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Femoral Nerve Injury after Primary Total Hip Arthroplasty is More Common in Patients with Prior Femoral Artery Catheterization
James W. Pritchett
INTRODUCTION: Nerve injury following total hip arthroplasty (THA) is a possible complication that is included in informed consent. Ninety-five percent of femoral artery catheterizations (FACs) utilize a right-side approach and can cause scar around the femoral nerve. The effect of FAC on femoral nerve injury during THA has not been investigated previously.
METHODS: The joint implant database was searched for patients who had primary THA after prior FAC from 2005-2015 (study group). Patients who underwent bilateral THA without prior FAC served as the control group. Proprietary software was used to query the database according to the International Classification of Diseases procedural codes for primary THA and FAC. Chi-square testing was used to determine significant differences between groups (p < 0.05).
RESULTS: There were 62,016 patients in the study group and 441,013 patients in the control group. The left femoral nerve injury rate in the control group was 0.53% and 0.55% in the study group. The right femoral nerve injury rate in the control group was 0.51% and 1.53% in the study group (p < 0.0001). A total of 91% were missed at the time of surgery but 69% of the femoral nerve injuries were identified within 90 days of THA.
DISCUSSION AND CONCLUSION: Patients with a previous history of right femoral artery catheterization have a significantly higher rate of right femoral nerve injury when undergoing THA. Orthopaedic surgeons should be aware of this increased risk of femoral nerve injury -
Perilymphatic IRX-2 cytokine therapy to enhance tumor infiltrating lymphocytes and PD-L1 expression preceding curative-intent therapy in early stage breast cancer
Joanna Pucilowska, Venkatesh Rajamanickam, Katherine Sanchez, Valerie Conrad, Alison Conlin, Shagheyegh Aliabadi-Wahle, Shu-Ching Chang, Gary Grunkemeier, Nikki Moxon, Staci Mellinger, Maritza Martel, James Egan, Monil Shah, and David B Page
Background: Cytokines are being explored as a therapeutic strategy to modulate the tumor microenvironment and facilitate immunotherapy benefit in breast cancer. Here, we investigate a locoregional therapeutic approach whereby cytokines (IRX-2) are administered into the subcutaneous peri-areolar tissue (in an anatomic distribution similar to sentinel lymph node mapping) to facilitate immune cell recruitment/activation within the draining lymph nodes and tumor in ESBC. IRX-2 is derived from ex vivo phytohemagglutinin-stimulated lymphocytes and contains multiple cytokines including IL-1β, IL-2, TNF-α, IFN-γ, IL-6, IL-8, and GM-CSF, with stable concentrations from lot to lot. Preclinically, IRX-2 activates T-cells and natural killer (NK) cells, facilitates antigen presentation, and enhances activity of anti-PD-1/L1 in a SCC7 model. In a preceding head/neck squamous cell carcinoma phase I trial, perilymphatic IRX-2 was safe and increased TILs. Here, we report the final clinical results of a phase Ib trial evaluating the feasibility and immunologic activity of IRX-2 in ESBC.
Methods: Beginning 21 days prior to surgical resection, enrolled operable patients with stage I-III ESBC (all subtypes) received the pre-operative IRX-2 regimen consisting of a single low-dose cyclophosphamide (300 mg/m2 to facilitate T-regulatory cell depletion), followed by 10 days of subcutaneous peri-areolar IRX-2 injections into the affected breast (1 mL × 2 at tumor axis and at 90°). Endpoints were feasibility (primary endpoint), stromal TIL (sTIL) count (pre-treatment versus post-treatment, blinded average of two pathologist reads using San Antonio H&E sTIL guidelines), PD-L1 expression (Nanostring) and enumeration of peripheral immune cells by flow cytometry.
Results: All patients (n=16/16) completed and tolerated the regimen with no surgical delays or treatment-attributed grade III/IV toxicities. Common adverse events (occurring in >15% subjects) attributed to IRX-2 injections were: injection site reaction (grade 1, n=8/16), bruising (grade 1, n=7/16), and pain (grade 1, n=3/16). Common adverse events attributed to low-dose cyclophosphamide were: fatigue (grade 1, n=5/16) and nausea (grade 1/2, n=3/16). Treatment was associated with an increase in sTIL score (Wilcoxon signed-rank p=.04), with 4/10 sTIL-low tumors (0-10% score) re-categorized to sTIL-moderate (11-50% score). Increases in PD-L1 RNA expression were observed (Wilcoxon signed-rank p=.04) in 12/16 tumors (median 57% increase, range: -53% to 185% increase), as well as increases in Nanostring NK and Th1 cell signatures. In blood, increases in CD4 and CD8 effector T-cell activation (ICOS, HLA-DR, and CD38) and T-reg depletion were observed.
Conclusions: IRX-2 was well tolerated with preliminary evidence of sTIL increase, PD-L1 upregulation, and peripheral lymphocyte activation. Based upon these data and preclinical evaluations demonstrating synergy with checkpoint inhibition, the IRX-2 regimen is being evaluated for clinical efficacy in conjunction with pembrolizumab and neoadjuvant chemotherapy (doxorubicin, cyclophosphamide, paclitaxel) in patients with stage II-III triple negative breast cancer.
