1
|
Tsoulis MW, Hsu Blatman KS, Chow VW, Stewart KO, Wang R, Reigh EL. A nurse-driven penicillin allergy risk score in the preoperative setting was associated with increased cefazolin use perioperatively. J Clin Anesth 2024; 95:111443. [PMID: 38484506 DOI: 10.1016/j.jclinane.2024.111443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/19/2024] [Accepted: 03/07/2024] [Indexed: 04/29/2024]
Abstract
STUDY OBJECTIVE To characterize and assess the effects of a preoperative, nurse-driven penicillin allergy risk stratification tool on rates of perioperative cefazolin and second-line antibiotic use. DESIGN Quasi-experimental quality improvement study of penicillin-allergic surgical patients undergoing procedures for which cefazolin is indicated. SETTING Outpatient Perioperative Care Clinic (PCC) for preoperative surgical patients at a tertiary care center. PATIENTS 670 and 1371 adult penicillin-allergic PCC attendants and non-attendants, respectively. INTERVENTION A paper penicillin allergy risk stratification questionnaire was administered during the PCC visit. Nurses were educated on its use. MEASUREMENTS Antibiotic (cefazolin, clindamycin, vancomycin) use rates in the 24 months before and 17 months after intervention implementation in November 2020 (November 2018 - April 2022) were assessed in penicillin-allergic PCC attendants with statistical process control charts. Multivariable logistic regression assessed antibiotic use rates pre- and post-intervention adjusting for age, sex, surgical specialty and penicillin allergy history severity. Similar analyses were done in penicillin-allergic PCC non-attendants. MAIN RESULTS Of 670 penicillin-allergic PCC attendants, 451 (median [IQR] age, 66 (Sousa-Pinto et al., 2021 [14])) were analyzed pre-intervention and 219 (median [IQR] age, 66 (Mine et al., 1970 [13])) post-intervention. One month after implementation, process measures demonstrated an upward shift in cefazolin use for PCC attendants versus no shift or other special cause variation for PCC non-attendants. There were increased odds of cefazolin use (aOR 1.67, 95% CI [1.09-2.57], P = 0.019), decreased odds of clindamycin use (aOR 0.61, 95% CI [0.42-0.89], P = 0.010) and decreased odds of vancomycin use (aOR 0.56, 95% CI [0.35-0.88], P = 0.013) in PCC attendants post-intervention. This effect did not occur in PCC non-attendants. There was no increase in perioperative anaphylaxis post-intervention. CONCLUSIONS A simple penicillin allergy risk stratification tool implemented in the preoperative setting was associated with increased use of cefazolin and decreased rates of second-line agents post implementation.
Collapse
Affiliation(s)
- Michael W Tsoulis
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA
| | - Karen S Hsu Blatman
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA; Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA
| | - Vinca W Chow
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA; Department of Anesthesiology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Kathleen O Stewart
- The Dartmouth Institute for Health Policy and Clinical Practice, 1 Medical Center Drive, Lebanon, NH 03766, USA; Collaborative Healthcare-associated Infection Prevention Program, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Rebecca Wang
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA; The Dartmouth Institute for Health Policy and Clinical Practice, 1 Medical Center Drive, Lebanon, NH 03766, USA; Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Erin L Reigh
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA; Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA.
| |
Collapse
|
2
|
Abess AT, Deiner SG, Briggs A, Whitlock EL, Charette KE, Chow VW, Shaefi S, Martinez-Camblor P, O'Malley AJ, Boone MD. Association of neurocognitive disorders with morbidity and mortality in older adults undergoing major surgery in the USA: a retrospective, population-based, cohort study. Lancet Healthy Longev 2023; 4:e608-e617. [PMID: 37924842 PMCID: PMC10654795 DOI: 10.1016/s2666-7568(23)00194-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Neurocognitive disorders become increasingly common as patients age, and increasing numbers of surgical interventions are done on older patients. The aim of this study was to understand the clinical characteristics and outcomes of surgical patients with neurocognitive disorders in the USA in order to guide future targeted interventions for better care. METHODS This retrospective cohort study used claims data for US Medicare beneficiaries aged 65 years and older with a record of inpatient admission for a major diagnostic or therapeutic surgical procedure between Jan 1, 2017, and Dec 31, 2018. Data were retrieved through a data use agreement between Dartmouth Hitchcock Medical Center and US Centers for Medicare and Medicaid Services via the Research Data Assistance Center. The exposure of interest was the presence of a pre-existing neurocognitive disorder as defined by diagnostic code within 3 years of index hospital admission. The primary outcome was mortality at 30 days, 90 days, and 365 days from date of surgery among all patients with available data. FINDINGS Among 5 263 264 Medicare patients who underwent a major surgical procedure, 767 830 (14·59%) had a pre-existing neurocognitive disorder and 4 495 434 (85·41%) had no pre-existing neurocognitive disorder. Adjusting for demographic factors and comorbidities, patients with a neurocognitive disorder had higher 30-day (hazard ratio 1·24 [95% CI 1·23-1·25]; p<0·0001), 90-day (1·25 [1·24-1·26]; p<0·0001), and 365-day mortality (1·25 [1·25-1·26]; p<0·0001) compared with patients without a neurocognitive disorder. INTERPRETATION Our findings suggest that the presence of a neurocognitive disorder is independently associated with an increased risk of mortality. Identification of a neurocognitive disorder before surgery can help clinicians to better disclose risks and plan for patient care after hospital discharge. FUNDING Department of Anesthesiology and Perioperative Medicine at Dartmouth Hitchcock Medical Center.
