Saint Vincent Hospital Research Articles

The carbon footprint of a surgical pathology laboratory in France.

The health sector contributes to climate disruption through greenhouse gas (GHG) emissions. It accounts for 8% to 10% of France's GHG emissions. Although the medical community has been alerted to the problem, more data are needed. This study aimed to determine the carbon footprint of a surgical pathology laboratory. The study was conducted in the surgical pathology laboratory at Saint Vincent hospital (Lille) in 2021. It represented 17,242 patient cases corresponding to 54,124 paraffin blocks. The 17 staff members performed cytology, immunohistochemistry, and in situ hybridization. The study included all inputs, capital equipment, freight, travel, energy consumption, and waste. Carbon emission factors were based on the French Agence De l'Environnement et de la Maîtrise de l'Energie database. In 2021, the pathology laboratory's carbon footprint was 117 tons of CO2 equivalent (t CO2e), corresponding to 0.5% of Saint Vincent hospital's total emissions. The most significant emissions categories were inputs (60 t CO2e; 51%), freight associated with inputs (24 t CO2e; 20%), and travel (14 t CO2e; 12%). Waste and energy generated 10 t CO2e (9%) and 9 t CO2e (8%), respectively. The pathology laboratory's carbon footprint was equivalent to the yearly carbon impact of 11 French inhabitants. This footprint is dominated by inputs and associated freight. This suggests an urgent need to develop ecodesign and self-sufficiency in our routine practices.

Self-Sustainability with Therapeutic Phlebotomy, a Solution to the National Blood Crisis?

CONCLUSION Hereditary hemochromatosis (HH) is a genetic condition associated with iron overload in the human body. The mainstay of treatment remains therapeutic phlebotomy. On August 1st, 2022, the American Red Cross approved using blood obtained from therapeutic phlebotomy for transfusion. While normal individuals can donate blood only as often as once in 56 days, individuals with HH can have phlebotomy as often as once weekly. Utilizing the blood collected from these patients could be a significant resource to mitigate the shortage of blood needed for transfusion. We aimed to quantify the number of units of blood removed by therapeutic phlebotomy from individuals with HH and assess its potential contribution to total units of blood required in a community hospital for two years (2021 and 2022). We retrospectively reviewed electronic medical records of adult individuals who underwent therapeutic phlebotomy at Saint Vincent Hospital between January 1, 2021, and December 31, 2022. Patients with hereditary hemochromatosis were identified based on a positive genetic test for HFE gene mutations. We collected data including gender, race, age at diagnosis, and the number of units of blood removed from patients during the study period. The total number of units transfused in the in-patient care services and operating room was obtained. A descriptive statistic was performed using R version 4.2.2 statistics software. A total of 112 patients received therapeutic phlebotomy over two years (2021 and 2022) of whom 65% (N=73) had a diagnosis of HH. A majority of the patients were males (60%, 44/73) and were non-Hispanic/Latino (85%, 62/73). The mean age at diagnosis of HH was 62 [standard deviation (SD): 17] years. The median number of units of blood removed by phlebotomy per patient with HH was 3 (2-5), the annual distribution is as displayed in Table 1. A total of 504 units of whole blood was removed through therapeutic phlebotomy from 73 patients during the study period. The total requirement for blood transfusion across all the departments in the hospital was 6065 units (2,733 units in 2021 and 3,332 units in 2022). The total number of units removed through therapeutic phlebotomy in HH patients represented 8.31% (504/6065 Units) and 82.49% (504/611 Units) of total units of blood requirement for the entire hospital and operating room respectively (Table 2). The units of blood removed through therapeutic phlebotomy of patients with HH, could potentially help sustain 8.31% of total blood requirement of the hospital. Primarily, over 82% of the demand from the operating room could be fulfilled if the entirety of the blood from therapeutic phlebotomy were to be transfused. Overcoming technical challenges in utilizing the blood from therapeutic phlebotomy for transfusion in routine clinical practice could help mitigate the national blood crisis and aid in self-sustainability of blood products at a community level. Our study highlights the need for broader efforts to create awareness and incentivizing re-utilization of blood obtained from therapeutic phlebotomy.

External Validation of PRISM Score in Multiple Myeloma Patients in a Community Setting: A Retrospective Cohort Study

