Faculty Bibliography

BACKGROUND:Patients with advanced-stage chronic obstructive pulmonary disease (COPD) may suffer severe respiratory exacerbations and need to decide between accepting life-sustaining treatments versus foregoing these treatments (choosing comfort care only). We designed the InformedTogether decision aid to inform this decision and describe results of a pilot study to assess usability focusing on participants' trust in the content of the decision aid, acceptability, recommendations for improvement, and emotional reactions to this emotionally laden decision. METHODS:Study participants ( N = 26) comprising clinicians, patients, and surrogates viewed the decision aid, completed usability tasks, and participated in interviews and focus groups assessing comprehension, trust, perception of bias, and perceived acceptability of InformedTogether. Mixed methods were used to analyze results. RESULTS:Almost all participants understood the gist (general meaning) of InformedTogether. However, many lower literacy participants had difficulty answering the more detailed questions related to comprehension, especially when interpreting icon arrays, and many were not aware that they had misunderstood the information. Qualitative analysis showed a range of emotional reactions to the information. Participants with low verbatim comprehension frequently referenced lived experiences when answering knowledge questions, which we termed "alternative knowledge." CONCLUSIONS:We found a range of emotional reactions to the information and frequent use of alternative knowledge frameworks for deriving meaning from the data. These observations led to insights into the impact of lived experiences on the uptake of biomedical information presented in decision aids. Communicating prognostic information could potentially be improved by eliciting alternative knowledge as a starting point to build communication, in particular for low literacy patients. Decision aids designed to facilitate shared decision making should elicit this knowledge and help clinicians tailor information accordingly.

OBJECTIVES/OBJECTIVE:To determine mortality and costs associated with adherence to an aggressive, 3-hour sepsis bundle versus noncompliance with greater than or equal to one bundle element for severe sepsis and septic shock patients. DESIGN/METHODS:Prospective, multisite, observational study following three sequential, independent cohorts, from a single U.S. health system, through their hospitalization. SETTING/METHODS:Cohort 1: five tertiary and six community hospitals. Cohort 2: single tertiary, academic medical center. Cohort 3: five tertiary and four community hospitals. PATIENTS/METHODS:Consecutive sample of all severe sepsis and septic shock patients (defined: infection, ≥ 2 systemic inflammatory response syndrome, and hypoperfusive organ dysfunction) identified by a quality initiative. The exposure was full 3-hour bundle compliance. Bundle elements are as follows: 1) blood cultures before antibiotics; 2) parenteral antibiotics administered less than or equal to 180 minutes from greater than or equal to two systemic inflammatory response syndrome "and" lactate ordered, or less than or equal to 60 minutes from "time-zero," whichever occurs earlier; 3) lactate result available less than or equal to 90 minutes postorder; and 4) 30 mL/kg IV crystalloid bolus initiated less than or equal to 30 minutes from "time-zero." Main outcomes were in-hospital mortality (all cohorts) and total direct costs (cohorts 2 and 3). MEASUREMENTS AND MAIN RESULTS/RESULTS:Cohort 1: 5,819 total patients; 1,050 (18.0%) bundle compliant. Mortality: 604 (22.6%) versus 834 (26.5%); CI, 0.9-7.1%; adjusted odds ratio, 0.72; CI, 0.61-0.86; p value is less than 0.001. Cohort 2: 1,697 total patients; 739 (43.5%) bundle compliant. Mortality: 99 (13.4%) versus 171 (17.8%), CI, 1.0-7.9%; adjusted odds ratio, 0.60; CI, 0.44-0.80; p value is equal to 0.001. Mean costs: $14,845 versus $20,056; CI, -$4,798 to -5,624; adjusted β, -$2,851; CI, -$4,880 to -822; p value is equal to 0.006. Cohort 3: 7,239 total patients; 2,115 (29.2%) bundle compliant. Mortality: 383 (18.1%) versus 1,078 (21.0%); CI, 0.9-4.9%; adjusted odds ratio, 0.84; CI, 0.73-0.96; p value is equal to 0.013. Mean costs: $17,885 versus $22,108; CI, -$2,783 to -5,663; adjusted β, -$1,423; CI, -$2,574 to -272; p value is equal to 0.015. CONCLUSIONS:In three independent cohorts, 3-hour bundle compliance was associated with improved survival and cost savings.

