Rochester General Hospital Research Articles

Impact of Pulmonary Rehabilitation Stewardship Program on COPD Patients, Quality Improvement Project.

BackgroundPulmonary rehabilitation (PR) has multiple benefits in COPD patients. There are multiple barriers to utilize PR including lack of knowledge about the benefits of PR by providers.ObjectiveWe are conducting a Quality Improvement project to improve the referral rate of patients hospitalized for acute exacerbation of COPD to PR.MethodsAll patients admitted with a primary diagnosis of acute exacerbation of COPD requiring systemic steroids to Rochester General Hospital in the period between 7/1/2019 and 7/31/2019 were reviewed retrospectively. Between 7/15/2020 and 11/15/2020, we started a PR stewardship program, where we daily review patients hospitalized with acute COPD exacerbation, and then a note will be placed in the chart for the primary team to consider referring patients to PR upon discharge, patients’ charts were reviewed after discharge. The rate of referral before and after the intervention was compared.ResultsDuring the pre-intervention period, 16 patients (mean age 67.7) with confirmed COPD by spirometry were hospitalized for COPD exacerbation, among them only 2 were referred to PR upon discharge (12.5%). During the post intervention period, 16 patients (mean age 65.0) were admitted with acute COPD exacerbation, among them 10 were referred to PR upon discharge (62.5%) [50% difference (16.5%–71%, 95% CI), P value = 0.004].ConclusionIn our QI improvement project, we conclude that having a PR stewardship program to review patients hospitalized with COPD exacerbation significantly improves the referral rate to PR, and might help to improve utilization of those programs by patients who need them.

National Trends of Sex Disparity in the American College of Cardiology/American Heart Association Guideline Writing Committee Authors Over 15 Years.

National Trends of Sex Disparity in the American College of Cardiology/American Heart Association Guideline Writing Committee Authors Over 15 Years.

The Certainty of a Post-Bone Marrow Diagnosis: A Study of the Yield of Bone Marrow Biopsies in a Community Hospital Setting

Introduction: Most studies on the diagnostic yield of bone marrow biopsy including the one by Hot et al. have focused on the yield of bone marrow biopsies in diagnosing the source of fever of unknown origin. However, there have not been any studies performed to our knowledge looking at overall practice patterns and yield of bone marrow biopsies for diagnoses other than fever of unknown origin. We aim to determine the most common indications for performing bone marrow biopsies in a community-based teaching hospital as well as the yield of the biopsies in patients with specified and unspecified pre-test indications to estimate the rate of uncertain post-test diagnoses. Methods: We performed a retrospective data collection study at Rochester General Hospital, NY. A comprehensive search was conducted in our electronic medical data to identify all patients who underwent bone marrow biopsies over a 5 year period from January 2011 - December 2016 for indications other than fever of unknown origin. Patient data including demographics, pre-bone marrow biopsy diagnosis and post-bone marrow diagnosis was obtained. All patients above the age of 18 who underwent bone marrow biopsy for indications other than fever of unknown origin or follow up treatment of a hematological malignancy were included. Results: A total of 223 biopsies were performed. The median age was 59 years (age range- 23-95). One hundred and sixteen patients were male and 107 were female. The most common indications for performing bone marrow biopsy were evaluation of the following possible conditions: multiple myeloma (n=54), myelodysplastic syndrome [MDS] (n=47), lymphoma (n=28) and leukemia (n=18) as well as non-specific indications such as pancytopenia (n=40), anemia (n=22) and thrombocytopenia (n=11). The proportion of cases confirmed by bone marrow biopsy was 45/54 (83%) with the pre-marrow diagnosis of multiple myeloma, 34/47 cases (72%) with the pre-marrow diagnosis of MDS, 15/18 (83%) with the pre-marrow diagnosis of leukemia and 13/28 (46%) in those with the pre-marrow diagnosis of rule out lymphoma. Thirteen cases (18%) with possible MDS had post-bone marrow diagnoses of leukemia, anemia of chronic disease, myelofibrosis or medication-related changes. Five out of twenty two cases (23%) for anemia and 3/11 cases (27%) for thrombocytopenia without otherwise specified pre-bone marrow etiology had uncertain diagnosis after bone marrow biopsy. Conclusion: In about a fifth of patients necessitating a bone marrow, the diagnosis is discordant and can be surprising. It is also worth reporting that in these discordant results, non-hematological causes such as medications, anemia due to chronic diseases or conditions such as cirrhosis or splenomegaly from other etiologies were among the final diagnoses. Interestingly, 20% of the patients with unspecified pre-bone marrow diagnoses such as anemia or thrombocytopenia in our study had an unclear post-bone marrow diagnosis despite undergoing bone marrow biopsy. Our findings are a reminder that the bone marrow exam does not always lead to a definitive diagnosis and the need by exclusion to include in the differential non-hematological etiologies such as nutritional deficiencies, chronic kidney disease or autoimmune disorders. Disclosures No relevant conflicts of interest to declare.