Background: Newly diagnosed Multiple Myeloma (MM) patients have a 10 to 20 times higher risk of developing venous thromboembolism (VTE) than the general population. The pathogenesis may involve several factors such as activation of procoagulant factors, acquired activated protein C resistance, and inflammation. In addition to the general risk factors for venous thromboembolism such as older age, immobility, and surgery, some MM treatment-related factors such as the use of immunomodulatory drug therapy and abnormal cytogenetics contribute to the increased risk. The PRISM score (Prior VTE, Race, IMiD, Surgery, Metaphase Cytogenetics) is a risk prediction tool for VTE in MM and was published in 2022. The score ranges from 0 to 18 and patients were stratified into three groups: low (0), intermediate (1-6), and high risk (≥ 7). Our primary objective was to assess the external validity of the PRISM score in our community hospital setting. Methods: All consecutive newly diagnosed MM treated at Saint Vincent Hospital from 1/1/2008 to 12/22/2022 were included in our analysis. Patients receiving therapeutic anticoagulation for other indications or a diagnosis of VTE within 6 months preceding the MM diagnosis were excluded. Variables were collected through a retrospective chart review during MM treatment initiation. Model discrimination was assessed by calculating the area under the receiver operating characteristic curve (AUROC). Logistic regression was used to calculate the odds ratio (OR) of VTE occurrence in the risk prediction model. Results: A total of 214 patients with newly diagnosed MM and available data on VTE occurrence were included. The median age of our cohort at treatment initiation was 74 years (range 31- 96). The median BMI was 27.8. 56% were male, and 44% were female. The mean PRISM score was 2.9, and 73% of MM were IgG/IgA subtype. IMiD-based induction regimen was used in 63 % of patients. A total of 24 patients (11.2%) were diagnosed with VTE after treatment initiation, of which 8 (3.7%) patients had a previous history of VTE. Prophylactic aspirin was used in 53.8% and abnormal metaphase cytogenetics was identified in 13% of MM cases. The median time to VTE from induction therapy was 4.8 months. The PRISM score was low in 116 patients, intermediate in 89, and high in 9 patients. The AUROC of the model was 0.759 (95% CI, 0.644-0.874) (1). The cumulative incidence of VTE at 6 months, 12 months, and more than 1 year was 6%, 7%, and 11.2% of the patients respectively. Each 1-point increase in the score was associated with a significantly higher chance of VTE occurrence in the model [ HR= 1.53, 95% CI (1.27-1.85), P<0.001]. Among the parameters, patients with a history of VTE [ HR= 1.55, 95% CI (1.26-1.91), P<0.001] and with abnormal metaphase cytogenetics [HR= 2.35, 95% CI (1.37-4.05), P<0.001] had a higher strength of association with the development of VTE after induction (2). Furthermore, among 9 patients with a high-risk PRISM score (≥ 7), 7 (77%) developed VTE within the first 6 months after treatment initiation. Conclusions: Our findings suggest that PRISM [AUROC=0.75, 95% CI (0.644-0.874), P<0.001] score could statistically predict VTE outcomes in our patient population. Abnormal metaphase cytogenetics was a significant predictor of VTE in the validation cohort. Abnormal cytogenetics has been well established to be an indicator of aggressive tumor biology and proliferation in stroma-independent MM. It has been established to be a predictor of VTE in acute myeloid leukemia as well. Also, high-risk scores were predictive of earlier development of VTE after treatment induction. Our study strengthens the evidence of using PRISM as a predictive tool. Further studies are needed to enhance the sensitivity of our existing tool.

External validation of venous thromboembolism risk prediction models in patients with multiple myeloma in a community setting: A retrospective cohort study.

e20027 Background: Newly diagnosed Multiple Myeloma (MM) patients have a 10 to 20 times higher risk of developing venous thromboembolism (VTE) than the general population. Three risk prediction models have been recently established to ascertain the degree of VTE risk: SAVED (Surgery, Asian race, VTE history, Elderly and Dexamethasone), IMPEDE VTE (Immunomodulatory drugs (IMiD), BMI, Pelvic fracture, Erythropoietin stimulating agent, Dexamethasone/Doxorubicin, Asian Ethnicity, VTE history, Tunneled line, Existing thromboprophylaxis) and PRISM scores (Prior VTE, Race, IMiD, Surgery, Metaphase Cytogenetics). Our primary objective was to assess the external validity of three VTE risk prediction models in a community hospital setting. Methods: All consecutive newly diagnosed MM treated at Saint Vincent Hospital from 1/1/2012 to 12/22/2022 were included in our analysis. Patients receiving therapeutic anticoagulation for other indications or a diagnosis of VTE within 6 months prior to MM diagnosis were excluded. Variables were collected by retrospective chart review at the time of MM treatment initiation. Model discrimination was assessed by calculating the area under the receiver operating characteristic curve (AUROC). Logistic regression was used to calculate the odds ratio (OR) of VTE occurrence with candidate variables in the risk prediction model. Results: The 160 patients with newly diagnosed MM and available data on VTE occurrence were included. The median age of our cohort at treatment initiation was 74 years (range 31-96); 55% were male, and 75% were Caucasians. IMiD-based induction regimen was used in 68.1 % of patients. The median SAVED score was 1 (IQR:0-2), IMPEDE VTE was 4 (IQR: 2-6), and PRISM score was 2 (IQR: 0-2). The most common thromboprophylactic agent used was aspirin (53.8%). The median time to VTE from induction was 4.8 months. The cumulative incidence of VTE at 12 months was 13.1%. Each 1-point increase in the score was associated with a significantly higher chance of VTE occurrence across all three models (Table). Factors significantly associated with the development of VTE were prior VTE history (OR:2.28, 95% CI:1.31-3.97,p = 0.003) and age greater than 80 years (OR:4.03, 95% CI:1.47-11.02,p = 0.006). Conclusions: Our findings suggest that all three PRISM (AUROC = 0.70), SAVED (AUROC = 0.72), and IMPEDE VTE (AUROC = 0.73) scores could statistically predict VTE outcomes in our patient population. The inclusion of more parameters in the IMPEDE VTE score may have led to its outperformance in risk stratification. [Table: see text]

Incidence of venous thromboembolism with immune checkpoint inhibitors in a community setting: A single-center retrospective study.

