Saint Francis Hospital Research Articles

Impact of Stewardship Pharmacist Driven MRSA Nasal Surveillance and De-escalation of Anti-MRSA Therapy

Background: Intravenous vancomycin is commonly used as initial empiric coverage for pneumonia but is often unnecessary. MRSA nasal surveillance cultures (MRSA nasal swab) have been highlighted in recent literature and the 2019 IDSA Pneumonia Treatment Guidelines as a tool to avoid unnecessary MRSA coverage in pneumonia. A negative MRSA nasal swab can be utilized by clinicians to de-escalate anti-MRSA therapies for pneumonia. The purpose of this study is to determine if implementing stewardship pharmacist driven MRSA nasal surveillance increases use of the test and reduces the inappropriate use of vancomycin for MRSA coverage in patients with pneumonia. Method: This study was a retrospective chart review and was approved by the Trinity Health of New England Institutional Review Board. For this initiative, a stewardship pharmacist evaluated all patients receiving vancomycin for anti-MRSA therapy at Saint Francis Hospital and Medical Center in Hartford, CT. If the patient’s indication was pneumonia and a MRSA nasal swab had not been ordered, the pharmacist contacted the patient’s provider and requested an order for it. Upon receipt of a negative MRSA nasal swab result, the pharmacist recommended discontinuation of vancomycin to the provider if appropriate. Outcomes from the first four weeks of the pharmacist-driven initiative (April 10, 2023 to May 5, 2023) were compared to the four weeks prior to the initiative (March 13, 2023 to April 7, 2023) as a control group. The primary outcome of this study was percentage of patients who received a MRSA nasal swab. Secondary outcomes included percentage of patients who had vancomycin appropriately de-escalated based on MRSA nasal swab results and mean length of vancomycin therapy. Result: 116 patients met inclusion criteria: 61 in the control group and 55 in the intervention group. Percentage of swabs ordered increased from 36.1% (22/61) without pharmacist intervention to 80.0% (44/55) with pharmacist intervention (p < 0 .0001). There were also increased rates of vancomycin de-escalation in patients with pharmacist intervention, with 58.2% (32/55) of patients in the intervention group having vancomycin discontinued following a negative MRSA swab compared to 19.7% (12/61) in the control group (p < 0 .0001). Conclusion: The results suggest implementing a pharmacist driven MRSA nasal surveillance program into practice could increase the number of MRSA nasal swabs ordered and in turn promote more timely de-escalation of vancomycin in patients with pneumonia. The results from this study can be used to support the wide-spread use of pharmacist driven MRSA nasal surveillance protocols at other institutions.

A Retrospective Analysis of Needle Thoracostomies at a Tertiary Level 2 Trauma Center.

A tension pneumothorax is a condition that results in elevated pressure within the pleural space. The effective management of tension pneumothorax relies on needle decompression, commonly performed at the second intercostal space (ICS) midclavicular line (MCL). However, some literature suggests that catheters placed in the second intercostal space midclavicular line are prone to higher failure rates compared to the fifth intercostal space midaxillary line (MAL) (42.5% versus 16.7%, respectively). In this study, we aim to identify and scrutinize the prevalence of prehospital needle decompression from one tertiary care center over eight years and examine their trends, efficacies, or pitfalls. It is hypothesized that preclinical providers are performing needle decompression prematurely and unnecessarily. A set of 90 patient records obtained using the trauma registry at Saint Francis Hospital, Tulsa, Oklahoma, were retrospectively reviewed to evaluate the management and outcomes of tension pneumothorax, as well as the indications documented for needle decompression. Patient charts were reviewed via Epic Hyperspace (Epic, Madison, WI). The Oklahoma Emergency Medical Service Information System (OKEMSIS) also provided information contributing to the sample population. The most documented indications for needle decompressions included diminished or absent breath sounds (52.70%), hypoxia (15.54%), hypotension, and hemodynamic instability (6.76%). Emergency medical services (EMS) reported improvements in 51 (56.67%) patients after needle thoracostomy. Improvements in vital signs after needle decompression were sporadic. The most common complication was catheter dislodging, which occurred most in the second intercostal space midclavicular line. Only nine patients had an oxygen saturation (SpO2) below 92% and a systolic blood pressure (SBP) below 100 mm Hg prior to receiving needle decompression. Current practices for tension pneumothorax show little improvement in vital signs before and after needle decompression. Vital signs prior to needle decompression often do not indicate tension pneumothorax physiology. Preclinical providers may be inappropriately performing needle decompressions, an invasive procedure with complications.

