Patients with MS with one or more CV risks showed increased lesion burden and more advanced brain atrophy.
Background Clostridium difficile infection (CDI) is the most common healthcare-associated infection. C. difficile PCR assays do not differentiate between colonization (seen in up to 21% of inpatients) and symptomatic disease, highlighting the importance of testing only symptomatic patients.MethodsInterventions included system-wide implementation of C. difficile testing guidelines, face-to-face education of licensed providers, and Best Practice Alerts (BPAs) embedded in the electronic health record (EHR) C. difficile PCR order. The guidelines recommend testing only when ≥ 3 liquid bowel movements within a 24-hour period, without laxatives, oral contrast or new enteral feeds in the preceding 24 hours, and without recent C. difficile PCR test (negative ≤ 7 days or positive < 30 days). We reviewed 100 consecutive C. difficile PCR orders across two hospitals pre- and post-intervention to assess compliance with guidelines; performed weekly review of all C. difficile PCRs, all BPA responses and all hospital-onset CDI. Cost savings were calculated based on published estimates of CDI attributable costs.ResultsHospital-onset CDI rates fell from 0.75 to 0.48 cases per 1000 patient-days, with an estimated costs savings of $259,555 per quarter and $1.04 million per year. There were no deaths due to CDI and no morbidity due to delayed CDI diagnosis. C. difficile PCR guideline compliance increased from 39% to 53%; orders decreased by 50% post-intervention. Receipt of laxatives and < 3 episodes of diarrhea were the most common reasons for guideline noncompliance. BPAs fired an average of 150 times/month. The most common trigger for BPA was laxative use. Providers canceled PCR orders in 40% of BPA events.ConclusionInterventions incorporating testing guidelines, face-to-face education, and EHR-embedded decision support resulted in fewer C. difficile PCRs orders, increased guideline compliance, lower rates of hospital-onset CDI and cost savings of $1 million per year without an increase in CDI-attributable death or morbidity.Disclosures All authors: No reported disclosures.
Introduction: Leydig stromal cell tumors are uncommon ovarian tumors that produce testosterone leading to hyperandrogenism. We present a case of a 63 year old lady with significantly elevated testosterone levels that did not have clear ovaries visualized on imaging, but was subsequently found to have a Leydig cell tumor on pathology after ovarian resection. Clinical Case: A 63 year old female with a past medical history of COPD, hypothyroidism, hyperlipidemia, hypertension and uterine fibroids status post hysterectomy and left oophorectomy in 1995 was referred to endocrinology for hirsutism. The patient reported first noticing abnormal hair growth approximately one year prior to presentation having developed increasingly coarse and thick facial hair, abdominal wall hair, and chest hair. On physical examination, she was noted to have coarse hair across her upper lip and chin continuous along the jawline along with fine, dark hair diffusely across her anterior abdomen. Initial laboratory cell evaluation revealed total testosterone 378 ng/dL, free testosterone 53ng/dL, DHEAS 64 ug/dL. Repeat labs drawn three months later confirmed the markedly elevated total testosterone of 362 ng/dL and free testosterone 44.2 ng/dL, concentrations normally seen in males. A CT scan of the abdomen and pelvis was done and did not reveal any masses. In addition, no ovaries were appreciated on imaging. A transvaginal ultrasound also did not reveal any clear ovaries. The patient ended up undergoing a right oophorectomy. Histological examination was consistent with a Leydig cell tumor. Following oophorectomy, her testosterone concentrations normalized (5ng/dL) and hirsutism began to regress. Clinical Lesson: Hyperandrogenism in women is typically classified into non-tumorous and tumorous. The differential for non-tumorous hyperandrogenism includes PCOS, congenital adrenal hyperplasia (CAH), and ovarian hyperthecosis. Tumorous causes include ovarian tumors such as Sertoli-Leydig cell tumors, hilus cell tumors, and theca cell tumors. Adrenal tumors secreting testosterone are extremely rare. Often with these tumors, there is significantly increased testosterone levels (> 140ng/dL) and rapid progression of symptoms. Sex cord stromal tumors account for only 5-8% of all ovarian tumors with Leydig stromal tumors a rare group that accounts for less than 0.1% of all ovarian tumors. The tumors are functional producing testosterone leading to marked hyperandrogenism and virilization. They are also usually benign and unilateral. This patient had hyperandrogenism manifested by hirsutism with markedly elevated testosterone concentrations. In addition, this case is unique in that a CT scan and transvaginal ultrasound did not clearly demonstrate her right ovary. Despite having a normal appearing right ovary during surgery, patient was found to have Leydig cell tumor following histological examination.
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