2019 Research Forum

2019 Kern Medical Research Forum

Introduction

Welcome to the 19 th Annual Kern Medical Research Forum.

The purpose of the Kern Medical Research Forum is to foster in-depth comprehension of research, and promotion of scholarly pursuits among residents, faculty, physicians, medical students, nurses, pharmacists, physical therapists, and mental health clinicians for the advancement of medical science. The Forum serves to highlight research activities, recognize special contributions and innovations to health care and medical education.

Research and scholarly activity are inclusive requirements of all approved residency-training specialty programs at Kern Medical. Participation in medical and scientific research contributes to the advancement of high quality patient care and serves to recognize Kern Medical as a best practice, science-based, tertiary referral center.

Prior to this evening, we received multi-patient studies and unique case report abstracts representative of the scholarly activities in the majority of the residency specialties. The multi-patient abstracts were blind-scored; the top scoring abstracts were chosen for the oral presentation competition. A research-experienced jury panel will score the presentations.

This year’s Forum will showcase posters by California State University Bakersfield students and faculty. We would like to acknowledge the hard work of all the participants. The achievements reflected in the posters displayed and the program presentations represent commitment to scholarly activities.

Randolph Fok MD PhD Chief, Maternal-Fetal Medicine Chair, Institutional Review Board

Russell V. Judd MS Chief Executive Officer

2019 Research Forum Program - Thursday, May 2

5:00 PM Poster Review Session

Research Judges Sara Abdijadid DO MS UCLA-Kern Psychiatry Residency Program, Associate Program Director: Clerkship Director – Medical Students; Health Sciences Clinical Instructor, David Geffen School of Medicine at UCLA

5:30 PM Welcome

Jeff Jolliff PharmD BCPS BCACP AAHIVP CDE Senior Clinical Pharmacist & Residency Program Director

Randolph Fok MD PhD Chief, Maternal-Fetal Medicine Chair, Institutional Review Board Opening Remarks Russell V. Judd MS Chief Executive Officer 6:00 PM Research Presenters

Rick A. McPheeters DO FAAEM Chief of Emergency Medicine, Kern Medical; Vice Chair of Emergency Medicine, David Geffen School of Medicine at UCLA 6:45 PM Faculty Research Royce H. Johnson MD FACP Professor of Medicine David Geffen School of Medicine at UCLA; Chief, Division of Infectious Disease; Medical Director of the Valley Fever Institute Current Research in the Immunopathogenesis of Coccidioidomycosis 7:00 PM Judging Panel Results and Awards

Ronald Crandall MS IV, Department of Radiology Automated and Standardized Quantification of Mild Cerebral Small Vessel Disease in Computed Tomography Simmer Kaur MD R2, Department of Medicine Rigorous and Practical Quality Indicators in Sickle Cell Disease Care at Kern Medical Samir Salameh MD R3, Department of Medicine BMI as an Indicator of Outcome in ICU Patients with Acute Respiratory Failure

Randolph Fok MD PhD Chief, Maternal-Fetal Medicine Chair, Institutional Review Board Erica Easton MS Executive Director, Kern Medical Foundation

Presenter Profiles

Ronald Crandall MS IV Department: Radiology

Samir Salameh MD R3 Department: Internal Medicine Medical School: Damascus University, Syria Hometown: Homs, Syria Next Stop: Remain in Bakersfield to work at Kern Medical in the Department of Medicine

Simmer Kaur MD R2 Department: Internal Medicine Medical School: Ross University School of Medicine College: California State University, Fullerton Hometown: Orange County, CA Next Stop: Finishing Internal Medicine residency and applying for Hematology-Oncology Fellowship

Medical School: Ross University of School of Medicine College: Undergraduate: University of Wisconsin-Madison Graduate: Tulane University School of Medicine Hometown: Benbrook, TX Next Stop: Computational Radiology Research

Faculty Presenter Profile

Royce H. Johnson, MD, FACP Royce Johnson, MD, FACP is the Chief of the Division of Infectious Disease in the Department of Medicine at Kern Medical. He also serves as Director of the Tuberculosis Clinic, Hospital Epidemiologist, Hospital Employee Health Physician, and Associate of the Division of Pulmonary and Critical Care Medicine at Kern Medical. Additionally, he is the Medical Director of the Valley Fever Institute, dedicated to fighting the battle against Valley Fever in Kern County. Dr. Johnson has been with Kern Medical since 1975, where he served as Vice Chair in the Department of Medicine until 1987. He also served as Director of Pulmonary Function Laboratory and Respiratory Therapy Service, and Chief of the Division of Pulmonary and Critical Care Medicine from 1975-1979. He was a Private Practice physician with Kern Faculty Medical Group and was Chair in the Department of Medicine for 11 years. Dr. Johnson also served as the Director of Kern Medical’s Cancer Registry/Program for 16 years. He has been Director of Hansen’s Disease Clinic since 2001 and has been Director of Quality in the Department of Medicine. Dr. Johnson has been a Professor of Medicine with the David Geffen School of Medicine at UCLA since 1992. Dr. Johnson has been awarded “The Best Doctors in America” on 8 separate occasions. He received the Lifetime Achievement Award in Cocci Study Group Infectious Disease Association of California, and received the American Red Cross-Kern Chapter Health Care Hero Award. He continues to be apart of lectures, publications, conferences and trials.

