Is Routine Continuous EEG for Traumatic Brain Injury Beneficial?

Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and subclinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of "routine" cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.

Surgical outcomes and failure-to-rescue events after colectomy in teaching hospitals: a nationwide analysis.

BACKGROUND: The relationship between failure-to-rescue (FTR) after colectomy is not well understood, particularly in teaching institutions. We sought to examine this relationship using a large national database. METHODS: Patients undergoing colectomy from 2010 to 2012 were identified in the Nationwide Inpatient Sample database. FTR events were defined as deaths following deep vein thrombosis or pulmonary embolism, sepsis, gastrointestinal bleed, acute myocardial infarction, acute kidney injury, pneumonia, respiratory failure, shock. We compared outcomes between teaching hospitals (TH) and nonteaching hospitals (NTH). RESULTS: A total of 220,369 patients underwent colectomy; 50.2% were performed at TH. Overall mortality was 3.7% with 96% of deaths attributed to at least one FTR event. More complications occurred in NTH, but there was no difference in mortality or FTR rates. However, TH had higher incidences of deep vein thrombosis or pulmonary embolism and sepsis leading to postoperative mortality, whereas NTH had higher rates of acute myocardial infarction and gastrointestinal bleed. CONCLUSIONS: A substantial proportion of mortality is attributed to FTR events after colectomy in both TH and NTH. Further investigation targeting specific complications is warranted.

High-value care in the surgical intensive care unit: effect on ancillary resources.

BACKGROUND: Changes in health care policies have influenced transformations in hospital systems to be cost-efficient while maintaining robust outcomes. This is particularly important in intensive care units where significant resources are used to care for critically ill patients. We sought to determine whether high-value care processes (HVCp) implemented in a surgical intensive care unit (SICU) have an impact on commonly used ancillary tests. MATERIALS AND METHODS: An implementation phase using a Lean Six Sigma approach was performed in October 2014 at a 24-bed large academic center SICU with aims to decrease orders of excessive daily laboratory tests and X-rays. The HVCp implemented included use of daily checklists, staff education, and visual reminders emphasizing the importance of appropriate laboratory tests and chest X-rays. Preintervention (July 2014-October 2014) and post-intervention (November 2014-June 2015) phases were compared. RESULTS: Average SICU census, case mix index (4.3 versus 4.4, P = 0.57), all patient refined severity of illness (3.2 versus 3.2, P = 0.91), and SICU mortality (7.1% versus 5.1%, P = 0.18) were similar in both phases. A significant reduction of excessive laboratory tests was evident after the implementation period. Eight hundred sixty-five arterial blood gases/mo were obtained in the preintervention phase compared with 420 arterial blood gases/mo after intervention (P = 0.004), representing a 51.4% reduction. Similar results were obtained with complete blood counts, basic metabolic profiles, coagulation profiles, and chest X-rays (12%, 17.8%, 30.2%, and 20.3% reductions, respectively), a total estimated cost savings of $59,137/mo and prevention of excess phlebotomy of approximately 4 L of blood/mo. CONCLUSIONS: By implementing an HVCp including a checklist, visual reminders, and provider education, we significantly reduced the use of commonly ordered ancillary tests in the SICU without affecting outcomes, resulting in an annual cost savings of $710,000.

Detection and preliminary characterization of CD8+T lymphocytes specific for Wilms' tumor antigen in patients with non-Hodgkin lymphoma.

Wilms' tumor antigen (WT1) is overexpressed in many different solid tumors and hematologic malignancies. However, little is known about WT1 expression or WT1-specific immune responses in patients with non-Hodgkin lymphoma (NHL). In a cross-sectional survey study, we investigated the immune recognition of WT1 by patients with NHL. Utilizing a WT1 overlapping peptide library, we discovered that a large percentage of patients with NHL of all grades maintain WT1-specific T cells. Ex vivo frequencies of these T cells measured from unfractionated samples by the CD137 activation marker assay were high in many patients (some > 1% CD8+). Using standard in vitro techniques we discovered that they were cytotoxic to WT1 peptide library-loaded T2 cells and WT1 antigen-primed autologous Epstein-Barr virus-transformed B cell lines (EBV-LCLs) and expressed interferon gamma (IFN-γ). In addition, we detected WT1 mRNA transcripts in diseased lymph node tissues of patients with NHL utilizing real-time quantitative polymerase chain reaction (RT-qPCR) technology. These results are the first example of strong T cell reactivity against WT1 in patients with NHL which also demonstrate strong cytotoxicity against peptide-loaded tumor cells. The potential for developing WT1 as a target for immunotherapy in NHL deserves further exploration.

CD154 expression is associated with neutralizing antibody titer levels postinfluenza vaccination in stem cell transplant patients and healthy adults.

We undertook a prospective longitudinal study to examine humoral and cellular immune responses to influenza vaccination in hematopoietic cell transplant (HCT) patients and healthy adults. Healthy volunteers and HCT patients had blood samples taken prior to influenza vaccination and 30, 90, and 180 days postvaccination. Serum from pre- and postvaccination time points were tested for influenza A IgG and IgM by ELISA as well as tested for neutralizing antibody (NAb) titers via hemagglutination inhibition assay. Polychromatic flow cytometry was used to examine CD4(+) T cells for levels of interferon (IFN)-γ, tumor necrosis factor (TNF)-α, and CD154 (CD40 ligand) expression after stimulation with inactivated flu virus. In healthy subjects, we found a significant increase in Influenza A IgG and IgM levels as well as an increase in NAb titers pre- and post-influenza vaccination. Notably, NAb titers of most HCT patients did not rise to a protective level postvaccination. CD4(+) T cell expression of CD154 and cytokine responses were significantly reduced in HCT recipients compared to healthy adults. A lack of B cell reconstitution and dysfunctional CD4 T cell costimulation (as marked by low CD154 expression) is associated with low NAb levels postvaccination in HCT patients.