Ketamine for Super-Refractory Status Epilepticus in Palliative Care. A Case Report and Review of the Literature.

We report a case of super refractory status epilepticus uncontrolled by multiple anti-seizure medications in an individual with acute liver failure due to hepatic cirrhosis and an obstructive ileocecal mass plus multiple bilateral lung lesions presumed to be metastatic. A ketamine infusion was initiated late in his hospitalization which eliminated the convulsive seizures in less than an hour. The abatement of convulsive seizures allowed his grieving wife to return to her husband's bedside to witness the withdrawal of life sustaining treatment and be present during the final 24 hours of his life. We review the medical literature on the role of Intravenous (IV) Ketamine in the treatment of super refractory status epilepticus.

The Influence of Palliative Care Consultation on Health-Care Resource Utilization During the Last 2 Months of Life: Report From an Integrated Palliative Care Program and Review of the Literature.

BACKGROUND: We reviewed 104 consecutive deaths of veterans receiving care in the Dayton VA Medical Center from October 10, 2015 to April 11, 2016. The purpose of our study was to test our hypothesis that palliative care consultation would be associated with reduced health care resource utilization for individuals approaching end of life. METHODS: Medical records were reviewed and data entry recorded on a spreadsheet. Non-parametric statistical methods were used to compare four outcome variables from veterans with palliative care consultation (PCC) vs. those without PCC. These variables included the number of ED visits, hospitalizations, hospital days, and ICU days all during the last two months of life. Predictor variables included PCC vs. no PCC and PCC before vs. PCC during the last two months of life. The study sample was comprised of 102 patients after excluding two outlier cases with ethical challenges in surrogate decision-making. RESULTS: Of the 102 consecutive veteran deaths, palliative care consultation was associated with a lower number of ICU days during the last two months of life. For 96 veterans with PCC, the frequency of ED visits and acute care hospitalizations, as well as the number of ICU and hospital days, were all significantly less after PCC compared to before PCC during the last two months of life. The timing of PCC had no effect on the outcomes of interest. CONCLUSION: Palliative care consultation has a notable effect on health care resource utilization during the last two months of life.

Clinician Perspectives on Challenges to Patient Centered Care at the End of Life.

Discussions regarding patient preferences for resuscitation are often delayed and preferences may be neglected, leading to the receipt of unwanted medical care. To better understand barriers to the expression and realization of patients' end of life wishes, a preventive ethics team in one Veterans Affairs Medical Center conducted a survey of physicians, nurses, social workers, and respiratory therapists. Surveys were analyzed through qualitative analysis, using sorting methodologies to identify themes. Analysis revealed barriers to patient wishes being identified and followed, including discomfort conducting end-of-life discussions, difficulty locating patients' preferences in medical records, challenges with expiring do not resuscitate (DNR) orders, and confusion over terminology. Based on these findings, the preventive ethics team proposed new terminology for code status preferences, elimination of the local policy for expiration of DNR orders, and enhanced systems for storing and retrieving patients' end-of-life preferences. Educational efforts were initiated to facilitate implementation of the proposed changes.

Examining the validity of AHRQ's patient safety indicators (PSIs): is variation in PSI composite score related to hospital organizational factors?

Increasing use of Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) for hospital performance measurement intensifies the need to critically assess their validity. Our study examined the extent to which variation in PSI composite score is related to differences in hospital organizational structures or processes (i.e., criterion validity). In site visits to three Veterans Health Administration hospitals with high and three with low PSI composite scores ("low performers" and "high performers," respectively), we interviewed a cross-section of hospital staff. We then coded interview transcripts for evidence in 13 safety-related domains and assessed variation across high and low performers. Evidence of leadership and coordination of work/communication (organizational process domains) was predominantly favorable for high performers only. Evidence in the other domains was either mixed, or there were insufficient data to rate the domains. While we found some evidence of criterion validity, the extent to which variation in PSI rates is related to differences in hospitals' organizational structures/processes needs further study.

Open disclosure of adverse events: transparency and safety in health care.

