen positive for HCV (22.7%, p = .01). SAS aged 25-44 were also more likely to screen positive (14.6%, p = .01). Overall SAS demographics also demonstrate the presence of significant social vulnerabilities among this cohort, specifically high rates of homelessness (4.4%) and incarceration (4.9%). Conclusion: Routine HCV screening at a SANE clinic suggests a relatively high prevalence of HCV among SAS as compared to the general population, particularly in younger, male, and incarcerated patients. These results highlight the importance of universal HCV screening and risk counseling in this setting and suggest opportunities for future focused interventions aimed at harm reduction and social disparities.

Erin Ward

University of Alabama at Birmingham

Title: The Role of Race and Ethnicity in Team Dynamics

Background: Current emphasis is focused on increasing diversity within healthcare teams to better serve a more diverse patient population. Teamwork has been integrated into the undergraduate biomedical science curriculum to help students learn to work effectively in teams, which aligns with their goals of working effectively on inter-professional healthcare teams. Studies have suggested that racial and ethnic factors affect team dynamics and can play a significant role in the learning process, specifically for underrepresented minority students (URM). We sought to determine if racial or ethnic factors affected peer evaluation scores within diverse teams and to determine if a correlation exists between the racial/ethnic composition of a team, peer evaluation scores, and overall grades. Hypotheses/Aim: We hypothesize that the racial and ethnic composition of teams influences peer evaluations and course grades, specifically for URM undergraduates. Methods: To assess teamwork within two undergraduate courses, microbiology and pathophysiology, the Comprehensive Assessment of Team Member Effectiveness (CATME) tool was used for peer evaluation of teammates. Data were collected from courses in 2018-2021. Demographic information, CATME peer evaluation scores, and course grades for individual students, demographics, and teams were analyzed for trends. Results: There were 348 students enrolled in the courses, 64.5% female and 32.5% male. On average CATME scores were highest among Asian and White students compared to URMs and students with higher final grades had higher average CATME scores. The racial and ethnic composition of teams differentially affects peer evaluation scores for African American (AA) and Latino students and has no effect on peer evaluation scores of Asian or White students. Conclusion: Racial and ethnic composition of teams is an important criterion when forming teams, specifically for AA students, who tend to perform better on teams with a higher percentage of AA students. Grades are a major factor driving overall peer evaluation scores which can further affect overall class grades which already favor White and Asian team members. A better understanding of the influence of the racial and ethnic composition of teams, including healthcare teams, can potentially increase team cohesiveness and team function, leading to better care and treatment of patients.

N. Robert Estes II and Steve Otero

University of Alabama at Birmingham, Department of Chemistry and Department of Clinical and Diagnostic Sciences, Biomedical Sciences Program

Introduction: The STITCH technique for laparotomy closure has been shown to be associated with decreased incisional hernia rates but has not been widely accepted. The reasons behind the lack of integration and application of the trial’s findings have not been elucidated in the greater surgical community. Identifying surgeon perspectives on the trial is a critical first step to developing interventions to enhance widespread adoption of STITCH trial technical tenets. Methods: In this initial phase of our mixed methods study, quantitative surveys with embedded qualitative responses were distributed to practicing surgeons and surgical residents around the country. Survey questions were based on the previously validated Theoretical Domains Framework (TDF) for skill acquisition. The TDF uses a large body of previous research of behavioral theory, to identify a unified series of 12 domains to account for behavioral change in clinical practice. The Patient Safety Behaviors Questionnaire is a quantitative survey that operationalizes the TDF and has been previously validated for understanding healthcare provider adoption of new interventions; this was adapted for use in the context of the STITCH trial. The survey was first pilot-tested amongst practicing surgeons and individual interviews performed to assess usability. The second phase of the study will include individual semi-structured qualitative interviews with surgeons across the country. Results: One hundred thirty participants responded to the survey. Respondents were relatively evenly split by training and experience, with 23.62% trainees, 24.41% in early (1-5 years) practice, 18.11% in mid (6-10 years) practice, and 33.86% with 11+ years of experience. While 93.08% were aware of experts’ recommendations to use the technique, only 57.26% of participants agreed with the technique. We noted that a similar percentage (66.7%) did not note deficits in the knowledge domain of the TDF. Most (74.19%) felt they had access to the resources needed (environmental limitations domain), but ultimately only 33.33% of respondents felt that there would be negative consequences for patients if STITCH techniques were not used. Finally, few felt that there was a limitation in the Action Planning domain, and only 12.9% felt that they could not implement the techniques if they had wanted to do so. In the embedded qualitative portion, many cited the lack of long-term outcomes data, the need for additional studies, and/or the lack of investigation of a more diverse, heterogenous population as limitations to STITCH implementation. Some surgeons noted equipment discrepancies (needle size versus suture size), difficulty in the ability to execute 5mm bites correctly, and the appropriateness for their respective fields as additional barriers. Trainees felt there was little option to utilize techniques that differed from supervising attendings’ beliefs. Conclusion: We identified that most surgeons were aware of the study findings but only a slight majority agreed with the recommendations, citing multiple barriers to implementation. Faculty surgeons may impact resident selection of suture. Additional insight is expected to be derived from future qualitative interviews in the second portion of our study.

