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Traumatic brain injury (TBI) is a risk factor for venous thromboembolism (VTE). The risk of VTE after decompressive craniectomy (DC) and its effects on the outcomes are unknown. We assessed the incidence of VTE, associated risk factors, and effects on the outcomes.Using the National Inpatient Sample database, the hospitalizations of patients aged ≥18 years with a severe TBI diagnosis from 2004 to 2014 were extracted. The outcome was discharge status without mortality. Multivariable logistic and linear regressions were used.Of the 349,165 TBI hospitalizations, 23,813 (6.82%) had undergone DC and 14,175 (4.06%) had developed VTE. The VTE incidence was higher after DC compared with no DC (6.14% vs. 3.91%; P0.0001). DC (odds ratio [OR], 1.29; P0.005) was an independent predictor for the development of VTE. Age (OR, 1.26; P0.005), chronic lung disease (OR, 1.58; P0.05), electrolyte imbalance (OR, 1.43; P0.05), liver disease (OR, 0.10; P0.05), urinary tract infection (OR, 1.56; P0.05), pneumonia (OR, 2.03; P0.0001), and sepsis (OR, 1.57; P0.05) were significantly associated with the development of VTE. Obesity (OR, 2.09; P0.05) and spine injury (OR, 2.03; P0.05) showed a trend toward significance. VTE was associated with worse discharge outcomes (OR, 1.40; P0.05), longer lengths of stay (OR, 1.01; P0.00001), and higher costs (P0.0001).Our study showed an independent association between DC and an increased risk of VTE for patients with severe TBI. The development of VTE after DC increased the proportion of poor outcomes, prolonged the length of stay, and increased the hospitalization costs. Older patients with obesity, an electrolyte imbalance, chronic lung disease, spine injury, and infections were at a greater risk of VTE after DC. These risk factors could help in considering VTE prophylaxis for these patients.

Decompressive craniectomy is recommended to reduce mortality in severe traumatic brain injury (TBI). Disparities exist in TBI treatment outcomes; however, data on disparities pertaining to decompressive craniectomy utilization is lacking. We investigated these disparities, focusing on race, insurance, sex, and age.Hospitalizations (2004-2014) were retrospectively extracted from the Nationwide Inpatient Sample. The criteria included are as follows: age ≥18 years and indicators of severe TBI diagnosis. Poor outcomes were defined as discharge to institutional care and death. Multivariable logistic regression models were used to assess the effects of race, insurance, age, and sex, on craniectomy utilization and outcomes.Of 349,164 hospitalized patients, 6.8% (n = 23,743) underwent craniectomy. White (odds ratio [OR] = 0.50, 95% confidence interval [CI] = 0.44-0.57; P0.001) and Black (OR = 0.45, 95% CI = 0.32-0.64; P = 0.003) Medicare beneficiaries were less likely to undergo craniectomy. Medicare (P0.0001) and Medicaid beneficiaries (P 0.0001) of all race categories had poorer outcomes than privately insured White patients. Black (OR = 1.2, 95% CI = 1.08-2.34; P = 0.001) patients with private insurance and Black (OR = 1.39, 95% CI = 1.22-1.58; P 0.0001) Medicaid beneficiaries had poorer outcomes than privately insured White patients (P 0.0001). Older patients (OR = 0.74, 95%, CI = 0.71-0.76; P 0.001) were less likely to undergo craniectomy and were more likely to have poorer outcomes. Females (OR = 0.82, 95% CI = 0.76-0.88; P 0.001) were less likely to undergo craniectomy.There are disparities in race, insurance status, sex, and age in craniectomy utilization and outcome. This data highlights the necessity to appropriately address these disparities, especially race and sex, and actively incorporate these factors in clinical trial design and enrollment.

The true incidence of sepsis in surgical cohorts in Ireland remains unclear. According to inpatient audits, patients in surgical diagnostic groups (DRG) who developed sepsis had a longer length of stay and higher mortality rate compared with medical DRG patients who developed sepsis. We investigated sepsis incidence on a general surgical ward to identify risk factors and strategies to improve management. Demographics, admission and discharge details, infection risk factors, infection, and sepsis were studied prospectively on a surgical ward in July 2018. The mean age of 164 patients was 60.5 years (range 18–93 years), 107 (65.2%) were admitted electively, 16 (9.8%) were colonised with a multidrug-resistant organism (MDRO), and 30 (18.3%) were classified as frail on admission. Twelve (7.3%) developed sepsis (ward sepsis rate 118.2/10,000 bed days used). ‘Sepsis’ was documented in six cases and the national sepsis screening form used in four patients. Patients with sepsis were three times as likely to be MDRO-colonised (OR 3.56; 95% CI = 0.86–14.82; p = 0.065) or frail (OR 3.63; 95% CI = 1.07–12.35; p = 0.03), four times as likely to be an inpatient at the end of the study (OR 4.22, 96% CI 1.23–14.49; p = 0.01), and three times as likely to be readmitted (OR 3.46, 95% CI 1.02–11.76; p = 0.03). Sepsis was under-documented, and barriers exist with use of the national sepsis screening form. Frailty, which is a sepsis risk factor, should be assessed pre-operatively to maximise prevention.