Multiple Myeloma: Where Do We Lose Ground Along the Treatment Pathway?

Introduction: Despite progress made in the treatment of multiple myeloma (MM), a significant percentage of patients are unable to receive second line of therapy. Our study evaluated the burden of infectious complications, and other factors that may play a role in hindering patients from receiving subsequent lines of therapy at a comprehensive teaching hospital. Methods: Patients with MM treated between 2014 and 2019 at Rochester General Hospital were selected from the MM registry. Tool was designed on REDCap for retrospective data collection from electronic medical records. Patients who declined therapy, never received treatment, had smoldering myeloma, or with a concomitant immunocompromising state were excluded. Out of 159 patients, 119 were eligible for analysis. We studied the relationship between patient demographics, clinical characteristics, treatment regimens, and outcomes. Binary logistic regression was used to determine which factors were significant in determining advancement in the line of treatment. The chi-squared statistic was used to determine significance with a Type I error rate set at 0.05. Results: The median age at diagnosis of MM was 68.5 years (Interquartile range=59.2-76.9), 55.4% (n=66) were males, 72.3% (n=86) were Caucasian. Revised International Staging System (R-ISS) staging was available for 77 patients, 27.3% (n=21) were stage I, 58.4% (n=45) were stage II, and 14.3% (n=11) were stage III. Cytogenetics were available for 93 patients, 76.3% (n=71) were standard risk and 23.7% (n=22) were high risk [17p del, t(4;14) or t(4;16)]. A three-drug induction regimen was administered to 61.3% (n=73) patients. Autologous stem cell transplant was performed in 39.5 % (n=47). Sixty-seven patients (56.3 %) received second line therapy. Twenty-six patients did not have a relapse after the first line at the time of data censorship. Patients who did not receive a second line treatment after relapse or progression were 21.8% (n=26). The factors prohibiting proceeding to a second line regimen (can be multiple) included patient preference/poor performance status (n=15), death while on first line treatment (n=15), advanced age (n=6) and prohibitive co-morbidity (n=4). Binary logistic regression showed age to be a significant negative predictor for receiving second line therapy. The odds ratio (OR) of receiving second line therapy was 0.88 for every year increase in age, 95% CI (0.78-0.95), p=0.007 (Figure 1). One or more documented infections within 6 months of diagnosing MM or until transplant date occurred in 32.8% (n=39). Types of infections are depicted in Figure 2. Documented infection was a borderline significant negative predictor for receiving second line therapy with OR =0.23, 95% CI (0.05-1.003), p=0.059. Race, pre-existing chronic kidney disease (CKD), gender and high-risk cytogenetics were not significant predictors of receiving second line therapy (Figure 1). Conclusion: Our study identified advancing age as a significant negative predictive factor to receipt of second line therapy in MM. Documented infections, while borderline significant, had a high impact as to whether a patient receives second line therapy. Strategies such as a formalized geriatric assessment, tailored treatment for frail patients, and infection prevention measures might increase odds of receiving second line therapy and may result in improved outcomes. Disclosures Jamshed: Takeda, Amgen and Celgene: Honoraria.

Reflection: The Personal Is Public.