Collapse
Affiliation(s)
- Alexander T Abess
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
| | - Stacie G Deiner
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Alexandra Briggs
- Department of Surgery, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Elizabeth L Whitlock
- Department of Anesthesia and Perioperative Care, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Kristin E Charette
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Vinca W Chow
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Pablo Martinez-Camblor
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Alistair James O'Malley
- Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Myles Dustin Boone
- Department of Anesthesiology and Perioperative Medicine, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| |
Collapse
|
3
|
Theophanous RG, Chow VW, Convissar DL, Haskins SC, Jones RA, P Kalagara HK, Bronshteyn YS. Point-Of-Care Ultrasound Screening for Proximal Lower Extremity Deep Venous Thrombosis. J Vis Exp 2023. [PMID: 36847361 DOI: 10.3791/64601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Acute lower extremity deep venous thrombosis (DVT) is a serious vascular disorder that requires accurate and early diagnosis to prevent life-threatening sequelae. While whole leg compression ultrasound with color and spectral Doppler is commonly performed in radiology and vascular labs, point-of-care ultrasound (POCUS) is becoming more common in the acute care setting. Providers appropriately trained in focused POCUS can perform a rapid bedside examination with high sensitivity and specificity in critically ill patients. This paper describes a simplified yet validated approach to POCUS by describing a three-zone protocol for lower extremity DVT POCUS image acquisition. The protocol explains the steps in obtaining vascular images at six compression points in the lower extremity. Beginning at the level of the proximal thigh and moving distally to the popliteal space, the protocol guides the user through each of the compression points in a stepwise manner: from the common femoral vein to the femoral and deep femoral vein bifurcation, and, finally, to the popliteal vein. Further, a visual aid is provided that may assist providers during real-time image acquisition. The goal in presenting this protocol is to help make proximal lower extremity DVT exams more accessible and efficient for POCUS users at the patient's bedside.
Collapse
Affiliation(s)
| | - Vinca W Chow
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center
| | | | - Stephen C Haskins
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery; Department of Anesthesiology, Weill-Cornell Medical College
| | - Robert A Jones
- Department of Emergency Medicine, MetroHealth Medical Center/Case Western Reserve University
| | | | | |
Collapse
|
4
|
Bachman SA, Chow VW, Kuwayama DP, Hickerson LC. Management of Hemorrhage and Heart Transplant in Non-Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:3078-3080. [PMID: 32423735 DOI: 10.1053/j.jvca.2020.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/27/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Sarah A Bachman
- Division of Anesthesia, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Vinca W Chow
- Division of Anesthesia and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David P Kuwayama
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Leigh C Hickerson
- Division of Anesthesia and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| |
Collapse
|
5
|
Sigurdsson MI, Eoh EJ, Chow VW, Waldron NH, Cleve J, Nicoara A, Swaminathan M. Utility of Angle Correction for Hemodynamic Measurements with Doppler Echocardiography. J Cardiothorac Vasc Anesth 2018; 32:1768-1774. [PMID: 29752056 DOI: 10.1053/j.jvca.2018.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The routine application angle correction (AnC) in hemodynamic measurements with transesophageal echocardiography currently is not recommended but potentially could be beneficial. The authors hypothesized that AnC can be applied reliably and may change grading of aortic stenosis (AS). DESIGN Retrospective analysis. SETTING Single institution, university hospital. PARTICIPANTS During phase I, use of AnC was assessed in 60 consecutive patients with intraoperative transesophageal echocardiography. During phase II, 129 images from a retrospective cohort of 117 cases were used to quantify AS by mean pressure gradient. INTERVENTIONS A panel of observers used custom-written software in Java to measure intra-individual and inter-individual correlation in AnC application, correlation with preoperative transthoracic echocardiography gradients, and regrading of AS after AnC. MEASUREMENTS AND MAIN RESULTS For phase I, the median AnC was 21 (16-35) degrees, and 17% of patients required no AnC. For phase II, the median AnC was 7 (0-15) degrees, and 37% of assessed images required no AnC. The mean inter-individual and intra-individual correlation for AnC was 0.50 (95% confidence interval [CI] 0.49-0.52) and 0.87 (95% CI 0.82-0.92), respectively. AnC did not improve agreement with the transthoracic echocardiography mean pressure gradient. The mean inter-rater and intra-rater agreement for grading AS severity was 0.82 (95% CI 0.81-0.83) and 0.95 (95% CI 0.91-0.95), respectively. A total of 241 (7%) AS gradings were reclassified after AnC was applied, mostly when the uncorrected mean gradient was within 5 mmHg of the severity classification cutoff. CONCLUSIONS AnC can be performed with a modest inter-rater and intra-rater correlation and high degree of inter-rater and intra-rater agreement for AS severity grading.