Many patients suffering adverse events in health care turn to the legal system to learn what happened to them and to seek compensation. Health care providers have ethical, professional, and legal duties to disclose the harmful effects of care to the patient, regardless of how small the risk. The purpose of open disclosure is to explain what happened to the patient and to seek a just outcome for patient and provider. This article explores our experience of managing and implementing an open disclosure program in an acute and chronic tertiary care facility with university affiliation in the Veterans Health Administration.

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

CONTEXT: Mislabeled laboratory specimens are a common source of harm to patients, such as repeat phlebotomy; repeat diagnostic procedure, including tissue biopsy; delay in a necessary surgical procedure; and the execution of an unnecessary surgical procedure. Mislabeling has been estimated to occur at a rate of 0.1% of all laboratory and anatomic pathology specimens submitted. OBJECTIVE: To identify system vulnerabilities in specimen collection, processing, analysis, and reporting associated with patient misidentification involving the clinical laboratory, anatomic pathology, and blood transfusion services. DESIGN: A qualitative analysis was performed on 227 root cause analysis reports from the Veterans Health Administration. Content analysis of case reports from March 9, 2000, to March 1, 2008, was facilitated by a Natural Language Processing program. Data were categorized by the 3 stages of the laboratory test cycle. RESULTS: Patient misidentification accounted for 182 of 253 adverse events, which occurred in all 3 stages of the test cycle. Of 132 misidentification events occurring in the preanalytic phase, events included wrist bands labeled for the wrong patient were applied on admission (n = 8), and laboratory tests were ordered for the wrong patient by selecting the wrong electronic medical record from a menu of similar names and Social Security numbers (n = 31). Specimen mislabeling during collection was associated with "batching" of specimens and printed labels (n = 35), misinformation from manual entry on laboratory forms (n = 14), failure of 2-source patient identification for clinical laboratory specimens (n = 24), and failure of 2-person verification of patient identity for blood bank specimens (n = 20). Of 37 events in the analytic phase, relabeling all specimens with accession numbers was associated with mislabeled specimen containers, tissue cassettes, and microscopic slides (n = 27). Misidentified microscopic slides were associated with a failure of 2-pathologist verification for cancer diagnosis (n = 4), and wrong patient transfusions were associated with mislabeled blood products (n = 3) and a failure of 2-person verification for blood products before release by the blood bank (n = 3). There were 13 events in the postanalytic phase in which results were reported into the wrong patient medical record (n = 8), and incompatible blood transfusions were associated with failed 2-person verification of blood products (n = 5). CONCLUSIONS: Patient misidentification in the clinical laboratory, anatomic pathology, and blood transfusion processes were due to a limited set of causal factors in all 3 phases of the test cycle. A focus on these factors will inform systemic mitigation and prevention strategies.

Incorrect surgical procedures within and outside of the operating room.

OBJECTIVE: To describe incorrect surgical procedures reported from Veterans Health Administration (VHA) Medical Centers from 2001 to mid-2006 and provide proposed solutions for preventing such events. DESIGN: Descriptive study. SETTING: Veterans Health Administration Medical Centers. PARTICIPANTS: Veterans of the US Armed Forces. INTERVENTIONS: The VHA instituted an initial directive, "Ensuring Correct Surgery and Invasive Procedures," in January 2003. The directive was updated in 2004 to include non-operating room (OR) invasive procedures and incorporated requirements of The Joint Commission Universal Protocol for preventing wrong-site operations. MAIN OUTCOME MEASURES: The categories included 5 incorrect event types (wrong patient, side, site, procedure, or implant), major or minor surgical procedures, location in or out of the OR, therapeutic or diagnostic events, adverse event or close call, inpatient or ambulatory events, specialty department, body segment, and severity and probability of harm. RESULTS: We reviewed 342 reported events (212 adverse events and 130 close calls). Of these, 108 adverse events (50.9%) occurred in an OR, and 104 (49.1%) occurred elsewhere. When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2%] each), whereas orthopedics was second to ophthalmology for number of reported adverse events occurring in the OR. Pulmonary medicine cases (such as wrong-side thoracentesis) and wrong-site cases (such as wrong spinal level) were associated with the most harm. The most common root cause of events was communication (21.0%). CONCLUSIONS: Incorrect ophthalmic and orthopedic surgical procedures appear to be overrepresented among adverse events occurring in ORs. Outside the OR, adverse events by invasive radiology were most frequently reported. Incorrect surgical procedures are not only an OR challenge but also a challenge for events occurring outside of the OR. We support earlier communication based on crew resource management to prevent surgical adverse events.