Steven Lee Cochrun

University of Alabama at Birmingham, Department of Surgery

America's Hernia Society

Background: Liver transplantation (LT) from HCV positive donors has become an option to expand a limited donor pool with the advent of Direct-Acting Antiviral therapy (DAA). Current guidelines for post-LT Hepatitis C treatment includes Glecaprevir/Pibrentasvir (Mavyret) with the goal to achieve a Sustained Virological Response (SVR) post-transplantation.

Hypothesis/Aim: Our study focuses on Glecaprevir/Pibrentasvir’s efficacy in achieving SVR and an undetectable Viral Load (VL) in HCV Donor (D+)/Recipient (R-) transplanted patients.

Methods: We performed a retrospective cohort review of 13 HCV D+/R- patients who underwent LT at the University of Alabama-Birmingham Medical Center from January 2019 to November 2020. Patient demographics, co-morbidities, liver cirrhosis etiology, HCV VL and genotype was recorded. Patients received a standard 12 weeks of Glecaprevir/Pibrentasvir initiated at the time of VL detection on post-op day 3. Other data included post-LT complications, mortality, graft rejection, and time to achieve undetectable VL post-LT.

Results: Our cohort consisted of 13 patients; 92% male, 62% white, 12 orthotopic liver transplants, and 1 simultaneous liver kidney transplant with an average age 58 +/- 11, BMI of 30 +/- 6 and MELD-Na 27 +/- 8. Liver cirrhosis etiology included NASH (50%), Alcohol (33%), NASH/Alcohol (8%) and other (9%). HCV genotypes at the time of VL detection included 1a (54%), 2 (8%), and 3 (31%). Among the HCV D+/R- recipients (n=13), all patients completed treatment and 92% (n=12) achieved SVR at 12 weeks. Mean VL detected within the first week post-LT was 10.7 million +/- 9.7 million and mean undetectable VL was achieved within 34 +/- 21 days. Following treatment completion, one patient had graft rejection and one patient mortality was noted due to events following post-operative complications.

Conclusion: Patients treated with Glecaprevir/Pibrentasvir following LT from HCV positive donors had overall excellent graft survival with most patients achieve SVR at 12 weeks and maintaining undetectable VL post-transplantation. Glecaprevir/Pibrentasvir is an effective treatment for patients receiving LT from HCV positive donors.

Yassmin Hegazy

University of Alabama Birmingham, Department of Medicine

Department of Hepatology

The didactic education experience is a fundamental element in internal medicine residency training. This type of educational activity is an important complement to the experiential learning experiences of medical residents, helping to prepare them for the next step in their education and practice, whether that is the licensing examination, fellowship training, or clinical practice coupled with continuing medical education. This education therefore plays a pivotal role in residents’ transitions along the medical education continuum beyond medical residency. The limited access to specialty speakers in community-based programs creates inequity in the achievement of educational goals for residents in training. A national platform matching residency programs with needed subspecialty speakers via a web-based live format can provide a breakthrough solution for this issue. A pilot program was launched, whereby speakers from three university programs provided subspecialty lectures to two community-based residency programs. The pilot program was met with enthusiasm from both the giving and receiving ends, as evidenced both by informal feedback and a preliminary survey. The goal of the current proposal is to build on this success by expanding the program to internal medicine residency programs nation-wide. This expansion will be supported by a speaker-to-program matching software. The program can ultimately expand to residencies in specialties beyond internal medicine as well.