Importance Chimeric antigen receptor (CAR) T-cell therapy for relapsed or refractory hematologic malignant neoplasm causes severe neurologic adverse events ranging from encephalopathy and aphasia to cerebral edema and death. The cause of neurotoxicity is incompletely understood, and its unpredictability is a reason for prolonged hospitalization after CAR T-cell infusion. Objective To identify clinical and laboratory parameters predictive of neurotoxicity and to develop a prognostic score associated with its risk. Design, Setting, and Participants This single-center diagnostic/prognostic accuracy study was conducted at Brigham and Women’s Hospital/Dana Farber Cancer Institute from April 2015 to February 2020. A consecutive sample of all patients undergoing CAR T-cell therapy with axicabtagene ciloleucel for relapsed or refractory lymphoma were assessed for inclusion (n = 213). Patients who had previously received CAR T cells or who were treated for mantle cell lymphoma were excluded (n = 9). Patients were followed up for a minimum of 30 days from the date of CAR T-cell infusion. Main Outcomes and Measures The primary outcomes were measures of performance (accuracy, sensitivity, specificity, area under the curve) of a diagnostic tool to predict the occurrence of CAR-associated neurotoxicity, as graded by the Common Terminology Criteria for Adverse Events criteria. Results Two hundred four patients (127 men [62.2%]; mean [SD] age, 60.0 [12.1] years) were included in the analysis, of which 126 (61.8%) comprised a derivation cohort and 78 (38.2%), an internal validation cohort. Seventy-three patients (57.9%) in the derivation cohort and 45 patients (57.7%) in the validation cohort experienced neurotoxicity. Clinical and laboratory values obtained early in admission were used to develop a multivariable score that can predict the subsequent development of neurotoxicity; when tested on an internal validation cohort, this score had an area under the curve of 74%, an accuracy of 77%, a sensitivity of 82%, and a specificity of 70% (positive:negative likelihood ratio, 2.71:0.26). Conclusions and Relevance The score developed in this study may help predict which patients are likely to experience CAR T-cell–associated neurotoxicity. The score can be used for triaging and resource allocation and may allow a large proportion of patients to be discharged from the hospital early.

The true incidence of sepsis in surgical cohorts in Ireland remains unclear. According to inpatient audits, patients in surgical diagnostic groups (DRG) who developed sepsis had a longer length of stay and higher mortality rate compared with medical DRG patients who developed sepsis.We investigated sepsis incidence on a general surgical ward to identify risk factors and strategies to improve management.Demographics, admission and discharge details, infection risk factors, infection, and sepsis were studied prospectively on a surgical ward in July 2018.The mean age of 164 patients was 60.5 years (range 18-93 years), 107 (65.2%) were admitted electively, 16 (9.8%) were colonised with a multidrug-resistant organism (MDRO), and 30 (18.3%) were classified as frail on admission. Twelve (7.3%) developed sepsis (ward sepsis rate 118.2/10,000 bed days used). 'Sepsis' was documented in six cases and the national sepsis screening form used in four patients. Patients with sepsis were three times as likely to be MDRO-colonised (OR 3.56; 95% CI = 0.86-14.82; p = 0.065) or frail (OR 3.63; 95% CI = 1.07-12.35; p = 0.03), four times as likely to be an inpatient at the end of the study (OR 4.22, 96% CI 1.23-14.49; p = 0.01), and three times as likely to be readmitted (OR 3.46, 95% CI 1.02-11.76; p = 0.03).Sepsis was under-documented, and barriers exist with use of the national sepsis screening form. Frailty, which is a sepsis risk factor, should be assessed pre-operatively to maximise prevention.

Background: Sepsis can lead to significant morbidity and mortality if not recognised and managed early. On the basis of national mortality reports, Irish guidelines recommend that patients at risk of neutropenia, patients with sepsis or those with a systemic inflammatory response (SIRS) with one plus co-morbidity should receive Sepsis Six. We assessed the implementation of the Sepsis Six on a surgical ward in our institution. Methods: All inpatients on a surgical ward in July 2018 were prospectively assessed for the presence of infection and sepsis. If the Sepsis Six was required, implementation of each of the Sepsis Six elements was recorded. Results: Of 164 patients, 40.2% (66/164) developed an infection of whom 47% (31/66), met the criteria for requiring Sepsis Six. Of these, 7.3% (12/164) patients had sepsis, with 3% (5/164) developing septic shock. Patients required Sepsis Six for the following reasons: ³1 co-morbidity and ³2 SIRS criteria(n=19); new onset organ failure (n=12) and neutropenic risk(n=0).Only 12.9% (4/31) patients received all of the Sepsis Six elements within one hour; 77.4% (24/31) received some and 9.67% (3/31) did not receive any elements. Blood cultures were taken in 54.8% (17/31) of cases but only 32.3% (10/31) patients had their lactate level checked. Conclusion: Further research action is required to better understand and improve Sepsis Six implementation. This should facilitate improved sepsis recognition and enhance patient care.

Chimeric antigen receptor T cell therapy has become an important tool in the treatment of relapsed and refractory malignancy; however, it is associated with significant neurological toxicity. We characterized the neurological toxicity associated with chimeric antigen receptor T-cell therapy in a consecutive series of 100 patients up to 2 months post transfusion, 28 of whom were obtained from chart review and the others by prospective observation. The underlying neoplasms were lymphoma (74%), myeloma (14%), leukaemia (10%), and sarcoma (2%). The median age of the cohort was 64.5 years old and 39% of patients were female. The most commonly occurring neurological symptoms were encephalopathy (57%), headache (42%), tremor (38%), aphasia (35%) and focal weakness (11%). Focal neurological deficits are frequently observed after chimeric antigen receptor T-cell therapy and are associated with regional EEG abnormalities, FDG-PET hypometabolism, and elevated velocities on transcranial Doppler ultrasound. In contrast, structural imaging was typically normal. As this form of treatment is more widely adopted, recognition of the frequently encountered symptoms will be of increasing importance for the neurologists and oncologists caring for this growing patient population.