Rapid Response: To Scan or Not to Scan? The Utility of Noncontrast CT Head for Altered Mental Status.

OBJECTIVES: The aims of the study were the following: (1) to determine how often computed tomography (CT) scans of the head are obtained on rapid responses called for altered mental status (AMS), (2) to determine whether CT imaging of the head is required during all rapid responses called for AMS, (3) to determine which patients would benefit from CT scans of the head in this setting, (4) to note whether an adequate neurologic exam was documented, (5) to determine the cost of CT scans that did not change management, and (6) to examine the role of medications leading to AMS. METHODS: The study was a retrospective chart review at Abington Jefferson Hospital. Data collected included the age, sex, time of rapid response, clinical condition of the patient, whether an arterial blood gas and blood glucose were done, and whether a neurological exam was documented in the resident's rapid response team note. The patien's medications were also reviewed. Computed tomography scan findings as well as changes made in a patient's care as a result of the scan were recorded. Any findings that did not lead to a change in management were considered a "negative" scan. RESULTS: Overall, 610 rapid responses were activated from January to August 2016. One hundred four (17.04%) of the total rapid responses were for AMS and 83 (79.8%) of these patients underwent noncontrast CT scan of the head. The mean (SD) age of the patients was 74.7 (13.6) years. A total of 56.6% were female. The most frequent clinical conditions documented at the time of rapid responses were noted as confused (33.7%, 28/83), either lethargic or unconscious (32.5%, 27/83), and concern for stroke (21.7%, 18/83). A total of 96.4% (80/83) of the CT scans done were negative for any acute changes. The three patients with positive scans (3/83) had a change in management as a result of the scans. If patients with symptoms concerning for stroke and unconscious patients are excluded, the total number of remaining patients is 56. Of these, zero patients had a positive scan. A total of 64.7% of the rapid response teams were activated either in the afternoon (31.3%) or at night (33.7%). A total of 33.7% had a complete neurological exam documented. A total of 66.2% were either incomplete (34.9%) or absent (31.3%). Sixty percent of the patients who had a CT head for AMS also had a blood sugar checked at bedside. Thirty-eight percent had an arterial blood gas. More than half the patients were taking one or more sedating medications (45/83, 57.8%). Most patients were not on anticoagulants (79.5%). CONCLUSIONS: The findings of this study suggest that CT scan of the head is useful in older patients, patients with symptoms concerning for stroke, or cases of sudden onset of impaired consciousness. Noncontrast CT scans of the head are not useful for other presentations of AMS.

Characteristics and Outcomes of Patients with Partial Do Not Resuscitate Orders in a Large Community Hospital.

Background Formal writing of do not resuscitate (DNR) orders first appeared in the literature in the late 20th century. Recently, providers have also noticed the presence of partial DNR orders while caring for patients. We sought to determine the effect of these orders on the clinical outcomes of the patients. Methods The study was a retrospective chart review covering a period of approximately 30 months. Patients included in the study were over 18 years of age and had a partial DNR order (i.e., chemical code, do not defibrillate (DND), do not intubate (DNI), intubate only, no cardiopulmonary resuscitation (CPR)) entered during hospitalization. Primary medical problems were categorized by organ system and the outcome was stated in terms of their disposition and mortality. Results A total of 71,143 code orders were entered during the study period, with partial DNR orders accounting for 1.8% of these orders (chemical code 2%, DND 0.8%, DNI 48%, intubate only 38%, and no CPR 10%). About 38% of all patients were discharged to home, 32% were discharged to a facility, and 11% were discharged on hospice. More than half of the patients did not have a palliative care consult. Of all the patients having partial code orders, about 150 patients had a rapid response team called on them and five patients had a cardiac arrest with a code blue activated on them. The mortality of these patients was significantly higher than other patients possibly due to confusing code orders. Surprisingly, a higher percentage of patients (19%) with a mean age significantly lower (p < 0.001) than discharged patients had inpatient mortality.  Conclusion Our study demonstrates the first reported prevalence of partial DNR orders in the general inpatient population and its possible detrimental effects on the patient clinical course. This study offers several opportunities for quality improvement, such as developing prompts for the healthcare team to involve palliative care services more often for such patients.