Mohamed Shoreibah

University of Alabama at Birmingham

Decreasing sepsis mortality is an institutional priority. To meet this need, an escape tabletop simulation was developed with a focus on sepsis for our learners, facilitators, and budget. By merging the escape room concept and serious games, a new opportunity for simulation emerged. This simulation happens with a moderating facilitator and 5-7 participants around a table. Supplies are portable and require 20 minutes to setup. All elements are either on or connected to the table. It takes 1 hour or less to prebrief, simulate, and debrief. Prebriefing includes elements of best practice and rules of simulation engagement. Participants have 30 minutes to complete the challenge. Debriefing is designed as a self-guided experience to support novice facilitators. Designed with elements of best practice, numbered cards are randomly chosen by the participants. In numerical order, each participant reads their card to facilitate the self-guided debriefing. This simulation is designed for any member of the interprofessional, clinical or non-clinical, team including students and practicing professionals. Surveys with a 5-point Likert scale were used to evaluate participant experience. Qualitative data was collected to evaluate what they felt was beneficial versus what could be improved. Evaluations demonstrated the overwhelming majority of responders felt the experience was valuable and would recommend to others. A tabletop escape simulation is a low-resource, cost-effective activity. For $200.00, anyone can replicate this experience to introduce and reinforce a variety of skills. In addition, the objectives of the experience can be adjusted to meet the needs of any learner group.

April Belle, DNP, RN, CCNS <abelle@uabmc.edu>

University of Alabama at Birmingham, UAB Clinical Simulation

UAB Health System

Teaching the fundamentals of sterile technique and sterile gloving to a large group of students presented a challenge. Demonstrating these skills at the front of a classroom or lecture hall did not allow students to observe the technical intricacies required to maintain sterility. The goal of this activity was to allow the students to experience the equivalent of a 1:1 instructional session while in a large group setting. This activity occurred in a large classroom with 35 pre-licensure nursing students. Each student stood at a table and with a pair of sterile gloves, sterile bowl, non-fenestrated sterile drape, and sterile 2” x 2” gauze. Two overbed tables with supplies matching the students’ were placed at the front of the classroom, one beside the projection screen and one beside the podium. A document camera was adjusted to display an over-head view of the overbed table beside the podium. This activity has since been completed using a webcam attached to equipment, such as a surgical instrument stand, to allow for optimal positioning to replicate the use of a hovercam. During the activity, one instructor stood beside the projection screen, teaching the principles of sterile technique, and demonstrating while guiding the students through the steps of setting up a sterile field and donning and doffing sterile gloves. Simultaneously, the other instructor demonstrated the skills under the camera while the image was projected on the screen, mirroring the students’ workstation. This allowed the students to view the minute details associated with proper sterile technique as they prepared their sterile fields and donned and doffed sterile gloves along with their instructors. While instructional videos provide similar perspective and detail, this activity allowed student engagement. Students were able to ask questions, request repeat demonstrations, and return demonstrate during periodic checkpoints in the activity. Feedback from students was consistently positive and students demonstrated increased confidence in demonstration of sterile technique. Educators recognized the enhanced quality of instruction when using this method of teaching precision skills to large groups. This method has since been successfully implemented when teaching other skills, including venipuncture, IV start, and tracheostomy care.

Caroline Littleton & Victoria Bolus <cblittleton@uab.edu>

UAB School of Nursing

Objectives: The role of community service as part of medical education is well established. The SARS-CoV-2 pandemic highlighted the role of social determinants of health and the disproportionate impact of COVID-19 in Alabama’s Black Belt region. Their low vaccination rates pose a challenge to public health and risks worse outcomes in these counties. Our organization, Equal Access Alabama, a UAB medical student initiative, aims to encourage pre-health students, medical students and house staff to develop a deeper understanding of the challenges faced by socioeconomically disadvantaged Alabamians and leverage this knowledge to increase access to vaccines.

Settings and Participants: This effort targeted 12 Alabama counties. Students from several schools within UAB, Samford University, and Auburn VCOM partnered with Spirit of Luke/A Promise to Help (a mobile healthcare clinic) and Community of Hope Health Clinic (a primary care clinic and AHEC affiliate) to identify communities needing vaccinations. Alabama state & regional (West Central and Southeast) Area Health Education Centers (AHECs) supplied the vaccine. Ministers, mayors, and council members were involved in outreach efforts to create a community-academic partnership.

Description: This campaign aimed to augment the state’s response to the public health crisis. Our collaboration with local leaders established connections with individuals/communities open to receiving vaccinations. We also expanded our reach by contacting public officials, public health organizations and community leaders. All volunteers were required to complete a training session to enable them to screen individuals for vaccine eligibility, dilute and administer the vaccine and conduct post-vaccination monitoring. Volunteers were prepared to address concerns stemming from vaccine hesitancy. We also tailored our approach to each community, by setting up a stationary clinic and/or a mobile team traveling door-to-door.