Table of Contents

DEPARTMENT OF CLINICAL PHARMACY Evaluation of an Insulin Infusion Protocols After Staff Education .......................................................... 8 Frantze Agtarap PharmD R1, Alice Peng PharmD, Jeff Jolliff PharmD The Impact of Education on Compliance for Kern Medical’s Heparin Protocol......................................... 10 Robert Chiles PharmD R1, Jasmine Ho PharmD, Jeff Jolliff PharmD DEPARTMENT OF EMERGENCY MEDICINE Chief Complaint: “There is Something Burning in My Mouth” ....................................................................12 Daniel Quesada MD, Jagdipak Heer MD, Silva Boyajian MD R3, Phillip Aguiniga-Navarrete RA, Laura Castro MS RA Mercury Ingestion ......................................................................................................................................... 14 Manish Amin DO, Alex Huang MD R2, Sudha Challa MD, Phillip Aguiniga-Navarrete RA, Laura Castro MS RA, Donya Sarrafian RA Early Diagnosis of Heterotopic Pregnancy in a Primigravid Without Risk Factors in the Emergency Department .................................................................................................................................................... 16 Elizabeth Siacunco MD R2, Rachel O’Donnell MD, Daniel Quesada MD, Kieron Barkataki DO, Phillip Aguiniga-Navarrete RA, Dale Robbins PA-C Syphilitic Neuroretinitis ....................................................................................................................................18 Matthew Stapleton MD R4, Jagdipak Heer MD, Rachel O’Donnell MD, Daniel Quesada MD, Phillip Aguiniga-Navarrete RA, Luke Kim RA Steal Phenomena with Tonsillar Arteriovenous Malformation .................................................................... 20 Manish Amin DO, Krishan Chaddha DO R2, Phillip Aguiniga-Navarrete RA, Sudha Challa MD, Madison Garrett RA Retained Catheter in the Aorta .................................................................................................................... 22 Alex Huang MD R2, Daniel Quesada MD, James Rosbrugh MD, Phillip Aguiniga-Navarrete RA, Alexander Wan RA Rare Cause of Inguinal Pain in a 39-Year-Old Male .................................................................................. 24 Nathan Wang MD R2, Kieron Barkataki DO, Daniel Quesada MD, Rachel O’Donnell MD , James Rosbrugh MD, Phillip Aguiniga-Navarrete RA Surgical Site Infections in Emergency Department Patients and the Effects of Handwashing with Chlorhexidine ................................................................................................................................................ 26 Shelah Hayes MD R1, Adam Johnson MD R3, Matthew Stapleton MD R4, Doan Nguyen MS IV, Daniel Quesada MD, Rachel O’Donnell MD Acquired Pediatric Right Diaphragmatic Hernia Following AICD Placement.......................................... 28 Adria Ottoboni MD, Larissa Morsky MD R3, Laura Castro RA, Mark Rhoades RA A Rare Case of Hiccups as the Only Presenting Symptom of an Underlying Pneumomediastinum ..... 30 Sean Sayani MD R3, Rachel O’Donnell MD , Daniel Quesada MD, Kieron Barkataki DO, Phillip Aguiniga-Navarrete RA

Phlegmasia Cerulea Dolens from Pelvic Mass .......................................................................................... 32 Vikram Shankar MD R3, Rachel O’Donnell MD, Daniel Quesada MD, Kieron Barkataki DO, Phillip Aguiniga-Navarrete RA Pediatric Paraspinal Abscess ...................................................................................................................... 34 Rachel O’Donnell MD, Daniel Quesada MD, Kieron Barkataki DO, Sean Sayani MD R3, Phillip Aguiniga-Navarrete RA, Madison Garrett RA Atraumatic Avulsion of the Tibial Tubercle ................................................................................................. 36 Adam Johnson MD R3, Roxana Ardebili MS IV, Kieron Barkataki DO DEPARTMENT OF MEDICINE A Case of Meth-Induced Cardiomyopathy and Acute Myocardial Infarction ...................................... 38 David Aguirre MD, Jeffrey Coleman MD R2, Sarah El-Halees MS IV A Case of Gliomatosis Cerebri .................................................................................................................... 40 David Aguirre MD, Nosheen Hasan MD R2, Sarah El-Halees MS IV A Case of Acute Onset Heart Failure in a Previously Healthy 26-Year-Old Female .............................. 42 David Aguirre MD, Fowrooz Joolhar MD, Nosheen Hasan MD R2, Sarah El-Halees MS IV A Case of Acute Spontaneous Spinal Epidural Hematoma ..................................................................... 44 Nosheen Hasan MD R2, Arash Heidari MD, Katayoun Sabetian MD, Haris Rana MS III A Case of AML and Trisomy 8 with Concomitant Factor VII Deficiency ................................................. 46 Leila Moosavi MD R3, Jonathan Bowen MS IV, Carlos D’Assumpcao MD R1, Jeffrey Coleman MD R2, Arash Heidari MD, Everardo Cobos MD A Case of Hepatitis C: Two Decades of Waiting for Godot or Cure ......................................................... 48 Harleen Sandhu RA, Arash Heidari MD, Drew Mahoney MS III, Royce H. Johnson MD A Case of Opioid-Induced Systemic Vasculitis ......................................................................................... 50 Kulraj Grewal MS IV, Mandakini Patel MD R3, Simmer Kaur MD R2, Greti Petersen MD, Bao Quynh Huynh MD A Devastating Case of Disseminated Coccidioidomycosis in a Previously Undiagnosed AIDS Patient ... ...........................................................................................................................................................................52 Golriz Asefi MD Graduate RA, Jeff Jolliff PharmD, Arash Heidari MD A Fatal Case of Coccidioides Meningoencephalitis with Isolated Ventricular Hydrocephalus and Interventricular Hemorrhage ....................................................................................................................... 54 Golriz Asefi MD Graduate RA, Ramanjeet Sidhu MD R3, Rasha Kuran MD, Joseph Chen MD, Katayoun Sabetian MD, Arash Heidari MD A Rare Case of Acute Pancreatitis Due to Very Severe Hypertriglyceridemia Treated with Subcutaneous Insulin and Lipid Lowering Drugs ....................................................................................... 56 Tushar Bajaj MD R1, Sundeep Grandhe MD R2, David Holt MS III, Saman Ratnayake MD A Rare Case of Disseminated Coccidioidomycosis of the Gallbladder ................................................. 58 Kulraj Grewal MS IV, Mandakini Patel MD R3, Simmer Kaur MD R2, Greti Petersen MD, Arman Froush DO, Saad Thara MD R2, Augustine Munoz MD, Arash Heidari MD

