Post-operative Delirium: Can Retraining on the CAM-ICU Tool Increase Nurses’ Confidence in Patient Assessment?

Background: Delirium is defined as an acute condition consisting of confusion, altered mental status, and disorganized thought processes. Patients who develop delirium have higher mortality rates, increased lengths of stay in the hospital, worse clinical outcomes, and place a higher burden on hospital staff. Affecting up to fifty percent of cardiac surgery patients, delirium is recognized as a major post-operative complication highlighting the importance of early detection. The Confusion Assessment Method for the ICU (CAM-ICU) is a widely accepted screening tool used to detect delirium in the ICU setting. Despite being clinically validated, many nurses lack adequate training on how to use this assessment tool. Furthermore, nurses may not prioritize delirium assessment out of the vast and complex patient care tasks in the intensive care setting. Nurses who receive additional training in delirium and accurate use of CAM-ICU can ensure that the appropriate nursing interventions are implemented to delirium patients. Objective: This quality improvement project aims to determine if augmenting education on the administration of the delirium assessment tool can improve nurses’ confidence in their screening proficiency in the clinical setting. Nurses working on a 12-bed cardiovascular intensive care unit of a hospital located in a suburb of Atlanta will watch four educational videos, review the CAM-ICU Complete Training Manual, and answer questions on five case studies. Methods: Using pre- and post- education surveys, nurses would rate their level of confidence using the CAM-ICU tool to gauge if the education delivered was effective at increasing their self-reported competency level

Connected: Using a Novel In-House Communication System to Efficiently Deliver Imaging Results

Introduction: The primary objective was to investigate the effectiveness of a fully staffed electronic communication system (1Connect) in delivering timely critical imaging results and incidental findings. The secondary objective was to evaluate the financial impact of this system on a radiology practice. Methods: From January 2014 through June 2016, the 1Connect database was retrospectively reviewed and sorted by category of submission type: Critical (1-hour communication time), STAT (2 hours), or Unexpected finding (3 business days). The percent of successful communications completed within the appropriate time frame was calculated for each priority category and used as a measure of the system’s efficiency and effectiveness. The financial impact of 1Connect was then estimated using an average radiologist salary in Portland, Maine, combined with the radiologist time saved using this system. Results: More than 96% of time-sensitive results (critical and STAT categories) were communicated within their predetermined time limits with the 1Connect system. Using this system, the estimated value of radiologist time saved by 1Connect staff was approximately $50 997 per year. Conclusions: Spectrum Radiology’s 1Connect system presents a novel approach that supports timely and cost-effective communication of imaging findings to treating providers. While patient outcomes and safety were not evaluated in this study, patient care is likely enhanced when critical findings are promptly communicated to referring providers

Hormones, muscles and oncological outcome in men with rectal cancer

Paper I. The aim was to elucidate if testosterone (T) dose-dependently increase muscle size in abdomen and pelvis, analogous to the known anabolic influence on appendicular muscles. Participants were young (age 18-50) healthy men participating in the 5a-reductase trail, a double blinded RCT. Endogenous T production was supressed and replaced with four dosages (50, 125, 300, or 600 mg) of T enanthate. Magnetic Resonance Imaging scans from baseline and end of study was used to analyse change in muscle areas of the lower trunk and pelvis. The estimated change (95% CI) of muscle area increase per 100 mg of T enanthate dosage increase was 0.622 cm2 (0.394, 0.850) for psoas; 1.789 cm2 (1.317, 2.261) for paraspinal muscles; 2.530 cm2 (1.627, 3.434) for total abdominal muscles; 0.455 cm2 (0.233, 0.678) for obturator internus; 0.082 cm2 (0.003, 0.045) for ischiocavernosus. Areas were also associated on-treatment T and free T levels. In conclusion, the abdominal and pelvic muscle are responsive to T administration, opening up for future studies regarding T treatment in frail men with risk for falls and men with pelvic dysfunction. Paper II. Preoperative radiotherapy (RT) is used in treatment of rectal cancer (RC) to enhance local control. Acute testicular failure with risk for permanent damage to T production is a less known adverse effect of RT. The aim was to elucidate long-term effects on T production, and the association of elevated luteinizing hormone (LH) and cancer recurrence. This was a longitudinal prospective cohort study including men with rectal- or prostate cancer stage I-III. Exposure was RT, quantified by mean cumulative testicular dose (TD). Testicular function was assessed by sampling of T, LH and follicle stimulating hormone (FSH) at baseline and at follow-ups after one and two years. Exposed men were additionally sampled preoperatively. Within two years after surgery, T levels recovered, but LH and FSH levels were significantly higher in exposed. Changes in LH and FSH were related to TD. Elevated LH one year after surgery inferred an incidence rate ratio for cancer recurrence in five years of 3·19 (95% C.I.: 0·97-11.2, mid-p=0·036). Paper III. The aim was to analyse the impact of RT induced primary testicular failure on severe postoperative adverse events (AE, Clavien-Dindo grade 3+) in men treated for RC. 104 men were included from the previous cohort study. T and LH were sampled at baseline and after RT. The association between of primary testicular failure and severe postoperative AE was analysed using longitudinal regression. 25% had severe postoperative AE (AE+). Baseline data did not differ significantly between groups. The AE+ group had comparably higher LH/T-ratio after RT. 0.603 (0.2-2.5) vs 0.452 (0.127-5.926, p=0.035). The longitudinal regression analysis found that preoperative change in T (OR 0.844, 95% CI 0.720-0.990, p=0.034), LH/T-ratio (OR 2.020, 95% CI 1.010-4.039, p=0.047) and low T (<8 nmol/L, OR 2.605, 95 CI 0.951-7.139, p=0.063) were associated to severe postoperative AE. Preoperative RT induced decline in T seems to be a risk factor for severe postoperative AE in men with RC. Paper IV. Sarcopenic signs have been related to worse cancer specific survival and the skeletal muscles in men are sensitive to T. The effect of RT induced testicular failure may therefore be of importance in men treated for RC. Based on the cohort study in Paper II, 102 men with RC were included. Using CT or MRI scans from routine examinations at baseline and one year after surgery, skeletal muscle (SM) area at 3rd lumbar vertebra was measured. Testicular function was evaluated by measurement of serum T and LH. The association between change in T (and calculated free T) and SM as well as systemic cancer recurrence and SM were analyzed. Change in free T level is associated with change in psoas major area (p=0.005) and abdominal muscle area (p<0.001). Systemic cancer recurrence was associated with changes in total SM area (-5.96 (-10.7 - -1.24) cm2, p=0.013). In conclusion, Abdominal and pelvic muscles are as androgen sensitive as appendicular muscles, and impaired testicular endocrine function due to RT impacts muscle area. Preoperative decrease in T increase risk of severe postoperative AE. Elevated LH and decreased muscle area are associated with systemic cancer disease