Implementation of an abdominal closure bundle to reduce surgical site infection in patients on a gynecologic oncology service undergoing exploratory laparotomy.

OBJECTIVE: Surgical site infections (SSI) are associated with increased morbidity, mortality, and healthcare costs. This study investigated whether implementation of an abdominal closure bundle reduces surgical site infection rates. We aimed to identify sub-populations that would benefit the most from this intervention. METHODS: We conducted a retrospective cohort study of all patients that underwent exploratory laparotomy by a Gynecologic Oncologist from January 1, 2011 to April 1, 2017. The abdominal closure bundle was implemented on May 6, 2014. SSI rates were assessed overall and within subgroups. RESULTS: 875 patients were included in the analysis. Overall, SSI rate was reduced, albeit not significantly, from 48/471 (10.2%) to 32/404 (7.9%) (p=0.148) with implementation of the closing bundle. In patients that underwent a tumor debulking procedure, SSI was noted in 36/277 (13.0%) in the pre-bundle group and 14/208 (6.7%) in the post-bundle cohort (p=0.017). In patients with malignant pathology, the pre-bundle cohort had an SSI rate of 38/282 (13.5%), which reduced to 18/215 (8.4%) in the post-bundle group (p=0.049). In patients with FIGO stage III or IV disease, the SSI rate was reduced from 21/114 (18.4%) to 8/87 (8.4%) with implantation of the closure bundle (p=0.028). In patients with intra-operative ascites, SSI rate decreased from 19/119 (15.9%) pre-bundle to 4/104 (3.8%) in the post-bundle group (p=0.002). CONCLUSIONS: Implementation of an abdominal closure bundle was not associated with a significant reduction in overall SSI rate. However, multiple subpopulations associated with advanced gynecologic cancer benefited from this intervention.

The Use of High-dose Insulin Infusion and Lipid Emulsion Therapy in Concurrent Beta-blocker and Calcium Channel Blocker Overdose.

Patients admitted with the presumed coingestion of beta-blockers (BBs) and calcium channel blockers (CCBs) should be initially managed in accordance with standardized resuscitation protocols (the airway, breathing, and circulation (ABC) approach). Additionally, more specific interventions should be promptly attempted. Intravenous glucagon and calcium salts have long been used in the treatment of BB and CCB toxicities. We present a case of a severe, concurrent BB and CCB toxicity resulting in cardiovascular collapse refractory to vasopressors. The administration of high-dose insulin (HDI) and lipid emulsion therapy (LET) resulted in a significant improvement in hemodynamics with an overall favorable outcome in the patient.

Venous thromboembolism after laparoscopic or robotic biliopancreatic diversion with duodenal switch. Ninety-days outcome of a 10 years' experience.

BACKGROUND: Venous thromboembolism (VTE) is a feared complication after bariatric surgery. Biliopancreatic diversion with duodenal switch (BPD-DS) is a complex bariatric procedure that is offered typically to super morbidly obese patients. Scarce data exist in reporting VTE outcome and identifying the risk factors associated with it after BPD-DS. OBJECTIVE: To determine the risk factors for VTE after BPD-DS at 90-day follow-up. SETTING: A nonprofit regional referral center and teaching hospital in Pennsylvania. METHODS: A retrospective chart review was performed on prospectively collected data over 10 years, between January 1, 2006 and December 31, 2016. Patients who underwent laparoscopic or robotic BPD-DS were included. Preoperative variables, selected risk factors, and methods of VTE prophylaxis were analyzed. RESULTS: A total of 662 patients who underwent BPD-DS were identified. The mean age was 44.7 ± 10.4 (20-72) years; 474 patients were female (71.7%), and the mean body mass index of the cohort was 50.5 ± 7.5 (34-98) kg/m2. Overall, 16 patients (2.4%) experienced VTE complication at 90-days follow-up post-BPD-DS with 100% follow-up rate; deep vein thrombosis was experienced by 10 patients (1.5%), and 6 patients (0.9%) experienced pulmonary embolism (1 patient experience both). None of those patients had a previous history of VTE. Only operative time (P value = .009) and length of stay (P value ≤ .001) were associated with VTE events. Other factors such as age, sex, body mass index, previous history of VTE, preoperative heparin injection, preoperative inferior vena cava filter insertion, intermittent compressive device use, interval heparin time, and postoperative chemical prophylaxis did not show a statistical association. A logistic regression analysis showed a statistically significant increase of VTE outcome with length of stay; odds ratio of 1.161, (95% confidence interval, 1.048-1.285), P value = .004. CONCLUSION: With proper preoperative evaluation and aggressive VTE prophylaxis protocol, the risk of VTE post-BPD-DS is comparable to other bariatric procedures. Every effort should be adopted to shorten the length of stay, and thus reduce VTE risk.

