Pharmacologic Pain Management Trends among Adults Hospitalized with Cellulitis: An Evidence-Based Practice Project.

BACKGROUND: Nurses commonly administer opioids, following "as needed" order sets, to patients hospitalized for acute pain conditions like cellulitis. Practice guidelines recommend limiting opioid administration for acute pain management. At two hospitals in the Pacific Northwest, an opioid stewardship committee was formed to align with best practice. AIMS: The main objective was to describe changes to inpatient rates of opioid and non-opioid administration following implementation of evidence-based opioid stewardship efforts. DESIGN: Observational, retrospective, evidence-based practice project. SETTINGS: One 200-bed and one 680-bed hospital in Washington State. PARTICIPANTS/SUBJECTS: Data were included from patients aged 18 years or older hospitalized for cellulitis. METHODS: Demographic and pain-related data were extracted from the electronic health record (n = 4,523 encounters) guided by the symptom management framework. The proportion of patients receiving opioid or non-opioid medications before and after implementation of evidence-based practice opioid stewardship interventions was calculated descriptively. A logistic regression tested factors related to administration of an opioid medication. RESULTS: The proportion of patients receiving an opioid decreased following opioid stewardship efforts while those receiving non-opioid analgesics remained stable. Factors significantly influencing inpatient opioid administration were: average inpatient pain score, pre-hospital opioid prescription, length of stay, and year of hospitalization. CONCLUSIONS: Analgesic administration treating painful, acute cellulitis at two hospitals in the Pacific Northwest included opioid and non-opioid medications. The proportion of patients receiving opioids decreased following best practice opioid stewardship actions. Opportunities may exist for nurses to collaborate with providers to improve inpatient analgesic administration practices.

Digital polymerase chain reaction strategies for accurate and precise detection of vector copy number in chimeric antigen receptor T-cell products.

BACKGROUND AIMS: Vector copy number (VCN), an average quantification of transgene copies unique to a chimeric antigen receptor (CAR) T-cell product, is a characteristic that must be reported prior to patient administration, as high VCN increases the risk of insertional mutagenesis. Historically, VCN assessment in CAR T-cell products has been performed via quantitative polymerase chain reaction (qPCR). qPCR is reliable along a broad range of concentrations, but quantification requires use of a standard curve and precision is limited. Digital PCR (dPCR) methods were developed for absolute quantification of target sequences by counting nucleic acid molecules encapsulated in discrete, volumetrically defined partitions. Advantages of dPCR compared with qPCR include simplicity, reproducibility, sensitivity and lack of dependency on a standard curve for definitive quantification. In the present study, the authors describe a dPCR assay developed for analysis of the novel bicistronic CD19 × CD22 CAR T-cell construct. METHODS: The authors compared the performance of the dPCR assay with qPCR on both the QX200 droplet dPCR (ddPCR) system (Bio-Rad Laboratories, Inc, Hercules, CA, USA) and the QIAcuity nanoplate-based dPCR (ndPCR) system (QIAGEN Sciences, Inc, Germantown, MD, USA). The primer-probe assay was validated with qPCR, ndPCR and ddPCR using patient samples from pre-clinical CAR T-cell manufacturing production runs as well as Jurkat cell subclones, which stably express this bicistronic CAR construct. RESULTS: ddPCR confirmed the specificity of this assay to detect only the bicistronic CAR product. Additionally, the authors' assay gave accurate, precise and reproducible CAR T-cell VCN measurements across qPCR, ndPCR and ddPCR modalities. CONCLUSIONS: The authors demonstrate that dPCR strategies can be utilized for absolute quantification of CAR transgenes and VCN measurements, with improved test-retest reliability, and that specific assays can be developed for detection of unique constructs.

Mediastinal plasmacytoma detected by echocardiography and biopsied with EUS-FNA.

Mediastinal ultrasound is currently being performed by a variety of different practioners but all need to be familiar with major pathology outside their narrow fields. We are reporting the first case where echocardiography led to the discovery of a mediastinal mass which upon endoscopic-ultrasound guided fine needle aspiration biopsy (EUS-FNA) was found to be a plasmacytoma. The differential diagnosis of mediastinal masses is briefly reviewed.

Computed tomography diagnosis of ischemia and complete obstruction in small bowel obstruction: a systematic review.

This review was designed to describe the diagnostic performance of computed tomography (CT) in assessing bowel ischemia and complete obstruction in small bowel obstruction (SBO). A MEDLINE search (1966-2004) identified 15 studies dealing with the CT diagnosis of ischemia and complete obstruction in SBO. Ischemia was defined by operative findings, and complete obstruction was defined by enteroclysis or operative findings. Aggregated sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated. Eleven of 15 studies reported on the CT diagnosis of ischemia in SBO based on 743 patients. The aggregated performance characteristics of CT for ischemia in SBO were sensitivity of 83% (range, 63-100%), specificity of 92% (range, 61-100%), PPV of 79% (range, 69-100%), and NPV of 93% (range, 33.3-100%). Seven of 15 studies evaluated the CT classification of complete obstruction based on 408 patients. The aggregated performance characteristics of CT for complete obstruction were sensitivity of 92% (range, 81-100%), specificity of 93% (range, 68-100%), PPV of 91% (range, 84-100%), and NPV of 93% (range, 76-100%). This review demonstrates the high sensitivity of CT for ischemia in the setting of SBO and suggests that a CT scan finding of partial SBO is likely to reflect a clinical condition that will resolve without surgical intervention.