1235. A Retrospective Review of Antimicrobial Stewardship Audit and Feedback: Assessing Acceptance of Stewardship Recommendations During the COVID-19 Pandemic

Abstract Background Antimicrobial stewardship is an underutilized strategy to mitigate the impact of antimicrobial resistance. It is well documented that many Antimicrobial Stewardship Programs (ASPs) were tasked with assisting healthcare teams in navigating the COVID-19 pandemic, leaving less time/fewer resources for day-to-day ASP activities. The aim of this study was to evaluate the acceptance of stewardship recommendations during a season when the ASP had less time to perform regular educational activities and handshake stewardship. Methods A retrospective study of patients receiving antimicrobial therapy at Saint Francis Hospital during 12/30/2020-10/01/2022, for which audit and feedback by the ASP was conducted. A well-established ASP existed prior to the pandemic. Independent variables included the reason for intervention, type of infection by organ system, and type of intervention. Interventions included recommendations to stop antibiotics, de-escalation, duration of therapy, ID consultation, or change the route of administration. The primary outcome was the audit and feedback acceptance rate, and the secondary outcome was whether the intervention resulted in infectious disease consultation. Results 297 patients underwent audit and feedback. Interventions most accepted by providers included changing the route of administration (100%) and consulting ID formally (92%). Adjusting the duration of therapy was the least accepted intervention at 78%. Regardless of intervention, 33% of providers requested a formal ID consult. The number of interventions varied sporadically, coinciding with periods of decreased availability by the ASP team and during peak waves of the COVID-19 pandemic. Conclusion Our ASP team, despite decreased resources while battling an ongoing pandemic, were still able to perform audit and feedback to providers with a good acceptance rate of recommendations, consistent with current literature. Having not only an existing but robust ASP prior to the pandemic, allowed continued success with ASP intervention acceptance rates, despite less dedicated time for typical ASP activities during the pandemic. Fostering good relationships between providers and ASP teams, as well as continued support and funding from hospital leadership, are vital to ongoing success. Disclosures All Authors: No reported disclosures

Siriraj Stroke Score Validity in Distinguishing Ischemic from Haemorrhagic Stroke among Patients with Stroke at Saint Francis Hospital in Kampala, Uganda

Siriraj Stroke Score Validity in Distinguishing Ischemic from Haemorrhagic Stroke among Patients with Stroke at Saint Francis Hospital in Kampala, Uganda

Rosa Maria Rodrigues Pereira (1958-2022).

Her interest in bone metabolism started during her internship in rheumatology; she was particularly intrigued by osteoporosis and the negative effects of corticosteroids on the bone. In the 1990s, she began interacting with the endocrinology service led by Professor Aurelio Borelli, probably the only place in São Paulo University that subscribed to the main journals focused on bone research. Despite her limited experience in a basic research laboratory, she decided to face the challenges of a bench research-based postdoctoral fellowship and joined the laboratory of Professor Ernesto Canalis at Saint Francis Hospital, Hartford, CT, USA. She learned bone cell biology and became proficient with the bench research techniques that she established in her lab in São Paulo after her return to Brazil. She created and directed the Laboratory of Bone Metabolism, which became a center of excellence for training students and young physicians from different specialties. She was able to secure financing to acquire one of the few high-resolution peripheral quantitative computed tomography machines available in Brazil. She became a go-to specialist in rare and challenging bone diseases, many of which made their way into high-impact publications. Prof Pereira developed original research directions and extensively published. Her research focused on bone and mineral disorders related to rheumatic diseases, including pediatric rheumatology and inflammatory vascular diseases. During her career, she published 391 original articles, 85 book chapters, and 8 books. She made major contributions to the use of vitamin D, including a randomized clinical trial, whose results were published in JAMA in 2021, demonstrating that among hospitalized patients with COVID-19, a single high dose of vitamin D3 did not impact the length of hospital stay. Prof Pereira contributed to the development of the Brazilian National Guidelines for Prevention and Treatment of Osteoporosis and was the coordinator of the São Paulo Ageing and Health Study, a population-based prospective cohort study in Brazil, which resulted in more than 17 publications focusing on bone microarchitecture and fragility fractures. The outstanding quality of her work has been recognized by more than 80 national and international awards. She held leadership roles with high-profile journals, including the International Advisory Board of The Lancet Rheumatology, and served as the Regional Editor of Journal of Bone and Mineral Research. Prof Pereira was instrumental in the creation of the Brazilian Association of Bone Assessment and Osteometabolism (ABRASSO) in 2007, contributing to the organization of the scientific program at their conferences, where she proudly showcased the results of her research. Despite her many professional commitments, Prof Pereira was a compassionate physician who was fully dedicated to patients with rheumatologic diseases during her 40-year career. She led weekly rheumatology rounds and inspired many students and residents who had the fortune of coming under her wings during her 4-decade-long career. Prof Pereira mentored 7 postdoctoral students, 33 doctoral students, 5 master's degree students, and 22 undergraduate students. They will certainly continue to have the legacy of patient care and academic excellence. Prof Pereira was tireless and determined. Her work schedule included weekdays and weekends; she continued her hectic schedule until just a few weeks before she was overcome by illness. Prof Pereira exemplifies how effective leadership can have long-lasting positive effects on others and on our field at large. Her work and legacy will remain a source of inspiration for new generations of clinicians and researchers who will continue to advance our knowledge of rheumatology and metabolic bone diseases. Prof Pereira will be missed by her family, many lifelong colleagues, friends, and patients. She is survived by her husband, Ricardo, a great motivator and supporter of her academic career. We are now committed to turning sadness into a strength and celebrating Prof Pereira's personal and scientific legacy. The peer review history for this article is available at https://publons.com/publon/10.1002/jbmr.4767. The peer review history for this article is available at https://publons.com/publon/10.1002/jbmr.4767.