In this article, the author from Rochester General Hospital reflects on COVID impact: "Communication has sometimes suffered cold and automated relationship outcomes but there are oases in this dessert." Personal signals in a public world are humanizing artifacts in a new sterile and hypercontrolled virtual reality.

Elucidating the role of antibiotics on PAL release from E.coli

Sepsis can result from a systemic bacterial infection, followed by an over‐exuberant immune response, which leads to widespread inflammation. Severe sepsis can result in organ failure and in severe cases, death. Past studies have proposed a role for bacterial Peptidoglycan‐Associated Lipoprotein (Pal) in the pathogenesis of Gram‐negative bacterial sepsis. In this study, we confirmed that Pal is released from Gram‐negative bacteria, Escherichia coli (E. coli), under certain culture conditions, including in the presence of certain antibiotics. Our preliminary results suggest that different antibiotics have differential effects on Pal’s release from E.coli. Since the majority of sepsis patients are administered antibiotics, our findings may be of great significance to the medical field and the sepsis research community.Support or Funding InformationRIT FEAD/DRIG and NIH Bootcamp , RIT LSAMP program, Dr. Michael Pichichero Rochester General Hospital Research Institute

Chief Nursing Officer Council Partners With Sustainability Department to Develop a Model of Success for Reducing the Organization’s Carbon Footprint

The health care industry, a major contributor to greenhouse gas emissions and landfill waste, must focus on sustainable efforts. The American Nurses Association (ANA) Scope and Standards of Practice deems nurses accountable to achieve sustainable goals in the workplace. This article shows how the chief nursing officer (CNO) council of one health care system partnered with the organization’s sustainability department to integrate sustainability efforts into daily operations across the system. Each CNO was tasked to determine key performance indicators for their location, identify facility champions, and support sustainability efforts. Some joint initiatives included education, waste reduction and diversion, 501(c)3 donation, and device reprocessing. The health care industry, a major contributor to greenhouse gas emissions and landfill waste, must focus on sustainable efforts. The American Nurses Association (ANA) Scope and Standards of Practice deems nurses accountable to achieve sustainable goals in the workplace. This article shows how the chief nursing officer (CNO) council of one health care system partnered with the organization’s sustainability department to integrate sustainability efforts into daily operations across the system. Each CNO was tasked to determine key performance indicators for their location, identify facility champions, and support sustainability efforts. Some joint initiatives included education, waste reduction and diversion, 501(c)3 donation, and device reprocessing. Deborah C. Stamps, EdD, MBA, MS, RN, GNP, NE-BC, is system vice president at Rochester Regional Health/Quality, Safety & Innovation Institute, in Rochester, New York. She can be reached at [email protected] . Michael G. Waller, PhD, is Director of Sustainability, Special Assistant to the CEO at Rochester Regional Health. Susan M. Foley, PhD, RN, is a consultant at Rochester Regional Health, Wegman Center for Workforce Development. Jennifer Gales, MSN, RN, is Vice President, Chief Nursing Officer at Unity Hospital in Rochester. Rebecca Alley, BSN, MS, RN-B, is Chief Nursing Officer at Alexander Park Medical Group in Rochester. Cindy Lovetro, MS, BS, RN, LNHA, is Chief Nursing Officer, Long Term Care at Rochester Regional Health. Kristin Opett, BSN, RN, MSHA, is Vice President, Chief Nursing Officer at Rochester General Hospital, Rochester Regional Health. Theresa Glessner, DNP, RN, ACNP, BC, NEA-BC, CCRN, is Vice President, Chief Nursing Officer at Newark Wayne Community Hospital in Newark, New York. Sheri Faggiano, MSN, RN, is Vice President, Chief Nursing Officer at United Memorial Medical Center in Batavia, New York.

Mycoplasma Pneumonia in Children and Adolescents.