Table of Contents

A Rare Case of Stage IV Basaloid Squamous Cell Cancer with Intrapulmonary and Brain Metastases ..... 60 Sundeep Grandhe MD R2, Tushar Bajaj MD R1, Hanh Duong MS III, Saman Ratnayake MD Acute Tubular Dysfunction with Lower Doses of Cisplatin ......................................................................... 62 Simmer Kaur MD R2, Sabitha Eppanapally MD, Arash Heidari MD An Atypical Presentation of Severe Non-Traumatic Rhabdomyolysis Resulting in Multi-Organ Dysfunction .................................................................................................................................................... 64 David Aguirre MD, Houtan Afshar MD R1, Prabina Shrestha MS IV An Extensive Complex Type A Acute Aortic Dissection with Thrombus in Aortic Arch: A Therapeutic Dilemma ......................................................................................................................................................... 66 Robin Boyer MS IV, Carlos D’Assumpcao MD R1, Fowrooz Joolhar MD, Aslan GhandForoush DO, Tiffany Win MD An Unusual Case of Paraquat-Induced Rhabdomyolysis and Hepatic Injury Presenting with Takotsubo Cardiomyopathy............................................................................................................................................ 68 Sara Jaka MD R1, Jessica McFarland MS IV, Emily Gunz MS IV, Tasneem Khan MS III, Leila Moosavi MD R3, Carlos D’Assumpcao MD R1, Tana Parker MD, Fowrooz Joolhar MD, Arash Heidari MD, Tiffany Win MD An Unusual Case of SLE Induced Pericarditis in a Young Hispanic Male ................................................ 70 Jonathan Bowen MS IV, Christina Donath MS IV, Marwa Afridi MS IV, Leila Moosavi MD R3, Azadeh Ghassemi MS IV, Fowrooz Joolhar MD, Tiffany Win MD Anticoagulation Conundrum: Mechanical Mitral Valve Thrombosis in Pregnant Patient on Enoxaparin ... 72 Ahana Sandhu MD R3, Kieran Doyle MS IV, Kathleda Tangonan MS IV, Ramanjeet Sidhu MD R3, Fowrooz Joolhar MD Atypical Presentation of Obstructive Anuria .............................................................................................. 74 Tushar Bajaj MD R1, Hanh Duong MS III, Dave Holt MS III, Jasmine Ho PharmD, Sudhagar Thangarasu MD, David Aguirre MD BMI as an Indicator of Outcome in ICU Patients with Acute Respiratory Failure..................................... 76 Samir Salameh MD R3, Tushar Bajaj MD R1, Alyssa Targovnik MS IV, Bianca Puello MS IV, Ayham Aboeed MD Coccidioides: A Stealthy Alien Forever ...................................................................................................... 78 Golriz Asefi MD Graduate RA, Tung Trang MD, Royce H. Johnson MD, Arash Heidari MD Concomitant CNS Toxoplasmosis and Seronegative Disseminated Coccidioidomycosis in a Newly Diagnosed AIDS Patient ................................................................................................................................ 80 Michael Valdez MS IV, Leila Moosavi MD R3, Arash Heidari MD Devastating Case of Cryptococcal Meningitis in an HIV Negative Host ................................................. 82 Golriz Asefi MD Graduate RA, Simmer Kaur MD R2, Yoel Olazabal Pupo MD R3, Carol Stewart-Hayostek MD, Arash Heidari MD Extrapulmonary Coccidioidomycosis Presenting as Abdominal Distension ........................................... 84 Carlos D’Assumpcao MD R1, Amit Sah MS IV, Charles Clark MD R1, Matthew Gilbert MS III, Serghei Burcovschii MD R1, Emily Gunz MS IV, Jessica McFarland MS IV, Leila Moosavi MD R3, Manasa Kalluri MD R1, Janushe Patel MD MPH, Arash Heidari MD First Reported Case of Malignant External Otitis Secondary to Secukinumab ....................................... 86 Golriz Asefi MD Graduate RA, Carlos D’Assumpcao MD R1, Ramanjeet Sidhu MD R3, Arash Heidari MD

Granulomatosis with Polyangitis Presenting as New Onset Scleritis and Hemoptysis ........................... 88 Maryam Talai-Shahir MD R3, Arash Heidari MD, Mandakini Patel MD R3, Carlos D’Assumpcao MD R1, Augustine Munoz MD, Bao Quynh Huynh MD Group A Streptococcus Puerperal Sepsis After Spontaneous Abortion .................................................. 90 Christina Sugirtharaj MPH MS IV, Simmer Kaur MD R2, Andre Sahakian MS IV, Mandakini Patel MD R3, Arash Heidari MD, Greti Petersen MD Heliotrope Rash Preclusing Metastatic Ovarian Cancer .......................................................................... 92 Thy Nguyen MS IV, Maryam Talai-Shahir MD R3, Arash Heidari MD Hemophagocytic Lymphohistocytosis Induced by Pregnancy and Post-Partum ................................ 94 Mariam Abdelmisseh MD R3, Gowri Renganathan MD R2, Alyssa Targovnik MS IV, Kyle Foster MS IV, Amber Brewster MS IV, Everardo Cobos MD Hyperbilirubinemia and Transaminitis Secondary to Hyperemesis Gravidarum ................................... 96 Simmer Kaur MD R2, Tamara Hilvers MS IV, Arash Heidari MD Ivemark Syndrome - Surgical Evaluation .................................................................................................. 98 Serghei Burcovschii MD R1, Shrey Patel MS III, Nakisa Kia’i MS III, Ahmad Malik MS III, Hannah Schiett MS III, Basel Shoua MD R3, Tushar Bajaj MD R1, Mohamed Hammami MD Leptomeningeal Carcinomatosis From Carcinoma of Unknown Primary ............................................. 100 Jonathan Bowen MS IV, Leila Moosavi MD R3, Amit Sah MS IV, Arash Heidari MD, Everardo Cobos MD Multifocal Osseous Coccidioidomycosis Masquerading as Multiple Myeloma ....................................102 Manasa Kalluri MD R1, Carlos D’Assumpcao MD R1, Matthew Gilbert MS III, Amit Sah MS IV, Emily Gunz MS IV, Jessica McFarland MS IV, Leila Moosavi MD R3, Janushe Patel MD MPH, Arash Heidari MD Ramsey-Hunt Syndrome Complicated by Bacterial Meningitis Subarachnoid Hemorrhage and Cerebellar Stroke ..........................................................................................................................................104 Golriz Asefi MD Graduate RA, Carlos D’Assumpcao MD R1, Greti Petersen MD, Arash Heidari MD Relapsing Polychondritis Presenting as Optic Neuritis and Lymphocytic Meningitis: A Case Report ........ .........................................................................................................................................................................106 David Contreras MD R1, Varun Bali MD R2, Katayoun Sabetian MD, Bao Quynh Huynh MD, Sandra Sofinski MD, Arash Heidari MD Rigorous and Practical Quality Indicators in Sickle Cell Disease Care at Kern Medical ......................108 Simmer Kaur MD R2, Christina DiCorato MD Graduate RA, Christina Sugirtharaj MPH MS IV, David Aguirre MD, Everardo Cobos MD Stenotrophomonas Maltophila Bacteremia with Suspected Endocarditis in Patient with Implantable Cardioverter Defibrilator and Congestive Heart Failure Secondary to Amphetamine Abuse .............110 Ahana Sandhu MD R3, Kieran Doyle MS IV, Kathleda Tangonan MS IV, Tiffany Win MD, Fowrooz Joolhar MD, Arash Heidari MD Takotsubo Cardiomyopathy in Patient with Hypovolemic Shock and Methamphetamine Use ..........112 Ahana Sandhu MD R3, Kieran Doyle MS IV, Kathleda Tangonan MS IV, Tiffany Win MD, Fowrooz Joolhar MD Tubo-Ovarian Abscess on Fire ....................................................................................................................114 Carlos D’Assumpcao MD R1, Matthew Gilbert MS IV, Arash Heidari MD