Collapse
Affiliation(s)
- Martin I Sigurdsson
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Eun J Eoh
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Vinca W Chow
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Nathan H Waldron
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jayne Cleve
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Alina Nicoara
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | | |
Collapse
|
6
|
Abstract
Fragmented and variable perioperative care exposes patients to unnecessary risks and handoff errors. The perioperative surgical home aims to optimize quality, value-based care. We performed a retrospective evaluation of how a preoperative assessment center could coordinate care through e-mails sent to a patient's healthcare team that initiate discussion on critical clinical information. During 100 clinic days on which 8122 patients were evaluated, 606 triggered e-mails, with a potential impact on 19 elements across the perioperative care spectrum. Four cases were canceled, and 42 cases were rescheduled. By fostering information exchange, these communications could advance patient-centered, value-enhanced quality and safety outcomes.
Collapse
Affiliation(s)
- Vinca W Chow
- From the Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | | |
Collapse
|
7
|
Wang ZH, Yu D, Li HK, Chow VW, Ng CC, Chan HB, Cheng SB, Chew EC. Alteration of nuclear matrix protein composition of neuroblastoma cells after arsenic trioxide treatment. Anticancer Res 2001; 21:493-8. [PMID: 11299786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The aims of the present study were to assess the effects of arsenic trioxide on the nuclear matrix protein profiles of mouse neuroblastoma cells. Arsenic trioxide induces apoptosis of acute promyelocytic leukemia cells. Our results demonstrated that 2 microM As2O3 could significantly inhibit the growth of Neuro-2a cells. As early as 24 hours after As2O3 treatment, we began to observe the alteration of nuclear matrix proteins and apoptosis in tumor cells by TUNEL assay but not by DNA ladder. An increase expression of Hsc in nuclear matrix proteins of 2 microM As2O3 treated cells was also noted. Our results also showed that before a mass range of apoptosis occurred, the composition of nuclear matrix proteins had altered. Hence the alteration of nuclear matrix proteins, such as increased expression of Hsc, may be a sensitive indicator for the detection of early apoptosis.
Collapse
Affiliation(s)
- Z H Wang
- Department of Anatomy, Chinese University of Hong Kong, China
| | | | | | | | | | | | | | | |
Collapse
|
8
|
Chen HB, Chen L, Zhung JK, Chow VW, Wu BQ, Wang ZH, Cheng SB, Chew EC. Expression of laminin in metastatic melanoma cell lines with different metastatic potential. Anticancer Res 2001; 21:505-8. [PMID: 11299788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Cancer metastasis is a complex multi-step process in which tumor cells leave the primary site and develop a secondary tumor in distant organs. Laminin plays an important role in this process. The expression of laminin in four melanoma cell lines with different metastatic potentials was investigated by immunohistochemistry, immunogold electron microscopy and Western blotting. Our results showed that the expression of endogenous laminin and the percentage of the positive cells are higher with increased metastatic potentials. It is, thus, suggested that endogenous laminin may contribute to the different metastatic properties in the melanoma cell line.
Collapse
Affiliation(s)
- H B Chen
- Department of Histology and Embryology, Shantou Medical College, Shantou, China
| | | | | | | | | | | | | | | |
Collapse
|