1. Catherine Krafft, MD* 2. Cynthia Christy, MD†,‡ 1. *Department of Pediatrics and 2. †Division of Pediatric Infectious Diseases, University of Rochester School of Medicine and Dentistry, Rochester, NY 3. ‡Rochester General Hospital, Rochester, NY * Abbreviations: CAP: : community acquired pneumonia EM: : erythema multiforme FDA: : Food and Drug Administration MIRM: : Mycoplasma pneumoniae– induced rash and mucositis PCR: : polymerase chain reaction SJS: : Stevens-Johnson syndrome Mycoplasma pneumoniae is a frequent cause of respiratory infections, including community-acquired pneumonia, in school-age children. However, as the science surrounding the diagnosis of this pathogen improves, our knowledge of its epidemiology, including asymptomatic carriage, and the management of this disease is evolving. After completing this article, readers should be able to: 1. Understand the microbiology and epidemiology of Mycoplasma pneumoniae infection. 2. Describe the variable clinical presentation of M pneumoniae infection and extrapulmonary manifestations. 3. Understand the difficulties associated with diagnosing infection with M pneumoniae and current recommendations for diagnosis. 4. Appropriately treat patients with suspected Mycoplasma infection. A 9-year-old girl presents to her pediatrician with a fever, decreased energy, and a cough for 10 days. She was initially evaluated 4 days ago when she had rhinorrhea, a cough, and decreased energy over the previous week. Her examination at that time was notable only for a mildly erythematous posterior oropharynx and nasal discharge. She was diagnosed as having a viral upper respiratory tract infection, and supportive care measures were recommended. Since that visit, her cough is more persistent and she has developed fevers. On examination her temperature is 100.8°F (38.2°C), heart rate is 100 beats/min, respiratory rate is 40 breaths/min, and oxygen saturation is 90% on room air. She is generally well-appearing. Her physical examination is remarkable for an erythematous posterior oropharynx, nasal discharge, and bilateral diffuse crackles on auscultation of her lungs. What is the next step in diagnosis and management? ### Microbiology Mycoplasma pneumoniae is a tiny, pleomorphic bacteria belonging to the class Mollicutes and is the smallest self-replicating bacteria pathogenic in humans, its only known host. M pneumoniae is unique in having no …

771. A Quality Improvement Initiative to Reduce 30-days Sepsis-Related Readmissions by Internal Medicine Residents

BackgroundEarly readmissions after sepsis treatment are associated with an increased cost of care and poor outcome. Based on nationwide Medicare data, one-third of sepsis survivors get readmitted and wide variation exists between hospitals. Internal medicine residents aimed to determine the most common factors associated with readmission after hospitalization for sepsis at Rochester General Hospital and Unity Hospital in Rochester, New York.MethodsThis quality improvement (QI) project involved a retrospective chart review of 30 days sepsis-related readmissions from January to July 2017. We used Rochester General Hospital and Unity Hospital electronic database of the admitted patients with ICD 9/ICD 10 diagnoses for sepsis at admission or during the hospital course. This data were used for interpreting predominant risk factors for readmission. Based on the specific determinants, a “readmission alert” is being implemented in the electronic medical record to address the specific area of concern with relevant interventions. In the next phase of the performance improvement, six-monthly follow-up retrospective chart review will be carried out to look for the outcome.ResultsOf 2,221 patients admitted with a sepsis diagnosis from January to July 2017, 462 (20.8%) were readmitted within 30 days of discharge of which the majority were older than 65 years (66.4%). 66 (16.6%) patients had a septic shock on readmission and 19.3% died within 30-days of discharge after readmission. In 39.7% of cases, there was no primary care provider(PCP) communication at discharge. In 137 (65.5%) cases, Infectious disease(ID) consults service was not involved in care on initial admission. 242 (60.8%) readmitted patients had a follow-up clinic appointment more than a week after discharge. 12.5% of patients were discharged with IV antibiotics on initial admission, whereas 32.9% of the readmitted patients were not provided visiting nursing services after initial discharge.ConclusionReducing sepsis-related readmission requires a multidisciplinary collaboration of primary care providers, visiting nursing services and infectious disease consult team. This pilot QI project results indicate that early follow-ups are important for reducing readmission.Disclosures All authors: No reported disclosures.