Table of Contents

DEPARTMENT OF OBSTETRICS & GYNECOLOGY Interesting Ectopic Study - Record Review Study ......................................................................................116 Julia Canders MD R4, Sally Wonderly MD Granulomatous Disease Using the Pathway of Sampson’s Theory of Retrograde Menstruation to Infect the Abdomen.................................................................................................................................................118 Roxanne McDermott MD R4, Antonio Garcia MD FACOG, Victoria Flores MD R3 DEPARTMENT OF PSYCHIATRY History of Drug Abuse and the Use of Pro re nata (PRN) Medication on an Inpatient Psychiatric Unit ...... .........................................................................................................................................................................120 Nazila Sharbaf Shoar MS IV, Mantavya Punj MS IV, Frederick Venter MS IV, Sara Abdijadid DO MS Multiple Neuroimaging Modalities Consistently Implicating Location of Auditory Verbal Halluncinations (AVH) in Patients with Schizophrenia to the Left Temporal Gyri ....................................122 Surag Gohel MD R3, Arezou Babaesfahani MS IV, Peter De Mola MS IV, Mohammed Molla MD Aripiprazole-Induced Neutropenia in a Geriatric Patient: A Case Report .............................................124 Tyler Torrico MS III, Nakisa Kia’i MS III, Carlos Meza MD R2, Sara Abdijadid DO MS

Postpartum Fall Prevention Post Epidural in Maternal Child .....................................................................134 Carina Wong RN, Denise Sedano RN, Nikki Cervera RN, Taylor Dransart RN, Jericka Venus RN Donor Breastmilk Supplementation and Breastfeeding Rates ..................................................................136 Jasmine Nunez RN, Stephanie Cebreros RN, Monique Lugo RN Blood Culture Contamination Rates Reduced with the Introduction of Steripath Device in the Emergency Department ...............................................................................................................................138 Latoya Boon RN, Bailey Conner RN, Gabrielle Fabbri RN, Hanna Grisham RN, Brogan Hernandez RN, Daisy Mora RN, Jayme Moretti RN, Emmanuel Tien RN, Haley Wayts RN Gastric Residuals in the NICU .......................................................................................................................140 Florisse Gutierrez RN, Victoria Kleinknight RN, Tina Lawhon RN, Miranda Arnold RN Increasing Incentive Spirometer Usage in the Acute Care Setting .........................................................142 Lindsee Handel RN, Jessica Williams RN, Gloria Baez RN, James Gisborn RN, Andy del Valle RN The Implementation of Labor Coaches in Labor and Delivery .................................................................144 Mae Casabar RN, Vanessa Delgado RN, Jeanette Jaime RN Personal Protective Equipment Compliance of Visitors on Medical Surgical Unit .................................146 Harpreet Bal RN, Gabriela Hendrix RN, Stephanie Montes RN, Nicole Spiropoulos RN CALIFORNIA STATE UNIVERSITY BAKERSFIELD (CSUB) Is a High Fat Diet Always Bad? The Effects of a Low and High Fat Diet and the Selective Serotonin Reuptake Inhibitor, Fluoxetine (Prozac), in an Animal Model of Depression ..........................................148 Morgan Musquez, Alam Alvarado, Leticia Herrera, Irene Cabanillas, Isabel C. Sumaya PhD Increased Spatiotemporal Gait Asymmetry in Older Adults is Related to Fall Risk and Falls ................149 Jagjeet Gill, Oscar Obregon, Andrew Rosales, Brian Street PhD

DEPARTMENT OF RADIOLOGY Automated and Standardized Quantification of Mild Cerebral Small Vessel Disease in Computed Tomography ..................................................................................................................................................126 Ronald Crandall MS IV, Sudha Challa MD

RIO BRAVO FAMILY MEDICINE First Reported Case of Osteopoikilosis Mimicking Disseminated Osseous Coccidioidomycosis .........128 Golriz Asefi MD Graduate RA, Monica Kumar MD R1, Tana Parker MD, Arash Heidari MD

ACKNOWLEDGMENTS Kern Medical, Faculty Presentation, Excellence in Research Judges Panel, Abstract Blind-Scoring Judges ............................................................................................................................................................150

DEPARTMENT OF NURSING Implementing Standardized Procedures to Improve Throughput in the Immediate Care Center .......130 Gloria Bae RN, Maria Espinosa RN, Albeza Guerrero RN, Huong Lambert RN, Sara Lopez RN, Andrea Melton RN, Gloria Torres RN CAUTI Prevention Using an Audit Tool to Encourage a Nurse-Driven Protocol .......................................132 Rebecca Babb RN, Rasalba Cadena B-RN, Trishawana Gonzalez RN, Cynthia Murillo RN, Melisa Palos RN