BACKGROUND/AIMS/OBJECTIVE:Opiate use for inflammatory bowel disease (IBD), particularly high-dose (HD) use, is associated with increased mortality. It's assumed that opiate use is directly related to IBD-related complaints, although this hasn't been well defined. Our goal was to determine the indications for opiate use as a first step in developing strategies to prevent or decrease opiate use. METHODS:A retrospective cohort was formed of adults who were diagnosed with IBD and for whom outpatient evaluations from 2009 to 2014 were documented. Opiate use was defined if opiates were prescribed for a minimum of 30 days over a 365-day period. Individual chart notes were then reviewed to determine the clinical indication(s) for low-dose (LD) and HD opiate use. RESULTS:=0.0071) was more common among HD than among LD. CONCLUSIONS:Our findings show that most IBD patients using opiates, particularly HD users, used opiates for IBD-related complaints. Future research will need to determine the degree to which these complaints are related to disease activity and to formulate non-opiate pain management strategies for patients with both active and inactive IBD.

Subtle lameness makes it difficult to ascertain which is the affected limb. A study was conducted to investigate a change in the thermal pattern and temperature of the thermal image of the paw print in a lame pelvic limb compared to a non-lame pelvic limb of dogs confirmed by orthostatic analysis. Fourteen client owned dogs with a unilateral pelvic limb lameness and 14 healthy employee dogs were examined and the pelvic limbs radiographed. Thermal images of the paw print were taken after each dog was kept in a static position on a foam mat for 30 seconds. Average temperatures and thermographic patterns were analyzed. Analysis was performed in a static position. The asymmetry index for each stance variable and optimal cutoff point for the peak vertical force and thermal image temperatures were calculated. Image pattern analysis revealed 88% success in differentiating the lame group, and 100% in identifying the same thermal pattern in the healthy group. The mean of the peak vertical force revealed a 10.0% difference between the left and right pelvic limb in healthy dogs and a 72.4% between the lame and non-lame limb in the lame dog group. Asymmetry index analysis revealed 5% in the healthy group and 36.2% in the lame group. The optimal cutoff point for the peak vertical force to determine lameness was 41.77% (AUC = 0.93) and for MII 0.943% (AUC = 0.72). The results of this study highlight the change in the thermal pattern of the paw print in the lame pelvic limb compared to a non-lame pelvic limb in the lame group and the healthy group. Medical infrared imaging of the paw prints can be utilized to screen for the lame limb in dogs.

OBJECTIVES:To evaluate knowledge, beliefs, and practices regarding delirium of physicians, nurse practitioners (NPs), and registered nurses (RNs). DESIGN:Anonymous cross-sectional paper survey. SETTING:New York metropolitan area tertiary care hospital. PARTICIPANTS:RNs, NPs, and physicians (N = 164). MEASUREMENTS:The survey assessed knowledge, beliefs, and practices regarding delirium and prior delirium or geriatric training. RESULTS:Of the 200 surveys distributed, 164 were completed (82% response rate). Of these, 61.7% were RNs, 13.6% were NPs, and 20.7% were physicians. Mean participant age was 36.3. The majority (80.1%) were female; 56.5% were white, 18.1% Asian, 8.7% Hispanic, 8.0% black, and 8.7% other. Of the seven potential barriers to delirium screening assessed, the three most frequently reported were lack of conceptual understanding of delirium (48.0%), similarity of delirium and dementia (41.4%), and the fluctuating nature of delirium (38.1%). Physicians were more likely than NPs and RNs to report being confident in identifying delirium (P = .002) and to score higher on the delirium knowledge assessment (P < .001). Participants who received geriatrics training were significantly more likely than those who did not to be confident in identifying delirium (P = .005) and to score higher on overall delirium knowledge assessment (P = .003). CONCLUSION:Geriatric training is associated with more confidence in delirium screening and higher delirium knowledge scores. There is an urgent need to broaden the approach to delirium education of nurses and physicians caring for hospitalized older adults using comprehensive multidisciplinary geriatric educational models.

