Citations

AbstractInterruptive alerts can negatively impact clinical workflows and contribute to alert fatigue, provider frustration, and burnout. Given that interruptive alert overriding is a heterogeneous and recurring phenomenon, occurring across different organizational contexts with varying characteristics and circumstances, we hypothesize a pragmatic approach with multimodal interventions to address malfunctioning alert populations and maintain those contributing to better patient care.This study aimed to develop a systematic approach to screen, identify, and correct malfunctioning interruptive alerts within a tertiary healthcare system.We performed screening by assessing the alert population, exploring available resources, and defining alert population inclusion and exclusion criteria. We identified interruptive alerts and then conducted an exploratory analysis. We shared insights from discussions with our expert panel to validate our findings and find gaps in current alert monitoring. We then performed focus groups and interviews as part of a root cause analysis. To address the findings of these investigations, we prioritized which alerts to improve, evaluated solutions, and recommended steps to improve our governance structure.We developed an approach to assess around 1,500 unique alerts in a tertiary center from January to June 2023. We introduced two approaches to visually analyze alert populations: alert-focused analysis and people- and systems-focused analysis. We utilized an expert panel to further enhance the power and speed of alert evaluation and then investigated one emerging alert with focus groups, identifying root causes for its malfunction. This alert demonstrated how enterprise practice changes, coupled with design and cultural issues, can trigger significant alert malfunctions.A multi-modal intervention approach is needed to evaluate interruptive alerts and act quickly on findings. Utilizing both analytical and nonanalytical methods can work in synergy to facilitate this framework. Such approaches may reduce time and be valuable tools for optimally allocating resources to tackle institutional alert challenges.

Abstract Background Malignant peripheral nerve sheath tumors (MPNSTs) are rare, aggressive sarcomas, with 40% associated with neurofibromatosis type 1 (NF1). Surgical excision is the main treatment for localized disease; however, local recurrence (LR) remains high. Radiotherapy (RTx) is increasingly used to enhance local control in STS, but its use remains controversial due to the potential for increased major wound complications and an increased risk of secondary malignancies in NF1 patients. This study investigated the use and impact of RTx on local control in MPNSTs, particularly in the NF1 setting. Methods Surgically treated primary MPNSTs from 1988 to 2019 in the MONACO multicenter cohort were included. Differences in demographics, treatment, and RTx use between NF1 and non-NF1 cases were examined. Factors influencing RTx administration and LR were assessed via multivariable analyses. Results Among 499 patients (33.1% NF1), 143 (28.7%) experienced LRs. Radiotherapy was administered to 56.3% of patients (57.0% in the NF1 group), with 27.3% receiving neoadjuvant and 72.7% adjuvant RTx. RTx was administered significantly more often to high-grade and extremity tumors. While RTx did not affect overall survival, it reduced LR risk in sporadic cases (hazard ratio [HR] 0.530; 95% confidence interval [CI], 0.354–0.793) but not in the NF1 subgroup (HR 1.00; 95% CI, 0.545–1.85). In NF1 patients, a microscopically positive margin (R1) was the only risk factor for LR development (HR 2.1; 95% CI, 1.19–3.79). Conclusions RTx is frequently used in the treatment of MPNSTs, regardless of NF1 status. While it may affect the LR rate in sporadic cases, its impact on NF1 patients is less clear.

Background/Objectives: Traditional hearing aid noise reduction algorithms offer no additional benefit in noisy situations for bimodal cochlear implant (CI) users with a CI in one ear and a hearing aid (HA) in the other. Recent breakthroughs in deep neural network (DNN)-based noise reduction have improved speech understanding for hearing aid users in noisy environments. These advancements could also boost speech perception in noise for bimodal CI users. This study investigated the effectiveness of DNN-based noise reduction in the HAs used by bimodal CI patients. Methods: Eleven bimodal CI patients, aged 71–89 years old, were fit with a Phonak Audéo Sphere Infinio 90 HA in their non-implanted ear and were provided with a Calm Situation program and Spheric Speech in Loud Noise program that uses DNN-based noise reduction. Sentence recognition scores were measured using AzBio sentences in quiet and in noise with the CI alone, hearing aid alone, and bimodally with both the Calm Situation and DNN HA programs. Results: The DNN program in the hearing aid significantly improved bimodal performance in noise, with sentence recognition scores reaching 79% compared to 60% with Calm Situation (a 19% average benefit, p < 0.001). When compared to the CI-alone condition in multi-talker babble, the DNN HA program offered a 40% bimodal benefit, significantly higher than the 21% score seen with the Calm Situation program. Conclusions: DNN-based noise reduction in HA significantly improves speech understanding in noise for bimodal CI users. Utilization of this technology is a promising option to address patients’ common complaint of speech understanding in noise.

