West Virginia School of Osteopathic Medicine

Isovolemic hemodilution red cell exchange (IHD-RCE) (as compared to standard, or STD-RCE) may: reduce per-procedure RBC use, result in a lower fraction of cells remaining (FCR), and provide an "iron unloading" benefit. We review the published literature to explore whether these benefits have been realized in real-world settings. A literature search was conducted in PubMed, Embase, EBSCOhost, and Cochrane Library. Additional studies were identified through bibliography review. To be included, studies required STD-RCE versus IHD-RCE comparison groups. Data, including RBC utilization, actual FCR, ferritin levels, pre-hemoglobin S% (HbS%), and procedure intervals were extracted and analyzed using descriptive statistics. The initial search and bibliography review yielded 70 studies; 48 were excluded for not meeting inclusion criteria; of the remainder, 3 reports met full inclusion criteria and were retained for data extraction. Compared to STD-RCE, IHD-RCE reliably reduced red cell requirements, with reduction (in mL/mL Total Blood Volume) from 0.55 (0.42-0.66) to 0.49 (0.34-0.54), among 15 patients (p = 0.02); and (in mL/kg) from 39.5 ± 4.6 to 35.5 ± 4.1 (p < 0.001) in another 20 patients. While actual FCR was lower than programmed FCR with both STD-RBCx and IHD-RBCx, the magnitude of this difference was not significantly different (n = 15). Among 26 patients for whom ferritin levels were reported, a clear reduction was not observed. Furthermore, no clear safety signals were observed. Conversion to IHD-RCE appears safe and reduces per-procedure RBC utilization by approximately 1 unit. IHD-RCE did not demonstrate a clear iron-unloading benefit over STD-RCE.

Cefazolin is the preferred prophylactic antibiotic for many surgical procedures but is often unnecessarily avoided in patients with reported penicillin and/or cephalosporin allergies. This quality improvement project aimed to increase cefazolin use for preprocedural prophylaxis in these patients. Quasi-experimental quality improvement study Safety net healthcare system in the United States Patients with reported penicillin and/or cephalosporin allergies undergoing procedures requiring antibiotic prophylaxis and anesthesiology services from January 2022 to October 2023 Interventions included the development of allergy management algorithms, educational sessions, electronic medical record updates, and audit and feedback by pharmacists The primary outcomes were changes in proportions of procedures for which cefazolin, clindamycin, and vancomycin were used for preprocedural antibiotic prophylaxis. The secondary outcomes were changes in proportions of procedures in which appropriate dose and timing of preprocedural antibiotic prophylaxis were administered. Data from 3414 patients undergoing various procedures requiring antibiotic prophylaxis and anesthesiology services during the study period were analyzed. The use of cefazolin increased from 30% pre-intervention to 73% post-intervention (p < 0.001), while clindamycin use decreased from 51% to 13% (p < 0.001), and vancomycin use decreased from 5.8% to 3.9% (p = 0.012). Appropriate antibiotic dosing increased from 89% to 93% (p = 0.048), and appropriate timing of preprocedural antibiotics improved from 49% to 74% (p < 0.001). A multi-pronged intervention significantly increased cefazolin use in patients with reported penicillin and/or cephalosporin allergies, leading to optimized antibiotic prophylaxis and reduced use of less effective alternatives.

Migration of orthopedic screws into the bladder is a rare postoperative complication following surgical fixation of pelvic fractures. We present a case of a 61-year-old man who sustained a type 3 anteroposterior compression injury with pubic symphysis diastasis, left sacroiliac joint dislocation, and lumbar spine transverse process fracture. At the time of presentation open-reduction internal fixation of his pubic symphysis and closed-reduction percutaneous screw fixation of the left sacroiliac joint was performed. At his 6 month post operative visit, the patient was seen for follow up and reported mild pelvic pain and new urinary symptoms, including hematuria and recurrent urinary tract infections, which lead to further investigation. Imaging revealed findings concerning for migration of one of the pubic symphysis screws with bladder involvement. Cystoscopy confirmed the presence of a foreign body in the bladder. The patient subsequently underwent removal of the pelvic hardware, definitive bladder repair and left sacroiliac arthrodesis, followed by an uneventful postoperative course. This report describes the delayed presentation of spontaneous screw migration after repair of an open book pelvic fracture and describes the diagnostic and management considerations for patients with urinary symptoms after pubic symphysis open reduction internal fixation.