Major depressive disorder and patient satisfaction in relation to methadone pharmacokinetics and pharmacodynamics in stabilized methadone maintenance patients.

Many patients enrolled in methadone maintenance treatment experience significant interdose opioid withdrawal. Mood states have been related to patient satisfaction with treatment and may influence how methadone patients experience opioid withdrawal. The objective of this study was to investigate the influence of major depressive disorder on response to methadone in patients on methadone maintenance treatment. Seventeen methadone patients (7 depressed and 10 not depressed) had pharmacokinetic and pharmacodynamic assessments (opioid withdrawal, drug effects, and mood) over one 24-hour dosing interval. Subjects were also divided based on their satisfaction with methadone treatment: 12 holders and 5 nonholders. Depressed subjects experienced more dysphoric opioid effects as measured by the Addiction Research Centre Inventory (area under the effect versus time curve, 14 +/- 32 vs -31 +/- 47, P < 0.04) and had higher scores on the Subjective Opioid Withdrawal Scale (area under the effect versus time curve, 33 +/- 97 vs -74 +/- 67, P < 0.02) over the dosage interval. Hamilton Depression scores significantly correlated with trough subjective opioid withdrawal scale scores (r = 0.7, P < 0.004). Nonholders had significantly higher exposure to unbound (S)-methadone compared with holders, specifically: trough concentration (6.1 +/- 2.7 ng/mL vs 2.7 +/- 1.7 ng/mL, P < 0.01), average steady-state concentration (7.6 +/- 4.0 ng/mL vs 4.1 +/- 2.5 ng/mL, P < 0.05), maximum concentration (14.6 +/- 7.1 ng/mL vs 7.5 +/- 4.2 ng/mL, P < 0.04), and area under the curve (183 +/- 95 h*ng/mL vs 99 +/- 61 h*ng/mL, P < 0.05). Study findings suggest that (S)-methadone may relate to patients' dissatisfaction with methadone treatment. Depressed methadone patients may be more sensitive to negative opioid effects and opioid withdrawal.

A systematic review on diagnostic accuracy of CT-based detection of significant coronary artery disease.

OBJECTIVES: Systematic review of diagnostic accuracy of contrast enhanced coronary computed tomography (CE-CCT). BACKGROUND: Noninvasive detection of coronary artery stenosis (CAS) by CE-CCT as an alternative to catheter-based coronary angiography (CCA) may improve patient management. METHODS: Forty-one articles published between 1997 and 2006 were included that evaluated native coronary arteries for significant stenosis and used CE-CCT as diagnostic test and CCA as reference standard. Study group characteristics, study methodology and diagnostic outcomes were extracted. Pooled summary sensitivity and specificity of CE-CCT were calculated using a random effects model (1) for all coronary segments, (2) assessable segments, and (3) per patient. RESULTS: The 41 studies totaled 2515 patients (75% males; mean age: 59 years, CAS prevalence: 59%). Analysis of all coronary segments yielded a sensitivity of 95% (80%, 89%, 86%, 98% for electron beam CT, 4/8-slice, 16-slice and 64-slice MDCT, respectively) for a specificity of 85% (77%, 84%, 95%, 91%). Analysis limited to segments deemed assessable by CT showed sensitivity of 96% (86%, 85%, 98%, 97%) for a specificity of 95% (90%, 96%, 96%, 96%). Per patient, sensitivity was 99% (90%, 97%, 99%, 98%) and specificity was 76% (59%, 81%, 83%, 92%). Heterogeneity was quantitatively important but not explainable by patient group characteristics or study methodology. CONCLUSIONS: Current diagnostic accuracy of CE-CCT is high. Advances in CT technology have resulted in increases in diagnostic accuracy and proportion of assessable coronary segments. However, per patient, accuracy may be lower and CT may have more limited clinical utility in populations at high risk for CAD.

