Kelly Pennington

Reprocessing of single-use endoscopic variceal band ligation devices: a pilot study

Background and study aims The preferred management of bleeding esophageal varices includes endoscopic band ligation. Endoscopic ligation devices (ELDs) are expensive and designed for single use, limiting their uptake in developing countries. We aimed to assess the efficacy of reprocessing ELDs using terminal microbial cultures and adenosine triphosphate (ATP) testing. Materials and methods ELDs were recovered after clinical use and their components (cap, handle, and cord) were subjected to reprocessing. This included manual cleaning, automated high-level disinfection (HLD), and drying with forced air. Using sterile technique, ELD components were sampled for ATP at three stages: before manual cleaning, after manual cleaning, and after HLD. Components were sent to an external laboratory for culturing. Cultures were interpreted as positive upon identification of Gram-negative bacilli. Results A total of 14 clinically used ELDs were studied, and 189 ATP tests and 41 cultures were evaluated. Overall, 95 % (39/41) of components and 86 % (12/14) of ELDs were culture-negative or did not yield Gram-negative bacilli. Two components (5 %; one handle and one cord) harbored Gram-negative bacilli in quantities of 1 CFU per component. There was no apparent correlation between ATP at any juncture of reprocessing and terminal cultures. Conclusions Reprocessing of ELDs is effective, resulting in infrequent and minimal microbial contamination. Microbial culturing can be used to ensure adequacy of ELD reprocessing if pursued. Until reusable ELDs are commercially available, continued efforts to better define the adequacy and long-term effects of reprocessing ELDs are needed.

Evaluation of TEAM dynamics before and after remote simulation training utilizing CERTAIN platform

ABSTRACT Objective: The current study examines the feasibility and potential effects of long distance, remote simulation training on team dynamics. Design: The study design was a prospective study evaluating team dynamics before and after remote simulation. Subjects: Study subjects consisted of interdisciplinary teams (attending physicians, physicians in training, advanced care practitioners, and/or nurses). Setting: The study was conducted at nine training sites in eight countries. Interventions: Study subjects completed 2–3 simulation scenarios of acute crises before and after training with the Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN). Measurements and main results: Pre- and post-CERTAIN training simulations were evaluated by two independent reviewers utilizing the Team Emergency Assessment Measure (TEAM), which is a 11-item questionnaire that has been validated for assessing teamwork in the intensive care unit. Any discrepancies of greater than 1 point between the two reviewers on any question on the TEAM assessment were sent to a third reviewer to judge. The score that was deemed discordant by the third judge was eliminated. Pre- and post-CERTAIN training TEAM scores were averaged and compared. Of the nine teams evaluated, six teams demonstrated an overall improvement in global team performance following CERTAIN virtual training. For each of the 11 TEAM assessments, a trend toward improvement following CERTAIN training was noted; however, no assessment had universal improvement. ‘Team composure and control’ had the least absolute score improvement following CERTAIN training. The greatest improvement in the TEAM assessment scores was in the ‘team’s ability to complete tasks in a timely manner’ and in the ‘team leader’s communication to the team’. Conclusion: The assessment of team dynamics using long distance, virtual simulation training appears to be feasible and may result in improved team performance during simulated patient crises; however, language and video quality were the two largest barriers noted during the review process.

Management and diagnosis of tuberculosis in solid organ transplant candidates and recipients: Expert survey and updated review

Background: Optimal screening and management of latent tuberculosis infection (LTBI) and active tuberculosis (TB) in solid organ transplant (SOT) candidates and recipients is necessary to prevent morbidity and mortality. Methods: We conducted a cross-sectional survey of TB and transplant experts across the United States reviewing the clinical practice preferences on key management issues related to LTBI and TB in SOT candidates and recipients. Results: Thirty TB and 13 SOT experts were surveyed (response rate = 53.8%). Both groups agreed that tuberculin skin test (TST) and chest x-ray screening in SOT candidates was useful (78.6% and 84.6%, respectively). TST after SOT was not useful for most transplant experts and TB experts (0% vs. 32.1%, respectively), but both groups were split on usefulness of interferon gamma release assays (IGRA) in SOT recipients (42.9% TB experts vs. 46.2% SOT experts). Most experts recommend LTBI treatment prior to SOT if close monitoring is assured (82.1% TB experts vs. 76.9% transplant experts). LTBI treatment with isoniazid was preferred for patients on calcineurin inhibitors. Evaluation for suspected TB in SOT recipients varied, but most TB experts favored sputum testing (88.9%) whereas most transplant experts favored bronchoscopic testing (69.2%). Preferred TB treatment regimens in SOT recipients were similar to regimens recommended for immunocompetent patients. Conclusions: Most TB and transplant experts recommend evaluation and treatment for LTBI in SOT candidates. Liver transplant candidates, however, should only be treated if close monitoring can be assured and after consulting with a hepatologist. Practice preferences varied regarding the initial diagnostic approach for suspected TB in SOT recipients; however, most experts agreed that SOT recipients should receive similar treatments as immunocompetent patients.