The Longitudinal Decline of White Matter Microstructural Integrity in Behavioral Variant Frontotemporal Dementia and Its Association with Executive Function

Background: Previous longitudinal research has observed a decline in the integrity of several white matter (WM) tracts in behavioral variant frontotemporal dementia (bvFTD). However, without a clear relationship between these WM changes and observable behavioral changes, such as the decline in executive function (EF), it is unclear how these WM changes meaningfully reflect progression in bvFTD. The current study sought to validate the use of diffusion tensor imaging (DTI) in tracking the progression of bvFTD with its associated decline in EF. Methods: DTI scans were acquired at baseline and one-year follow-up from 23 patients with bvFTD and 26 healthy controls from the FTLDNI dataset. EF composite scores were derived multiple EF tests via confirmatory factor analysis on the larger FTLDNI dataset. The longitudinal changes in fractional anisotropy (FA) and mean diffusivity (MD) were examined via tract-based spatial statistics, separately, in both groups. FA and MD changes across time in bvFTD were regressed on EF changes. Results: Widespread clusters of significant FA decrease and MD increase, and a significant decline in EF scores were observed in patients with bvFTD, but not healthy controls. This EF decline was mostly associated with FA decrease and MD increase in the corpus callosum and anterior corona radiata. Conclusions: The bvFTD-associated decline of WM integrity was observed in several tracts, of which some were specific to EF decline. The current study presented valuable longitudinal evidence to support the use of DTI in tracking the progression of bvFTD and its associated EF decline. Funding Statement: This work is supported by funding from The University of Hong Kong May Endowed Professorship and the KKHo International Charitable Foundation. Data collection and sharing for this project was funded by the Frontotemporal Lobar Degeneration Neuroimaging Initiative (National Institutes of Health Grant R01 AG032306). The funders had no involvement in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Declaration of Interests: The authors report no conflicts of interest. Ethics Approval Statement: Ethics approval for the FTLDNI protocol have been granted by institutional review boards at their respective study sites. (Participants with FTDs underwent comprehensive neurological, neuropsychological and functional assessment, including informant interview at one of three study sites — University of California, San Francisco, Mayo Clinic, Rochester and Massachusetts General Hospital.) The FTLDNI is coordinated through the University of California, San Francisco, Memory and Aging Center. FTLDNI data are disseminated by the Laboratory for Neuro Imaging at the University of Southern California.

Developing an Intranasal Colonization Model for NTHi in Mice

Nontypeable Haeomphilius influenzae (NTHi) is a Gram‐negative pathogenic bacterium that can live as a commensal in the nasopharynx or can be the cause of Acute Otitis Media (AOM). Although there are currently no approved vaccines in the US to protect against NTHi, several NTHi recombinant protein vaccines are currently being studied for their safety and efficacy of protection. To assess the effectiveness of these prototype vaccines, we had to first establish NTHi colonization and AOM infection models in mice. To establish colonization, C57BL/6J mice were intranasally (IN) infected with PR8 (a mouse‐adapted H1N1 virus) prior to IN infecting with NTHi. Several coinfection protocols were tested to optimize NTHi colonization. Bacterial densities were determined at days 3 and 7 post‐NTHi infection by harvesting blood, nasal washes, and ear washes from the infected mice. Using this coinfection strategy, we were successful in developing a robust NTHi nasal colonization model in mice.Support or Funding InformationRochester Institute of Technology Honors Program Summer Fellowship and Rochester General Hospital Research Institute Summer Scholars FundThis abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Characterizing Cryptococcosis in the Immunocompetent: A Rochester General Hospital Experience

Characterizing Cryptococcosis in the Immunocompetent: A Rochester General Hospital Experience