e14681 Background: Immune activation and inflammation caused by immune checkpoint inhibitors (ICIs) are critical pathobiological drivers for venous thromboembolism (VTE). There is a paucity of data about VTE risk in cancer patients receiving ICI. We aimed to describe the incidence of VTE in cancer patients receiving ICI in a community setting. Methods: We conducted a single center, retrospective cohort study at Saint Vincent Hospital. The study cohort was created using our center's pharmacy database of patients who received any of the five ICIs (ipilimumab, nivolumab, pembrolizumab, atezolizumab, or durvalumab) between Jan 2017 and Dec 2022. VTE events including deep venous thrombosis, splanchnic vein thrombosis, and pulmonary embolism, were identified by chart review. We used a self-controlled risk-interval design, with "control period" and "at-risk period" being 6 months before and after the initiation of ICI treatment respectively. VTE events were also analyzed for subgroups: Single-agent ICI therapy (IA), Dual ICI therapy (IB), and ICI + chemotherapy (IC). Descriptive statistics and cox regression were used for statistical analysis. Results: Study population included 170 patients, with 75, 14, and 81 patients in subgroups IA, IB, and IC respectively. The mean age of the patients was 69.51 ± 10.05 years with a majority being males (62.4%). The most common cancer observed was non-small cell lung cancer (43.5%) followed by small cell lung cancer (6.9%), and malignant melanoma (5.7%). Pembrolizumab (55.3%) was the most common ICI used and nivolumab + ipilimumab (7.64%) was the most common dual ICI used. We noted a 1.25-fold higher incidence of VTE post-ICI use (Incidence rate ratio [IRR]: 11.76 per 100 person-year) compared to pre-ICI use (IRR: 9.41 per 100 person-year) at 6 months. On subgroup analysis, Group IB had the highest risk for VTE at 6 months (IRR: 28.57 per 100 person-year), followed by group IC and IA (IRR: 14.12 and 8.0 per 100 person-year respectively). IRR decreased to 6.62 per 100 person-year at 12-month interval indicating increased VTE risk in the first 6 months of ICI exposure. Type of ICI, adjuvant chemotherapy or type of cancer was not able to predict VTE risk on multivariate analysis. Conclusions: ICI treatment was associated with an increased incidence of VTE in our study cohort with the highest risk among patients on dual ICI followed by ICI + chemotherapy and ICI monotherapy. Future prospective studies are needed to identify risk factors and biomarkers to improve risk stratification and risk-adapted thromboprophylaxis.[Table: see text]

Optimal Blood Glucose Monitoring Interval for Insulin Infusion in Critically Ill Non-Cardiothoracic Patients: A Pilot Study.

Objective:The American Diabetes Association and the Society of Critical Care Medicine recommend monitoring blood glucose (BG) every 1-2 hours in patients receiving insulin infusion to guide titration of insulin infusion to maintain serum glucose in the target range; however, this is based on weak evidence. We evaluated the compliance of hourly BG monitoring and relation of less frequent BG monitoring to glycemic status.Materials and Methods:Retrospective chart review performed on 56 consecutive adult patients who received intravenous insulin infusion for persistent hyperglycemia in the ICU at Saint Vincent Hospital, a tertiary care community hospital an urban setting in Northeast region of USA. The frequency of fingerstick blood glucose (FSBG) readings was reviewed for compliance with hourly FSBG monitoring per protocol and the impact of FSBG testing at different time intervals on the glycemic status. Depending on time interval of FSBG monitoring, the data was divided into three groups: Group A (<90 min), Group B (91-179 min) and Group C (≥180 min).Results:The mean age was 69 years (48% were males), 77% patients had preexisting type 2 diabetes mellitus (T2DM). The mean MPM II score was 41. Of the 1411 readings for BG monitoring on insulin infusion, 467 (33%) were in group A, 806 (57%) in group B and 138 (10%) in group C; hourly BG monitoring compliance was 12.6%. The overall glycemic status was similar among all groups. There were 14 (0.99%) hypoglycemic episodes observed. The rate of hypoglycemic episodes was similar in all three groups (p=0.55).Conclusion:In patients requiring insulin infusion for sustained hyperglycemia in ICU, the risk of hypoglycemic episodes was not significantly different with less frequent BG monitoring. The compliance to hourly blood glucose monitoring and ICU was variable, and hypoglycemic episodes were similar across the groups despite the variation in monitoring.Significance of the Study:The importance of glycemic control in ICU has been well established and it is a resource intensive venture. However, there are no major studies highlighting the most optimal time interval for blood glucose checks in critically ill patients on insulin infusion. With this study we hypothesize that time duration between blood glucose checks can be increased safely without any untoward effects. Our study provides evidence for effective resource management with reducing the time spent with every glucose check and directly translating into high value care.

375. COVID 19 infection in a Massachusetts community hospital

BackgroundThe ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections has led to 105690 cases and 7647 deaths in Massachusetts as of June 16.MethodsThe study was conducted at Saint Vincent Hospital, an academic health medical center in Worcester, Massachusetts. The institutional review board approved this case series as minimal-risk research using data collected for routine clinical practice and waived the requirement for informed consent. All consecutive patients who were sufficiently medically ill to require hospital admission with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample were included.ResultsA total of 109 consecutive patients with COVID 19 were admitted between March 15 and May 31. Sixty one percent were men, the mean age of the cohort was 67. Forty one patients (37%) were transferred from nursing homes. Twenty seven patients died (24%) and the majority of the dead patients were men (62%). Fifty one patients (46%) required admission to the medical intensive care unit and 34 necessitated mechanical ventilation, twenty two patients on mechanical ventilation died (63%). The most common co-morbidities were essential hypertension (65%), obesity (60%), diabetes (33%), chronic kidney disease (22%), morbid obesity (11%), congestive heart failure (16%) and COPD (14%). Five patients required hemodialysis. Fifty five patients received hydroxychloroquine, 24 received tocilizumab, 20 received convalescent plasma and 16 received remdesivir. COVID 19 appeared in China in late 2019 and was declared a pandemic by the World Health Organization on March 11, 2020. Our study showed a high mortality in patients requiring mechanical ventilation (43%) as opposed to those who did not (5.7%). Hypertension, diabetes and obesity were highly prevalent in this aging population. Our cohort was too small to explore the impact of treatment with remdesivir, tocilizumab or convalescent plasma.ConclusionIn this cohort obesity, diabetes and essential hypertension are risk factors associated with high mortality. Patients admitted to the intensive care unit who need mechanical ventilation have a mortality approaching 50 %.Disclosures All Authors: No reported disclosures