Lessons Learned: Since June 2021, we have administered over 500 vaccine doses with the help 50 on-the-ground volunteers. We served people living in isolated rural areas, with targeted outreach to those from underrepresented racial/ethnic groups and incarcerated individuals. A consistent challenge was the low turnout at the stationary clinics. Reasons included unforeseen social events (funerals, community parties), lack of transport for patients, and insufficient community outreach. However, we observed that turnout was stable or increased when we returned to the same locations repeatedly. Word-of-mouth between community members appears to be an effective means of increasing community buy-in to the vaccination effort if our volunteers returned consistently. Most importantly, we remain committed to returning to clinical sites as often as is necessary to ensure everyone who desires the vaccine, may get one.

Dr. Gargya Malla & Raymond A Lopez <gmalla@uab.edu>

University of Alabama at Birmingham, Department of Epidemiology; University of Alabama at Birmingham, School of Medicine

Spirit of Luke/A Promise to Help, Community of Hope Health Clinic (CHHC)

Background: Pediatricians can play a major role in the prevention of pediatric firearm injuries. How frequently and effectively we provide firearm safety counseling to Primary Care Clinic (PCC) patients is poor. The objectives of this QI project are to improve the consistency and quality of firearm safety counseling in PCC and distribute gun locks to patients. Aim: To improve firearm safety counseling and gunlock distribution in PCC. Methods: This project has undergone multiple PDSA cycles including PCC “spotlights”, a didactic lecture, and resident surveys. The current focus is on retrospective chart review of 9-month-old and 24-month-old well checks in PCC and determining if the resident documented that a gunlock was provided and if firearm safety counseling was provided. Charts from June 2017 to present were reviewed. Results: To date, 1,269 well visits have been reviewed. Of these, residents documented that 7 gunlocks were distributed (0.6%) and firearm safety education was provided to 237/1269 (18.7%). Manual monthly gunlock counts demonstrate that, in reality, 86 gunlocks have been distributed from Jan 2020-April 2021. Conclusion: The discrepancy in resident documentation and manual gunlock counts is likely secondary to a busy clinic and a difficult to navigate Electronic Medical Record (EMR) system. A future PDSA cycle will include creating templates within the EMR to improve documentation. We hope to continue to expand the project to maximize firearm safety counseling and gun lock distribution in PCC.

Andrew Donahue, MD

University of Alabama at Birmingham

Lactic acidosis can occur in two different scenarios: Type A which occurs in the setting of organ hypoperfusion leading to reduced clearance of lactate most commonly associated with DKA, Type B which occurs due to impaired cellular metabolism leading to increased production of lactate most commonly associated with drugs, toxins, and rarely malignancy.

We present a rare case of sarcoma induced type B lactic acidosis. A 60 year old female presented initially with syncope and 20 pound unintentional weight loss.ALP 162 U/L, lactic acid 10 mg/dL, CRP 6.4 mg/L with an anion gap of 24 were prominent on labs. Lactate trended up to 17.9 on day 4 of admission. CT showed widely metastatic disease and liver biopsy showed high grade sarcoma likely originating from the uterus.

Studies have shown that malignant cells undergo a poorly understood biosynthetic reprogramming of energy production that enables them to divert from the normal oxidative process towards a glycolytic pathway with the generation of lactate, thus causing type B lactic acidosis. This reprogramming could be partly explained by an enhanced glycolytic pathway secondary to the production of -inducible factor-1a by oncogenic lesions.

Adam Bonner

University of Alabama at Birmingham- Huntsville Campus

Department of Internal Medicine

Title: Not all Parinaud Syndromes are Secondary to Pinealomas

Authors: Anthony L. Wilson MS3, Clark C. Ingram MS3, Tejanand G Mulpur MD

Departmental Affiliation: UABSOM Huntsville Campus, Department of Neurology

Learning Objectives · Consider hemorrhagic and ischemic strokes in adult patients presenting with eyelid retraction · Early correction of blood pressure and hydrocephalus can allow for a complete return to baseline in patients with hemorrhagic causes of Parinaud syndrome

Introduction

Parinaud syndrome is described by the triad of impaired vertical gaze, convergence retraction nystagmus, and pupillary hyporeflexia.1 The pathophysiology involves compression of vertical gaze centers located within the rostral midbrain, pretectal area, and superior colliculus.2 Here, we describe a patient suffering a hemorrhagic stroke of the right thalamus, which extends in the rostrocaudal direction into the third ventricle and causes compression of the anterior surface of the tectum. Pressure transmitted through the tectum causes impingement of the superior colliculus via mass effect. Clinically, this patient presented with the Parinaud Syndrome triad, which later reversed with management of blood and intracranial pressure (ICP).