Abscess, Abscess Everywhere! A Case of Metastatic Klebsiella Infection

SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Virulent forms of klebsiella pneumoniae have been described in literature, mostly from Taiwan and other Asian countries with predominant ocular, pulmonary, hepatic and cerebral involvement. We describe one such case who presented to the intensive care unit at Rochester General Hospital. CASE PRESENTATION: A 58 year old Vietnamese gentleman admitted with altered mental status, was found to have septic shock with respiratory failure requiring intubation and intensive care monitoring. Examination was significant for tachycardia and soft tissue swelling on the left anterior shin alone. Initial laboratory studies showed leukocytosis, lactic acidosis and elevated liver enzymes. CT head was unrevealing while chest x-ray showed left midlung airspace disease with bilateral pleural effusions. CSF analysis revealed leukocytosis and elevated protein levels. Patient was started on broad spectrum antibiotics and antiviral medications. Further work up with a CT chest (fig.1) revealed innumerable nodules with a right pleural effusion consistent with metastatic disease. CT abdomen (fig.2) demonstrated multiple nodules in the liver and an exophytic mass in the right kidney indicative of abscesses. Further investigation with MRI brain showed multiple cerebral abscesses while retinal exam was consistent with left sided chorioretinits. At this point, infective endocarditis was considered as a possible source of infection but trans-esophageal echocardiography did not show vegetations. Subsequently, blood cultures grew klebsiella pneumoniae and cultures from incision and drainage of the left anterior shin mass was also positive for klebsiella pneumoniae. He underwent drainage of the liver abscess and right sided empyema and completed a total of 8 weeks of therapy with piperacillin/ tazobactam for metastatic klebsiella infection. Following a prolonged hospital course that included tracheostomy for a short time, patient was discharged to a skilled nursing facility. Six months after initial presentation, the patient is able to live independently at home. DISCUSSION: Few cases of metastatic klebsiella infection have been reported in literature and the reason for predominance of this syndrome in Asian ethnicity is unknown. Genetic susceptibility plays an important role but infection with virulent K1 strain of klebsiella pneumoniae is implicated in patients with ocular, CNS and liver involvement. CONCLUSIONS: Our case illustrates metastatic klebsiella infection as an etiology for patients presenting with multi organ septic involvement which is generally associated with a high rate of morbidity and mortality. Increased knowledge about this syndrome especially in a critical care setting would facilitate early diagnosis and treatment. Reference #1: Sobirk SK, Struve C, Jacobsson SG. Primary Klebsiella pneumoniae Liver Abscess with Metastatic Spread to Lung and Eye, a North-European Case Report of an Emerging Syndrome. Open Microbiol J. 2010; 4:5-7 DISCLOSURE: The following authors have nothing to disclose: Kevin Dsouza, Kadambari Vijaykumar, Micheal Gurell No Product/Research Disclosure Information

Myelodysplastic Syndromes: From Conductiong Clinical Trials of Novel Therapies to Evaluating Real-Life Effectiveness of Exisiting Therapies

Amer Zeidan speaks to Laura Dormer, Editorial Director: Amer Zeidan is Assistant Professor of Medicine (Hematology) at Yale Cancer Center. He completed a hematology/oncology fellowship and a clinical research fellowship in myelodysplastic syndromes (MDS) at Johns Hopkins University where he also earned a Master of Health Science degree in Clinical Investigation. He received his MBBS degree from the Faculty of Medicine, University of Jordan (Amman, Jordan), before completing his internal medicine residency at Rochester General Hospital (USA). His clinical interest is in the management of hematologic malignancies. The focus of his clinical/translational research is the development of novel therapies for MDS and myeloid hematologic malignancies. The second area of research interest for him is effectiveness and outcomes research in hematologic malignancies, especially MDS.

Morbid adherence of the placenta-a disease of nonvillous trophoblast?

Morbid adherence of the placenta-a disease of nonvillous trophoblast?

