Supraventricular tachycardia of the sick, a unique entity.

OBJECTIVE: This study explored a unique form of atrioventricular nodal reentrant tachycardia (AVNRT) in which certain acutely ill patients have a first episode of supraventricular tachycardia (SVT) with a short RP interval. METHODS: A retrospective chart review was conducted of patients at a single institution who developed SVT with short RP and yielded 19 patients. RESULTS: None of the 19 patients had a prior history of AVNRT or any other arrhythmia. The mean age was 58 years, the majority of patients were male (13/19), and there was a presence of hypertension (10/19), diabetes mellitus (5/19), hyperlipidemia (7/19), congestive heart failure (2/19), coronary artery disease (3/19), obstructive sleep apnea (2/19), and active cancer (8/19). The reasons for admission were planned surgery (8/19), sepsis (8/19), drug abuse (2/19), and neurological disorder (2/19). The AVNRT either terminated spontaneously or following the administration of adenosine. The patients were treated with amiodarone (12/19), metoprolol (6/19), or diltiazem (1/19). Follow-up (mean: 370 days) details revealed that patients were on amiodarone (3/19), metoprolol (6/19), were not taking any cardiac medication (5/19), or had passed away (5/19). Only 1 patient had a recurrence of AVNRT, and none of the patients required ablation therapy. CONCLUSION: 'AVNRT of the sick' has not been previously described in the medical literature, to our knowledge. It can be successfully treated with medications and the chance of recurrence after resolution of the acute illness is small.

Optimizing the Approach to Patients With Pleural Effusion and Radiologic Findings Suspect for Cancer.

BACKGROUND: When patients present with pleural effusion and structural abnormalities consistent with malignancy on imaging, the traditional approach has been to perform a thoracentesis and await the results before proceeding to more invasive diagnostic procedures. The objective of this study was to evaluate whether concurrent thoracentesis and tissue biopsy is superior to sequential sampling. METHODS: Retrospective chart review was performed for patients who had a pleural cytology from May 2014 until January 2017. Patients without parenchymal, pleural, or mediastinal abnormalities and those with a prior primary thoracic malignancy were excluded. Patients with an effusion and additional suspect findings were grouped based upon whether initial approach was concurrent versus sequential. The following outcomes were documented: lag time to diagnosis from thoracentesis, lag time to hematology/oncology (HONC) service consult, time to molecular study results, lag time to therapy, and time to death. RESULTS: Of 565 cases, 45 met criteria, 28 (62%) having undergone concurrent and 17 (38%) sequential sampling. The median lag time to biopsy for the concurrent group, 3 days, was significantly shorter than the 9-day lag time for the sequential group (P=0.006). Five patients in the sequential group and one in the concurrent group were lost to follow-up. Patients in the concurrent group had earlier diagnosis and oncology visits (2 d, 7 d) than those in the sequential group (6.5 d, 16 d) (P<0.001 and <0.039, respectively). Time from diagnosis to death did not differ for the 2 groups. CONCLUSION: For patients presenting with pleural effusion accompanied by additional suspect findings, concurrent tissue sampling, and thoracentesis may both reduce loss to follow up and accelerate care.

Impact of targeted educational interventions on appropriateness of stress ulcer prophylaxis in critically ill adults.

BACKGROUND: Acid suppression therapy (AST) is routinely used in critically ill patients to prevent stress-related mucosal bleeding (SRMB). OBJECTIVE: Our objective was to determine the impact of a structured educational intervention on AST used for prevention of SRMB on appropriateness of AST. METHODS: A single-center, retrospective, cohort study of appropriate use of AST in critically ill patients admitted to the medical intensive care unit (ICU) at an academic medical center between January to June of 2014 (no intervention) and January to June of 2015 (intervention) was conducted. The percentage of patients prescribed inappropriate AST, inappropriate AST at ICU transfer and hospital discharge, doses of inappropriate AST, and adverse effects associated with AST use were compared between periods using chi-square tests. RESULTS: Patients in the intervention group (n=118) were 5 years older than patients in the no intervention group (n=101). AST was inappropriately initiated more frequently in the no intervention group (23% vs. 11%, p=0.012). Continuation of inappropriate AST at ICU transfer and hospital discharge was similar between groups (60% vs. 53%, p=0.277 and 18% vs. 14%, p=0.368, respectively). CONCLUSION: Patients had appropriate AST initiated and inappropriate AST withheld more frequently when formal education was provided. This low-cost intervention strategy can be implemented easily at institutions where pharmacists interact with physicians on rounding services and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.

Impact of Targeted Educational Interventions on Clostridium difficile Infection Treatment in Critically Ill Adults.

Background: Clostridium difficile infection (CDI) is a growing clinical and economic burden throughout the world. Pharmacists often are members of the primary care team in the intensive care unit (ICU) setting; however, the impact of pharmacists educating other health care providers on appropriateness of CDI treatment has not been previously examined. Objective: This study was performed to determine the impact of structured educational interventions on CDI treatment on appropriateness of CDI treatment and clinical outcomes. Methods: This was a single-center, retrospective, cohort study of patients with CDI in the medical ICU at an academic medical center between January and June 2014 (pre-period) and 2015 (post-period). All patients were evaluated for appropriate CDI treatment before and after implementing pharmacist-provided educational interventions on CDI treatment. Results: Patients in the post-period were prescribed appropriate CDI treatment more frequently than patients in the pre-period (91.7% vs 41.7%; p = .03) and received fewer inappropriate doses of a CDI treatment agent (14 doses vs 30 doses). Patients in the pre-period had a shorter ICU length of stay [1.5 days (range, 1-19) vs 3.5 days (range, 2-36); p = .01] and a similar hospital length of stay [9.5 days (range, 4-24) vs 11.5 days (range, 3-56); p = .30]. Total time spent providing interventions was 4 hours. Conclusion: Patients had appropriate CDI treatment initiated more frequently in the post-period. This low-cost intervention strategy should be easy to implement in institutions where pharmacists interact with physicians during clinical rounds and should be evaluated in institutions where interactions between pharmacists and physicians occur more frequently in non-rounding situations.