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Incorporating Standardized Simulation into the Clinical Academy, a Transition into Practice (TIP) Program
Rachelle Reid
Session Objectives:
- Describe evidence-based justification for incorporating simulation into Transition into Practice (TIP) programs
- Evaluate current simulation curriculum design and standardization process and compare with elements utilized by Providence St. Joseph Health
- Develop an outline for Transition into Practice simulation facilitator education and development
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Catch the Wave: Incorporating QSEN Competencies in a Transition into Practice Program
Rachelle Reid and Michelle Scortzaru
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Service Operations Center Improves Hospital Flow and Reduces ED Boarding!
Jeanne Rhynsburger, Patty Palmer, and Michelle Hansen
Swedish Edmonds 3 year journey to optimize hospital flow by opening a Service Operations Center – flow management hub.
Notable improvements included:
- Patient visit times decreased 27 minutes per patient
- Emergency department (ED) admit times decreased 68 minutes per patient
- Boarding hours decreased 20%.
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High Risk, High Reward: How Team-Based Care Helps the Most Complex Patients
Deborah Satterfield, Kathleen Fraser, Mary McLaughlin-Davis, and Vanessa Casillas
Complex patients, challenging patients, costly patients, we all have them. With a team-based care model, caring for these patients can become gratifying, even fun. Led by a primary care physician, a psychologist, and case managers from three organizations, this session will explore an integrated case management approach that uses case managers, behavioral health, and PharmDs.
After this presentation you will be able to:
- 1. Discuss the value of an integrated case management approach in complex populations
- Describe the value and use of behavioral health providers and PharmDs in the care of complex patients
- Explain how to structure and lead complex case conferences and how to use risk stratification to determine which patients will benefit
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Knowledge Management & Data Literacy
Sony Shah
Using Knowledge Management and Data Literacy to enable caregivers to have ready access to Organizations’ documented base of facts, source of information and solutions.
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Modeling Safe Sleep Practices for the Newborn in the Hospital: Is it Happening?
Marietta Sperry and Kimberly Kohlieber
Background: Nurses have been noted to model unsafe sleep practices for the newborn in the hospital, despite having been extensively trained. Parents report they repeat this behavior at home. There is a reluctance of nurses to comply, notwithstanding implementation of Back to Sleep programs and documentation of parents being taught safe sleep practices, causing a plateau in the reduction sudden infant death syndrome (SIDS).
Methods: Systematic review of literature from CINHAL, Indiana State University Library, Google Scholar, and PubMed from last five years.
Results: Nurses were found to agree with many guidelines. Personal bias, or habit influenced poor implementation. Although provided with the knowledge, infants were continually placed in unsafe sleep positions, resulting in an inconsistency from knowledge to practice by nurses.
Discussion: Every nurse must model a consistent safe sleep message at every bedside interaction throughout the hospital stay. Interventions could include nurse re-education with mandatory declaration of education, and a Nurse Champion to follow up on unsafe sleep observations. Education should resolve the perceived risk of aspiration for supine positioning by nurses, the primary reason for non-compliance. Under educated parents use sleep positions modeled by nurses. Nurses must be educated that modeling unsafe sleep behaviors, such as using rolled blankets, bulb syringes to support side lying, or propping the bassinet up in the crib cannot be used in the hospital. Non-supine positioning should be utilized only when medically indicated, and with clear education for parents.
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Ovarian Cancer
Krishnansu S Tewari, Richard T. Penson, and Bradley J. Monk
From the Publisher:
Now updated quarterly for the life of the edition, DeVita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology, 11th Edition, carries on a tradition of excellence while keeping you continually up to date in this fast-changing field. Every quarter, your eBook will be updated with late-breaking developments in oncology, including new drugs, clinical trials, and more. These quarterly updates ensure that your purchase remains fresh and relevant to your practice—a unique, living reference to enhance and improve your patient care.
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Regional Strategies to Collaboratively Measure Affordability
Meredith Roberts Tomasi, Katie Dobler, and Pamela Mariea-Nason
Learn how Oregon and other states and regions are addressing health care quality and affordability with multi-payer regional data, cost reporting, and community stakeholder collaborations. This session will create a common understanding of terminology and share reports in use today. Participants will draft an affordability roadmap, deepen their knowledge of how to identify meaningful partnerships, and understand how any organization fits into the conversation.
After this presentation you will be able to:
- 1. Discuss the terminology, data elements, and regional resources already working with quality and cost data across the country, and explain how Oregon uses regional data and multi-stakeholder partnerships to address barriers to affordability
- Identify key champions of effective multi-stakeholder collaborations, and develop an affordability asset map for a community
- Generate ideas to create a collaborative community approach to understanding and optimizing the use of data
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Somatic Mutations and Immunotherapy
Eric Tran
A volume in the Translational Oncology series, Immunotherapy in Translational Cancer Research explores the recent developments in the role that immunotherapy plays in the treatment of a wide range of cancers. The editors present key concepts, illustrative examples, and suggest alternative strategies in order to achieve individualized targeted therapy. Comprehensive in scope, Immunotherapy in Translational Cancer Research reviews the relevant history, current state, and the future of burgeoning cancer-fighting therapies. The book also includes critical information on drug development, clinical trials, and governmental resources and regulatory issues.