Debunking the myth of the ‘mentally ill’ mass shooter

The Depression and Bipolar Support Alliance (DBSA) acknowledges the heaviness that many people around the country are feeling in the wake of the mass shootings at Robb Elementary School in Uvalde, Texas, and Saint Francis Hospital in Tulsa, Oklahoma, which, sadly, follow on the heels of shooting incidents earlier this year in Buffalo, Dallas, and Los Angeles.

Assessment of the effects of rapid diagnostic biofire blood culture identification panel in hospitalized patients

Background: Bloodstream infections (BSIs) have life-threatening consequences; they contribute to increased global morbidity and mortality, particularly in critically ill patients. Consequently, early implementation of effective antimicrobial therapy is crucial. Microbiology stewardship efforts, such as rapid diagnostic testing, streamline healthcare resources while also optimizing clinical outcomes. These outcomes include decreased mortality, fewer days of hospitalization, and more efficient time to appropriate anti-infective regimens. Biofire Blood Culture Identification (BCID) is a 2-stage multiplexed PCR system yielding multiple pathogen etiologies, as well as antimicrobial resistance genes. Results are published ~60 minutes after a blood-culture Gram stain turns positive. The purpose of this study was to assess the clinical impact of rapid diagnostic PCR testing, which was introduced at Saint Francis Hospital in March 2020. Methods: We conducted a single-center, retrospective observational chart review before and after implementation of Biofire BCID, surveying all positive cultures from December 2019 through June 2020. Medical records were more thoroughly reviewed for patients who met study inclusion criteria. The primary outcome of interest, time to appropriate antimicrobial therapy, included both days to targeted therapy in the setting of a probable pathogen, and days to antibiotic discontinuation in the case of a likely contaminant (nonpathogenic normal skin flora introduced into culture at the time of collection or processing). Secondary outcomes included in-hospital mortality (death during hospitalization), and inpatient length of stay (LOS). Wilcoxon rank-sum tests were used for primary outcomes and Fisher exact tests were used for secondary outcomes. Results: Among 643 patients with positive blood cultures, 410 (63.8%) met the criteria. In the study, 220 patients before the intervention and 190 patients after the intervention were reviewed. The difference in mean days to targeted therapy with a probable pathogen and days to antibiotic discontinuation with a likely contaminant were both observed at a significance level (3.62 vs 1.79, P Inpatient mortality rates were higher prior to launching Biofire BCID, but they were not statistically significant (15.5% vs 14.2 %; P = .782). The average LOS before and after implementation was 12.6 days (range, 2–92 days), and 10 days (range, 2–68 days), respectively. This parameter was also not statistically significant (P = .597). Conclusions: We detected a trend toward a significant reduction in time to appropriate antimicrobial therapy following the launch of Biofire BCID. Incorporation of molecular rapid diagnostics for BSI evaluation should be the standard of care in hospital settings.Funding: NoneDisclosures: None

Decade of Patient Experience Improvement at a Tertiary Care Urban Hospital.