Analysis of Efficacy and Tolerability of Bruton Tyrosine Kinase Inhibitor Ibrutinib in Various B-cell Malignancies in the General Community: A Single-center Experience.

BACKGROUND: Ibrutinib, an irreversible inhibitor of Bruton tyrosine kinase (BTK), is a novel drug that has shown significant efficacy and survival benefit for treatment of various B-cell malignancies. The primary objective of the present study was to investigate the efficacy of ibrutinib therapy in various B-cell malignancies in the general community. The secondary objectives included studying the adverse effects, ibrutinib-induced peripheral lymphocytosis, and effect on immunoglobulin levels. PATIENTS AND METHODS: The present study was a retrospective observational cohort analysis conducted at Abington Jefferson Health. The clinical response was determined from the hematologist's assessment and evaluated independently using the response criteria for each B-cell malignancy. Adverse effects were graded according to the Common Terminology Criteria for Adverse Events, version 4.0. The Wilcoxon signed-rank test was used to compare immunoglobulin levels before and after ibrutinib. Forty five patients with B-cell malignancies and receiving ibrutinib therapy were eligible. RESULTS: The median age was 73 years (range, 49-96 years), and 84.4% of the patients had received ≥ 1 previous therapy. The best overall response rate of all cohorts combined was 63.8%. The greatest overall response rate was observed in patients with chronic lymphocytic leukemia or small lymphocytic lymphoma (76.1%), followed by those with Waldenström macroglobulinemia (75%). Of the 45 patients, 88.9% experienced adverse effects. Antiplatelet activity of ibrutinib was most commonly observed (30.5%). Of note, 5 patients (11%) developed new-onset atrial fibrillation after drug initiation. Peripheral lymphocytosis after drug initiation was observed in most patients, with a peak level at 1 month (median lymphocyte count, 2.7 × 103 cells/µL). Although the IgG levels at 3, 6, and 12 months had decreased (P = .01 for all) compared with the levels before ibrutinib, the IgA levels had not increased at 3, 6, 12, and 24 months (P = .6, P = .5, P = .3, and P = .9, respectively). CONCLUSION: Ibrutinib is a highly effective and tolerable drug for B-cell malignancies in the general community. In contrast to the previously reported rate of 5% to 7%, we observed a higher rate (11%) of atrial fibrillation, which might have resulted from the smaller sample size in the present study and the multiple comorbidities. Nonetheless, this treatment-limiting side effect requires further elucidation. Paradoxical lymphocytosis at the outset of therapy was a common and benign finding. In conjunction with the reported trials, the IgG levels decreased in the first year of continued therapy. However, the IgA levels did not increase, even after 2 years of therapy.

Evaluation of prediction strategy and care coordination for COPD readmissions.