Case Presentation

A 60-year-old male with a history of alcohol abuse, congestive heart failure, hypertension, hyperlipidemia, and peripheral vascular disease presents to the emergency department after hitting multiple cars while acutely intoxicated. His blood pressure is 217/116 mm Hg. The patient is obtunded and briefly arousable by sternal rub. Imaging obtained shows acute right thalamic hemorrhage with extension posteriorly, causing indirect pressure on the superior colliculus.(Figure 1,2) Early signs of hydrocephalus are noted. Aggressive blood pressure control (<140 mm Hg) was achieved with hydralazine, metoprolol, labetalol, and nicardipine. Neurosurgery recommended a right frontal external ventricular drain to control intracranial pressure. Shortly after, he had vertical gaze impairment, lid retraction, and posturing of his head to look upward. The patient remained under strict monitoring of ICP and blood pressure. Gaze palsy improvement was noted clinically and correlated with hemorrhage resolution on repeat scans. (Figure 3) The patient returned to baseline neurological status within 4 weeks.

Discussion

Parinaud syndrome, also known as dorsal midbrain syndrome, was first reported by French ophthalmologist Henri Parinaud in 1883.3 Etiologies of Parinaud syndrome include pineal gland tumors, arteriovenous malformation, dilation of the third ventricle, lesions to the posterior commissure, multiple sclerosis, and midbrain infarction. Early recognition and intervention in patients with Parinaud syndrome secondary to hemorrhagic stroke and pressure on the tectum can lead to the reversal of ophthalmologic symptoms. Clinicians should monitor hemorrhage regression and ICP correction, which may correlate with symptom resolution.4

References

1. Shields M, Sinkar S, Chan W, Crompton J. Parinaud syndrome: a 25-year (1991-2016) review of 40 consecutive adult cases. Acta Ophthalmol. 2017 Dec;95(8):e792-e793. doi: 10.1111/aos.13283. Epub 2016 Oct 24. PMID: 27778456.

2. Feroze KB, Patel BC. Parinaud Syndrome. [Updated 2021 Feb 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441892/

3. Keane J. R. (1990). The pretectal syndrome: 206 patients. Neurology, 40(4), 684–690. https://doi.org/10.1212/wnl.40.4.684

4. A Case of Parinaud Syndrome After Intracranial Hemorrhage. J Korean Ophthalmol Soc. 2009;50(1):172-175. Published online January 15, 2009 DOI: https://doi.org/10.3341/jkos.2009.50.1.172

Anthony L. Wilson

University of Alabama at Birmingham School of Medicine, Huntsville Campus

Department of Neurology

Introduction: Hypercalcemia is a common clinical problem and a known red flag for malignancy. Commonly, this elevation in calcium is humorally induced (PTHrP), with solid tumors being common culprits. However, hypercalcemia is rare in most hematologic cancers with multiple myeloma and T cell lymphoma/leukemia being notable exceptions. In chronic lymphocytic leukemia (CLL), the elevated calcium can be due to PTHrP, bone lesions, elevated calcitriol, and rarely due to leukemic/lymphoma transformation (Richter’s syndrome). We describe a rare case of a patient with significant CLL tumor burden and hypercalcemia, elevated PTHrP, and calcitriol. Case Description: A 63-year-old male with a history of CLL (11q deletion) with 4 recurrences over 15 years, currently enrolled in a clinical trial with CD20 bi-specific antibody, presented with hypercalcemia of 13.9 mg/dL (8.4-10.4). The imaging showed interval increase in splenic size and adenopathy without evidence of bone lesions. There was no evidence to suggest Richter’s transformation or plasma cell dyscrasias. Laboratory results were significant for a suppressed PTH 1.5 pg/mL (12-88), vitamin D 24 ng/mL (20-100), alkaline phosphatase 174 Units/L (37-117), calcitriol 109 pg/mL (18-72), PTHrP 21 pMol/L (<4.2), and LDH 477 Units/L (120-240). Patient was treated with zolendronic acid and calcitonin and was discharged as hypercalcemia improved. He was hospitalized a few days later with calcium 16.6 mg/dL. Hypercalcemia is managed with calcitonin, IV fluids and denosumab. In addition, he also received prednisone and denosumab. Educational tool: Concerning hypercalcemia in hematologic malignancies like CLL, we propose the following pneumonic/phrase: if it’s not endocrine (parathyroid, vitamin D), it’s something “OTHER” [Osteolytic bone lesions, Tumor burden, Humoral hypercalcemia, Extra cancers (MM), Richter’s transformation]. Discussion: Hypercalcemia in CLL is very rare and is a negative prognostic marker. In our patient, PTHrP is elevated which is consistent with humoral hypercalcemia. Calcitriol is not elevated in cases of PTHrP elevation in CLL reported in the literature. We hypothesis that at a certain threshold of PTHrP elevation, it could cause elevation in calcitriol level, or the tumor is producing both. Other possible causes include granulomatous disease but is less likely in this case.

