Drugs are a significant cause of liver injury. Drug-induced liver injury (DILI) can cause acute hepatitis, cholestasis, or a mixed pattern. Ceftriaxone is a commonly used antibiotic and has been associated with reversible biliary sludge, pseudolithiasis, and cholestasis. A 32-year-old male with sickle cell disease was admitted to the hospital for acute sickle cell crisis. On the second day of hospitalization, he developed cough and rhonchi with chest X-ray revealing right middle lobe infiltrates. Ceftriaxone and azithromycin were initiated. Subsequently, he developed conjugated hyperbilirubinemia and mild transaminitis. His total bilirubin trended upwards from 3.3 mg/dL on admission to 17 mg/dL. It was predominantly conjugated bilirubin, with preadmission bilirubin levels of 3-4 mg/dL. His transaminases were mildly elevated as well compared to previous levels. Extensive workup for bilirubin elevation was unremarkable. Ceftriaxone was switched to levofloxacin and the hyperbilirubinemia improved. On ambulatory follow-up, his bilirubin remained below 4 mg/dL. Ceftriaxone may be associated with marked direct hyperbilirubinemia particularly in sickle cell patients with chronic liver chemistry abnormalities. In the case of elevated bilirubin with concomitant ceftriaxone use, elimination of the offending agent should be considered.

The abscopal effect is an extremely rare phenomenon occurring when irradiation or treatment of a primary tumor burden not only results in debulking of the targeted site but also reduces tumor size at distant sites from the intended treatment area. We present the abscopal effect occurring in a patient with low-grade marginal zone lymphoma who subsequently received radioactive iodine therapy for papillary thyroid carcinoma. She was 67 years old when a routine complete blood count at her primary care physician's office yielded a persistent leukocytosis of 14,500/μL with lymphocytosis of 9,870/μL. Immunophenotyping and fluorescence in situ hybridization (FISH) analysis confirmed low-grade marginal zone lymphoma. Over eight years, her peak leukocyte and lymphocyte counts were 24,100/μL and 18,100/μL, respectively. Subsequently, she was diagnosed with papillary thyroid carcinoma after presenting with a new complaint of dysphagia. A total thyroidectomy was performed, followed by 172.1 millicuries of oral I-131 sodium iodine radioactive ablation therapy. Following treatment, her leukocyte and lymphocyte counts were 3,100/μL and 1,100/μL, respectively. Over the next four years, her leukocyte and lymphocyte counts remained within normal limits and she remained symptom free. To our knowledge, there has never been a published report describing the use of radioactive iodine causing abscopal effect benefits for patients with underlying lymphoproliferative diseases.

Introduction: Real time checklists, adopted from high reliability industries, have been used in many healthcare settings to assure that key care deliverables and processes are applied consistently. The purpose of this quality improvement initiative is to describe the development and implementation of a daily rounding critical cardiac care checklist and assess its impact on increasing compliance with guideline-recommended cardiac performance measures. Methods & Design: This is a prospective, observational cohort study in the coronary care unit (CCU) of a university-affiliated major teaching hospital in southeastern Michigan, from Jan 2014-Jan 2015. Each CCU cardiac patient served as their own control, utilizing each patient day for monitoring of adherence to 20 key care deliverables (based on eligibility) as audited by a quality technician using an aligned checklist. The rate of adherence to the items on the checklist, and the rate of corrections which occurred within 24 hours of being identified as an omission were measured monthly. The results were then summed up into four quarters and compared between teaching and non-teaching services. Results: During the study period, the total number of patients enrolled was 550 patients. These patients were followed for a total number of 1457 days. The overall rate of initial adherence to the items on the checklist was 88.4%, and it improved to 95.5% with the use of the checklist in the final adherence rates. Both initial and final rates of adherence were found to be higher on the teaching service compared to the non-teaching service. Conclusion: The use and application of a daily CCU checklist by an assigned quality technician can identify and correct deficiencies in desired care. Despite the intensity of the interventions, the enhanced engagement and alignment of the nursing and physician staff and the reliable processes put into place, the goal of achieving 100% adherence rates to eligible and appropriate clinical measures was not achieved. This project provided a great deal of insight into the barriers, challenges and limitations that need to be overcome for successful implementation, utilization, value and sustainability of an applied healthcare checklist, to improve intended and desired performance measures and drive favorable outcomes in a real world setting.