Department of Clinical Pharmacy

Applicant: Frantze Agtarap, PharmD R1 Principal Investigator & Faculty Sponsor: Jeff Jolliff, PharmD, BCPS, BCACP, AAHIVP, CDE

Table 2. Compliance to Insulin Infusion Protocols after staff education

Evaluation of an Insulin Infusion Protocol After Staff Education

Frantze Agtarap PharmD, Alice Peng PharmD, Jeff Jolliff PharmD

INTRODUCTION Diabeticketoacidosis (DKA)andhyperosmolar hyperglycemicstate(HHS), describedcollectivelyashyperglycemic crisis, are the two most serious acute metabolic complications of diabetes. Intravenous insulin infusion is the standard of care for the treatment of patients with hyperglycemic crises. American Diabetes Association (ADA) recommends the utilization of insulin infusion protocols, which have been shown to improve time to resolution and decrease hospital length of stay. However, previous studies have shown that compliance to insulin infusion protocols is a common issue across hospitals, such as Kern Medical. In previous reviews, compliance to the two insulin infusion protocols utilized at Kern Medical have been suboptimal due to providers ordering the incorrect protocol and demand of nursing resources. An educational campaign on the appropriate use of the protocols was provided to healthcare providers and nurses; however, the long term impact of staff education has not been evaluated. PURPOSE To describe the impact of a pharmacist-led educational campaign on insulin infusion protocol adherence as well as safety and efficacy outcomes related to insulin infusions. METHOD A retrospective chart review was conducted on all patients admitted to Kern Medical for the treatment of DKA and/or HHS from zero to twenty-four months after staff education was provided. Inclusion criteria were all adult patients with a clinical diagnosis for DKA and/or HHS and an electronic order of an insulin infusion protocol. Patients were excluded if there was a lack of documentation, were pregnant, required surgery during admission, used for organ preservation after death, or if the duration of the insulin infusion was <3 hours. The results on compliance and performance metrics of the insulin infusion protocols will compare the pre-education cohort and post-education cohort at 0-6 months, 6-12 months, and 12-24 months after staff education. RESULTS Table 1. Compliance to Insulin Infusion Protocols before and after staff education

Table 3. Safety and Efficacy of Insulin Infusion Protocols before and after staff education

Table 4. Safety and Efficacy of Insulin Infusion Protocols before and 0 to 6 months after staff education

DISCUSSION: Overall, educational intervention significantly improved appropriate insulin infusion protocol prescribing by physicians and decreased the number of late blood glucose checks by nurses. However, it failed to improve overall blood glucose monitoring and overall frequency of hypoglycemic events. Given the low frequency of hypoglycemic events, this evaluation was not powered to detect a difference in hypoglycemia. Furthermore, the effect of staff education on appropriate protocol ordering by physicians, timing of BG (blood glucose) checks, and correct infusion rate adjustments significantly decreased over time, suggesting staff education should be provided on a recurring basis (i.e. annually).

CONCLUSIONS: Staff education had an overall positive impact by significantly improving the selection of the appropriate insulin protocol and decreasing the amount of late BG checks, but results highlight the need for education on a recurring basis.

8

Frantze Agtarap PharmD R1, Alice Peng PharmD, Jeff Jolliff PharmD Department of Clinical Pharmacy, Kern Medical, California Evaluation of Insulin Infusion Protocols After Staff Education

Discussion The effect of staff education on appropriate insulin infusion prescribing by physicians, timing of BG checks, and correct infusion rate adjustments significantly diminished over time, suggesting staff education should be provided on a recurring basis. Correct transition from DKA/HHS Protocol to STND Protocol, correct transition from an insulin infusion to SQ long-acting insulin, and safety and efficacy endpoints were not statistically significant, however this study was inadequately powered for these endpoints. The results of this study suggest staff education should be provided every 6 to 12 months. However, this study was not designed to assess factors that may have contributed to the diminished effect of the educational campaign. For example, these results may be confounded by the addition of new residents 6 months after the educational campaign was provided, high nursing turnover rate, or infrequent use of the insulin infusion protocols. Further data is required to assess these in the future. Conclusions • The effect of the educational campaign significantly diminished over time • Results highlight the need for staff education on a recurring basis Acknowledgements Special thanks to: • Brittany Andruszko, PharmD

Methods

Introduction

American Diabetes Association recommends the use of standardized insulin infusion protocols for the treatment of hyperglycemic crisis. Potential complications of insulin infusions: • Hypoglycemia, electrolyte disturbances, cerebral edema Kern Medical utilizes two protocols: • Hyperglycemic Crisis (DKA/HHS) Protocol • Standard Insulin Infusion (STND) Protocol Previous study: Peng, A, et al. Kern Medical. 2017 • Outcome: Evaluated the effect of staff education on compliance to the insulin infusion protocols before and 0-3 months after education intervention was provided • Education Intervention: Overview of hyperglycemic crisis treatment, goals and complications of each protocol, and how to use Kern Medical’s protocols • Conclusion: Staff education significantly improved the selection of the appropriate infusion protocol To determine the effect of staff education over time on: • Compliance • Appropriate insulin infusion protocol ordered • Correct transition from DKA/HHS Protocol to STND Protocol • Correct transition from an insulin infusion to subcutaneous (SQ) long- acting insulin

Data Collection • Retrospective chart review • Pre-education (Pre-Edu) cohort:

Exclusion Criteria • Lack of documentation • Used for trauma/surgery • Used for labor and delivery • Used for hyperglycemia treatment (not crisis) • Used for organ preservation after death • Duration of insulin infusion <3 hours

• July 1, 2016 to September 30, 2016

• Post-education (Post-Edu) cohort:

• January 1, 2017 to January 1, 2019 • 0 to 6 months • 6 to 12 months • 12 to 24 months

Results

Table 1. Compliance with Insulin Infusion Protocols

Post-Education

P-value

0-6 N=23

6-12 N=21

12-24 N=39 0-6 vs 6-12 0-12 vs 12-24

Time interval Post-Edu, months

BG checks, n

301

244

484

Appropriate protocols ordered, n (%) Correct transition from DKA/HHS to STND, n (%) Correct transition from insulin infusion to SQ long-acting insulin, n (%) Timing of BG checks Within ±15 minutes of scheduled BG check, n (%) >15 minutes late, n (%) >15 minutes early, n (%) Infusion rate adjustment, n Correctly adjusted, n (%) Incorrect rate despite correct sensitivity index, n (%) Did not follow STND protocol, n (%)