STUDY OBJECTIVE: We evaluate the association of intravenous fluid resuscitation initiation within 30 minutes of severe sepsis or septic shock identification in the emergency department (ED) with inhospital mortality and hospital length of stay. We also compare intravenous fluid resuscitation initiated at various times from severe sepsis or septic shock identification's association with the same outcomes. METHODS: This was a review of a prospective, observational cohort of all ED severe sepsis or septic shock patients during 13 months, captured in a performance improvement database at a single, urban, tertiary care facility (90,000 ED visits/year). The primary exposure was initiation of a crystalloid bolus at 30 mL/kg within 30 minutes of severe sepsis or septic shock identification. Secondary analysis compared intravenous fluid initiated within 30, 31 to 60, or 61 to 180 minutes, or when intravenous fluid resuscitation was initiated at greater than 180 minutes or not provided. RESULTS: Of 1,866 subjects, 53.6% were men, 72.5% were white, mean age was 72 years (SD 16.6 years), and mean initial lactate level was 2.8 mmol/L. Eighty-six percent of subjects were administered intravenous antibiotics within 180 minutes; 1,193 (64%) had intravenous fluid initiated within 30 minutes. Mortality was lower in the within 30 minutes group (159 [13.3%] versus 123 [18.3%]; 95% confidence interval [CI] 1.4% to 8.5%), as was median hospital length of stay (6 days [95% CI 6 to 7] versus 7 days [95% CI 7 to 8]). In multivariate regression that included adjustment for age, lactate, hypotension, acute organ dysfunction, and Emergency Severity Index score, intravenous fluid within 30 minutes was associated with lower mortality (odds ratio 0.63; 95% CI 0.46 to 0.86) and 12% shorter length of stay (hazard ratio=1.14; 95% CI 1.02 to 1.27). In secondary analysis, mortality increased with later intravenous fluid resuscitation initiation: 13.3% (180 minutes). Median hospital length of stay also increased with later intravenous fluid initiation: 6 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 7 days) versus 7 days (95% CI 6 to 8 days) versus 8 days (95% CI 7 to 9 days). CONCLUSION: The time of intravenous fluid resuscitation initiation was associated with improved mortality and could be used as an easier obtained alternative to intravenous fluid completion time as a performance indicator in severe sepsis and septic shock management.

The goal of this study was to determine how B-cell-activating factor of the TNF family (BAFF) availability influences selection of the autoreactive B-cell repertoire in NZB/W and NZW/BXSB lupus-prone mice bearing the site-directed heavy-chain transgene 3H9 that encodes for anti-dsDNA and anti-cardiolipin (CL) autoantibodies. We used a bone marrow chimera system in which autoreactive 3H9 transgenic B cells were allowed to mature in competition with wild-type cells and could be identified by green fluorescent protein. The light-chain repertoire associated with the 3H9 heavy chain in naive and antigen-activated B-cell subsets was assessed using single-cell polymerase chain reaction. We found that deletion of autoreactive transgenic B cells occurred in the bone marrow of both strains regardless of BAFF availability, and there were only modest and physiologically non-relevant effects on the naive B-cell repertoire. BAFF inhibition had different effects on selection of the germinal center repertoire in the two strains. In the NZW/BXSB strain, BAFF inhibition phenocopied the loss of one TLR7 allele in that it influenced the selection of 3H9-encoded autoreactive B cells in the germinal center but did not prevent somatic mutation. In the NZB/W strain, BAFF inhibition did not alter the selection of 3H9-encoded B cells in the germinal center, but it influenced selection of a subset of germinal center cells into the plasma cell compartment. Our data underscore the complexity of regulation of the autoreactive B-cell repertoire by BAFF and may help to explain the heterogeneity of responses observed after BAFF inhibition in humans.