Multicenter, Retrospective Evaluation of Therapeutic Efficacy of Ruxolitinib for Chronic Gvhd Treatment

Background Several agents have been investigated for beyond second-line treatment of chronic graft-versus-host disease (GVHD). Ruxolitinib has been recently approved for steroid-refractory acute GVHD, while a prospective randomized study is ongoing to examine its efficacy in steroid-resistant chronic GVHD (cGVHD). The present study evaluated the efficacy of Ruxolitinib in terms of 1) overall response rate (ORR), 2) clinical benefit (CB), 3) dose reduction of corticosteroid exposure, 4) failure-free survival (FFS) and 5) overall survival (OS), in patients heavily pretreated for steroid-resistant cGVHD. Patients and methods A total of 47 patients who developed cGVHD after HCT and treated with Ruxolitinib for cGVHD from March 2016 to April 2020, at three different sites (Princess Margaret Cancer Center, Canada; Vancouver General Hospital, Canada and Saint Vincent Hospital, Australia), were evaluated in the retrospective study. Patients and disease characteristics are as follows: median age 52 years; classical 35 (71%), overlap syndrome 14 (29%). Of note, 27 patients (57.4%) had a previous history of acute GVHD. The ORR and CB were assessed at months 3, 6 and 12, retrospectively. Responses were evaluated according to NIH scoring/staging/response assessment as part of standard clinical practice. CB was assessed considering clinical response as well as steroid dose reduction. For systemic steroid dose reduction, prednisone dose per kg per day was captured prior to Ruxolitinib start, at months 3, 6 and 12. Treatment failure was defined as 1) resistance requiring treatment switch, 2) non-relapse mortality (NRM), 3) relapse, 4) intolerance to treatment. FFS and OS were calculated from the day of starting Ruxolitinib therapy for cGVHD treatment. Results A total of 47 patients had moderate (11/47, 24.4%) to severe (33/47, 73.3%) cGVHD except one who had mild grade cGVHD with a high-risk feature (thrombocytopenia at the time of Ruxolitinib start). The median number of organ involvement was 3 (range 1-7). Over half of patients (63.8%) received Ruxolitinib as 4th line or beyond for cGVHD treatment, while median number of previous lines of therapy was 3 (range 1-9). All 47 patients (100%) had been previously treated with systemic steroids; other previous treatments included ECP therapy (53.2%), Imatinib (29.8%), Ibrutinib (23.4%), Rituximab (21.3%). Ruxolitinib was started at 10-15 mg daily as initial dose, then maintained at 20mg daily in two divided doses on months 3, 6 and 12.With a median follow-up duration of 12 months, ORR was attained in 35.7%, 36.0% and 35.0% at 3, 6 and 12 months, respectively (Figure A). Of note, ORR in patients with sclerotic changes was 56%, and 61.5% in those with lung involvement. Patients resistant to TKI (i.e. Imatinib or Ibrutinib) for cGVHD treatment showed similar ORR compared to those naïve to TKI therapy.The CB was observed in 53.5%, 66.7% and 72.2% at months 3, 6 and 12, respectively (Figure B). Patients resistant to TKI for cGVHD treatment did not show any difference in CB compared to those naïve to TKI therapy.In terms of prednisone dose reduction, by 12 months , half of patients (50.0%) could taper prednisone doses below 0.1mg/kg/day, while the proportion of patients on prednisone dose below 0.1mg/kg/day was 9.3%, 20.0%, 17.4%, and 50.0% at month 0, 3, 6 and 12, respectively (Figure C). The group who achieved CB at 3 months showed a significantly lower dose of prednisone at 12 months (0.078mg/kg/day) compared to those without clinical benefit at 3 months (0.197mg/kg/day; p=0.033; Figure D).Out of 37 patients evaluated, 11 failures (29.7%) were noted, including resistance requiring a switch to other therapy (n=7), NRM (n=2) and intolerance (n=2). The FFS rate at 1 year in the overall population was 68.5% (Figure E). The FFS at 1 year in those having CB at 3 months vs not was 86.5% vs 51.4% (p=0.025).The OS at 1 year was 90.9% (Figure F). The OS at 1 year in those having a CB at 3 months vs not was 100% vs 78.8% (p=0.053). Conclusion: This multicenter retrospective study revealed that Ruxolitinib is an effective treatment option for patients with cGVHD, with good ORR and CB. The achievement of CB in the first 3 months correlated well with steroid dose reduction. It suggests that Ruxolitinib is a feasible GVHD treatment option, even for patients who were heavily pretreated for cGVHD or failed previous TKI drug. Figure 1 Disclosures Hamad: Abbvie: Honoraria; Novartis: Honoraria. OffLabel Disclosure: Ruxolitinib treatment for steroid resistant chronic GVHD

Hypocalcemia with Immune Checkpoint Inhibitors: The Disparity among Various Reports.