David Heaner

University of Alabama at Birmingham

Introduction: Rapid correction of hyponatremia is universally known to cause Central Pontine Myelinolysis (CPM). It can rarely develop in patients with diabetes mellitus (DM) due to abrupt fluctuations in serum osmolality. We present a patient with CPM due to poorly controlled DM to highlight the importance of adequate control of blood glucose level.

CASE DESCRIPTION A 65-year-old nonalcoholic, nonsmoker, right hand dominant man known to have type 2 diabetes, hypertension, hyperlipidemia, chronic kidney disease, coronary artery disease and ischemic cardiomyopathy, who presented to the emergency department with progressive generalized weakness and slurred speech for two weeks. Vital signs were within normal range (Temperature was 36.7°C, blood pressure 108/51 mmHg, pulse 85 bpm, respiratory rate 19 breath per minute, oxygen saturation 97% on room air). Neurological examination was remarkable for dysarthric speech, decreased motor strength symmetrically bilaterally 4/5 in lower extremities and sensation was intact to fine touch, sharp sensation and vibration. Laboratory test results was significant for serum glucose 547 mg/dl, serum sodium, 127 meq/L with corrected sodium level of 134 meq/L, blood urea nitrogen 54 mg/dl, creatinine 2.0 mg/dl and HbA1c of 18.4%. Patient underwent further evaluation with brain imaging. CT head without contrast did not reveal any acute intracranial abnormality. MRI brain with and without contrast demonstrated non-enhancing diffusion abnormalities bilaterally within the pons suggestive of osmotic demyelination. Patient’s blood glucose was strictly controlled with improvement in his symptoms, and he was discharged home at hospital day 4.

Discussion: Central Pontine Myelinolysis can present in the setting of severe hyperglycemia or days to weeks following correction of hyperglycemia. The most common neurological symptoms include gait ataxia, dysarthria, dysphagia, and pseudobulbar affect. High clinical suspicion is essential as symptoms may be mild and lesions are only detectable by MRI brain. Patient education and strict blood glucose control is crucial in preventing CPM in the setting of severe hyperglycemia.

Jennifer Lamar

University Of Alabama at Birmingham School of Medicine, Huntsville Campus

Introduction: Hemophagocytic Lymphohistiocytosis (HLH) is a rare exaggerated immune response causing deposition of lymphocytes and histiocytes throughout multiple organ systems causing organomegaly and ultimately organ failure. This case study serves to illustrate the clinical features and diagnosis of HLH. Early identification and treatment will decrease the risk for life-threatening complications. Case description: A 39-year-old Hispanic male with no past medical history presented with left scrotal pain and swelling. On admission physical exam was significant for fever, left scrotal swelling and tenderness. Patient had severe pancytopenia with hemoglobin of 7.9 g/dL, platelet count of 13 x10^3/mcL, and severe neutropenia of 0.36 x10^3/mcL. Additionally, ferritin was elevated at 82,191 ng/mL, and hypofibrinogenemia was present. Scrotal ultrasound was suggestive of increased vascularity and possible epididymitis. He was started empirically on Ceftriaxone and Doxycycline. Due to persistent fevers and neutropenia, antibiotics were broadened to Cefepime and Vancomycin along with Doxycycline. He was transferred to the intensive care unit for probable bone marrow failure and atypical bacterial infection in the setting of HLH syndrome. Bone marrow biopsy revealed hypercellular marrow, increased lymphocytes, histiocytes and hemophagocytosis. Patient was started on Dexamethasone 10 mg IV daily and etoposide 75 mg/m2, dose adjusted due to abnormal liver function tests. Antibiotics were subsequently discontinued. Urology was consulted for a left unilateral orchiectomy for definitive pathology. Procedure was deferred due to persistent thrombocytopenia. Patient remains hospitalized, receiving supportive care and HLH treatment.