Intraventricular hemorrhage (IVH) is a well-recognized complication in preterm infants, but its presentation as fever can be easily overlooked, leading to extensive sepsis workups and delayed diagnosis. This case report presents two late preterm infants who developed fever as the primary presenting symptom of IVH. Distinguishing IVH-related fever from that due to infectious causes can be challenging in this vulnerable population, where overuse of antimicrobials carries significant risks, including altered microbiome development, necrotizing enterocolitis, and antimicrobial resistance. Incorporating early diagnostic evaluation for IVH through cranial ultrasound in late preterm infants presenting with unexplained fever may avoid unnecessary tests and promote judicious antimicrobial use while improving overall neonatal outcomes.

Rates of participation in community-based diabetes prevention programs (DPPs) are low among patients with prediabetes. This may be due, in part, to low rates of referrals to these programs from health systems. One key opportunity to augment clinicians' referrals to and patients' participation in DPPs may be through electronic health record referrals (eReferrals). We undertook a quality improvement initiative in a large, academic health system. Using the EpicCare Link feature of Epic (Epic Systems Corporation), we created an eReferral to local community-based DPPs. Eligibility criteria required that patients have an age of at least 18 years, a body mass index of at least 25 kg/m2, and prediabetes or a history of gestational diabetes. We conducted a retrospective evaluation of implementation outcomes from June 1, 2021 to June 30, 2022 using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) evaluation framework. During the evaluation period, 577 patients were referred to DPPs and 21% enrolled, defined as attending an information session and registering for a program. Thirty percent of 350 targeted primary care clinicians used the eReferral across 14 primary care clinics. Among all 124 referring clinicians, referral rates varied widely with a range of 1 to 46 referrals per clinician; 11% of referring clinicians contributed more than 50% of all referral orders. The large majority of referred patients (73% to 81%) met DPP eReferral eligibility criteria. An eReferral is a promising, scalable strategy to connect patients with prediabetes to community DPPs. Additional strategies are needed to enhance clinicians' use of the eReferral and patients' subsequent program engagement to fully optimize the reach and effectiveness of DPPs.

Acute coronary syndrome (ACS) in the postpartum period is a rare but serious complication, particularly in patients with a recent history of preeclampsia. Preeclampsia is a multifactorial disorder characterized by hypertension, proteinuria, and peripheral edema due to abnormal placentation and vascular remodeling. We present the case of a 21-year-old healthy female patient with no history of cardiovascular disease (CVD), one week postpartum after cesarean delivery for severe preeclampsia, who developed a non-ST elevation myocardial infarction (NSTEMI). Cardiac catheterization revealed a left anterior descending (LAD) artery aneurysm with 99% stenosis, necessitating urgent stenting. Despite the rarity, the aneurysm was suspected to be secondary to preeclampsia-related endothelial dysfunction. The patient was managed with dual antiplatelet therapy, heparin, and blood pressure control. After stabilization and discharge, she maintained regular follow-up with her primary care physician to discuss secondary prevention of further cardiovascular adverse events. Postpartum ACS, especially secondary to coronary artery aneurysm (CAA), is exceedingly rare but highlights the importance of cardiovascular monitoring in patients with a history of preeclampsia. This case underscores the need for further research into endothelial dysfunction and thrombogenicity in preeclampsia to improve screening, prevention, and management strategies.

During the COVID-19 pandemic, changes in migraine headaches have been observed. This case series of seven patients seeks to identify changes in migraines following COVID-19 infection and discuss the mechanisms by which these changes may have occurred. The study was composed of seven subjects with prior COVID-19 infection and a preceding history of migraine disorder. Most of the subjects presented with increased frequency and intensity of migraines shortly or immediately following COVID-19 infection. Many also described a shift in pain from local to diffuse headache. Additionally, some subjects developed other neuropsychiatric symptoms consistent with long COVID that included brain fog and, unusually, aphasia. After COVID-19 infection, six subjects had reduced efficacy for their medications and had to alter their regimen. Standard treatments such as Botox and anti-calcitonin gene-related peptide (anti-GCRP) had varied success among the cases. It is important to note that the pathophysiology of migraines during COVID-19 is still unclear and other factors can play a role. Nevertheless, individuals with a history of migraines noticed worsening symptoms and changes in medication efficacy following COVID-19 infection.