Immune-related adverse events affecting parathyroid function are rarely reported with immune checkpoint inhibitors (ICPIs). Activating calcium-sensing receptor antibodies causing autoimmune hypoparathyroidism with nivolumab was recently reported. KEYNOTE-189 and CHECKMATE-067 trials reported a 21–29% hypocalcemia event rate, but the etiology of hypocalcemia was not reported. A chart review was performed to study patients receiving ICPI from 2015 to 2018 at multiple sites affiliated with Saint Vincent Hospital. The study population was divided into two groups based on the presence or absence of calcium altering conditions or medications. True hypocalcemia incidence was calculated after correcting calcium for albumin from the initiation of ICPI to their last follow-up. Group 1 (n = 83) includes patients with no calcium altering conditions or medications. Group 2 (n = 98) includes patients on calcium supplements (n = 17), vitamin D (n = 44), bisphosphonates (n = 24), >stage IIIB chronic kidney disease (CKD) (n = 5), and bone metastasis (n = 38). Hypocalcemia events in Group 1 vs. Group 2 were 8.4% and 19.3%, respectively. Our entire study demonstrated 26.8% vs. 1.1% of Grade I vs. II hypocalcemia events. However, after correcting the calcium for albumin, hypocalcemia incidence was 0.56% (n = 1). No further workup was done to investigate the etiology as that patient passed away. Our data suggest that the true hypocalcemia incidence after using albumin-corrected calcium values is very low in patients receiving IPCI, even in the presence of calcium altering factors. The percentage of patients with hypocalcemia is much higher and similar to the KEYNOTE-189 and CHECKMATE-067 trials when serum calcium values without albumin correction are used. Thus, the higher reported incidence of hypocalcemia in these trials is likely due to the reporting of serum calcium without albumin correction.

Hypocalcemia with immune checkpoint inhibitors: The disparity among various reports.

e15153 Background: Immune-related adverse events affecting parathyroid function are rarely reported with immune checkpoint inhibitors (ICPI). Activating calcium-sensing receptor antibodies causing autoimmune hypoparathyroidism with nivolumab was recently published by Piranavan et al. KEYNOTE-189 and CHECKMATE-067 trials reported a 21-29% hypocalcemia event rate. The purpose of our study is to identify the hypocalcemia incidence in patients receiving ICPI at a single institution with multiple sites. Also, we aimed to investigate hypoparathyroidism as the etiology in these patients, if hypocalcemia was detected. Methods: A chart review to study patients receiving ICPI from 2015 to 2018 at multiple sites affiliated with Saint Vincent Hospital. The study population was divided into two groups based on the presence or absence of calcium altering conditions or medications. True hypocalcemia incidence was calculated after correcting calcium for albumin from the initiation of ICPI to their last follow-up. Results: Group 1 (N = 83) includes patients with no calcium altering conditions or medications. Group 2 (N = 98) includes patients on calcium supplements (N = 17), vitamin D (N = 44), bisphosphonates (N = 24), &gt; stage IIIB CKD (N = 5), and bone metastasis (N = 38). Hypocalcemia events in Group 1 vs. Group 2 were 8.4% and 19.3%, respectively. Our entire study demonstrated 26.8% vs. 1.1% of Grade I vs. II hypocalcemia events. However, after correcting the calcium for albumin, hypocalcemia incidence was 0.56% (N = 1). No further workup was done to investigate the etiology as that patient passed away. Conclusions: Our data suggest that the true hypocalcemia incidence after using albumin-corrected calcium values is very low in patients receiving IPCI, even in the presence of calcium altering factors. The percentage of patients with hypocalcemia is much higher and similar to the KEYNOTE-189 and CHECKMATE-067 trials when serum calcium values without albumin correction are used. Thus, the higher reported incidence of hypocalcemia in these trials is likely due to the reporting of serum calcium without albumin correction.

Choice of birth place among antenatal clinic attendees in rural mission hospitals in Ebonyi State, South-East Nigeria.

BackgroundLow utilization of health facilities for delivery by pregnant women poses a public health challenge in Nigeria.AimTo determine the factors that influence the choice of birth place among antenatal clinic attendees.MethodologyThis was a cross-sectional study of the eligible antenatal clinic attendees recruited at Mater Misericordiae Hospital, Afikpo and Saint Vincent Hospital, Ndubia in Ebonyi State from February 1, 2016 to June 30, 2016. Analysis was done using EPI Info 7.21 software (CDC Atlanta Georgia).ResultsA total of 397(99.3%) completely filled questionnaires were collated and analysed. Approximately 71% of the health facilities closest to the respondents had maternity services. It took at least 1 hour for 80.9% of the respondents to access health facilities with maternity services. Most (60.2%) of the respondents had at least one antenatal clinic attendance and majority of them did so at public hospitals. Approximately 43.8% of the respondents were delivered by the skilled birth attendants. The respondents’ age and the couple’s educational level, history of antenatal clinic attendance, distance of the health facility and availability of transport fare had a significant effect on delivery by skilled birth attendants. The common determinants of birth place were nearness of the health facilities, familiarity of healthcare providers, improved services, sudden labour onset and cost. Also 61.7% of the respondents chose to deliver in public health facilities due to favourable reasons but this could be hampered by the rudeness of some healthcare providers at such facilities. A significant proportion of private health facilities had unskilled manpower and shortage of drugs.ConclusionA greater proportion of women will prefer to deliver in health facilities. However there are barriers to utilization of these facilities hence the need to address such barriers.