Positive Pneumocystis jirovecii Sputum PCR Results with Negative Bronchoscopic PCR Results in Suspected Pneumocystis Pneumonia

Introduction The diagnostic standard for Pneumocystis jirovecii pneumonia (PCP) is direct microscopic identification; however, in recent years, polymerase chain reaction (PCR) from bronchoalveolar lavage (BAL) samples to detect Pneumocystis nucleic acids has proven to be more sensitive and specific. Sputum samples have been presumed inferior to bronchoscopic samples secondary to variability and adequacy of sample collection. We observed several cases of positive sputum PCP-PCR results with negative PCP-PCR BAL results. The aim of the current study was to further characterize the clinical setting and outcomes in patients with positive sputum PCP-PCR samples and negative BAL PCP-PCR samples. Methods We identified all patients who underwent P. jirovecii-PCR testing at Mayo Clinic between 2011 and 2016. Patients with a positive sputum and negative BAL sample collected within a 14-day time frame were identified and underwent further chart review for demographics, immunocompromised state, and clinical outcome. Results From 2011 to 2016, 4431 respiratory samples from 3021 unique patients were tested for the presence of P. jirovecii by PCR. Fifty-five samples (1.2% of all samples collected) belonging to 24 unique patients (0.79% of patients tested) were identified as having a positive and negative sample collected within 14 days. Of these 24 patients, 10 (46%) patients had a positive sputum or tracheal secretion sample with negative BAL or bronchial washings. Out of these 10 patients, 8 were immunocompromised and 9 underwent treatment for PCP with 6 patients improving. Conclusion Our results suggest that discordant P. jirovecii-PCR testing results from sputum and bronchoscopic specimens are an infrequent occurrence. Patients with positive P. jirovecii-PCR sputum/tracheal secretion samples and negative bronchoscopic samples appear to be clinically infected and respond to PCP treatment. Sputum P. jirovecii-PCR testing may be a viable alternative to invasive testing.

Characteristics of Mycobacterium avium complex (MAC) pulmonary disease in previously treated lung cancer patients

Introduction Mycobacterium avium complex (MAC) is responsible for a large portion of non-tuberculous mycobacterial (NTM) infections worldwide. Host factors such as active malignancy, immunosuppression, chronic obstructive pulmonary disease (COPD) and bronchiectasis increase the risk of MAC infection. However, the relationship between previously treated lung cancer with subsequent development of MAC pulmonary disease and treatment outcomes have not been previously studied. Methods We retrospectively identified all patients with lung cancer and MAC pulmonary disease documented in medical records at Mayo Clinic between January 2005 and October 2016. Patients who were diagnosed with MAC pulmonary disease before or at the time of lung cancer diagnosis were excluded. Patients meeting all inclusion criteria underwent chart review for prior oncologic treatments, clinical characteristics, and MAC treatment response. Results We identified 13 patients with MAC pulmonary disease and prior lung cancer, including 4 men and 9 women. Eight patients had structural lung disease that can predispose to MAC pulmonary disease, including bronchiectasis (23.0%) and COPD (46.2%). Four (30.8%) had no apparent immunosuppression or other risk factor(s) for MAC pulmonary disease. Primary pulmonary malignancies included pulmonary carcinoid, adenocarcinoma, and squamous cell carcinoma. Ten (76.9%) patients were started on antimicrobial treatment for MAC, and 8 (61.5%) patients completed MAC treatment with 6 (46.1%) patients achieving symptomatic improvement. Conclusion MAC pulmonary disease in previously treated lung cancer can occur without apparent risk factors for this NTM infection. Symptomatic improvement with MAC antimicrobial therapy appears to be lower than expected but comorbidities might influence outcomes in this patient population.

Reliability and validity of the checklist for early recognition and treatment of acute illness and injury as a charting tool in the medical intensive care unit