0.0187 0.5027

0.0049

23 (100) 9 (52.9)

16 (76.2) 24 (61.5)

7 (36.8)

13 (43.3)

1

17 (73.9) 12 (57.1) 22 (56.3)

0.3422

0.4983

0.0101 0.5359 0.0112 0.3133 0.0854 0.5918 0.7586 0.5083

252 (83.8) 182 (74.6) 364 (75.2)

0.0996 0.2853 0.3074

23 (7.6) 26 (8.6)

23 (9.4)

51 (10.5)

Objectives

39 (16.0) 69 (14.3)

301

244

484

0.0343

275 (91.2) 216 (88.6) 415 (85.7)

2 (0.7) 9 (3.0)

7 (2.9) 5 (2.0) 5 (2.0) 11 (4.5)

8 (1.7) 12 (2.5) 20 (4.1) 29 (6.0)

1 1

0.0396 0.001

Did not follow DKA/HHS protocol, n (%) 5 (1.7)

Other, n (%)

10 (3.4)

Figure 1. Effect of staff education over time

Effect of staff education over time

• Jessica Beck, PharmD • Jasmine Ho, PharmD • Janet Yoon, PharmD

100 120

• Timing of blood glucose (BG) checks • Correct adjustment of insulin infusion rate

0 20 40 60 80

References

• Peng, A, et al. Evaluation of education on insulin infusion use. Kern Medical. 2017. • AACE/ADA Task Force on Inpatient Diabetes. American College of Endocrinology and American Diabetes Association consensus statement on inpatient diabetes and glycemic control. Endocr Pract . 2009;15(No. 4). • Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care 2009 Jul;32(7):1335-1343. (ADA Consensus statement). • Kelly, J. Continuous Insulin Infusion: When, where, and How? Diabetes Spectrum . 2014 Aug; 27(3): 218–223. • Finfer, S, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med . 2009 Mar 26;360(13):1283-97.

• Safety

Appropriate protocol ordered Appropriate timing of BG check Correct rate adjustment

• Hypoglycemic events

Percent (%)

• Efficacy:

• Time to BG <250mg/dL • Time to anion gap (AG) <12mg/dL

Pre-Edu

0-3

3-6

6-12

12-24

Time Interval (months)

9

Applicant: Robert Chiles PharmD R1 Principal Investigator & Faculty Sponsor: Jasmine Ho PharmD

RESULTS

The Impact of Education on Compliance of Kern Medical’s Heparin Protocol

Robert Chiles PharmD R1, Jasmine Ho PharmD, Jeff Jolliff PharmD

*The percentage of time in therapeutic range was an average of 15.9% higher in 2017 vs 2019 (95% CI= 2.85% to 28.96%)

INTRODUCTION According to the Institute of Safe Medication Practice (ISMP), unfractionated heparin is considered a high-alert medication that requires cautious monitoring, prescribing, dispensing, and administration. At Kern Medical, there are two heparin protocols for specific indications: venous thromboembolism (VTE) and acute coronary syndrome (ACS). In 2016, a medication use review (MUE) of heparin showed suboptimal time within therapeutic range, which prompted changes in both heparin protocols to weight based infusion rate adjustments. In the new heparin protocol, healthcare providers are provided with targeted therapeutic ranges, initial dosing recommendations, dose adjustment recommendations based on patient’s weight, and monitoring parameters. Physicians would order the specific heparin protocol and nurses would follow the outlined steps for heparin management stated on the protocol sheet while clinical pharmacy provides monitoring and dosing recommendations for all patients on IV heparin. The updated protocol was implemented in 2017; however, the follow up evaluation revealed room for improvement with protocol compliance which prompted a pharmacist-led staff education campaign regarding the proper use of the new heparin protocols. PURPOSE To evaluate the effectiveness of the staff education on heparin protocol adherence and possible impact on time in therapeutic range. METHOD A pharmacist-led education campaign was conducted to physician residents and staff nurses from May to July 2018. Retrospective chart review was performed evaluating charts prior to the education campaign. They were compared to those who were treated with intravenous heparin post educational campaign from July 2018 to February 2019. Exclusion criteria include different target aPTTs from the protocol, indications other than VTE or ACS, lack of documentation using the required heparin flowsheet, and discontinuation of heparin infusion within 6 hours of initiation of therapy. The results of compliance to heparin protocol and efficacy of therapeutic outcomes from the pre- and post-education campaign were compared.

DISCUSSION The educational campaign was successful in improving compliance with heparin protocols in terms of utilization of correct heparin flowsheet, ordering heparinized PTT, and noting total body weight. However, the overall proportion of time in which patients were in therapeutic range decreased from 2017 to 2019. A subgroup analysis was conducted to assess the reason of decreased efficacy. There was a trend toward longer time to reach therapeutic range and overall less time in therapeutic range in patients where bolus doses were omitted. However, the subgroup analysis was not sufficiently powered to detect this difference. Further analysis is warranted and underway to further improve the outcomes associated with heparin protocols. CONCLUSIONS The heparin education campaign of 2018 was effective in improving heparin protocol compliance. However, the proportion of time in therapeutic range decreased during this time, which warrants further investigation and possible protocol revision.

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THE IMPACT OF EDUCATION ON COMPLIANCE OF KERN MEDICAL’S HEPARIN PROTOCOL

Robert Chiles PharmD R1, Jasmine Ho PharmD, Jeff Jolliff PharmD

Kern Medical Department of Clinical Pharmacy

Results

Introduction

Discussion

Table 1: Demographics

At Kern Medical, there are two heparin protocols for specific indications: venous thromboembolism (VTE) and acute coronary syndrome (ACS). In 2016, a medication use evaluation (MUE) of heparin showed suboptimal time within therapeutic range, which prompted changes in both heparin protocols from fixed dose to weight based infusion rate adjustments. The updated protocol was implemented in 2017; however, the follow up MUE revealed room for improvement with protocol compliance which prompted implementation of a new heparin flowsheet and “Heparinized PTT” orders (which prompts lab to process aPTT as “STAT” and notify RN with results to minimize delays to infusion adjustments). A pharmacist-led staff education campaign regarding the proper use of heparin protocols was provided to nursing personnel and physician residents in July 2018.

