The Use of Prasugrel and Ticagrelor in Pipeline Flow Diversion

Background: Despite the routine clopidogrel/aspirin anti-platelet therapy, complications like thromboembolism, continue to be encountered with PED. We studied the safety and the efficacy of prasugrel in the management of clopidogrel non-responders treated for intracranial aneurysms. Methods: 437 consecutive neurosurgery patients were identified between January 2011 and May 2016. Patients allergic or having \u3c30% platelet-inhibition with a daily 75mg of clopidogrel were dispensed 10mg of prasugrel daily (n=20) or 90mg of ticagrelor twice daily (n=2). The average follow-up was 15.8 months (SD=12.4 months). Patient clinical well being was evaluated with the modified Rankin Scale (mRS) registered before the discharge and at each follow-up visit. To control confounding we used multivariable mixed-effects logistic regression and propensity score conditioning. Results: 26 of 437(5.9%) patients (mean of age 56.3 years; 62 women [14,2%]) presented with a sub-arachnoid hemorrhage. 1 patient was allergic to clopidogrel and prasugrel simultaneously. All the patients receiving prasugrel (n=22) had a mRS\u3c2 on their latest follow-up visit (mean=0.67; SD=1.15). In a multivariate analysis, clopidogrel did not affect the mRS on last follow-up, p=0.14. Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (odds ratio[OR], 0.17; 95%Confidence Interval [CI95%], 0.01-2.70; p=0.21) neither with an increased thromboembolic accident rate (OR, 0.46; CI95%, 0.12-1.67; p=0.36) nor with an increased hemorrhagic event rate (OR, 0.39; CI95%,0.91-1.64; p=0.20). None of the patients receiving prasugrel deceased or had a long-term recurrence nor a hemorrhagic event, only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. 3 patients on clopidogrel passed during the study: (2) from acute SAH and (1) from intra-parenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR, 2.18; CI95%,0.11-43.27; p=0.61). The same associations were present in propensity score adjusted models. Conclusion: In a cohort of patients treated with PED for their intracranial aneurysms, prasugrel (10mg/day) is a safe alternative to clopidogrel resistant, allergic or non-responders

Assessing the Burden of Unnecessary Central Venous Catheters in Patients on Medical-Surgical Floors

Project goals: Our project goals are to: a) assess the burden of unnecessary PICCs and other non-tunneled central lines on med-surg units at TJUH and b) understand the underlying reasons behind the problem. In the first phase of our project we conducted an audit of med-surg unit PICCs and other non-tunneled central lines with the goal of obtaining a rough estimate of the number of line days that are unnecessary. SMART AIM By December 31, 2017, the TJUH medical-surgical floors will reduce the number of unnecessary PICC lines by 30%.https://jdc.jefferson.edu/patientsafetyposters/1024/thumbnail.jp

Sepsis Education and Training in Medical School

Purpose: According to the National Institutes of Health, severe sepsis strikes more than one million Americans every year. Despite the extensive research that has gone into creating the different risk stratification tools for sepsis, there is still a fifteen to thirty percent mortality rate among patients diagnosed with sepsis. We believe this is due to a lack of robust education and training of medical students in sepsis identification, and thus, the purpose of this study was to determine the extent of training and education of medical students in the identification and treatment of sepsis. Methods: This study is aimed at the first-year residents at emergency medicine programs nationwide. Using the Qualtrics software available on the Thomas Jefferson University commons, we created a twenty-one question survey that collected data on knowledge, skills, and attitudes of first-year residents towards sepsis diagnosis and treatment, based on what they have formally learned in medical school. Thus far, we are continuing to collect data. Once data has been collected, we will undergo quantitative and qualitative analysis. Results and Conclusions: As of writing this abstract, we continue to collect data due to unforeseen circumstances. We will soon have data that can be analyzed. We believe the data will show a lack of robust curriculum at medical schools nationwide for the training of medical students in the diagnosing and treatment of sepsis. If this is proven true, programs can be created to add sepsis curriculum to formal medical education

Sternoclavicular joint arthropathy mimicking radiculopathy in a patient with concurrent C4-5 disc herniation

Background Patients with sternoclavicular joint arthropathy, which can result from septic arthritis, often present with localized sternoclavicular pain as well as shoulder pain. Such pain may be similar to the presenting symptoms of cervical intervertebral disc herniation. Clinical presentation A 47-year-old female presented with 1 month of significant pain in the neck as well as right anterior chest and deltoid. The patient was found to have reduced strength in the right deltoid muscle on physical examination. MRI revealed a C4-C5 herniated nucleus pulposus. The patient underwent successful C4-C5 anterior cervical discectomy, but subsequently developed painful swelling in the region of the right sternoclavicular joint with limited motor strength in the right shoulder and arm. A needle biopsy of the mass yielded negative results, but her erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) numbers did respond to antibiotics, consistent with infection of the sternoclavicular joint. A follow-up CT scan (6.5 months postoperatively) revealed apparent resolution right sternoclavicular joint arthropathy, thought the patient continued to experience pain. 15 months postoperatively, the patient was prescribed methotrexate due to persistent pain and mild weakness arising from a possible rheumatologic inflammation. 19 months postoperatively, the patient had full strength of the right shoulder and arm and visible decrease in swelling at the sternoclavicular joint. More than three years postoperatively, the patient was diagnosed with multiple myeloma, which was appropriately treated. At follow-up four years postoperatively, the patient had an MRI showing new C6-C7 herniated nucleus pulposus, but no longer had any right shoulder or chest pain or associated weakness. Conclusion This case demonstrates that sternoclavicular joint arthropathy results in symptoms that can mimic the presenting symptoms of shoulder or cervical spine pathology, such as shoulder and neck pain, necessitating careful diagnosis and management

Taking Free Flap Surgery Abroad: A Collaborative Approach to a Complex Surgical Problem.

Accessibility to health care, especially complex surgical care, represents one of the major health care disparities in developing countries. While surgical teams may be willing to travel to these areas to help address these needs, there are many logistical and ethical dilemmas inherent in this pursuit. We reviewed our approach to the establishment of the team-based surgical outreach program, wherein we perform head and neck free tissue transfer surgery in Haiti. We describe the challenges encountered in the delivery of surgical care as well as ethical dilemmas relevant to surgical outreach trips, highlighting an approach reliant on strong local cooperation. Despite the obstacles in place, our experience shows that free flap surgery can be successfully and ethically performed in these areas of great need