Each chapter is created to feature: development of the immunotherapy; challenges that have been overcome in order to scale up and undertake clinical trials; and clinical experience and application of research. This authoritative volume is edited by a team of noted experts from MD Anderson Cancer Center, the world’s foremost cancer research and care center and:
- Offers a comprehensive presentation of state-of-the-art cancer immunotherapy research that accelerates the pace of clinical cancer care
- Filled with the concepts, examples, and approaches for developing individualized therapy
- Explores the breath of treatments that reflect the complexity of the immune system itself
- Includes contributions from a panel international experts in the field of immunotherapy
Designed for physicians, medical students, scientists, pharmaceutical executives, public health and public policy government leaders and community oncologists, this essential resource offers a guide to the bidirectional interaction between laboratory and clinic immunotherapy cancer research.
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Don’t Wait: Find and Address Behavioral Health Issues
Patrick Triplett and Amy Nist
Medical/Surgical units often lack behavioral health specialty resources to identify and support individuals with mental health and substance misuse conditions. Not addressing these issues increases costs, imposes undue burdens on staff, intensifies patient agitation, and impairs the care experience for individuals and their families. Our behavioral health teams proactively identify, assess and intervene on patients in our medical/surgical units while supporting and teaching medical/surgical staff how to more effectively interact with these populations.
Objectives
Objectives for Johns Hopkins:- Describe some of the considerations that go into formation of a pro-active psychiatric consultation service
- Review metrics and purported quality measures used to assess psychiatric consultation programs
- Discuss the cultural and qualitative impacts of a successful pro-active psychiatric consultation program
Objectives for Providence St. Joseph Health:
- Discuss an actionable roadmap to implementing a proactive Behavioral Health Intervention Team in an inpatient setting
- Identify how proactively identifying and intervening in behavioral health issues (mental health and substance misuse) on medical units improves care for patients while improving employee satisfaction
- Define measurable outcomes to monitor program evaluation, development, and improvement in support of a sustainable Behavioral Health Intervention Team
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Left atrial pressure elevation limits exercise capacity in LVAD patients: Insights from left pressure sensor monitoring in a Heartmate II patient
Jacob Abraham, L Wang, and Kateri Spinelli
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Oral, Head and Neck Oncology and Reconstructive Surgery
R. Bryan Bell, Peter E. Andersen, and Rui P. Fernandes
From the Publisher:
Oral, Head and Neck Oncology and Reconstructive Surgery is the first multidisciplinary text to provide readers with a system for managing adult head and neck cancers based upon stage. Using an evidence-based approach to the management and treatment of a wide variety of clinical conditions, the extensive experience of the author and contributors in head and neck surgery and oncology are highlighted throughout the text. This includes computer aided surgical simulation, intraoperative navigation, robotic surgery, endoscopic surgery, microvascular reconstructive surgery, molecular science, and tumor immunology. In addition, high quality photos and illustrations are included, which are easily accessible on mobile devices.
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Transforming Cardiology Care Towards Patient Centered Specialty Practice
Xiaoyan Huang, Lesley Jones Larson, and Meredeth Rosenthal
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Right internal jugular access as an alternative to femoral access for CardioMEMS implantation
Rebecca Lewis, Lian Wang, Kateri Spinelli, Joshua Remick, Jeff Paulson, Jay Chappell, and Jacob Abraham
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Sperry's Validation of Patient Teaching: A Nursing Concept
Marietta Sperry
Systematic review of patient teaching outcomes to form a concept requiring validation of patient’s understanding of information disseminated. Concept map illustrating defining attributes, antecedents, consequences, empirical referents, and model case.
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Aortic root thrombus and myocardial infarction after LVAD treated with intra-aortic thrombolysis and systemic anticoagulation
Yan Xu, Laura Holton, and Jacob Abraham
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Pregnancy and Pertussis: Why the Change in TDAP Administration?
Marietta Sperry
Background and new guidelines vs. old guidelines. Systematic review of obstacles, recommendations, and conclusions.
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Skin to Skin in the Operating Room for Cesareans
Marietta Sperry
Is there a difference in outcomes with both mothers & babies in mothers that deliver by Cesarean Section who experience Skin to Skin Contact (SSC) in the Operating Room (OR) compared to those who do not have SSC after a Cesarean Delivery?
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Under Pressure: An EBP Project to Reduce Pressure Ulcers
Carrie Doyle
At the end of this presentation the learner will be able to:
- Describe the use of the FOCUS - PDSA cycle in an Evidence Based Practice quality improvement project.
- Discuss the value of utilizing stakeholders at the unit level to introduce evidence-based interventions to prevent pressure ulcers.
- Describe what to do when it all goes horribly wrong!
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