Figure 1: Indications

References • Post-education analysis showed a statistically significant increase in multiple compliance metrics including correct initial infusion rate, correct form use, notation of total body weight, and utilization of heparinized PTT • There was a significant decrease in percentage of time within therapeutic range and a trend toward longer time to reach the first therapeutic aPTT • Our subgroup analysis showed a trend of decreased percentage of time in therapeutic range and trend toward longer time to reach aPTT in those patients that did not receive a initial bolus, though the subgroup analysis was not sufficiently powered to detect this difference • Follow-up analysis is needed and underway to determine if the omission of bolus dosing was warranted in each case and if these omissions were responsible for the overall decrease in time within therapeutic range Conclusion • Overall, the educational campaign regarding the proper use of heparin protocols was effective in significantly improving protocol compliance • There will be continued education to nurses and physicians about the proper use of heparin protocols 1. Lexi-Comp Online, Lexi-Drugs Online, Hudson, Ohio: Lexi-Comp, Inc.; 2019. Updated Periodically 2. Taylor, Breann N., et al. “Evaluation of Weight-Based Dosing of Unfractionated Heparin in Obese Children.” J Pediatr , vol. 163, no. 1, 2013, pp. 150–153., doi:10.1016/j.jpeds.2012.12.095. 3. Khan, Samar U., et al. “Optimal Dosing Of Unfractionated Heparin In Obese Patients With Venous Thromboembolism.” Chest , vol. 128, no. 4, 2005, doi:10.1378/chest.128.4_meetingabstracts.406s-c. 4. Gerlach, Anthony, et al. “Comparison of Heparin Dosing Based on Actual Body Weight in Non-Obese, Obese and Morbidly Obese Critically Ill Patients.” Int J Crit Illn Inj Sci , vol. 3, no. 3, 2013, p. 195., doi:10.4103/2229-5151.119200. 5. Raschke RA., et al. The Weight-based Heparin Dosing Nomogram Compared with a Standard Care Nomogram: A Randomized Controlled Trial. Ann Intern Med . ;119:874–881. doi: 10.7326/0003-4819-119-9-199311010-00002

Pre-Edu n=23

Post-Edu n=39

P value

Pre-Edu

Post-Edu

0.965

57.3 ± 17.57 57.15 ± 15.39

Age [Avg. years ± SD]

ACS 35%

VTE 46%

ACS 54%

VTE 65%

Male: 27 Female: 12

Male: 12 Female: 11

0.2763

Sex [n]

0.261

80.63 ± 20 85.82 ± 15.38

Weight [Avg. kg ± SD]

Table 2: Heparin Protocol Compliance

Pre-Edu (n=23)

Post-Edu (n=39)

P value

8 (32)

20 (51)

0.292

Correct initial bolus dose [n(%)]

Objective

5 (20)

26 (66)

0.001

Correct initial infusion dose [n(%)]

To determine the effectiveness of staff education on the compliance and efficacy of heparin protocols.

11 (48)

39 (100)

< 0.001

Correct heparin flowsheet [n(%)]

Methods

3(13)

33 (84)

0.019

Total body weight noted [n(%)]

Retrospective chart review from 7/2018 to 2/2019 Inclusion Criteria: • Age ≥ 18 years old • Indication for VTE or ACS • Targeted aPTT listed in protocol Exclusion Criteria: • Discontinuation of heparin infusion within 6 hours of initiation therapy Primary outcome: protocol compliance

19 (87)

36 (92)

0.408

Baseline aPTT/CBC Noted [n(%)]

24/36 (67)

117/185 (63)

0.849

Infusion adjustments [correct/total adjustments (%)]

9 (39)

38 (97)

< 0.001

Heparinized PTT [n(%)]

Time to titrate heparin infusion (after lab results received) [mean hours ± SD]

0.43 ± 0.4

0.18 ± 0.4

0.0299

• Correct initial bolus dose • Correct initial infusion dose • Correct use of heparin flowsheet • Total body weight noted on flowsheet • Baseline aPTT/CBC noted • Utilization of “Heparinized PTT” • Correct infusion adjustments • Time to first therapeutic aPTT • Percentage of total hours therapeutic on drip

Table 3: Heparin Protocol Efficacy

Table 4: Post-Education Subgroup Analysis

Initial Bolus (n=25)

No Initial Bolus (n=14)

P value

Pre-Edu (n=23)

Post-Edu (n=39)

P value

Acknowledgements

Time to first therapeutic aPTT [mean hours ± SD] Percentage of time in therapeutic range [mean % ± SD]

Time to first therapeutic aPTT [mean hours ± SD] Percentage of time in therapeutic range [mean % ± SD]

16.59 ± 10.64 24.00 ± 23.96 0.189

13.3 ± 8.1 19.7 ± 17.6 0.104

Special thanks to: • Alice Peng, PharmD, BCPS • Janet Yoon, PharmD, BCPS • Brittany Andruszko, PharmD, BCIDP • Everett Yano, PharmD, CDE • Jay Joson, PharmD, APh, BCGP, BCPS, BC-ADM

Secondary outcome: efficacy

48.8 ± 24.43 37.48 ± 21.27 0.155

58.6 ± 25.6 42.7 ± 24.3 0.0178

• Jessica Beck, PharmD, BCPS • Shalom Sakowski, BSN, RN

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Department of Emergency Medicine

Applicant: Phillip Aguìñiga-Navarrete RA Principal Investigator & Faculty Sponsor: Daniel Quesada MD Chief Complaint: There is Something Burning in My Mouth

Daniel Quesada MD, Silva Boyajian MD R3, Jagdipak Heer MD, Phillip Aguìñiga-Navarrete RA, Laura C. Castro MS RA

INTRODUCTION Rhinocerebral mucormycosis is the most common presentation of the mucormycosis spectrum and is most commonly found in immunocompromised individuals.