The purpose of this quality management study was to demonstrate how one hospital made a journey from average patient experience to become a regional leader in the experience of patient care for nationally recognized quality and safety metrics. Saint Francis Hospital & Medical Center (SFHMC) located in Hartford, Connecticut, serves a diverse sociodemographic community as part of Trinity Health. "Recommend the Hospital" (RTH) has been the main marker of patient experience at SFHMC and Trinity Health across the United States as part of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). From 2010 to 2019, SFHMC implemented unit-based rounding hospital-wide, adopting charge nurse and executive leadership rounding as standard work. The intense support from senior leadership spurred the implementation of these changes across middle management and all frontline workers. The t test was used to determine differences between the mean RTH scores between SFHMC, Connecticut, and the United States. Patient experience at SFHMC was regularly assessed by Press Ganey surveys and HCAHPS, which demonstrated higher scores than averages for the state of Connecticut and the United States between 2010 and 2019 (both Ps < .001). SFHMC was the top performer with an RTH score of 83%, with the state average being 71% and the national average being 72%. In the years following the implementation of a multipronged low-cost strategy, hospital RTH scores rose linearly from the state and national average. SFHMC observed gains in patient safety and quality scores as measured by national benchmarks, including Leapfrog patient safety scores of 7 A's and 1 B over a 4-year period. SFHMC was the only hospital in Connecticut to receive an A grade 4 years in a row. A combination of nurse-led, unit-based rounding and executive team rounding with a consistent focus on patient experience resulted in significant improvement in RTH scores for a busy teaching urban hospital, with only a modest investment of resources. There was also improvement in quality and safety outcomes, which together with patient experience of care drove fiscal stability in an increasingly value-based health care environment.

Abstract P72: The Obesity Paradox: Association Between Body Mass Index (BMI) and Disability After Stroke

Background: Present rise in the incidence of obesity has led to several opposing reports regarding the association between obesity and stroke outcomes. The objective of this study was to investigate a proposed paradoxical relationship between body mass index (BMI) and functional status in ischemic stroke patients at time of hospital discharge. Methods: Saint Francis Hospital Comprehensive Stroke Center patient databases were utilized in identifying 948 patients eligible for retrospective chart review over a period of 15 months. Subjects were divided into 4 groups according to BMI: underweight (BMI &lt; 18.5 kg/m 2 ), normal weight (BMI 18.5-24.9 kg/m 2 ), overweight (BMI 25.0-29.9 kg/m 2 ), and obese (BMI ≥ 30.0 kg/m 2 ). Covariates, such as age, gender, prior to event modified Rankin scale (mRS), stroke recurrence, and smoking, were considered. Functional status and disability of stroke patients was scored via mRS at hospital discharge. Ordered logistic regression, Pearson’s chi-squared test, and Pearson’s r correlation were used for analysis to assess the association of BMI and functional status in ischemic strokes. Results: Of 948 eligible subjects, 49.9% were female and mean (SD) age was 69.4 (14.5) years. According to BMI, 22 (2.3%) were underweight, 247 (26.1%) normal weight, 319 (33.7%) overweight, and 360 (37.9%) obese. After adjusting for covariates, ischemic stroke patients with an increased BMI (OR, 0.98; 95% CI, 0.96-0.99) were not associated with increased disability risk upon discharge. Obese (16.2%) and overweight (14.1%) patients discharged with a mRS of 0 (back to baseline) or 1 more frequently compared to normal weight (6.1%) and underweight (0.21%) patients ( P &lt;0.001). Furthermore, an inverse association between BMI status and disability was significantly evident ( r = -0.17, P &lt; 0.001). Conclusion: Obese and overweight stroke patients discharge with a lower risk of disability than normal weight and underweight patients, supporting the existence of the “obesity paradox” in stroke. An inverse association between obesity status and functional outcome was identified and remained significant regardless of covariates.