Discussion: HLH is an aggressive and life-threatening condition that requires early diagnosis and treatment to prevent multi-organ injury and mortality. Per HLH 2009 modified criteria, a molecular diagnosis of HLH is definitive. Additional criteria include three of the following: fever, splenomegaly, cytopenias of at least 2 cell lines, hepatitis and at least one of the following: hemophagocytosis, hyperferritinemia, increased sIL2Rα, and absent or decreased NK function. A patient fulfilling these HLH criteria warrants urgent initiation of HLH treatment protocol.

Lauren Beggs

University of Alabama Huntsville Regional Campus Departments of Family and Internal Medicine

Toxoplasmosis caused by parasite Toxoplasma gondii is widely distributed infection with estimated prevalence of 25-30%. Immunocompetent patients are typically asymptomatic. However, T. gondii infection may present as ocular disease.

Maha Al Baghdadi

UAB Huntsville Regional Medical Campus

Introduction Acute thrombocytopenia requires prompt intervention to prevent adverse clinical outcomes. Thrombocytopenia has a broad differential, and careful analysis of the clinical scenario will provide clues that help to narrow the differential. The 4T score is a useful pre-test calculator, with good evidence, when HIT is a possible diagnosis.

Case Description We present a case of hyperacute drug-induced immune thrombocytopenia after tirofiban infusion for a spontaneous coronary artery dissection with a large thrombus burden. A 30 year old female was transferred to UAB after she was diagnosed with spontaneous coronary artery dissection complicated by a large thrombus burden not amenable to percutaneous intervention. She was anticoagulated with heparin and tirofiban, a glycoprotein IIb/IIIa inhibitor. Within 24 hours, she developed acute severe thrombocytopenia, large hematomas, and palpable purpura. Upon transfer, platelet transfusions, and IVIG were administered. Given the rapid onset of thrombocytopenia after exposure and a low 4T score, HIT was unlikely. With treatment, her platelets normalized, and the diagnosis was confirmed with the detection of tirofiban IgG antibodies.

Important Educational Tool Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings Lo et al, published in 2006, tasked physicians with scoring patients during retrospective review and prospective assessments of patients in which HIT was on the differential. The 4T scores were compared to the HIT antibody tests obtained during the initial hematology consultation. Discussion The 4T score has good sensitivity and poor specificity as depicted in Table 1. The utility of the 4T score, as outlined in the study, is best described after stratification of high, intermediate, and low-risk categories. The positive predictive value for scores >3 is highly variable. Intermediate and high scores have a high false-positive rate that may vary from institution to institution. The 4T score has excellent negative predictive value for scores < 3, and the false negative rate was <2% across both institutions. Therefore, negative scores should confer a high level of confidence in ruling out HIT.

Marquis Griffin <mjgriffin@uabmc.edu>

University of Alabama at Birmingham

Title:

A case of concealed Primary CNS Lymphoma masquerading as encephalopathy in elderly

Introduction:

Primary CNS Lymphoma (PCNSL) are a rare group of extra-nodal Non-Hodgkin Lymphoma (NHL) confined to Brain with incidence of 0.5 per 100,000 population. Even though better therapeutic options were introduced in the last decade, the survival rates are still inferior compared to other extracranial NHL.

Case Description

A 74-year-old healthy independent Caucasian woman presented with sudden cognitive decline in a span of 48 hours. Physical examination revealed a pleasantly confused elderly woman who was alert, partially oriented with short term memory loss. No other focal neurological deficits noted. Initial vitals and lab works were unremarkable. Incidentally, the brain imaging unveiled mass like lesions with enhancing components located along both sides of the lateral ventricle with extensive vasogenic edema. Further imaging with CT Chest, Abdomen and Pelvis was inconclusive confirming it to be primary CNS tumor. Biopsy of the lesion uncovered the final diagnosis of diffuse large B-cell lymphoma (DLBCL), non-germinal center B-cell–like (non-GCB) subtype. With her stable physical health except for confusion, treatment was considered despite moderate prognosis revealed by IELSG score of 2. High dose Methotrexate (MTX) in combination with Temozolomide along with Rituximab was planned to begin with whole brain irradiation later on.

Important educational tool

1. Eastern Cooperative Oncology Group (ECOG) Score to assess functional status. 2. International Extra-nodal Lymphoma Study Group (IELSG) Score to predict survival rate.