Abstract T P332: Stroke Patient Education -A Story of Improvement

Background: Rochester General Hospital (RGH) is a 559 bed acute care community hosp. in Rochester, N.Y. Designated as a Stroke Center in 2003, the Hosp. discharges 850 stroke & TIA pts. annually. The Stroke Coalition Team consists of members of the stroke pt. care areas & supporting depts. Group's purpose- provide a collaborative forum for sharing outcomes to improve stroke care. Each dept. has a core group to review actionable data for their areas. The Acute Stroke Unit (7800) Team’s purpose is to act on unit process improvement opportunities. May 2013- a negative trend with the Core Measure for pt. education was identified for the Coalition group. As a result, the 7800 leaders began investigating for root cause. Purpose of this QI program was to assure all pts. receive designated pt. education and documentation is complete. A secondary purpose was to improve the quality of the education. Methods: Four main barriers were identified: 1. RNs not understanding expectations 2. Novice RNs not comfortable in educating pts. and families 3. Electronic Medical Record (EMR)complexity - launched 11/12 4. Education complete but lacking documentation Action plan: 1 & 2. RN education A.Self-learning packet (SLP) that included: • Requirements of pt. education • How to document the education B. 1:1 support from CNS & Nurse Manager C. Daily chart audits to ID further opportunities & barriers to compliance D. RNs educated on teaching tools: •Welcome binder • AHA/ASA brochures for Stroke/TIA/diagnostic tests • Pt. educational TV offerings •Medical/nursing database 3. Complexity of EMR- Collaborated to make changes to the EMR templates. A. Automatic entry of the education template upon stroke order set B. Required education flagged C. Individualization of pt. education D. Standardized admission & discharge nursing notes 4. Lack of Documentation A. Discharge checklists made available B. Chart compliance audits (decreasing to random as compliance rose) Results: Rapid turn-around achieved. Recognized as best practice by Joint Commission during the Center’s 3/2014 re-designation. Conclusion: Rapid improvement possible with action upon data. Team approach allows for appropriate action to occur. Efforts continue to enhance compliance & pt. experience.

Passing the Gavel

IN 1995, I was so overwhelmed with learning the ins and outs of renal nutrition that I could not imagine that I would one day emerge as a leader in the field. I have many people to thank. Without them, I would have never have spent the last 15 years of my life working with the most amazing people. These are my heroes. Rebekah Mani was the renal dietitian’s dietitian. Early inmy training, shewas consulted by theKansas City Zoo to tailor a renal diet for one of the zoo’s aging primates. I remember looking on in amazement thinking, ‘‘When I grow up, I want to be just like her!’’Trained in India,Rebekahbrought experience from a country in which many could not afford dialysis. She worked with families who had no choice but to see their loved ones spend the remaining years of their lives without life-sustaining dialysis, as it was notwithin their reach.Her perspective on a person’s well-being always outweighed the nutrition guidelines I had been trained to follow. In her mind, restricting life was not a life. The renal lifestyle needed to be molded to fit all lifestyles and personal goals. She taughtme to lookpast theoryand rigid diets to SEE the person behind the patient. She taught me to LISTEN to a patient’s life story to understand the PERSON and not view them as a patient. She taught me VALUE and COMFORT in all the lives that we touched. Drs. Arnold Chonko, Franz Winklehofer, Jerad Grantham,BenjaminCowley, andDennisDiedrich at the University of Kansas Medical Center provided me great medical training in the field of nephrology. Each doctor took his time explaining to me how medical and nutrition interventions intertwined and how each approach could not work without the other. This groupof extraordinary physicians considered the renal dietitian a PARTNER in the care of the renal patient. Each physician challenged me to learn more about the disease process and how to THINK OUTSIDE OF THE BOX when approaching this field. Each understood that

Management of gestational trophoblastic disease

department editor Valerie Vetter practices in the Department of Obstetrics and Gynecology at Rochester General Hospital, Rochester, New York, and in the Department of Emergency Medicine at Highland Hospital, also in Rochester. No relationships to disclose.