281 Aspirin acceptance rate and perceived preeclampsia risk after the implementation of universal screening for preeclampsia

To determine the acceptance rate of low-dose aspirin (81 mg) after the implementation of universal screening for preeclampsia in the ultrasound unit using a questionnaire and assess the accuracy of the patient’s perception of risk. This is a retrospective cohort study of all women presenting for their first-trimester ultrasound at Saint Francis Hospital and Medical Center between December 1, 2017 and December 31, 2019. The women were screened for clinical risks of preeclampsia using a self-administered questionnaire developed from the United States Preventative Task Force (USPTF) risk-assessment recommendations. Those found to be at moderate or high risk for preeclampsia were recommended to take a low-dose aspirin (LDA). During their anatomy ultrasound, patients completed a follow-up questionnaire assessing aspirin compliance and perceived risk for developing preeclampsia. Descriptive statistics were used to calculate frequencies. Of 3,872 patients, 767 (19.8%) screened moderate or high risk for developing preeclampsia, 142 patients who had already been recommended by their obstetrician to take an LDA were excluded. The remaining 625 patients were recommended to take an LDA. 59.8% (374/625) subsequently completed the follow-up questionnaire. Of these, 93.8% (351/374) reported their perceived risk: 18.5% (65/351) reported no risk, 36.7% (129/351) low risk, 32.8% (115/351) moderate risk, and 12.0% (42/351) high risk. The acceptance rate of LDA was 77.3% (289/374). Only 25.6% (74/289) of those taking the aspirin accurately perceived their risk. When asked about the reason for taking the LDA, 70.1% (197/281) reported that LDA lowered their risk of preeclampsia or hypertension and 21.4% (60/281) reported it was recommended by their physician. A simple and quick intervention using a questionnaire in the ultrasound unit led to good acceptance of the LDA recommendation by patients found to be at moderate or high risk for developing preeclampsia even though only 1/4 of patients accurately perceived their risk for preeclampsia.

A Retrospective Study of Coinfection of SARS-CoV-2 and Streptococcus pneumoniae in 11 Hospitalized Patients with Severe COVID-19 Pneumonia at a Single Center.

BackgroundA lethal synergism between the influenza virus and Streptococcus pneumoniae has been identified. However, bacterial coinfection is considered relatively infrequent in hospitalized patients with COVID-19, and the co-prevalence of Streptococcus pneumoniae is low.Material/MethodsWe retrospectively analyzed the clinical characteristics and outcomes of patients subsequently admitted to AMITA Health Saint Francis Hospital between March 1 and June 30, 2020, with documented SARS-CoV-2 and S. pneumoniae coinfection.ResultsWe identified 11 patients with S. pneumoniae coinfection. The median age was 77 years (interquartile range [IQR], 74–82 years), 45.5% (5/11) were males, 54.5% (6/11) were white, and 90.9% (10/11) were long-term care facility (LTCF) residents. The median length of stay was 7 days (IQR, 6–8 days). Among 11 patients, 4 were discharged in stable condition and 7 had died, resulting in an inpatient mortality rate of 64%.ConclusionsAt our center, 11 patients with COVID-19 pneumonia who had confirmed infection with SARS-CoV-2 were diagnosed with Streptococcus pneumoniae infection while in hospital. All patients had pneumonia confirmed on imaging and a nonspecific increase in markers of inflammation. The in-hospital mortality rate of 64% (7 patients) was higher in this group than in previous reports. This study highlights the importance of monitoring bacterial coinfection in patients with viral lung infection due to SARS-CoV-2.

Abstract TP237: Improving Door to Needle (dtn) Times and Culture of Treating AIS Using a Stroke Alert RN (SA-RN)

Background and Purpose: In 2012 Saint Francis Hospital, a community hospital was challenged with extended DTN times, low treatment rates of AIS, and no formal inpatient stroke process. In 2012, primary stroke diagnosis volume was 614, only 13 patients were treated with Alteplase for AIS, with a DTN median of 92 minutes. Leaders were concerned with culture of not treating with Alteplase and desired improvement. Methods: Equip key clinical leaders for both Emergency and Inpatient stroke alerts, using a Neuro ICU nurse in the role of Stroke Alert Nurse (SA-RN) . 2012 SA-RN role was created to standardize assessments, NIHSS, administration of Alteplase, and monitoring post-procedure. Efforts were focused on improving time sensitive outcomes, i.e. DTN, LVO assessment, and BP control to mitigate s-ICH. The SA-RN role includes intensive training regarding care of the AIS patient. Audits were used to assure expected outcomes. Education included neuro anatomy and monthly case reviews allowing SA-RN Q&amp;A. Results: Positive trends seen were (1) increased stroke alert volume, (2) decreased DTN, (3) increased Alteplase administrations. Stroke alert volume, both from the ER and the inpatient units, grew as the staff became more comfortable with stroke identification. Stroke Alerts: 2012 (179), 2013 (322), 2014 (405), 2015 (840), 2016 (1312) Alteplase Administrations: 2012 (13), 2013 (19), 2014 (17), 2015 (73), 2016 (156) DTN median: 2012 (92m), 2013 (76m), 2014 (62m), 2015 (56m), 2016 (44m) Conclusion: The addition of a clinical leader in the role of SA-RN is recommended for a stroke program with limited resources. The SA-RN allows for consistency of assessment, Alteplase administration, decreased DTN, increased compliance with post-Alteplase monitoring standards, and therefore decreased risk of s-ICH. The SA-RN is for Saint Francis Hospital as a valuable, trusted and consistent member of the stroke team.