Modeling the impact of changing patient flow processes in an emergency department: Insights from a computer simulation study

We report on the use of discrete-event simulation modeling to support process improvements in a hospital emergency department (ED), namely the implementation of a split-flow process. Our partner hospital was effective in treating patients, but wait time and congestion in the ED created patient dissatisfaction, unsafe conditions and staff morale issues. The split-flow concept is an emerging approach to manage ED processes by splitting patient flow according to patient acuity and enabling parallel processing. We contrast the split-flow operational model to other types of ED triage. While early implementations of the split-flow concept have demonstrated significant improvements in patient wait times, a systematic evaluation of operational configurations is lacking.We created a discrete-event simulation model and established its face validity for Saint Vincent Hospital in Worcester, USA, a community-teaching, Level II Trauma Center. Seventeen scenarios were tested to estimate the likely impact of a split-flow process redesign, including staffing level changes and patient volume changes. The scenarios were compared in terms of Door-to-Doctor time and length-of-stay for different patient acuity levels.Findings from the study supported implementation of the split-flow improvements. Statistical analysis of data taken before and after the implementation indicate that waiting time measures were significantly improved and overall patient length-of-stay was reduced. To gauge the success of the current split-flow process at Saint Vincent we compare performance metrics from three different sources: benchmark metrics, hospital data prior to split-flow implementation, and performance metrics post implementation.

Compliance with the Adult Treatment Panel III guidelines for hyperlipidemia in a resident-run ambulatory clinic: A retrospective data analysis

One in every six adults (16.3% of the U.S. adult population) has high total cholesterol levels, and they are at double the risk of heart disease compared with people with optimal levels. To evaluate compliance of internal medicine residents with the latest National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines in treating patients with hyperlipidemia. Retrospective observational study. Ambulatory Clinic, Saint Vincent Hospital, Worcester, Massachusetts. Patients with a diagnosis of hyperlipidemia who attended the clinic during a 1-ear period, from December 2009 to November2010. A review of medical records was conducted to evaluate residents' compliance with the NCEP-ATP III guidelines for LDL cholesterol and non-HDL cholesterol management. Seven hundred seventy charts were reviewed. Only 212 (27.5%) met the inclusion criteria. Analysis of data revealed better compliance with drug therapy (44%-77%) and therapeutic lifestyle changes (44%-83%) when compared with follow-up recommendations (22%-31%). An increase in compliance also was noted in all areas of intervention when patients had an abnormal lipid profile. Compliance was assessed on the basis of electronic medical record documentation alone and hence we may be underestimating compliance with therapeutic lifestyle changes and follow-up recommendations. Compliance among internal medicine residents in the diagnosis, treatment and follow-up of patients with hyperlipidemia according to NCEP-ATP III guidelines was suboptimal and needs improvement.

Outcomes of Plasma Cell Disorder Patients with Abnormal Hepatitis B and C Screening Tests Prior to Autologous Stem Cell Harvest and Transplantation

Abstract 4472 Background:High dose melphalan with autologous stem cell transplant (ASCT) is a standard treatment for patients with multiple myeloma (MM) and AL amyloidosis. A standard part of the pre stem cell harvest (SCH)/SCT evaluation at most medical centers is a battery of infection screening tests. While the reactivation of hepatitis B with rituximab is well described, there are limited data on the outcomes or significance of abnormal test results in non-endemic areas in the context of ASCT. Moreover, it is unclear whether patients with plasma cell disorders (PCDs), with their dysregulation of humoral immunity, may have differing rates of abnormal test results on antibody based testing than patients without PCDs. Indeed, one study found hepatitis B seroconversions more commonly with MM post ASCT (Uhm et al, ASBMT 2007). We therefore conducted this retrospective study to examine the outcomes of abnormal infection screening in patients with PCDs and non PCDs undergoing SCH/SCT in the New York Metropolitan area. Method:We reviewed 639 consecutive patients who had autologous hematopoietic stem cell harvests (SCH) done at Saint Vincent Hospital, NY from February, 2000 to March, 2010. Of these patients, 555 had PCDs including multiple myeloma and AL Amyloidosis. The 84 non PCDs included lymphoma and solid tumors patients were used as a comparator group. Result:We first reviewed the rate of positive infectious screening tests and found no difference between PCDs (55 out of 555, 9.9%) and non PCDs (9 out of 84, 10.7%). Of these patients with abnormal screening results, 40 and 7 patients respectively went on to ASCT. 11 patients had more than one infection screening test abnormality, making a total of 76 abnormal tests.As shown in Table 1, 67.1% (51/76) were positive for Hep B core Ab, 19.7% (15/76) for Hepatitis C Ab, 6.5 % (5/76) for syphilis, 5.2 % (4/76) for HTLV and 1.3% (1/76) for HIV.Amongst the 44 patients with PCDs and positive anti-HBc total, 39% (17) were positive antiHBc Ig G antibody but negative for IgM, representing chronic carriers. 9% (4) were negative by both antiHBc Ig M and IgG, which may represent false positive tests, and this pattern was not seen in any of the 7 patients with non PCDs. Of the PCD patients who had Hepatitis B PCR testing, 1 showed chronic active hepatitis and 9 had undetectable viral load. 68.5% of positive Hepatitis B screening patient went on to SCT (including the patient with PCR + but IgM was negative) regardless of the status of test results without any treatment for hepatitis B.Of the 13 PCD patients with positive anti-HCV Ab screening, 46% (6) had active viral replication by PCR and 30% (4) had with undetectable viral load by PCR. 2 patients had negative repeat HCV testing. Only one patient with chronic active HCV infection (146,1200,000 IU/ml) by PCR got treatment by IFN and Ribavirin pretransplant and did not get ASCT. 66.6% of positive Hepatitis C screening patient went on to SCT.Five patients had RBC transfusions during the year preceding infection screening (3 with positive antiHBc total antibody, 1 with HCV antibody and 1 with HTLV antibody). One patient had IVIG transfusion 7 days before screening. There appeared to be no relationship to abnormal screening tests and MM subtype or hypogammaglobulinemia.Of those patients who went on to SCT, transient grade 1 transaminitis during transplant or by day 100 was found in 4 patients (6%) with positive hepatitis B screening. One patient had transient asymptomatic hepatomegaly. We observed no serious hepatic complications in chronic hepatitis B and C carriers without active disease and ASCT appears to be feasible and safe without any anti-viral treatment. ConclusionWith the exception of a possible excess of false positive hepatitis B testing in patients with PCDs, there are no other differences in rates of abnormal infection screening tests between PCDs and nonPCDs. The use of more specific viral testing like PCR and Western blot or highly sensitive immunoassay should be considered to avoid false positive results in the analysis of antibody based tests to avoid both unnecessary delays of SCT and anti-viral treatment. In the absence of clinical hepatitis and active viral replication, treatment for chronic Hepatitis B and C carriers does not appear to be required preASCT. Disclosures:Jagannath:Celgene: Membership on an entity's Board of Directors or advisory committees; Merck: Membership on an entity's Board of Directors or advisory committees; Millennium: Membership on an entity's Board of Directors or advisory committees. [Display omitted]

