Mechanical Thrombectomy for Submassive Pulmonary Embolism in an Adult with Duodenal Adenocarcinoma and Brain Metastases.

A 52-year-old African American man with small bowel adenocarcinoma metastatic to the brain and leptomeninges was found to have an acute pulmonary embolism while hospitalized for acute lower limb weakness, bowel, and urinary incontinence. He had an elevated troponin, echocardiographic findings concerning for right heart failure, and bilateral segmental and subsegmental pulmonary artery perfusion deficits with right pulmonary artery thrombus on CT angiography. Given the laboratory and radiographic findings with normotensive blood pressure, the patient was diagnosed with a submassive pulmonary embolism.  After deliberation with interventional radiology and hematology, the patient underwent mechanical thrombectomy and was treated with therapeutic anticoagulation. Mechanical thrombectomy revealed substantial clot burden in the central pulmonary arteries and yielded a significant improvement in hypoxia and dyspnea.  This case was an excellent exercise in therapeutic decision-making amidst a dynamic disease process that required integration of numerous clinical and diagnostic data points, including empiric anticoagulation with high clinical suspicion of acute pulmonary embolism, review of contraindications to anticoagulation and thrombolysis in metastatic malignancy, and the decision to pursue mechanical thrombectomy in the setting of contraindications to catheter-directed thrombolysis.

Hospitalists caring for patients with advanced cancer: An experience-based guide.

Every year, nearly 5 million adults with cancer are hospitalized. Limited evidence suggests that hospitalization of the cancer patient is associated with adverse morbidity and mortality. Hospitalization of the patient with advanced cancer allows for an intense examination of health status in the face of terminal illness and an opportunity for defining goals of care. This experience-based guide reports what is currently known about the topic and outlines a systematic approach to maximizing opportunities, improving quality, and enhancing the well-being of the hospitalized patient with advanced cancer.

Hospitalists on an inpatient tertiary care oncology teaching service.

PURPOSE: Hospitalists provide quality care in various inpatient settings, but the ability of hospitalists to provide quality inpatient care for patients with complex cancer has not been studied. This study explores outcomes with a hospitalist-led versus medical oncologist-led house staff team on an inpatient medical GI oncology teaching service. METHODS: This observational retrospective cohort study examined 829 patient discharges from August 2012 to January 2013 on the GI oncology inpatient teaching service at Memorial Sloan Kettering Cancer Center, a tertiary cancer center in New York, New York. We compared average length of stay (ALOS), 30-day readmission rates, establishment of new do not resuscitate (DNR) orders, nosocomial pneumonia and urinary tract infection (UTI) rates, radiographic and laboratory tests per patient, and disposition on discharge between hospitalist-led and oncologist-led teams. RESULTS: Median years of clinical experience was 6 (range, 4 to 9 years) for hospitalists and 7 (range, 0.5 to 36 years) for oncologists. ALOS (hospitalist led, 5.6 v oncologist led, 5.2 days; P = .30), readmission within 30 days (hospitalist led, 14% v oncologist led, 16%; P = .44), new DNR orders (hospitalist led, 18% v oncologist led, 19%; P = .90), nosocomial pneumonia (hospitalist led, 0.5% v oncologist led, 0.7%; P = .63) and UTI rates (hospitalist led, 0.5% v oncologist led, 0.7%; P = .63), number of radiographic studies and laboratory tests, and disposition on discharge were not significantly different between groups. CONCLUSION: A hospitalist-led inpatient service with house staff represents a novel approach for caring for hospitalized GI oncology patients with cancer.

30-day-or-sooner readmissions of gastrointestinal medical oncology patients following cancer center inpatient service discharge: characteristics and preventability.

PURPOSE: The Centers for Medicare and Medicaid Services recently initiated readmission reduction programs for certain noncancer index admissions. Intrinsic to this policy is the assumption that such readmissions are reasonably preventable and are due to inadequate management. For cancer patients, readmission frequency, characteristics, and their preventability have not been extensively evaluated. METHODS: We first electronically searched medical records of patients on our gastrointestinal oncology inpatient service to identify patients who had been discharged and then readmitted within 30 days. However, electronic review resulted in insufficient granularity of clinical records. Therefore, 50 of them were randomly selected for exhaustive manual review to assess the reasons for index admission and readmission, the nature of the index admission discharge plan, and whether the readmission was reasonably preventable or not, based on prespecified criteria. RESULTS: Between September 1, 2008, and March 1, 2013, 3995 gastrointestinal medical oncology patients had an index admission, of whom 876 (22%) had ≥ 1 readmission within 30 days. From the 50 manually reviewed records, the most common diagnosis categories for either the index admission or the readmission were infection, pain, and gastrointestinal issues. For 64% of these patients, the diagnoses of the index admission and the readmission were different. Disagreement between the care team and patient/family about the index admission discharge plan was documented in 10%. The readmission was determined to be preventable in 1 (2%) of the 50 manually reviewed cases. CONCLUSIONS: Readmissions in this cancer population are common and reflect the refractory nature of these diseases and the high disease burdens. The vast majority of readmissions in this population, by our criteria, were not preventable. Our ongoing research in this vulnerable population includes efforts to better characterize and communicate care options, especially in the cases in which there was disagreement between the care team and patient/family.