Gamified Twitter Microblogging to Support Resident Preparation for the American Board of Surgery In-Service Training Examination

We sought to determine if a daily gamified microblogging project improves American Board of Surgery In-Service Training Examination (ABSITE) scores for participants. In July 2016, we instituted a gamified microblogging project using Twitter as the platform and modified questions from one of several available question banks. A question of the day was posted at 7-o׳clock each morning, Monday through Friday. Respondents were awarded points for speed, accuracy, and contribution to discussion topics. The moderator challenged respondents by asking additional questions and prompted them to find evidence for their claims to fuel further discussion. Since 4 months into the microblogging program, a survey was administered to all residents. Responses were collected and analyzed. After 6 months of tweeting, residents took the ABSITE examination. We compared participating residents׳ ABSITE percentile rank to those of their nonparticipating peers. We also compared residents׳ percentile rank from 2016 to those in 2017 after their participation in the microblogging project. The University of Connecticut general surgery residency is an integrated program that is decentralized across 5 hospitals in the central Connecticut region, including Saint Francis Hospital and Medical Center, located in Hartford. We advertised our account to the University of Connecticut general surgery residents. Out of 45 residents, 11 participated in Twitter microblogging (24.4%) and 17 responded to the questionnaire (37.8%). In all, 100% of the residents who were participating in Twitter reported that daily microblogging prompted them to engage in academic reading. Twitter participants significantly increased their ABSITE percentile rank from 2016 to 2017 by an average of 13.7% (±14.1%) while nonparticipants on average decreased their ABSITE percentile rank by 10.0% (±16.6) (p = 0.003). Microblogging via Twitter with gamification is a feasible strategy to facilitate improving performance on the ABSITE, especially in a geographically distributed residency.

Comparison of myocardial strain in cancer patients undergoing chemotherapy with and without anthracycline.

e21600 Background: Cardiotoxicity has been reported in cancer patients treated with anthracycline- and non-anthracycline-based chemotherapy. Myocardial strain assessed by speckle-tracking echocardiography enables early detection of subclinical chemotherapy-induced cardiotoxicity. However, comparisons of strain indices in patients undergoing chemotherapy with and without anthracyclines have not been reported. The prupose of this study was to compare myocardial strain in patients treated with these two chemotherapy regimens. Methods: This study was approved by the institutional review board at Saint Francis Hospital. 43 adult cancer patients (30 with solid tumors, 6 with lymphomas, 6 with leukemias and 1 with multiple myeloma) treated with anthracyline-based or non-anthracycline-based chemotherapy, were studied with conventional 2D and 3D echocardiography, 2D speckle-tracking imaging, and cardiac biomarkers. Results: Of the 43 patients, 22 received anthracycline-based chemotherapy, with an average cumulative anthracycline dose of 235 mg/m2. The other 21 patients received non-anthracycline-based chemotherapy including VEGF inhibitors and HER-2 receptor antagonists. There was no difference in 2D or 3D left ventricular ejection fraction (LVEF) (60.9 ± 4.5% vs 62.0 ± 4.9% by 2D; 60.5 ± 5.4 % vs 62.1± 5.2% by 3D, p = 0.35 for both 2D and 3D), troponin or NT-proBNP between anthracyline-treated patients and non-anthracycline treated patients. However, global longitudinal strain (GLS) and global circumferential strain (GCS) were decreased in patients treated with anthracycline-based chemotherapy compared with patients treated with non-anthracycline-based chemotherapy (-17.8 ± 2.8 vs 19.9 ± 2.9, p = 0.018 for GLS; -21.6 ± 4.8 vs 24.8 ± 4.8, p = 0.041 for GCS). Conclusions: In contrast with patients treated with non-anthracyline-based chemotherapy, patients treated with anthracyclines had reduced myocardial systolic strain even at low cumulative doses. This occurred in the absence of detectable reductions in LVEF. Thus early assessement of myocardial strain abnormality and early intervention with cardioprotective agents may be considered for these patients.