Utility of the Frontal Plane QRS Axis in Identifying Non–ST-Elevation Myocardial Infarction in Patients With Poor R-Wave Progression

Poor R-wave progression (PRWP) is a common electrocardiographic phenomenon in which the anticipated increase in R-wave amplitude in successive precordial leads, V(1) to V(5), fails to occur. PRWP is prevalent in approximately 10% of hospitalized adult patients, predominantly in those with coronary artery disease. Debate is ongoing on its association with myocardial infarction (MI). However, studies that showed no association failed to appraise the significance of the QRS axis in relation to PRWP among such patients with MI. In our retrospective study, we consecutively identified 150 unselected adult patients with PRWP among 660 successive admissions to the general medical floors of a tertiary care teaching hospital (Saint Vincent Hospital, Worcester, Massachusetts). After excluding patients with anterior wall Q-wave MI (defined as the presence of a QS complex or Q-wave > or =1 mm deep in V(2) or V(3)), sudden unexpected death, MI after percutaneous coronary interventions or coronary artery bypass grafting during this hospitalization, Wolff-Parkinson-White syndrome, pacemakers, bundle branch blocks, and electrocardiograms that were of poor quality or affected by severe motion artifact, inconsistencies with patient identification, or errors in lead placement, 137 patients remained. The patients were then screened for non-ST-segment elevation MI (NSTEMI) during the present admission. The DePace criteria for PRWP were systematically used for all patients, and the QRS axis was calculated using limb leads based on Einthoven's equilateral triangle (normal was considered -30 degrees to 100 degrees ). Of the 137 study patients screened with PRWP, 38 had NSTEMI (25.3%). Thirty-one had a normal QRS axis (mean age +/- standard deviation 71.3 +/- 12 years), and 7 showed either right or left axis deviation (mean age +/- standard deviation 64.3 +/- 15 years). This proved to be statistically significant (p <0.0001) within this cohort of NSTEMI patients. In conclusion, PRWP determined using the DePace criteria in the presence of a normal QRS axis appears to be more significantly associated with the presence of overall MI within this cohort of NSTEMI patients.

Finding Common Ground: An Integrative Model of Geriatric Medicine and Geriatric Psychiatry Fellowship Education