Background: Proximal pole scaphoid fracture nonunions are challenging conditions to treat. When significant comminution of the proximal pole and avascular necrosis is present, scaphoid proximal pole reconstructive options are considered. The proximal pole of the hamate is a local autograft option; however, little has been described on the outcomes of this procedure. Methods: Patients who underwent proximal pole scaphoid reconstruction using proximal hamate autograft at 3 tertiary care centers were retrospectively reviewed. Radiographic union was classified by greater than 50% bony trabeculae across the reconstruction site on computed tomography scan. Results: Ten patients were included. Average age at the time of surgery was 27.9 years, and 60% were men. Average length of proximal hamate autograft harvested was 10 mm. All patients healed at an average of 14.3 weeks following surgery. At final follow-up, 3 patients reported no pain, 3 reported mild occasional pain, 2 reported moderate tolerable pain (1 at the hamate graft site), and 2 had no reports on their pain level. Conclusions: In small proximal pole scaphoid nonunions with fragmentation and avascular necrosis, ipsilateral proximal hamate autograft reconstruction of the scaphoid proximal pole is a viable and reproducible option with high rates of union and patient satisfaction.

Abstract Background Methylation class pleomorphic xanthoastrocytoma (mcPXA) comprises tumors with the DNA methylation signature of classical PXA but with a wider histologic spectrum, including overlap with glioblastoma (GBM). Methods To clarify the histologic and molecular scope of mcPXA and characterize its clinical behavior, a cohort of 469 tumor samples from 458 patients matching to mcPXA by the DKFZ classifier (v12.6 score ≥0.85) was interrogated. Results Patient median age was 23 years (range 1-73 years) with a female predominance (259 female/199 male). CDKN2A/B homozygous deletion was observed in 406 of 469 (87%) samples. In samples tested for BRAF p.V600E mutations (n = 279), 240 (86%) harbored the mutation. A chr7+/chr10− pattern was observed in 103 of 469 (22%) samples. Among samples tested for TERT promoter mutations (n = 143), 32 (22%) harbored the mutation. Progression-free and overall survival of patients with mcPXA were comparable to patients with methylation class IDH-mutant astrocytoma, low grade, but a GBM-like subset (ie, cases with a pre-methylation working diagnosis of GBM) showed shorter survival. Histologic features of high grade, including palisading necrosis and microvascular proliferation, were prognostic in mcPXA. Compared to patients with BRAF p.V600E-altered GBM, patients with mcPXA were younger and had a lower frequency of TERT promoter mutations. Conclusion Tumors in mcPXA share molecular characteristics with histologically defined PXA, and high-grade histologic features can help predict their clinical behavior. The use of an epigenetic classification of PXA reveals that this group of tumors is more common than previously appreciated and warrants in-depth study to identify efficacious therapeutic options.

Case: An upper trunk brachial plexus injury patient underwent ulnar motor fascicular to biceps motor nerve transfer. At 6 months postoperative, the patient had trace biceps firing but was diagnosed with an unrecognized rupture of the distal biceps tendon, requiring reconstruction. Another patient with C5-T1 injury was noted to have distal biceps tendon rupture at the time of gracilis muscle transfer. Both patients had gravity-assisted elbow flexion at 1-year follow-up. Conclusion: Biceps rupture is an uncommon concomitant injury with brachial plexus trauma and challenging to diagnose in the context of a paretic limb. Thorough history and intraoperative biceps tendon palpation will ensure these injuries are identified.