The Nosocomial Risk of Bacterial Contamination of Surgical Wards at Saint Francis Hospital in Katete District of Zambia

The Nosocomial Risk of Bacterial Contamination of Surgical Wards at Saint Francis Hospital in Katete District of Zambia

Haemoglobin A1c as a screening tool to identify pre‐diabetes and diabetes in postpartum women with gestational diabetes

AbstractThe primary objective of this study was to determine the right test and time for postpartum screening of women with gestational diabetes to identify diabetes mellitus or impaired glucose tolerance.Retrospective data were collected on women with gestational diabetes followed at the Center for Diabetes and Metabolic Care at Saint Francis Hospital and Medical Center, Hartford, Connecticut, USA.Of the 150 women included in this study, blood work was completed in 42 (28%) of the subjects. Of the women completing laboratory tests, 23 of them (56.1%) had an abnormal test result. Using the standard tests, 15 (41.7%) of the women tested positive based on HbA1c ≥5.7% (39 mmol/mol), six (16.7%) based on fasting glucose ≥100 mg/dl (5.6 mmol/L), and 10 (27%) based on 2‐hour 75 g oral glucose tolerance test (OGTT) ≥140 mg/dl (7.8 mmol/L). However, due to better negative predictive value, HbA1c was more accurate than 2‐hour OGTT.Of the standard testing available, HbA1c alone identified the majority of the subjects with an abnormal test. Copyright © 2016 John Wiley &amp; Sons.

BCR Signalosome-Oriented Phosphotyrosine Profiling of CLL

Abstract Introduction There is strong evidence that B-cell receptor (BCR) signaling has a critical role in the pathogenesis of B-cell malignancies such as non-Hodgkin's lymphoma (NHL) and chronic lymphocytic leukemia (CLL). The BCR signalosome, B-cell receptor signaling protein complex, is therefore a rational therapeutic target. This has already been proven by success in clinical trials of B-cell signaling inhibitors such as Ibrutinib and Idelalisib. It is becoming more important to know what combinations of new and traditional agents is best for each patient. Although genetic profiles may help to predict sensitivity to treatment to some degree, it is ideal to profile the BCR signaling state of each case to select most effective B-cell signaling inhibitors. Our goal is to develop a BCR signalosome-oriented molecular marker and investigate its clinical value. We focus on protein-protein interactions in the B-cell signalosome that are regulated by tyrosine kinases, their substrates, and SH2 domains. We hypothesized that the global tyrosine phosphorylation state determined by SH2 profiling, an SH2 domain-based molecular diagnostic approach, may meaningfully represent the B-cell signaling state of B-cell malignancies. Here we conducted SH2 profiling of 1) BCR signalosome peptides to determine specificity of BCR SH2 domain probes and 2) CLL patient samples to determine the presence of patient specific BCR SH2 profiles. Methods For microarrays, phosphorylation site databases were extensively searched and 368 tyrosine phosphorylation sites from the core 38 proteins which make up the BCR-signalosome were selected for peptide synthesis. Replicated peptide microarrays containing pairs of phosphorylated and unphosphorylated tyrosine motifs were separately probed with a set of BCR SH2 domains including BTK, BLNK, LYN, PI3K, SYK, and PLCg2. For clinical sample experiments, PBMC samples were collected from 35 CLL patients who visited UConn Health (UCH) and Saint Francis Hospital (SFH) between 2008 and 2014. The median age at study enrollment was 67 (46-98 years). Male patients constituted 63%. Binet stage A disease was present in 76% of the patients. Reverse-phase SH2 domain binding assay was performed as previously described using the BCR SH2 domains. Results According to the microarray results, 94% of BCR signalosome phosphotyrosines were bound by at least one SH2 domain (median 5 domains). A group of proteins including CD22, CD79A, CD45, and PLCg2 protein harbour tyrosine sites that can bind to more than 10 SH2 domains suggesting competition between these SH2 domains may exist in the cell. Specificity of BCR SH2 domains could be grouped into three levels: very specific (BTK, BLNK), medium (Lyn, PLCg2, SHP-1, etc) and broad (SHIP). We found a number of previously undocumented SH2-ligand interactions that may be involved in specific downstream signaling pathways. A clustering analysis of CLL samples revealed the presence of different patient groups such as BLNK-dominant and PLC-dominant. Of those clusters, we observed that a cluster with low BLNK signal and high LYN signal was enriched with clinically progressive type CLL cases. To test the prognostic impact of the BLNK/LYN profile, the CLL cases were divided into four groups by high (+) and low (-) BLNK and LYN SH2 binding and compared with PFS. There was a significant difference between the groups in a log-rank test, indicating that patients with the BLNK-low &amp; LYN-high profile progressed more rapidly. Of note, in the microarray experiments we identified that a group of BCR signaling proteins/peptides such as CD19, CD79A, and Dok1 show a similar BLNK-low &amp; LYN-high profile. Their involvements in the SH2 profile of CLL samples remain to be determined. Conclusion Aiming to develop a new molecular marker based on the BCR signaling state of B-cell malignancies, we applied SH2 profiling to BCR peptide microarrays and CLL/NHL patient samples. We confirmed that BCR signalosome-oriented SH2 probes have sufficient specificity to distinguish various signalosome tyrosine sites. SH2 profiling of CLL indicated that the BCR SH2 probes are able to distinguish CLL subgroups, one of which was correlated with a poor PFS. Further efforts are underway to determine the clinical marker value of the BCR signalosome profile, such as its utility in risk stratification, early detection of disease progression, and prediction or assessment of response to B-cell signaling inhibitor therapy. Disclosures Wasser: Amgen, Inc: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding.