OBJECTIVES: Factors that influence the likelihood of readmission for chronic obstructive pulmonary disease (COPD) patients and the impact of posthospital care coordination remain uncertain. LACE index (L = length of stay, A = Acuity of admission; C = Charlson comorbidity index; E = No. of emergency department (ED) visits in last 6 months) is a validated tool for predicting 30-days readmissions for general medicine patients. We aimed to identify variables predictive of COPD readmissions including LACE index and determine the impact of a novel care management process on 30-day all-cause readmission rate. METHODS: In a case-control design, potential readmission predictors including LACE index were analyzed using multivariable logistic regression for 461 COPD patients between January-October 2013. Patients with a high LACE index at discharge began receiving care coordination in July 2013. We tested for association between readmission and receipt of care coordination between July-October 2013. Care coordination consists of a telephone call from the care manager who: 1) reviews discharge instructions and medication reconciliation; 2) emphasizes importance of medication adherence; 3) makes a follow-up appointment with primary care physician within 1-2 weeks and; 4) makes an emergency back-up plan. RESULTS: COPD readmission rate was 16.5%. An adjusted LACE index of ≥ 13 was not associated with readmission (p = 0.186). Significant predictors included female gender (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.29-0.91, p = 0.021); discharge to skilled nursing facility (OR 3.03, 95% CI 1.36-6.75, p = 0.007); 4-6 comorbid illnesses (OR 9.21, 95% CI 1.17-76.62, p = 0.035) and ≥ 4 ED visits in previous 6 months (OR 6.40, 95% CI 1.25-32.87, p = 0.026). Out of 119 patients discharged between July-October 2013, 41% received the care coordination. The readmission rate in the intervention group was 14.3% compared to 18.6% in controls (p = 0.62). CONCLUSIONS: Factors influencing COPD readmissions are complex and poorly understood. LACE index did not predict 30-days all-cause COPD readmissions. Posthospital care coordination for transition of care from hospital to the community showed a 4.3% reduction in the 30-days all-cause readmission rate which did not reach statistical significance (p = 0.62).

Risk of Biliary Events After Selective Cholecystectomy During Biliopancreatic Diversion with Duodenal Switch.

BACKGROUND: Approximately 20 % of adults over 40 years of age in the USA develop cholelithiasis (Topart et al. Surg Obes Relat Dis. 9(4):526-30, 2013). Despite a higher incidence of biliary complications reported in postbariatric patients, it remains controversial whether simultaneous routine cholecystectomy should be performed during biliopancreatic diversion and duodenal switch (BPD/DS) or if a selective approach is more appropriate. The aim of this study was to evaluate incidence of biliary complications in patients who underwent BPD/DS without simultaneous cholecystectomy. METHODS: Retrospective review of all patients who underwent BPD/DS between 2006 and 2012 was performed. RESULTS: A total of 361 consecutive patients were included in the study with mean age of 44.8 years (range 20-72), mean body weight of 317.2 lbs (range 205-547), and average body mass index (BMI) of 50.5 kg/m(2) (range 34-71.4). Ninety-seven patients were males (26.8 %). Out of 239 patients who still had their gallbladder after the BPD/DS, 52 patients (22.7 %) developed subsequent biliary symptoms (13 patients (5.4 %) in the first year, 25 (11 %) in the second year, and 14 (6.1 %) beyond the second year). During the study period, 40 patients eventually underwent elective laparoscopic cholecystectomy, and 11 had urgent cholecystectomy (9 laparoscopic and 2 open). One patient underwent open common bile duct exploration for ascending cholangitis. Average follow-up was 31 months (12-72 months) with follow-up rate of 95.6 % at 12 months and 92.8 % at 18 months. CONCLUSIONS: Leaving normal gallbladder in situ after BPD/DS is associated with an acceptable risk of biliary events. Risk of developing common bile duct stones is low; however, it may create treatment challenges.

Risk Factors for Postoperative Unplanned Intubation: Analysis of a National Database.

Postoperative unplanned intubation (PUI) is a significant complication and is associated with severe adverse events and mortality. By participating in the National Surgical Quality Improvement Program (NSQIP), we learned that PUI occurred more frequently than expected at our institution. The aim of this study was to identify risk factors that are predictors of PUI at our institution. We reviewed the NSQIP data from our institution and the NSQIP national database for surgery patients from 2010 through 2013. The rate of PUI at our institution was 1.54 per cent compared with the national rate of 1.03 per cent. Perioperative risk factors were analyzed by multivariate logistic regression. Analysis of the national NSQIP database identified 14 independent risk factors for PUI. Analysis of the NSQIP data at our institution demonstrated that emergent cases, preoperative ventilator status, smoking, chronic obstructive pulmonary disease, and older age were independent risk factors. In conclusion, patients at our institution with these five risk factors were at higher risk of requiring PUI. These risk factors could be used to help identify patients at high risk and possibly help prevent postoperative respiratory failure and unplanned intubation.

Outcomes of Triplets reduced to Twins versus non-reduced Triplet Pregnancies.