Medical team training: applying crew resource management in the Veterans Health Administration.

BACKGROUND: Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS). METHODS: The VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew resource management (CRM), is intended to improve outcomes of patient care by enhancing communication between health care professionals. Unique features of MTT include a full-day interactive learning session (facilitated entirely by clinical peers in a health care context), administration of pre-and postintervention safety attitudes questionnaires, and follow-up semistructured interviews with reports of program activities and lessons learned. RESULTS: Examples of projects in these facilities include intensive care unit (ICU) teams' patient-centered multidisciplinary rounds, surgical teams' preoperative briefings and debriefings, an entire operating room (OR) unit's adoption of "Rules of Conduct" for expected staff behavior, and an ICU team's use of the model for daily administrative briefings. DISCUSSION: An MTT program based on applied CRM principles was successfully developed and implemented in 43 VA medical centers from September 2003 to May 2007.

Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC's emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement. OBJECTIVE: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO. DESIGN: Six Sigma Project with pre-post design. PARTICIPANTS: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals. MEASUREMENTS: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire. RESULTS: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products. CONCLUSIONS: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC's evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.

Stability of clonidine in clonidine-hydromorphone mixture from implanted intrathecal infusion pumps in chronic pain patients.

Clonidine is frequently added to opioids in implantable intrathecal pumps for the management of chronic pain. In such devices, a small non-retrievable volume is always present in the reservoir, and its effect on drug stability is unknown. Furthermore, stability of clonidine, when mixed with hydromorphone, has not been previously determined. This study examined the stability of clonidine when co-administered with hydromorphone in implanted intrathecal pumps. Samples of hydromorphone-clonidine before pump refill and from residual solution at subsequent refill were obtained from chronic pain patients. Clonidine concentration was measured using HPLC. Twenty paired samples from 3 patients were analyzed. All 3 patients had a SynchroMed pump implanted for 3-5 years. We found no loss in clonidine concentration during the time between refills (35 +/- 13 days), and no correlation between clonidine concentration and time interval between refills. In conclusion, clonidine, mixed with hydromorphone, is stable when delivered by implantable intrathecal pump for long-term use.

Tryptophan depletion and serotonin loss in selective serotonin reuptake inhibitor-treated depression: an [(18)F] MPPF positron emission tomography study.

BACKGROUND: Recurrence of depressive symptoms after tryptophan depletion (TD) in selective serotonin reuptake inhibitor (SSRI)-treated depression is an important, unexplained phenomenon. With [(18)F] MPPF positron emission tomography (PET), serotonin (5-hydroxytryptamine, 5-HT) 1A receptor binding potential (5-HT(1A)BP) was measured after TD in various brain regions in citalopram-treated depression. This 5-HT(1A)BP measurement is sensitive to changes in extracellular 5-HT in animal models. METHODS: Eight remitted patients with major depressive disorder received [(18)F] MPPF PET scans twice: once after TD and once after sham depletion. Behavioral measures were evaluated with the Hamilton Depression Rating Scale and visual analog scales. RESULTS: No effect on regional 5-HT(1A)BP was observed after TD, despite an 86% decrease in total plasma tryptophan and transient depressive relapse in six of eight patients. CONCLUSIONS: Large-magnitude changes in extracellular 5-HT are not crucial for the mood effects observed in SSRI-treated subjects after TD. Therefore, greater consideration must be given to other mechanisms that involve vulnerability to small perturbations in extracellular 5-HT, such as impairment of signal transduction.

Burden of dysthymia and comorbid illness in adults in a Canadian primary care setting: high rates of psychiatric illness in the offspring.