Incidence of “Hospital Acquired Peritonitis” in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients in Saint Francis Hospital, Hartford, CT

Incidence of “Hospital Acquired Peritonitis” in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients in Saint Francis Hospital, Hartford, CT

Robot Therapy Tipping Point

From the Departments of Neurology and Epidemiology, Brown University, Providence, RI; VARRD Center of Excellence for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence, RI; Neuroscience Research, Mandell Multiple Sclerosis Center, Saint Francis Hospital, Hartford CT (ACL); and VA Cooperative Studies Program, VA Connecticut Healthcare System, West Haven, Yale University (PDG). All correspondence and requests for reprints should be addressed to: Albert C. Lo, MD, PhD, Providence VA Medical Center, Building 32, 830 Chalkstone Ave, Providence, RI 02908-4799. Dr Albert Lo has received travel expense reimbursement from Hocoma. He has no other relevant disclosures. For all other disclosures, Dr Lo has received grants and travel reimbursement from the Department of Veterans Affairs and the National Multiple Sclerosis Society. He has received travel reimbursement from Novartis, the Department of Defense, and the University of Pennsylvania. He has received funding from Acorda Therapeutics for an investigator-initiated project. He has received honorarium from Scripps, Braintree, and Los Rancho Amigos. Albert Lo and Peter Guarino are federal government employees. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Individualization Through Standardization: Electronic Orders for Subcutaneous Insulin in the Hospital

The objective was to design electronic order sets that would promote safe, effective, and individualized order entry for subcutaneous insulin in the hospital, based on a review of best practices. Saint Francis Hospital in Evanston, Illinois, a community teaching hospital, was selected as the pilot site for 6 hospitals in the Health Care System to introduce an electronic medical record. Articles dealing with management of hospital hyperglycemia, medical order entry systems, and patient safety were reviewed selectively. In the published literature on institutional glycemic management programs and insulin order sets, features were identified that improve safety and effectiveness of subcutaneous insulin therapy. Subcutaneous electronic insulin order sets were created, designated in short: "patients eating", "patients not eating", and "patients receiving overnight enteral feedings." Together with an option for free text entry, menus of administration instructions were designed within each order set that were applicable to specific insulin orders and expressed in standardized language, such as "hold if tube feeds stop" or "do not withhold." Two design features are advocated for electronic order sets for subcutaneous insulin that will both standardize care and protect individualization. First, within the order sets, the glycemic management plan should be matched to the carbohydrate exposure of the patients, with juxtaposition of appropriate orders for both glucose monitoring and insulin. Second, in order to convey precautions of insulin use to pharmacy and nursing staff, the prescriber must be able to attach administration instructions to specific insulin orders.