INTRODUCTION: This study examined the outcomes of triplet pregnancies selectively reduced to twin pregnancies, compared with non-reduced triplet pregnancies using a standardized approach. MATERIAL AND METHODS: This study is an observational retrospective study of all women who presented to the Fetal Diagnostic Center between 1999-2009, had triplet pregnancies in the first trimester, received prenatal care and delivered at Abington Memorial Hospital. Data analysis was performed with SPPS version 15 for Windows using analysis of variance and Fisher's Exact test. RESULTS: 132 triplet pregnancies were identified. In the reduced group (n = 30) compared to the non-reduced triplet group (n = 102) average gestational age of delivery was longer 34.6 weeks versus 31.2 weeks gestation (P = <0.0005) and days in hospital were less 9.0 versus 26.7 days (P = .001). There was a significantly lower incidence of gestational diabetes and preterm labor in reduced pregnancies. Rate of loss, defined as delivery less than 24 weeks, were similar [3.3% versus 4.9%]. DISCUSSION: Women electing to reduce a triplet pregnancy to twins have higher gestational ages at delivery, lower rates of gestational diabetes and preterm labor, and spent fewer days in hospital than non-reduced triplet pregnancies.

Venous thromboembolism after laparoscopic biliopancreatic diversion with duodenal switch: analysis of 362 patients.

BACKGROUND: Venous thromboembolism (VTE), which manifests as deep venous thrombosis (DVT) or pulmonary embolism (PE), is relatively uncommon after weight loss procedures but has the strong potential to affect patient morbidity and mortality. This type of complication has been studied extensively in more common weight loss procedures, such as Roux-en-Y gastric bypass (RYGB). VTE has not been studied after biliopancreatic diversion with duodenal switch (BPD-DS), a bariatric procedure performed mainly for super morbidly obese patients, who are inherently associated with a higher incidence of co-morbidity. The objective of this study was to review VTE prevalence and identify risk factors associated with the postoperative occurrence of VTE in a collected data set of patients after laparoscopic BPD-DS. METHODS: The database of all patients who underwent laparoscopic BPD-DS between 2006 and 2012 was reviewed. Preoperative clinical information, which included history of VTE, inferior vena cava (IVC) filter placement, operative variables, and postoperative course, were reviewed. All VTE related events that occurred within 90 days postoperatively were collected and analyzed. RESULTS: Of 362 patients who underwent laparoscopic BPD-DS during the study period, 12 (3.3%) experienced a VTE complication. Eight (2.2%) patients presented with DVT; 4 (1.1%) patients presented with PE. VTE complications were more common in females than males (83.3% versus 16.6%, respectively). Age, body mass index (BMI), and time interval between preoperative and postoperative doses of heparin for DVT prophylaxis did not influence the occurrence of VTE complications. However, operative time (P = .02) and length of hospital stay (P = .0005) were identified as risk factors associated with postoperative VTE complications. No related mortality occurred in this study. CONCLUSION: The prevalence of VTE after BPD-DS is relatively low and comparable to other weight loss procedures. Overall risk of postoperative VTE after laparoscopic BPD-DS appears to be associated with the length of operation and hospital stay.

Clinical outcomes of penicillin skin testing.

BACKGROUND: Penicillin or cephalosporin allergy is a common problem with antibiotic drug prescribing in hospitalized patients. OBJECTIVES: To study the various clinical outcomes of penicillin skin testing (PST) in a community teaching hospital and to determine the percentage of patients who have an antibiotic drug modification after PST. METHODS: This study was a retrospective medical record review of all inpatients who underwent PST in 6.6 years. Information was collected on 101 patients using a detailed data collection form. Data were summarized using descriptive statistics, including frequencies and percentages. RESULTS: Of the 101 patients who underwent PST, 92 had a negative result and 5 had a positive result; in 4 patients the test result was indeterminate. There was a 96% (67/70) reduction in the use of vancomycin and a 96% (23/24) reduction in the use of fluoroquinolones after PST in patients with negative results. Forty-nine percent of patients with negative PST results were administered a penicillin-based drug, and 48% were given a cephalosporin. Cultures were positive most commonly for Staphylococcus aureus and enterococcus. There were no serious adverse reactions to PST or to the use of penicillins or cephalosporins after a negative PST result. CONCLUSIONS: Penicillin skin testing lowered the use of vancomycin and fluoroquinolones and increased the use of penicillin-based drugs and cephalosporins in patients with a history of beta-lactam drug allergies.