Albert B. Chandler Hospital

Introduction: The purpose of this study was to investigate the trauma community’s use of the CAM scoring for delirium, and what shortfalls they believe it has in practice. Additionally, we wanted to discover what can be done to improve delirium care. Methods: A ten-question mixed-methods survey was sent to the members of the Society of Trauma Nurses via Email listserv. The survey included two open-response questions, allowing three responses for each question, and eight multiple-choice questions about delirium and delirium scoring. Results: There were 130 respondents who completed the survey. The majority (42.5%%) are using CAM-B for scoring delirium, however, it was shocking that we discovered 35% indicated currently not using any scoring for delirium. Sleep/wake cycle bundle was reported as the most utilized intervention with CAM-positive patients. Mandatory screening was the most suggested change for improvement of delirium management. Conclusions: A significant amount (35%) of our participants were not using any screening tool for delirium. Education of providers and nurses of the importance of CAM scoring as well as improving the utilization of the CAM score across all areas of inpatient care was indicated as much needed by participants. Those surveyed did not think that facilities had protocolized interventions when a patient was CAM positive, and also they expressed frustration with using the tool screening patients with traumatic brain injury and dementia. This is a potential practice improvement area to improve patient outcomes. The new unifying definition of delirium is a one of the many ways we are improving care for these patients, however this study indicated that additional research is needed to discover the best ways to educate nurses and providers on the importance of delirium and utilizing EMR communication now that the platform has become more advanced.

A 22-year-old African American male patient presented to the emergency department (ED) with blood-tinged vomiting and chest tightness. Workup in the ED showed acute renal failure with pulmonary septic emboli on computed tomography (CT) imaging. He was admitted to the hospital. During his hospital stay, aerobic/anaerobic venous blood cultures were positive for Fusobacterium necrophorum, and an ultrasound of the internal jugular vein revealed a deep vein thrombosis (DVT) consistent with septic thrombophlebitis. He was subsequently diagnosed with Lemierre syndrome. Evaluation for oropharyngeal disease, a more common cause, was negative, making this an atypical presentation. The patient was initially treated with piperacillin-tazobactam, then tailored to metronidazole based on susceptibility for four weeks, and had a full recovery.

Emergency clinicians frequently care for patients with complications from underlying opioid use disorder. While many clinicians are comfortable addressing the immediate medical complications of opioid use disorder, too many do not offer evidence-based medications that stabilize the patient by alleviating withdrawal and cravings, and that also treat opioid use disorder, the underlying cause of the presentation. Because medication for opioid use disorder, namely methadone and buprenorphine, reduces the risk of death by up to 50%, this omission at a critical touchpoint in the health care system misses an opportunity to engage people in care and reduce fatal overdose. It also exposes the emergency department and health care facility to potential legal liability. Under federal civil rights laws, it is illegal to discriminate against people with opioid use disorder; discrimination may include failure to screen for and diagnose opioid use disorder and offer medications for opioid use disorder alongside a facilitated referral for outpatient treatment. Advocates for a more effective emergency department response to opioid use disorder can use these civil rights laws to press for the adoption of evidence-based practices for people with opioid use disorder. Legal advocacy is an important tool to utilize during this unrelenting overdose crisis.

Patients with chronic kidney disease and CAD have been denied revascularization because of fear of precipitating acute renal failure from contrast exposure. Skepticism on whether Ultra-Low contrast percutaneous coronary intervention (PCI) or Zero contrast PCI (ULC/ZC PCI) can be safely performed has limited its adoption. This observational registry enrolled 200 consecutive patients referred for elective PCI at a single center from June 2021 to December 2022. The study investigated whether the clinical outcomes of PCI performed with UL/ZC-PCI (n-48) were comparable to outcomes following standard PCI (n-152). Both groups were well matched in baseline and procedural characteristics. The groups had a highly statistical difference in the use of CV. Mean CV was 19.17 ± 7.29 cc in the ULC/ZC-group and 147.14 ± 73.55 cc in the control arm. The principal findings of the study were that the incidence of ontrast-induced acute kidney injury (AKI) was eightfold lower in patients receiving UL/ZC compared to the control group that received standard PCI. The incidence of all-cause mortality, myocardial infarction and major bleeding were similar in both groups. At 6 months, the decrement in renal function was lower in the group that received lower volumes of contrast. This single center observational registry demonstrated that UL-C/ZC-PCI is safe and effective in a broad spectrum of complex lesions. The skillsets needed to perform this are teachable, widely applicable and do not require a large upgrade of capital equipment. AKI rates and decrement in renal function at 6 months were both significantly lower in the UL-ZC group.

Octreotide could increase serum sodium in cirrhotics with hyponatremia by counteracting splanchnic vasodilation. Current supporting data is limited to case reports and series. The aim of the study is to assess the effect of octreotide on serum sodium in cirrhotic inpatients with hyponatremia compared with controls. This is a retrospective study including adult inpatients with cirrhosis, admitted for ≥5 days with Na <133 at baseline. We excluded those receiving other vasoconstrictor infusions, hypertonic saline, tolvaptan or dialysis. Controls represented an equal number of inpatients with cirrhosis not receiving octreotide. Sodium changes on days 5, 7 and 10 were evaluated with multivariable adjustment. Each group consisted of 156 patients. The octreotide subjects had more cirrhosis complications. Baseline sodium was lower in the octreotide group, and their change in sodium at day 5 was higher (6.6 ± 5.6 vs. 3.5 ± 5.3; P < 0.001). Significant differences were also noted on days 7 and 10 (7.84 ± 6.76 vs. 4.33 ± 6.2 and 7.99 ± 6.72 vs. 5.2 ± 6.56, respectively). The impact of octreotide was lessened but remained significant ( P = 0.019) in a mixed model adjusting for baseline sodium, creatinine, requirement of paracentesis, midodrine, albumin and fresh frozen plasma. More octreotide patients achieved hyponatremia resolution (55.1% vs. 42.3%; P = 0.031), but significance was not preserved in multivariate logistic regression. Octreotide administration is associated with an increase in serum sodium among inpatient cirrhotics with hyponatremia, even after accounting for confounders. Prospective randomized controlled trials are warranted.

Dr. DiDomenico is a member of the JACCP editorial board. All other authors declare no potential conflict of interest.

decongestive therapy estimated plasma volume status fractional excretion of urea nitrogen

Because the effects of age, menopausal status, weight and body mass index (BMI) on ovarian detectability by transvaginal ultrasound (TVS) have not been established, we determined their contributions to TVS visualization of the ovaries. A total of 29,877 women that had both ovaries visualized on their first exam were followed over 202,639 prospective TVS exams. All images were reviewed by a physician. While visualization of both ovaries decreased with age, one or both ovaries could be visualized in two of every three women over 80 years of age. Around 93% of pre-menopausal women and ~69% of post-menopausal women had both ovaries visualized. Both ovaries were visualized in ~72% of women weighing over 300 lbs. and in ~70% of women with a BMI over 40. Conclusions: Age had the greatest influence on the visualization of the ovaries. The ovaries can be visualized well past the menopause. Body habitus was not limiting to TVS ovarian imaging, and TVS should be considered capable of imaging one or both ovaries in two of every three women over 80 years of age. Thus, older and obese patients remain good candidates for TVS exams.