Ethical, Compassionate, and Cost-Effective Approach to Health Care Decisions of Unrepresented Patients: A Bioethics Quality Improvement Project.

BACKGROUND: Unrepresented patients are defined as patients who lack capacity and do not have surrogate decision makers. Nonemergent medical treatment of unrepresented patients is often not provided owing to lack of a surrogate or is delayed because of lengthy court proceedings resulting in increased suffering and increased length of stay. OBJECTIVE: Development of an institutional policy that allows a multidisciplinary team to make medical decisions for unrepresented patients provides an ethically sound, legally viable, medically appropriate, and financially responsible solution. METHODS: A retrospective review of deidentified bioethics logs over a 2-year period was conducted after the implementation of an Unrepresented Patient Committee policy. The primary outcomes were (1) total number of consults received and (2) average time to convene committee meeting. RESULTS: There was a substantial increase in unrepresented consult requests from an average of 2 requests per year before 2015 to 23 requests in 2015 and 20 requests in 2016. The committee meetings were convened on average within 4.8 days of a consult request in 2015 and within 5.8 days in 2016. Implementation of this policy in lieu of a court petition led to a considerable reduction in the time for decision-making resulting in better clinical care and decreased length of stay with an estimated cost avoidance of $1,968,250 over the study period. CONCLUSION: Implementing an Unrepresented Patient Committee policy has created an avenue for ethical and collective decision-making, improved quality and efficiency of medical care delivery, reduced length of stay, and decreased health care costs.

Chest Radiological Findings of Patients With Severe H1N1 Pneumonia Requiring Intensive Care.

INTRODUCTION: A new strain of human influenza A (H1N1) virus originated from Mexico in 2009 and spread to more than 190 countries and territories. The World Health Organization (WHO) declared it a level 6 (highest level) pandemic. In August 2010, WHO announced that the H1N1 2009 influenza virus had moved into the postpandemic period. The WHO also declared that this flu strain is expected to continue to circulate as a seasonal virus "for some years to come." The objective of this study is to describe the chest radiographic and computed tomography (CT) findings of patients with severe H1N1 pneumonia admitted to the intensive care unit (ICU) during the 2009 pandemic. HYPOTHESIS: Patients with severe H1N1 pneumonia requiring ICU admission have extensive radiographic and CT abnormalities. METHODS: Eighteen patients, aged 23 to 62 (mean 41), admitted to the ICU at UCLA-Olive View Medical Center with a primary diagnosis of pandemic H1N1 infection, confirmed either via rapid influenza detection test or by real-time reverse transcriptase polymerase chain reaction assay, formed the study population. All patients had chest x-ray (CXR) within 24 hours of admission and 5 patients had CT examinations. In this retrospective study, images were evaluated for the pattern (ground-glass opacities, consolidation, reticular opacities, and nodular opacities), distribution (unilateral/bilateral, upper/middle/lower lung zone, and central/peripheral/peribronchovascular), and extent (focal/multifocal/diffuse; number of lung zones) of abnormalities. RESULTS: All (100%) patients had abnormal CXR and CT studies. The predominant radiographic findings were ground-glass opacities (16 of 18; 89%), consolidation (16 of 18; 89%), and reticular opacities (6 of 18, 33%). The radiographic abnormalities were bilateral in 17 (94%) patients; involved lower lung distribution in 18 (100%) patients, and mid and lower lung distribution in 16 (89%) patients. Radiographic abnormalities were peribronchovascular in 11 (61%) patients and multifocal in 10 (56%). Sixteen (89%) patients had extensive abnormalities involving 3 or more lung zones. The patients requiring mechanical ventilation had a higher incidence of bilateral, diffuse consolidation in a peribronchovascular distribution on chest radiographs. The predominant CT abnormalities were consolidation (5 of 5; 100%), ground-glass opacities (5 of 5; 100%), and nodular opacities (3 of 5, 60%). The CT findings were peribronchovascular and multifocal in 4 (80%) patients and extensive and bilateral in all (100%) patients. CONCLUSIONS: Patients with H1N1 pneumonia admitted to the ICU had bilateral, extensive CXR, and CT abnormalities. Consolidations and ground-glass opacities were the most common imaging findings, predominantly affecting mid and lower lung zones. Imaging abnormalities were peribronchovascular and multifocal in a majority of patients.

West Nile Meningoencephalitis Presenting as Isolated Bulbar Palsy With Hypercapnic Respiratory Failure: Case Report and Literature Review.

BACKGROUND: Since the outbreak of West Nile virus (WNV) in the United States in 1999, the WNV neuroinvasive disease has been increasingly reported with a wide spectrum of neuromuscular manifestations. CASE: We submit a case of a 46-year-old male with a history of alcohol abuse, diabetes, hypertension, and hepatitis C who presented with fever, nausea, shortness of breath, and dysphagia. The patient rapidly developed hypercapnic respiratory failure and was found to have WNV meningoencephalitis without obvious neuromuscular weakness. His hospital course was significant for repeated failures of extubation secondary to persistent bulbar weakness eventually requiring tracheotomy. CONCLUSION: This is a unique case of WNV meningoencephalitis with bulbar palsy without other neuromuscular manifestations resulting in recurrent hypercapnic respiratory failure.

Combined endovascular and open operative approach for mycotic carotid aneurysm.

Mycotic aneurysms of the extracranial carotid artery are rare and warrant surgical intervention. Management involves open and endovascular approaches. We report the case of a 67-year-old woman with an Escherichia coli soft-tissue infection of the right retropharyngeal space and subsequent mycotic carotid aneurysm and thrombosis of the internal jugular vein. The patient presented with a pulsatile mass and right middle cerebral artery stroke. Our surgical management involved coil embolization of the aneurysm to provide for vascular control, with resection of the common carotid artery, internal carotid artery, and extracranial carotid artery branches, along with the internal jugular vein.