Background: Resuscitation of critically ill patients is complex and potentially prone to diagnostic errors and therapeutic harm. The Checklist for early recognition and treatment of acute illness and injury (CERTAIN) is an electronic tool that aims to provide decision-support, charting, and prompting for standardization. This study sought to evaluate the validity and reliability of CERTAIN in a real-time Intensive Care Unit (ICU). Materials and Methods: This was a prospective pilot study in the medical ICU of a tertiary care medical center. A total of thirty patient encounters over 2 months period were charted independently by two CERTAIN investigators. The inter-observer recordings and comparison to the electronic medical records (EMR) were used to evaluate reliability and validity, respectively. The primary outcome was reliability and validity measured using Cohens Kappa statistic. Secondary outcomes included time to completion, user satisfaction, and learning curve. Results: A total of 30 patients with a median age of 59 (42–78) years and median acute physiology and chronic health evaluation III score of 38 (23–50) were included in this study. Inter-observer agreement was very good (κ = 0.79) in this study and agreement between CERTAIN and the EMR was good (κ = 0.5). CERTAIN charting was completed in real-time that was 121 (92–150) min before completion of EMR charting. The subjective learning curve was 3.5 patients without differences in providers with different levels of training. Conclusions: CERTAIN provides a reliable and valid method to evaluate resuscitation events in real time. CERTAIN provided the ability to complete data in real-time.

Flow Cytometric Immune Profiling in Infliximab-Associated Tuberculosis

Tumor necrosis factor α antagonists are increasingly used to treat inflammatory and autoimmune disorders and are associated with increased risk of active tuberculosis. Diagnosis of active tuberculosis in patients taking tumor necrosis factor α antagonists can be challenging owing to increased incidence of extrapulmonary manifestations and false-negative results on current available diagnostic tests. We present a case of a young woman on infliximab for ulcerative colitis who presented with disseminated tuberculosis. As part of a research study, we performed flow cytometric immune profiling, which has previously not been reported in patients with active tuberculosis taking tumor necrosis α antagonists. The flow cytometry results were within the positive thresholds for tuberculosis infection. Flow cytometric immune profiling may be a valid diagnostic tool for patients taking tumor necrosis factor α antagonists.

Evaluation of Data Utilization during Transfers of Critically Ill Patients between Hospitals

Background: There is little scientific data to guide inter-hospital transport of critically ill patients. This leads to practice variation with how providers communicate healthcare information between facilities and inappropriate communication can lead to significant patient harm. We analyzed data used by accepting providers during hospital transfer to form a rational protocol for information exchange. Methods: We conducted a prospective observational study of inter-hospital patient transfers to our medical intensive care unit (ICU). We recorded data that receiving clinicians requested, and whether that information was available upon admission. Following observation, we asked providers to complete a survey indicating whether a data point was useful for clinical decision making for the particular clinical case they had received. We analyzed the relative frequency of data requests and the discordance between available and requested data. Results: Twenty-five physician-patient interactions were observed with 45 surveys completed by critical care providers. On average, 13 data points were utilized for patients with perceived “mild” illness versus 18 data points for patients with “severe” illness. The most requested data were code status (19/25), blood culture status (19/25), and medications administered to the patient (16/25). Other data points identified as useful were past medical history, vital signs, white blood cell count, hemoglobin, lactate, pH, PaCO2 and chest x-ray findings with minimal variability depending on presumed diagnosis (respiratory failure, sepsis or other). Code status (7/19), arterial/venous blood gas (5/12), lactate (4/10), and medical power of attorney (3/5) were the most frequently unavailable data points when requested. Conclusion: Critical care providers use a small number of data points during the inter-hospital admission process, but many of these are frequently unavailable. A formal structured hand off tool is needed to improve information management during inter-hospital transfer. Such a tool must emphasize resuscitation status, critical labs, and ongoing interventions.

1786: MYCOBACTERIUM AVIUM COMPLEX MASQUERADING AS NON-SMALL CELL LUNG CANCER RECURRENCE

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) clinical improvement followed tailored antibiotic therapy and after fourteen days of antibiotic therapy she was discharged home. Due to concerns for an underlying undiagnosed immunodeficiency, outpatient evaluation for chronic granulomatous disease among other immunodeficiencies was conducted and returned normal. Results: This case illustrates the potential for septic shock from an infrequently encountered bacterium in the United States. Although septic shock from Chromobacterium violaceum is rare, our patient’s clinical presentation was highly suggestive of the infection. Recognition of this bacteria as a potential cause of hepatic abscesses and septic shock is critical to institution of appropriate antibiotic therapy and patient survival.

1778: PNEUMOCYSTIS PNEUMONIA REMAINS A DIAGNOSTIC CHALLENGE WITH PCR IN ACUTE SETTINGS

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) Histoplasmosis Capsulatum “Broncholith” causing bronchial erosion. He was treated with a course of itraconazole for Histoplasmosis. Eventually urine histoplasma antigen and serum antibodies returned negative, consistent with chronic histoplasmosis. He was extubated day 30 and discharged to rehab on day 39 with good neurologic recovery. Results: To our knowledge, we report the first case of a pediatric patient with chronic Histoplasmosis leading to massive hemoptysis, requiring pneumonectomy and ultimately VV ECMO support. Histoplasmosis and other fungal infections should be on the differential for otherwise asymptomatic immunocompetent patients presenting with massive hemoptysis