OBJECTIVES/OBJECTIVE:The purpose of this study was to assess and compare the perceptions of hematologists, medical oncologists, cancer patients aged 65 years and older, and family members/caregivers regarding the value of a geriatric assessment (GA) in the management of older adults with cancer. METHODS:Participants included adults with cancer aged 65 years and older (n = 66), patient family members/caregivers (n = 32), and physicians (n = 42). A patient survey, a caregiver/family survey, and an online physician survey targeted to hematologists and medical oncologists were distributed at a large cancer center in a major academic health system in the New York metropolitan area. The χ(2) test or the Fisher exact test was used to compare the cohorts for responses to geriatric domains in a GA. RESULTS:Comparisons for each of the 17 GA domains between patient and family member and caregiver responses showed concordance, except for the perception of comorbidities; 16.7% of patients indicated that comorbidities were an issue, compared with 29.0% of family/caregivers (P = 0.047). Physicians indicated that a GA would be most helpful in addressing cognitive impairment (91.4%), falls (91.4%), and functional status (88.6%). CONCLUSIONS:A GA would be useful for physicians and older adults with cancer. Hematologists and medical oncologists recognize the utility of a GA and are receptive to a multidisciplinary geriatrics-oncology collaboration.

BACKGROUND:Traumatic pancreatic injuries are rare, and guidelines specifying management are controversial and difficult to apply in the acute clinical setting. Due to sparse data on these injuries, we carried out a retrospective review to determine outcomes following surgical or non-surgical management of traumatic pancreatic injuries. We hypothesize a higher morbidity and mortality rate in patients treated surgically when compared to patients treated non-surgically. METHODS:test and categorical variables using the chi-square and Fisher's exact tests. Univariate analysis was performed to determine the possible confounding factors associated with mortality in both treatment groups. RESULTS: = 0.010). CONCLUSIONS:Patients with traumatic pancreatic injuries treated operatively were more severely injured and suffered greater complications than those treated non-operatively. The greater morbidity and mortality associated with these patients warrants further study to determine optimal triage strategies and which subset of patients is likely to benefit from surgery.

BACKGROUND/AIMS:Frame application for gamma knife radiosurgery (GKR) may be perceived as painful by patients. This study was designed to assess the efficacy of EMLA (2.5% lidocaine/2.5% prilocaine) in pain reduction. METHODS:This was a prospective, randomized, and controlled trial approved by our institutional review board. Fifty-four patients undergoing outpatient GKR were divided into EMLA and placebo groups. Prior to frame placement, EMLA/placebo was applied to the patient's forehead. A visual analog scale (VAS) was used to measure pain during 4 intervals: frontal injections, occipital injections, frontal screw insertion, and overall discomfort. This study was designed to observe a difference of 1.0 on the VAS at a power of 95%. RESULTS:VAS for EMLA versus placebo for frontal injections (5.2 ± 2.7 vs. 5.7 ± 2.0, respectively; p < 0.45), back injections, (6.5 ± 2.2 vs. 5.9 ± 2.3, respectively; p < 0.30), frontal pins (4.6 ± 2.7 vs. 4.6 ± 2.2, respectively; p < 0.99), and overall discomfort (p < 0.29) were not significantly different. A comparison between back and frontal injections for EMLA (6.54 vs. 5.19, respectively; p < 0.16) and placebo (5.89 vs. 5.68, respectively; p < 0.69) showed no significant difference between group and location (p < 0.21). CONCLUSION:Application of EMLA did not significantly reduce pain when used preoperatively for frame fixation. EMLA is no longer used as part of our routine for patients undergoing GKR.