Fischer, Karen M.

Background Patients with advanced cancer experience a substantial amount of existential and emotional distress. Dignity therapy (DT) is a brief, individualized psychotherapy that aims to relieve existential distress and improve the experiences of individuals impacted by serious illness. Aim To evaluate the feasibility and acceptability of virtual DT (vDT) among patients with advanced cancer. Methods This pilot study recruited adult patients with advanced cancer and an expected prognosis >6 months. The vDT intervention consisted of 2 sessions of guided interviews focused on life review, discussion, and development of a generativity document (GD). Feasibility and acceptability were assessed quantitatively and with semi-structured interviews. Effectiveness measures (distress, dignity impact scale, quality of life [QOL]) were administered pre/post intervention. Results Thirty-one patients referred from a palliative care clinic were eligible. Twenty-one consented and 15 received a final GD. Patients who completed final assessments (N = 9) reported satisfaction with their experience and would recommend the therapy to others. Patients found the virtual component of the intervention acceptable, and the majority noted an improvement in their dignity. Qualitative analysis revealed themes of study team effectiveness, perspectives on intervention processes, benefits to self, and benefits to loved ones. Conclusion Participation in vDT intervention was feasible and acceptable for patients. Patients appreciated the connection with the interviewer, the process, and the benefit of having a document to share with loved ones. Preliminary effectiveness data suggest vDT improves sense of dignity.

Objectives: To investigate the association between hormone therapy use and severe outcomes due to COVID-19 in perimenopausal and postmenopausal women. Methods: Using the Rochester Epidemiology Project, we retrospectively searched for the records of women aged 40-65 years who had a documented case of COVID-19 between March 12 and September 29, 2020. We further identified those who were perimenopausal or postmenopausal. The rates of emergency department visits, hospitalizations, and deaths were compared by hormone therapy use. Logistic regression models were used to assess the odds of the combined outcome based on hormone therapy use. Results: Among the 689 patients included in this study, the median age was 56 years, and 77.5% were White. Compared with patients currently using hormone therapy, those with past/never use of hormone therapy were significantly older, had more risk factors for severe COVID-19, and had a higher incidence of diabetes. A total of 102 emergency department visits/hospitalizations/deaths occurred among both groups. Participants with current hormone therapy use had similar rates and risk of emergency department/hospitalization/death outcomes as those without hormone therapy, even after adjusting for age and severe COVID-19 risk factors. Conclusions: Severe COVID-19 outcomes were not significantly different between women with current versus past/never use of hormone therapy. Our study adds to the data suggesting no harm with hormone therapy use in women with severe symptoms of COVID-19.

This cohort study examines changes in oxygen consumption among patients with multiple morbidities undergoing cardiac rehabilitation.

Introduction Optimal hospital bed utilization requires innovative patient care models. We studied a novel hospitalist model utilizing telemedicine to facilitate collaboration with affiliated emergency departments (EDs) and support medical triage and care of ED patients with high likelihood of hospital admission. Methods Telehospitalists based at a tertiary care facility collaborated with four community EDs in the same healthcare network between January 1, 2022, and April 30, 2023. Telehospitalists supported ED clinicians in medical care decisions and facilitated patient disposition. Emergency department length of stay (LOS) and disposition were evaluated, as were hospital LOS, 30-day readmission, and in-hospital mortality. For patients discharged from the ED, 7-day ED readmission and subsequent hospitalization were evaluated. Results Telehospitalists discussed 550 “admit-likely” patients with ED clinicians: 105 patients (19.1%) discharged from the ED and avoided admission; 322 patients (58.5%) were admitted to local or nearby community hospitals; 123 patients (22.4%) transferred to the tertiary care facility. Emergency department LOS differed significantly among disposition groups, including patients discharged home (10.2 h), admitted to local hospitals (12.6 h), and transferred to tertiary care hospitalist services (14.9 h; p < 0.001). Hospital LOS and in-hospital mortality were not significantly different among disposition groups. Patients admitted locally had lower 30-day readmission compared to those transferred to tertiary care facility (odds ratio = 0.59 [0.36, 0.99], p = 0.048). Discussion Telehospitalists as triage clinicians is an innovative approach to support local ED clinicians and patients. Telehospitalists optimized hospital bed utilization and healthcare system resources by facilitating safe discharges to home and expediting tertiary care transfers when necessary.