Discussion

PCNSL is a highly aggressive NHL with grim prognosis. Immunochemistry helps to differentiate between GCB and Non-GCB type based on positive MUM1 markers which decides prognosis. However, the treatment of PCNSL despite the type remains the same with upfront regimen with Methotrexate at high doses >1.5g/m2 as rapid infusion along with Alkylating agents with or without Rituximab. The treatment is challenging in elderly especially with multiple co-morbidities. Whole Brain Irradiation is usually offered along for better outcome. Unlike other brain tumors, PCNSL often has a favorable response to both chemotherapy and radiation therapy, but compared with lymphomas outside the CNS, survival is usually inferior.

Peshitha Nimmagadda <pnimmagadda@uabmc.edu>

UAB Huntsville, Department of Internal Medicine

Introduction Treatment of hypertension is the most common cause of healthcare provider visits and long-term use of medications among nonpregnant adults. Approximately 50% of hypertensive adults do not have adequate blood pressure (BP) control which can contribute to serious health conditions including atherosclerosis, coronary artery disease and stroke. When patients measure their BP at home, it provides more accurate data for providers. Furthermore, self-monitoring of BP may lead to increased hypertension control, especially when paired with supportive interventions (e.g., telemonitoring). Medical students provided patient education and telemonitoring of BP control through a quality improvement initiative to control hypertension among priority populations. Engaging directly with patients provided valuable experience and insight.

Case Description A 51-year-old male with uncontrolled hypertension (>140/90 on two separate occasions) agreed to participate in this study and was provided a BP cuff and educational materials. He is a married nonsmoker with employment-based health insurance who has hypertension, hypercholesterolemia, and sleep apnea. His physical activity is limited by his job, but he denies problems with obtaining or taking his medications.

Educational Tool This project provides medical students with experience in managing hypertension. I called him on a biweekly basis for three months to collect his data and discuss his goals.I had two interactions with him in the clinic and four more via telephone. With each subsequent encounter, he appeared more engaged in gaining control of his BP, reporting increased exercise, etc.

Discussion This project has helped me realize the importance of supportive interventions in hypertension control. Initial data analysis shows an average BP of 150/90 mmHg with an average mean arterial pressure of 110 mmHg. This data will serve as the baseline for this patient’s BP. Data will be collected and trended as part of the final data analysis. Challenges with data collection include participant availability and reporting of accurate data. This patient appears more proactive in managing his hypertension, and supportive intervention is a potential tool for future practice.

Tyler Newell

University of Alabama, Department of Community Medicine and Population Health

American College of Preventive Medicine, Centers for Disease Control and Prevention

Introduction: Hydroxycut weight loss supplements have been known to cause hepatotoxicity with some patients requiring liver transplantation. This is a patient presenting to the hepatology service with acute liver injury in the setting of recent Hydroxycut weight loss supplement use.

Case Description: A 51 year-old Caucasian male with a past medical history of hypertension and depression presented with several months of abdominal pain with associated nausea, vomiting, darkening urine, and intermittent episodes of encephalopathy. He reported taking two pills of “Hydroxycut Black” weight loss supplements per day for the past several months. On presentation, his vitals were significant for hypertension (BP 163/121) and physical exam notable for hepatomegaly and diffuse abdominal tenderness. Labs were notable for MELD-Na 22 (Na 135, Tbili 2.1, INR 2.55, Cr 1.0), AST 12628, ALT 6303, Alkaline phosphatase 63, LDH 12892, and negative UDS, alcohol and Acetaminophen levels. Abdominal ultrasound was significant for moderate steatosis without cirrhosis. He was started on empiric IV Acetylcysteine and lactulose with symptomatic improvement and discharged four days post-presentation with improving liver function tests (AST 101, ALT 1297, INR 1.02).

Important Educational Tool: This case highlights the importance of taking a patient’s history of over the counter medication use that otherwise wouldn’t be apparent on a patient’s medication list or urine drug screen as well as obtaining a MELD-Na score to evaluate the severity of liver disease and need for transplantation.

Discussion: Hydroxcut products have been known to cause hepatocellular toxicity with elevations in aminotransferase levels and in some patients causing acute liver failure requiring transplantation. Ingredients in Hydroxycut Black including Garcinia cambogia and Green tea leaf extract have been associated with liver toxicity with significant peak in ALT (~2500), AST (~1600) and INR elevations (~1.2-6.45) and common symptoms including nausea, vomiting, and abdominal pain. Duration of use and recovery varies in patients with most patients improving with supportive care. This case demonstrates the importance of including dietary and herbal supplementation use in the differential diagnosis in patients presenting with elevated liver enzymes with a negative infectious and autoimmune workup.

Yassmin Hegazy

University of Alabama Birmingham, Department of Medicine

Department of Hepatology