Abstract Purpose To describe the creation and clinical deployment of an integrated stand‐alone hybrid automated chart review platform that is comprised of a database, oncology information system (OIS) interfaces, and a user interface (UI). Methods A consensus checklist was developed to homogenize the practices of clinical physics staff and physics residents for all plan types. Critical review of the single checklist's items led to the creation of a new concept, the “plan attribute,” which permits specialization of the final checklist based on the characteristics of a particular plan. Only relevant and applicable tests are automatically populated to form a plan checklist based on plan attributes. Each populated checklist in this hybrid automation platform includes elements of full automation, steps or functions that use automation to augment a human input or effort, as well as steps completed by humans. Logging and categorizing of deficiencies found during the chart check was also implemented. Results Chart check data was analyzed for an over 4‐year time span starting from the clinical deployment of the tool in October 2020. This analysis included a total of 427 073 tests spread among 7882 initial chart checks. The recorded deficiencies at three triage levels showed 7116 minor errors, 679 major errors, and 71 plan rejections. The plan rejection level is the highest chart deficiency, which required the plan to be rejected and sent back for serious remediation and/or new plan generation. Conclusion This report describes the successful development and implementation of a hybrid‐automated chart checking program. The software leverages modern database and software design to improve the per case performance and experience of a multi‐user group. Chart check database permits high‐level review and improvement in all aspects of plan check and user performance.

Abstract RAS pathway (RASp) mutations induce proliferative features, and promote transformation in chronic myelomonocytic leukemia (CMML). However, the unique clonal landscape and hierarchy of distinct RASp mutations remain unexplored. To characterize the landscape, architecture, and implications of unique RASp mutations in CMML, we evaluated a cohort of 814 patients with CMML. We identified 461 RASp mutations among 342 patients (42%). N/KRAS and CBL mutations were the most common, frequently involved the P-loop or RING domains, respectively, and frequently appeared as dominant events (63% and 65%, respectively). BRAF, NF1, and PTPN11 mutations spanned throughout the gene structure, and frequently appeared as subclonal events (75%, 64%, and 59%, respectively). CBL mutations frequently occurred in codominance with SRSF2 and multihit TET2, and were enriched for KIT mutations. PTPN11 mutations more frequently co-occurred with SETBP1 and DNMT3A mutations, and were infrequently codominant with TET2 or ASXL1. RASp mutations predicted for shorter overall survival (hazard ratio [HR], 1.55; 95% confidence interval [CI], 1.15-2.07; P = .0075) and leukemia-free survival (LFS; HR, 1.67; 95% CI, 1.26-2.20; P = .0011), influenced outcomes of myelodysplastic and TET2 mutant CMML, and cooperated with IDH2 and RUNX1 mutations to induce shorter LFS. These data set the bases for refined genomic classifications of CMML, and underscore the need to develop RAS-directed therapies for patients with CMML.

Context.— After-death care can be complicated and time-consuming for clinical staff, and frustrating for bereaved families. Delays and errors can have damaging legal and reputational consequences for hospitals. Offices of Decedent Affairs (ODAs) have been proposed as a solution, and their potential benefits have been described in several single institution reports. The literature lacks a contemporary and comprehensive review of existing ODAs and their approaches. Objective.— To describe the process of establishing a new ODA and to provide a snapshot of the spectrum of structure, function, and impact of existing ODAs in the United States. Design.— A survey was administered to 11 established ODAs spread across the continental United States. Programs were identified through the College of American Pathologists Autopsy Committee and a Medical Autopsy Listserv. Results.— Eleven ODAs returned the survey, representing more than 190 cumulative years of experience in decedent care in the hospital setting (median, 10 years). There was a wide range in staffing (both staff size and background) as well as scope of services offered. The median ratio of hospital deaths to full-time equivalent (FTE) staffing was 360 deaths per FTE. Respondents reported that ODAs unburden clinical providers and facilitate decedent management. Some respondents reported a quicker turnover of hospital beds and shorter intervals between pronouncement of death and autopsy. ODAs increased autopsy rates when the autopsy services were part of the ODA. Conclusions.— This survey provides practical information for hospitals considering establishing a new ODA and useful benchmarks for existing ODA programs.

Context.— Decedent Affairs Offices and Programs can serve as an avenue to assist medical centers in facilitating efficient and comprehensive decedent management, despite a paucity of literature on their roles, establishment, and efficacy. Objective.— To characterize the motivations and rationales for establishing Decedent Affairs Offices. Design.— A survey was administered to 11 established Decedent Affairs Offices/Programs, identified through the College of American Pathologists Autopsy Committee and a Medical Autopsy Listserv. The questions comprehensively cover establishment, operations, and outcomes data available by institution. Results.— Survey respondents reported the rationale for starting their programs and the benefits such offices can have. Conclusions.— Decedent Affairs Offices and Programs provide a useful option to medical centers to navigate the increasingly complex task of comprehensive decedent management. The present survey helps to delineate the similarities and differences between these programs at 11 institutions, to aid nascent programs in their establishment and growth over time.