Abstract Objectives In the general hospital wards, machine learning (ML)-based early warning systems (EWSs) can identify patients at risk of deterioration to facilitate rescue interventions. We assess subpopulation performance of a ML-based EWS on medical and surgical adult patients admitted to general hospital wards. Materials and Methods We assessed the scores of an EWS integrated into the electronic health record and calculated every 15 minutes to predict a composite adverse event (AE): all-cause mortality, transfer to intensive care, cardiac arrest, or rapid response team evaluation. The distributions of the First Score 3 hours after admission, the Highest Score at any time during the hospitalization, and the Last Score just before an AE or dismissal without an AE were calculated. The Last Score was used to calculate the area under the receiver operating characteristic curve (ROC-AUC) and the precision-recall curve (PRC-AUC). Results From August 23, 2021 to March 31, 2022, 35 937 medical admissions had 2173 (6.05%) AE compared to 25 214 surgical admissions with 4984 (19.77%) AE. Medical and surgical admissions had significant different (P &lt;.001) distributions of the First Score, Highest Score, and Last Score among those with an AE and without an AE. The model performed better in the medical group when compared to the surgical group, ROC-AUC 0.869 versus 0.677, and RPC-AUC 0.988 versus 0.878, respectively. Discussion Heterogeneity of medical and surgical patients can significantly impact the performance of a ML-based EWS, changing the model validity and clinical discernment. Conclusions Characterization of the target patient subpopulations has clinical implications and should be considered when developing models to be used in general hospital wards.

Introduction: Living in an area with high Area Deprivation Index (ADI) is linked to worse cardiovascular disease (CVD) outcomes. However, the association of ADI with type 2 diabetes (T2D), a major CVD risk factor, is incompletely described. This knowledge may guide primary CVD prevention. Method: Rochester Epidemiology Project is a medical record linkage system of persons in southeast Minnesota and southwest Wisconsin. We identified 253,890 persons (aged 4–98 yrs on July 1, 2015) in 9 counties with >90% population coverage. ADI scores, from 2015 home addresses, were grouped into quartiles of low (Q1) to high (Q4) deprivation. We excluded persons with type 1 diabetes (T1D) or history of T2D and identified new T2D cases (2015-2020) using ICD codes, HbA1c and medications. We examined the association between ADI quartile and risk of incident T2D using Cox regression with persons right censored at death, T2D, T1D or last visit. Models were adjusted for age and gender, and reported adjusted hazard ratios (aHR [95% confidence interval]). Results: Age, gender, and race statistically differed across ADI quartiles (Table). Age × ADI interaction was significant ( P <.001). T2D incidence ranged from 6.3 (Q1) to 9.0 (Q4) per 1000 person-years ( P <.001). Women vs. men/non-binary persons (combined due to limited non-binary persons) had 30% lower risk of incident T2D (aHR 0.70 [0.67–0.72]). Risk of incident T2D was higher in persons from higher ADI areas. At median age of 48.6 yrs, the risk was 30% higher in Q2 (aHR 1.3 [1.22–1.38]), 38% higher in Q3 (aHR 1.38 [1.30–1.47]) and 53% higher in Q4 (aHR 1.53 [1.43–1.62]) vs. Q1. Higher ADI was associated with higher incident T2D in younger persons, with risk attenuation with increasing age (Figure). Conclusion: In this population cohort, persons, particularly of younger age, living in more deprived areas had a higher risk of incident T2D. ADI may help identify areas for targeted T2D screening, with implications for CVD screening and prevention.

Background: Proper diagnosis in primary care is crucial due to the large number of skin cancer diagnoses each year and its associated growing economic burden. Understanding how primary care providers can be best trained in dermoscopy is instrumental in helping primary care providers differentiate benign and malignant cutaneous lesions so that appropriate action can be taken (eg, biopsy/referral to dermatology or reassurance). Objective: To assess the success of concise dermoscopy training among primary care providers. Design: A cohort study was conducted in primary care at Mayo Clinic, Rochester, including primary care physicians, nurse practitioners, and physician assistants in internal medicine and family medicine. Diagnostic accuracy was measured on standardized testing through image-based recognition and in clinical practice through observation of referral and biopsy patterns both before and after dermoscopy education, focused on the TADA plus method. Results: Forty-three primary care providers completed the image-based recognition tests, with significant improvement in mean score measured after dermoscopy training workshop (20%). Among the thirteen primary care providers who continued to use dermoscopy in clinical practice, a significant improvement (31%) in mean clinical diagnostic accuracy was observed comparing 1 year of practice data before versus after dermoscopy training. Conclusion: Improvement in diagnostic accuracy with utilization of the TADA plus method translates into clinical practice. Therefore, training primary care providers in dermoscopy may improve the dermatologic care patients receive in primary care, especially in rural or medically underserved areas where access to dermatology is limited.