PURPOSE A 50-year-old Hispanic male with a history of diabetes presented to the emergency department with a painful maxillary mass for twelve days. He had been previously treated with antibiotics without improvement. Review of systems were significant for fever, diaphoresis, weight loss and malodorous breath.

Physical exam revealed poor dentition, mild tenderness to palpation of the maxillary sinuses and a 2.5x4cm yellow, rubbery lesion on the hard palate (Image 1). The mass was pliable and adherent. Computed tomography of the face revealed irregularities of the hard palate, subcutaneous emphysema and chronic sinusitis (Image 2 and 3).

DISCUSSION Rhinocerebral mucormycosis, an infection of the nasal and paranasal sinuses, is themost common presentation of themucormycosis spectrum.1Five hundred cases are reported in the United States each year.2 The fungi are found in dead and decaying matter such as soil but thrive in acidic glucose-rich environments. 1,3 Infection begins with fungal seeding of the sinuses in an immunocompromised host (e.g. patients with malignancy, chronic steroid use, acquired immunodeficiency syndrome and diabetes), who are predisposed due to decreased phagocytic activity of neutrophils and monocytes.1,3 From the sinuses, the fungus spreads to the orbits, oropharynx and mouth.1 When left untreated, Mucor can extend into the brain, cranial nerves, lungs, gastrointestinal system and kidneys, leading to vasoocclusive thromboemboli, tissue infarction and necrosis.1Patients often present with indistinct symptoms such as headaches, low-grade fever, weakness, purulent nasal drainage, nasal congestion, nose bleeds, sinusitis, oral ulcers and facial and periorbital pain.1

Our patient promptly received intravenous antifungals, including amphotericin B upon admission. Flexible laryngoscopy showed necrotic changes. A bilateral inferior maxillectomy was performed and a prosthetic palatal obturator was fitted for the patient. He remained on intravenous amphotericin B and later switched to oral posiconazole for completion of the six-month treatment.

CONCLUSION The images displayed are a visual demonstration of Mucor’s invasive abilities, including the extent of bone destruction that it can cause. This case presentation reflects the significance of keeping a broad differential diagnosis, as a missed opportunity to diagnose this rare illness can result in death.

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Daniel Quesada 1 MD, Jagdipak Heer 1 MD, Silva Boyajian 2 MD R3, Phillip Aguiniga-Navarrete 3 RA, Laura Castro 3 , MS RA Chief Complaint: “There is Something Burning in my Mouth”

1 UCLA Health Sciences Clinical Instructor, Emergency Medicine, Bakersfield, CA 2 PGY-III, Emergency Medicine, Bakersfield, CA 3 Research Coordinator, Emergency Medicine, Bakersfield, CA

Case Presentation A 50-year-old Hispanic male with a history of diabetes presented to the emergency department with a painful maxillary mass. He had been previously treated with antibiotics without improvement. Review of systems were significant for fever, diaphoresis, weight loss and malodorous breath. Physical exam revealed poor dentition, mild tenderness to palpation of the sinuses and a 2.5x4cm yellow, rubbery lesion on the hard palate ( Image 1 ). The mass was pliable and adherent. Computed tomography of the face revealed irregularities of the hard palate, subcutaneous emphysema and chronic sinusitis ( Image 2 and 3 ).

References 1. Spellburg B, Edwards J, Ibrahim A. Novel Perspectives of Mucormycosis: Pathophysiology, Presentation and Management. Clinical Microbiology Reviews. July 2005;18(3):556-569. 2. Rees JR, Pinner RW, Hajjeh RA, Brandt ME, Reingold AL. The epidemiological features of invasive mycotic infections in the San Francisco Bay area, 1992-1993: results of population-based laboratory active surveillance. Clinical Infectious Diseases, Nov 1998;27(5):1138-47. 3. Prabhu, RM, Patel, R. Mucormycosis and entomophthoramycosis: a review of the clinical manifestations, diagnosis and treatment. Clinical Microbiology and Infection. March 2004;10:31-47. This case presentation reflects the significance of keeping a broad differential diagnosis as a missed opportunity to diagnose this rare illness can result in death. Educational Merit Capsule What do we already know about this clinical entity? Rhinocerebral mucormycosis is the most common presentation of the mucormycosis spectrum and is most commonly found in immunocompromised individuals. What is the major impact of the images? The images displayed are a visual demonstration of Mucor’s invasive abilities as well as the extent of bone destruction that it can cause. How might this improve emergency medicine practice?

Discussion Rhinocerebral mucormycosis, an infection of the nasal and paranasal sinuses, is the most common presentation of the mucormycosis spectrum. 1 500 cases are reported in the United States each year. 2 The fungi are found in dead and decaying matter such as soil but thrive in acidic glucose-rich environments. 1,3 Infection begins with fungal seeding of the sinuses in an immunocompromised host (e.g. patients with malignancy, chronic steroid use, acquired immunodeficiency syndrome and diabetes), who are predisposed due to decreased phagocytic activity of neutrophils and monocytes. 1,3 From the sinuses, the fungus spreads to the orbits, oropharynx and mouth. 1 When left untreated, Mucor can extend into the brain, cranial nerves, lungs, gastrointestinal system and kidneys, leading to vasoocclusive thromboemboli, tissue infarction and necrosis. 1 Patients often present with indistinct symptoms such as headaches, low-grade fever, weakness, purulent nasal drainage, nasal congestion, nose bleeds, sinusitis, oral ulcers and facial and periorbital pain. 1 Our patient promptly received intravenous antifungals, including amphotericin B upon admission. Flexible laryngoscopy showed necrotic changes. A bilateral inferior maxillectomy was performed and a prosthetic palatal obturator was fitted for the patient. He remained on intravenous amphotericin B and later switched to oral posiconazole for completion of the six-month treatment. His recovery was complicated by Bell’s palsy, from which he recovered.

Image 3. Computed tomography scan of the facial bones revealed extensive acute and chronic sinusitis of the sphenoid (white arrow) and ethmoid sinuses (white arrowhead).

Image 1. Demonstration of yellow, rubbery lesion found on the hard palate (white arrow) of the patient that upon biopsy revealed non-septated hyphae resembling Rhizopus species.

Image 2. Computed tomography scan of facial bones showing cortical irregularity of the hard palate as well as submucosal emphysema (white arrows).

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