Currently, the fastest-growing segment of the U.S. population is the group aged 85 and older; referred to as the oldest old, this group is expected to reach 10 million by 2030. They are more likely to live in metropolitan areas with many aging in place ( A Profile of Older Americans, 2006). Our institution, Saint Vincent's Hospital, Manhattan, serves the needs of the surrounding urban community in lower Manhattan, including older adults from culturally and socioeconomically diverse backgrounds. Often having grown to advanced age with little family or social support, many have to cope with functional decline, chronic medical illness, and complicating issues, such as cognitive impairment, bereavement, isolation, depression, and chronic mental illness. Meeting the needs of this population requires an interdisciplinary approach that includes a strong psychosocial component, as medical and psychiatric syndromes commonly coexist, are often overlapping in nature, and occur with a high frequency. Chronic medical illness is expected in older adults; 80% have at least one chronic condition, and 50% have two or more ( Healthy Aging, 2007). Mental disorders are less frequent than medical ones but still common in older persons, as evidenced by the Epidemiologic Catchment Area Survey (Regier et al., 1984). Using a structured psychiatric interview from which diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) were constructed, the prevalence in this sample of community-dwelling adults was 12.3%. Behavioral and cognitive issues that arise frequently complicate the care of older patients. For example, 1 of 10 older adults over age 65 will develop dementia, as will 40% to 50% of those over age 85 ( ADEAR, 2006). Moreover, there is a high frequency of behavioral symptoms in patients with dementia, including psychotic symptoms in up to 20% of Alzheimer's patients, depression in 40%, and aggression or agitation at some point in 80% ( BPSD, 2007). A study looking at behavioral disturbances in dementia (Alzheimer's and non-Alzheimer's) revealed that 61% had behavioral disturbances in the prior month, including apathy (27%), agitation (24%), and depression (24%) (Lyketsos et al., 2000). These figures are even higher in the nursing home population (Task Force on Nursing Homes and the Mentally Ill Elderly, 1989). In addition, depression is prevalent in the geriatric population and very often associated with negative life events, death of friends and family, and change of residence (Hybels & Blazer, 2003). Effective treatment of these conditions is challenging and complex; older adults are at higher risk for adverse drug reactions (Hanlon et al., 1997) and interactions that often present atypically as a geriatric syndrome (e.g., falls, mental status changes, loss of function, or failure to thrive). The geriatrician is expected to be able to address competently the medical, behavioral, and psychiatric aspects of a patient's condition. The future demographic trends, the stigmatization of mental illness, and general resistance to seeking treatment from mental health professionals among many elderly emphasize this (Klap, Unroe, & Unutzer, 2003). To care effectively for older adults, the geriatrician needs a strong foundation in geriatric psychiatry. Conversely, the geriatric psychiatrist needs to be aware of common medical comorbidities and drug interactions. Effective practice of either geriatric medicine or geriatric psychiatry requires clinicians to have a fund of geriatrics knowledge that encompasses aspects of both medicine and psychiatry in order to provide appropriate care to complex, frail adults. Therefore, it is important that geriatricians possess the skills necessary to recognize and manage common psychiatric and behavioral conditions occurring in older adults, especially since it is predicted that there will be a continued shortage of geriatric psychiatrists in the near future (Lieff et al. …

Rhythmic Artifact of Physiotherapy in Intensive Care Unit EEG Recordings

*Department of Neurology, NYP-Weill Cornell Medical Center, New York; †Saint Vincent's Hospital and Medical Centers, New York; and ‡Sir Ganga Ram Hospital, New Delhi, India. Address correspondence and reprint requests to N.K. Sethi, MD, Comprehensive Epilepsy Center, NYP-Weill Cornell Medical Center, 525 East, 68th Street, New York, NY 10021; e-mail: [email protected].

Cryptococcal meningitis after Imuran (azathioprine) therapy for autoimmune hepatitis

aDepartment of Neurology, Saint Vincent's Hospital and Medical Centers, New York, USA bSir Ganga Ram Hospital, New Delhi, India Correspondence to Dr Nitin K. Sethi, MBBS, MD, Saint Vincent's Hospital and Medical Centers, 153 West 11th Street, New York, NY 10011, USA Tel: +1 646 515 5168; e-mail: [email protected] Received 24 May 2006 Accepted 25 April 2007

Evidence Needed for Policy Decisions: Adherence Interventions and Medicare Part D

to Boehringer Ingelheim and Microbiotix Inc. Additional Contributions: The following individuals also contributed to this investigation: Steven Lamontagne, Egal Gudal, Courtney Carpenter, Charles Daniel, and Marc Restuccia, MD (medical director), Department of Emergency Medicine, Worcester Emergency Medical Services, Worcester, Massachusetts; Octavio Diaz, MD (director), Department of Emergency Medicine, Saint Vincent Hospital, Worcester; and Rosemarie Erlichman (infection control practitioner), UMass Memorial Medical Center, Worcester.

False negative rates of PET scanning in bronchoalveolar lung (BAL) cancer and its implication for diagnosis and staging

18196 Background: Positron Emission Tomography (PET) scanning is extensively used for the diagnosis and staging of NSCLC lung cancer. Studies have shown PET scanning has a higher sensitivity and specificity in NSCLC than conventional diagnostic studies. False negative results in bronchoaveolar (BAL) lung cancer have not been systematically studied. We conducted a retrospective review to report and evaluate the low sensitivity of PET scanning in BAL when compared to other types of NSCLC cancer. Methods: We reviewed records of all patients who were diagnosed with lung cancer at Saint Vincent Hospital from 2000 to 2005. A total of 1361 patient were identified with a pathologically confirmed diagnosed of lung cancer out of which PET scanning was done in 36. All of these 36 cases reported NSCLC cancer: 29 NSCLC (adenocarcinoma 8, squamus cell 4, undifferentiated 6, non-small cell carcinoma 10), 7 bronchoalveolar carcinoma (BAL). Results: Among the cases diagnosed with NSCLC lung cancer at our institution, PET scans were done in 36 cases. Adenocarcinoma was found in 8 cases, all of which had positive PET reports. Squamous cell carcinoma was found in 4 cases, non-small cell carcinoma (not otherwise specified) was found in 10 cases, carcinosarcoma was found in 1 case, and undifferentiated carcinoma was found in 6 cases, all of which had positive PET reports and no false negatives (n=29/29,100%). Surprisingly, in the 7 bronchoalveolar cancer cases, only one PET scan was positive with 6 false negative reports (n= 1/7, 14.2%). A bivariate analysis (chi-square with Yate’s correction for continuity) revealed that the PET scan false negatives are significantly higher (p &lt; 0.0000007) for BAL when compared to other types of NSCLC cancers. Conclusions: PET scanning does not appear to be sensitive in the stagging and detection of BAL lung cancer with sensitivity of 14%. Routine use of PET scans for staging and diagnosis of BAL is not supported by this study. No significant financial relationships to disclose.