Background Before the COVID-19 pandemic began, medical staff and academic department workers reported increasing levels of stress and burnout because of strain on the health care system. The COVID-19 pandemic exacerbated this strain and introduced several novel stressors, which included transitioning to remote work. Safe and scalable strategies are needed to help health care workers cope with these stressors. Aromatherapy may help address this need. Objectives To assess the effect of 2 aromatherapy interventions (essential oil blends termed STILL and FOCUS) on perceived mental/psychological health parameters for academic department workers working from home during the COVID-19 pandemic. Methods Participants were advised to use STILL for 5 days (Monday through Friday). After a 2-day washout period (Saturday and Sunday), participants were instructed to use FOCUS for 5 days (Monday through Friday). Participants completed a visual analog scale survey evaluating restlessness, fatigue, anxiety, stress, happiness, energy, relaxation, calmness, and well-being before and after each of the 2 intervention periods. Results Twenty academic department remote workers participated in the study. Mental/psychological health surveys were completed by 6 participants before and after using STILL and by 10 before and after using FOCUS. Five participants answered all survey questions before and after both interventions. Although mean (SD) perceived stress scores improved after both the STILL (4.3 [2.3] vs 1.8 [1.7], P = .03) and FOCUS (2.9 [2.3] vs 1.5 [1.4], P = .02) interventions, this improvement was not statistically significant after Bonferroni correction (adjusted α = .006). Most participants (73.3%) reported that participating in the study was worthwhile, and 81.3% indicated that they would recommend aromatherapy to others. Conclusions The STILL and FOCUS aromatherapy interventions did not significantly improve mental/psychological health parameters for remote academic department workers, although perceived stress was marginally improved and participants reported a perceived benefit from using aromatherapy.

ImportanceCorticosteroid injections (CSIs) are an important tool for pain relief in many musculoskeletal conditions, but the longitudinal effects of these treatments on bone health and fracture risk are unknown.ObjectiveTo determine whether cumulative doses of corticosteroid injections are associated with higher risk of subsequent osteoporotic and nonosteoporotic fractures.Design, Setting, and ParticipantsThis cohort study included adult patients receiving any CSI from May 1, 2018, through July 1, 2022. Eligible patients resided in Olmsted County, Minnesota, and were empaneled to receive primary care within the Mayo Clinic. Cox proportional hazards regression models were used to evaluate risk of fracture based on cumulative injected corticosteroid dose.ExposureReceipt of any CSI during the study period.Main Outcomes and MeasuresThe primary outcome was risk of fracture by total triamcinolone equivalents received. Secondary outcomes consisted of risks of fracture based on triamcinolone equivalents received in subgroups of patients not at high risk for fracture and patients with osteoporosis.ResultsA total of 7197 patients were included in the study (mean [SD] age, 64.4 [14.6] years; 4435 [61.6%] women; 183 [2.5%] Black and 6667 [92.6%] White), and 346 (4.8%) had a new fracture during the study period. Of these fractures, 149 (43.1%) were considered osteoporotic. In the adjusted Cox proportional hazards regression model, there was no association of higher fracture risk based on cumulative CSI dose (adjusted hazard ratio [HR], 1.04 [95% CI, 0.96-1.11]). There was also no associated higher risk of fracture in the non–high-risk (adjusted HR, 1.11 [95% CI, 0.98-1.26]) or osteoporosis (adjusted HR, 1.01 [95% CI, 0.90-1.11]) subgroups. Age, Charleson Comorbidity Index, and previous fracture were the only factors that were associated with higher fracture risk.Conclusions and RelevanceIn this cohort study of cumulative injected corticosteroid dose and risk of subsequent fracture, no association was observed, including in patients with a preexisting diagnosis of osteoporosis. Treatment of painful conditions with CSI should not be withheld or delayed owing to concern about fracture risk.