Characteristic heterotopic ossification of the proximal humerus after total shoulder arthroplasty.

OBJECTIVE: A bony spur in a characteristic location involving the proximal humerus is identified on post-operative radiographs in some patients with history of total shoulder arthroplasty. The spur is theorized to represent heterotopic ossification near the attachment site of the pectoralis major tendon on the proximal humerus which is partially detached and then reattached during total shoulder arthroplasty. In this study, we determine the morphology, incidence, demographic associations, and clinical impact of this finding. MATERIALS AND METHODS: This is a single-center, retrospective study of 500 patients who underwent total shoulder arthroplasty (250 standard and 250 reverse technique) between 2012 and 2017. Pre- and post-operative shoulder radiographs were reviewed to identify and measure the characteristic spur; inter-observer agreement was evaluated between the two reviewers. Incidence, demographic associations, and clinical significance were then determined. RESULTS: The study group included 268 men and 234 women with a mean age of 70 (42-89) years, and clinical follow-up of 25 (1-84) months. Characteristic heterotopic ossification was seen in 88 patients (17.6%) and was first noted radiographically at a mean (interquartile range) of 12.1 (11.5-12.8) months after surgery. Male sex (adjusted odds ratio (95% confidence interval), 3.00 (0.68-5.34), p \u3c 0.001) was independently associated with heterotopic ossification. No significant relationships between heterotopic ossification and adverse clinical outcomes were observed. CONCLUSION: Characteristic heterotopic ossification of the proximal humerus in patients status post total shoulder arthroplasty is a common imaging finding that is not associated with adverse clinical outcomes

Characteristic heterotopic ossification of the proximal humerus after total shoulder arthroplasty

OBJECTIVE: A bony spur in a characteristic location involving the proximal humerus is identified on post-operative radiographs in some patients with history of total shoulder arthroplasty. The spur is theorized to represent heterotopic ossification near the attachment site of the pectoralis major tendon on the proximal humerus which is partially detached and then reattached during total shoulder arthroplasty. In this study, we determine the morphology, incidence, demographic associations, and clinical impact of this finding. MATERIALS AND METHODS: This is a single-center, retrospective study of 500 patients who underwent total shoulder arthroplasty (250 standard and 250 reverse technique) between 2012 and 2017. Pre- and post-operative shoulder radiographs were reviewed to identify and measure the characteristic spur; inter-observer agreement was evaluated between the two reviewers. Incidence, demographic associations, and clinical significance were then determined. RESULTS: The study group included 268 men and 234 women with a mean age of 70 (42-89) years, and clinical follow-up of 25 (1-84) months. Characteristic heterotopic ossification was seen in 88 patients (17.6%) and was first noted radiographically at a mean (interquartile range) of 12.1 (11.5-12.8) months after surgery. Male sex (adjusted odds ratio (95% confidence interval), 3.00 (0.68-5.34), p \u3c 0.001) was independently associated with heterotopic ossification. No significant relationships between heterotopic ossification and adverse clinical outcomes were observed. CONCLUSION: Characteristic heterotopic ossification of the proximal humerus in patients status post total shoulder arthroplasty is a common imaging finding that is not associated with adverse clinical outcomes

Comparison of pre-revision magnetic resonance imaging and operative findings in mechanically assisted crevice corrosion in symptomatic metal-on-polyethylene total hip arthroplasties.

BACKGROUND: Failed total hip arthroplasty (THA) caused by mechanically assisted crevice corrosion (MACC) has serious consequences-notably, adverse local tissue reactions. Metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) has been used to evaluate failed THA for other reasons but has not been assessed for the analysis of cases of MACC in the setting of metal-on-polyethylene arthroplasties. METHODS: We examined the correlation between preoperative MARS MRI and surgical findings in a cohort of 20 consecutive patients undergoing revision THA for symptomatic MACC without other associated orthopedic diagnoses. Surgical findings included soft tissue and bone evaluation, presence and location of fluid, abductor disruption, composite tissue damage grade, and prosthesis trunnion damage at the time of revision. RESULTS: MARS MRI complex synovitis, thickened pseudocapsule, and extra-articular fluid extension each strongly correlated with both the soft-tissue damage grade and trunnion damage noted at surgery. Bone marrow edema was also found to strongly correlate with bone necrosis intraoperatively. CONCLUSION: MARS MRI is an excellent diagnostic tool for evaluation of patients with elevated serum Co after metal-on-polyethylene THA. Patients with complex synovitis, a thick pseudocapsule, bone marrow edema, and extra-articular fluid should strongly consider revision surgery