BACKGROUND: The burden of comorbid dysthymia and other comorbid psychiatric illnesses in a Canadian primary care setting was measured. Two groups of primary care patients: those who scored positive for comorbid dysthymia versus those who scored negative for any psychiatric disorder were compared. METHODS: This was a cross-sectional survey in a Health Service Organization (HSO) in Ontario, Canada. The subjects were patients of the HSO. The main outcome measures were: health status, mood, social adjustment, coping ability, children's psychiatric disorders, child development, family function, and health and social service utilization. RESULTS: Of the 6280 eligible adults who were patients at the HSO, 68.9% consented to be screened for psychiatric disorders; 5.1% screened positive for dysthymia, of which 90% had at least one comorbid psychiatric disorder. The following statistically significant differences were found between people with dysthymia and other comorbid psychiatric disorders versus people without any psychiatric disorder. People with dysthymia were more likely to have worse health status, worry more about their health, and report levels of pain that impaired their function; they had higher MADRS depression scores, lower social role function scores, lower social adjustment scores, and lower coping ability. More children of people with comorbid dysthymia met criteria for one or more childhood psychiatric disorders and there were more families with a parent with dysthymia that were dysfunctional. People with dysthymia used a greater proportion of health and social services, had higher per person annual health care costs (excluding hospital services), and had higher per person annual indirect costs (lost wages). CONCLUSION: This analysis demonstrated the burden of illness and costs that this disorder imposes on individuals, their families, and society as a whole.

Hormones and mood: from menarche to menopause and beyond.

The lifetime prevalence of mood disorders in women is approximately twice that of men. The underlying causality of this gender difference is not yet understood. There is increasing scientific attention to the modulation of the neuroendocrine system by fluctuating gonadal hormones. This review attempts to summarize our current state of knowledge on the role and potential relevance of estrogen and other sex steroids to psychiatric disorders specific to women from menarche to menopause. The sudden appearance of higher levels of estrogen in puberty alters the sensitivity of the neurotransmitter systems. Moreover, the constant flux of estrogen and progesterone levels throughout the reproductive years portends constant modification of the neurotransmitter systems. Premenstrual syndromes may be the result of an altered activity or sensitivity of certain neurotransmitter systems. Pregnancy and delivery produce dramatic changes in estrogen and progesterone levels as well as significant suppression along the HPA axis, possibly increasing vulnerability to depression. At menopause, estrogen levels decline while pituitary LH and FSH levels increase. The loss of modulating effects of estrogen and progesterone may underlie the development of perimenopausal mood disorders in vulnerable women. The pattern of neuroendocrine events related to female reproduction is vulnerable to change and is sensitive to psychosocial, environmental, and physiological factors. Further research is needed to be able to identify specific genetic markers which might help us better understand how the balance between estrogen, progesterone, testosterone, and other steroid hormones affect neurotransmitter function.

Association between smoking during radiotherapy and prognosis in head and neck cancer: a follow-up study.

BACKGROUND: The study objective was to confirm a previous finding that patients with stage III/IV squamous head and neck cancer (SHNC) who smoke during radiotherapy (RT) experience reduced survival. METHODS: An observational cohort study. Patients' smoking status was assessed weekly by questionnaire plus blood cotinine. Patients were assessed every 3 to 4 months for survival. Logistic regression and Cox proportional hazards analyses were used to detect the independent contribution of smoking on survival. RESULTS: Of 148 patients, 113 smoked during RT. Blood cotinine and smoking questionnaire responses were highly correlated (Spearman R = .69; p < .0005). Abstainers and very light smokers experienced better survival than light, moderate, and heavy smokers (median, 42 vs 29 months; p = .07). Tumor and nodal status and years smoked were the most important prognostic factors. Smoking during RT was not an independent predictor of survival, but baseline smoking status was (p = .016). CONCLUSION: Smoking status should be documented in all future trials of RT in SHNC to allow for pooled analyses with sufficient power to address this question.