Bates, Ruth

Incidental imaging findings require an assessment of risk and clinical relevance, as well as consideration of further evaluation. Incidental findings are common on imaging obtained in the hospital, with pulmonary nodules being among the most frequent findings that may require additional evaluation. We conducted a retrospective study to determine the factors associated with documentation of incidental findings in the hospital discharge summary, using pulmonary nodules reported on abdominal computed tomography (CT) as an example of incidental findings with well‐defined follow‐up guidelines. Between January 1, 2012 and December 31, 2014, 7173 patients underwent in‐patient abdominal CT without concurrent chest CT; of these patients, 62.2% were ≥60 years old, 50.6% were men, and 45.5% were current or former smokers. Incidental pulmonary nodules were reported in 402 patients (5.6%; 95% confidence interval [CI], 5.1%‐6.2%). Based on nodule size, reported size stability, and patients' smoking status, 208 patients (2.9%; 95% CI, 2.5%‐3.3%) required follow‐up surveillance, per the 2005 Fleischner Society guidelines. Of these 208 patients, 48 (23%) received discharge summaries that included documentation of the incidental findings, with 34 summaries including a recommendation for nodule follow‐up and 19 summaries including a time frame for repeat CT. Three factors were positively associated with the inclusion of the pulmonary nodule in the discharge summary: mention of the pulmonary nodule in the summary headings of the radiology report (P ≤ 0.001), radiologist recommendations for further surveillance (P ≤ 0.001), and medical discharging service (P = 0.016). These findings highlight the need for a multidisciplinary systems‐based approach to incidental pulmonary nodule documentation and surveillance.

Chronic thromboembolic pulmonary hypertension (CTEPH) occurs when pulmonary emboli fail to resolve with anticoagulation. For patients with inoperable or residual CTEPH, riociguat is currently the only therapy approved by the United States Food and Drug Administration. However, some patients with CTEPH may require therapy beyond riociguat, such as intravenous prostacyclins, which can present significant administration challenges in patients with complex comorbid conditions. We describe a 42‐year‐old man with T12 paraplegia complicated by CTEPH (functional class IV with substantial right ventricular dysfunction) and severe pressure ulcers. In order to facilitate goals of care (hospital discharge to a skilled nursing facility where parenteral prostanoids could not be administered), he underwent rapid transition from intravenous treprostinil to oral selexipag in the form of a cross‐taper over 6 days. The patient required readmission due to worsening symptoms and was transitioned back to intravenous treprostinil; he tolerated conversion to oral treprostinil for approximately 4 months, but it was subsequently discontinued due to nausea and modified goals of care. The patient underwent transition to hospice care 3 months later and eventually died from clinical deterioration. To our knowledge, this is the first report to describe transition from intravenous treprostinil to selexipag as well as conversion from parenteral treprostinil to oral treprostinil in a patient with CTEPH and illustrates the approaches to and potential issues with prostanoid transitions. Additional observations are necessary to better understand the relative roles of selexipag and oral treprostinil regarding comparative efficacy and tolerability.

While many hospitalized patients have orders to fast in preparation for interventions, the extent to which these orders are necessary or adhere to evidence‐based durations is unknown. In this study, we analyzed the length, indication, and associated outcomes of nil per os (NPO) orders for general medicine patients at an academic institution in the United States, and compared them to the best available evidence for recommended length of NPO. Of 924 NPO orders assessed, the indicated intervention was not performed for 183 (19.8%) orders, largely due to a change in plan (75/183, 41.0%) or scheduling barriers (43/183, 23.5%). When analyzed by indication, the median duration of NPO orders ranged from 8.3 hours for kidney ultrasound to 13.9 hours for upper endoscopy. For some indications, the literature suggested NPO orders may be unnecessary. Furthermore, in indications for which NPO was deemed necessary in the literature, the duration of most NPO orders was much longer than minimally required. These results suggest the need for establishing more robust practice guidelines or institutional protocols for NPO orders.