Impact of New Therapies On the Survival of Elderly (≥75 Years of Age) Previously Untreated Patients with Multiple Myeloma in a Community Hospital

Abstract 4251Multiple myeloma (MM) is an incurable clonal plasma cell malignancy. At least 50% of all MM patients are older than 70 years of age and 20% are older than 80 years of age (Siegel R, Naishadham D, Jemal A. CA Cancer J Clin. 2012 Jan-Feb;62(1):10–29). The approach to treatment of patients with MM depends on a multitude of factors including age, underlying comorbidities, and disease characteristics. Elderly patients are under-represented in clinical trials. The purpose of our study was to assess the overall outcomes and impact of novel agents in the treatment of newly diagnosed elderly (≥75 years of age) patients with MM in a community setting.We conducted a retrospective review of the records of MM patients seen at Rochester General Hospital, Rochester, NY, who were 75 years of age or older at the time of diagnosis of MM. The study period was from January 2001 to August 2012. Sixty-six patients met the study criteria. Patients with smoldering MM were excluded. Demographic information, comorbid conditions, disease characteristics, laboratory data, first line treatment given, response to treatment, and disease- and treatment-related complications were collected from medical records. Data were analyzed using SPSS software version 14. Univariate analysis was performed and the mean, median, and standard deviation were calculated. A statistically significant difference between variables was denoted by a p value < 0.05. Response to treatment was calculated using Bladé Criteria. Overall survival was estimated by using Kaplan-Meier curves. Grade III and IV toxicity was determined according to Common Terminology Criteria for Adverse Events (CTCAE) of the National Cancer Institute (NCI) version 4.0.Sixty-six patients (median age 81 years, range 75–95 years) with symptomatic MM were studied. Sixty-two percent were males. Twenty-seven percent had underlying diabetes mellitus, 29% had experienced a prior stroke or MI, and 68% had hypertension. Charlson Co-morbidity Index (CCI) was high (3–4) in 46% and very high (≥5) in 31%. Eastern Cooperative Oncology Group (ECOG) performance status (PS) was ≥3 in 27% of patients. Sixty-five percent of patients had IgG subtype, while 28% had IgA subtype. There was a predominance of kappa light chains over lambda (55% versus 42%). Twenty percent, 34%, and 40% of patients had International Staging System (ISS) stages 1, 2, and 3, respectively, while in 6% ISS could not be determined. The median hemoglobin level was 10.5 g/dL (range 6.1–14.8 g/dL), the median serum creatinine level was 1.3 mg/dL (range 0.1–8.0 mg/dL), the median serum albumin level was 3.2 g/dL (range 1.4–4.8 g/dL), and the median serum calcium level was 8.7 mg/dL (range 8.0–17.3 g/dL). As first line treatment 75% received standard therapy, while 25% received novel agents. The most commonly used standard therapies were cyclophosphamide + steroid (36%), melphalan + steroid (25%), and steroid alone (8%). First line therapy included bortezomib in 12%, thalidomide in 10%, and lenalidomide in 3% of patients. Median duration of first line treatment was 26 weeks (range 3–103 weeks). The median overall survival was 72 weeks (range 10–406 weeks). In those who received a novel agent as first line therapy the median overall survival was 127 weeks (range 38–318 weeks). Overall response rate (≥ partial response) was 55% in patients treated with a novel agent versus 23.6% in patients treated with standard therapy. There was no significant correlation between grade III/IV toxicity and the use of a novel agent (p=0.68). When including all non-transplant patients (> 65 years of age), there was a positive correlation between the use of a novel agent and overall survival at one year (Correlation coefficient, CC 0.281, p=0.01). The CC for elderly patients (≥ 75 years of age) was 0.175. The CC in 65–74 year-olds was 0.387. Percentage survival at one year was 59.6 % in patients ≥75 years of age versus 70.6% in those aged 65–74 years.In conclusion, our study shows that very elderly patients (≥75 years of age) with MM, who are considerably ill at baseline with a high or very high CCI and poor PS continue to experience shortened survival despite the use of new agents. However, notwithstanding this, the early use of novel agents has a positive impact on survival at one year, with improved response rates to new therapies, and without an increase in toxicity. Disclosures:Patel:Millennium Pharmaceuticals, Inc: Speakers Bureau; Eli Lilly and Company: Speakers Bureau.

Triaging the fittest

Surgical Intensive Care Unit and Tele-Critical Care Rochester General Hospital University of Rochester Anesthesiology and Critical Care Unity and Lakeside Hospitals; and The Szalados Law Firm Rochester, NY * See also p. 603. The author has not disclosed any potential conflicts of interest.