Moraes, Alice Gallo de

Background Poor financial literacy and financial behaviors negatively affect the wellness and professional duties of residents and fellow physicians. Major financial missteps can create significant personal stress, leading to worsening wellness and burnout. There are currently no available comprehensive financial literacy curricula for residents and fellows for educators to use to address this gap. Methods We created and assessed the educational impact of a comprehensive 4-module curriculum that covers fundamental personal finance topics which are universally applicable to all physicians regardless of their medical and surgical specialty. We delivered the entire curriculum 6 times between November 2023 and December 2024 to anesthesia residents, internal medicine residents, and critical care fellows. We assessed their self-reported baseline financial behaviors and their knowledge and self-efficacy with core financial topics using pretest and posttest surveys. Results For the 4 modules respectively, 66 (25%), 39 (15%), 44 (17%), and 35 (13%) of 260 possible trainees completed surveys. Self-efficacy significantly increased for creating a financial plan (p<0.001), investing (p<0.001), designing a debt payoff strategy (p=0.005), selecting an asset allocation (p<0.001), selecting optimal asset locations (p<0.001), and selecting appropriate health (p<0.001)/life (p<0.001)/disability (p<0.001) insurance plans. Resident knowledge significantly increased from pretest to posttest for all 4 modules: Financial Plan & Basics of Investing (p<0.001), Budgeting & Debt Management (p=0.010), Retirement Accounts & Asset Allocation (p<0.001), and Insurance (p<0.001). Mean trainee satisfaction with the overall curriculum on a 5-point scale (1-low, 5-high) was 4.2 (standard deviation 0.8). Conclusions We identified poor baseline financial literacy and behaviors in our resident and fellow physicians. This prioritized curriculum effectively adapted to the needs of multiple different training programs and was highly desired by trainees. This curriculum increased their knowledge and self-efficacy with several key topics in personal finance.

9557 Background: High-dose interleukin-2 (IL-2) is administered following tumor-infiltrating lymphocyte (TIL) therapy, yet cardiotoxicity frequently limits dose delivery. The clinical significance of peri-dose troponin elevations during IL-2 remains poorly defined. We evaluated troponin kinetics during IL-2 dosing and their association with significant cardiac events and IL-2 interruption. Methods: We retrospectively analyzed patients with metastatic melanoma treated with TIL therapy followed by inpatient high-dose IL-2 at Mayo Clinic Rochester (N = 24; 87 IL-2 doses). High-sensitivity troponin and ECGs were obtained before and after each IL-2 dose. Clinically significant cardiac events were defined as QTc prolongation > 480 ms, arrhythmias (excluding isolated sinus tachycardia), new ECG abnormalities, vasopressor requirement, or cardiology consultation. Dose-level outcomes included cardiac events and subsequent IL-2 dose interruption. Paired troponin changes were assessed using Wilcoxon signed-rank testing. Dose-level associations were evaluated using clustered logistic regression to account for repeated IL-2 doses within patients. Results: 24 patients received 87 IL-2 doses (median 3 [IQR 2 - 5]). Median age was 63 years (IQR 54 - 70), and 58% were male. Baseline troponin median was 11 ng/L (IQR 6 - 21); 38% had baseline troponin > 14 ng/L. Post-dose troponin exceeded 14 ng/L in 16/24 patients (67%) and 48/87 doses (52%). Median delta troponin was 0 ng/L (IQR −1 to 6; range −24 to 133), with post-dose levels higher than pre-dose values ( p = 0.02). Clinically significant cardiac events occurred in 33% of patients; no post-IL-2 reductions in left ventricular ejection fraction were observed. At the dose level, cardiac events occurred only when post-dose troponin exceeded 14 ng/L (15/48 [31%] vs 0/39 doses; p < 0.001). In clustered logistic regression, post-dose troponin ≥15 ng/L was independently associated with cardiac events (OR 9.6, 95% CI 1.5 - 60.6; p = 0.02) and subsequent IL-2 dose interruption (OR 3.4, 95% CI 1.1 - 10.7; p = 0.04). When modeled continuously, each 1-unit increase in log-transformed post-dose troponin was associated with higher odds of cardiac events (OR 3.3, 95% CI 1.6 - 6.7; p = 0.001) and IL-2 interruption (OR 2.8, 95% CI 1.6 - 4.9; p < 0.001). Baseline troponin correlated with peak post-dose troponin (ρ = 0.44, p = 0.04). Conclusions: Peri-dose troponin elevations are common during post-TIL high-dose IL-2; however, higher post-dose troponin independently identifies clinically significant cardiac toxicity and predicts IL-2 interruption after accounting for repeated dosing within patients. Baseline troponin modestly predicts peak elevations, supporting standardized, risk-stratified troponin monitoring and prospective evaluation of toxicity-adaptive IL-2 delivery strategies in TIL therapy.

Objectives: To evaluate evolving management, ICU admission, and outcomes for critically ill chimeric antigen receptor (CAR) T-cell patients over a 6-year period. Design: Multicenter retrospective cohort study from January 2018 to September 2023. Setting: Eight U.S. centers. Patients: Adult CAR T-cell patients requiring ICU admission. Interventions: None. Methods: Summary statistics included mean, sd , median, and interquartile range (IQR). Fisher exact test or chi-square test were used to evaluate association between year treated and other categorical variables. Cochran-Armitage test was performed to assess significance of trends across years. Multivariable logistic regression was performed to assess covariates associated with mortality. Measurements and Main Results: Demographics, toxicity management, ICU admission, support modalities, toxicity severity, and survival (ICU, hospital, and 3-mo) were compared year-to-year. From 2018 to 2023, 2238 patients received CAR T cells, with increasing number of patients treated yearly; 398 (17.8%) required ICU care. Of those admitted to the ICU, 66.1% were male, 89.2% had lymphoma, and median age was 64 years (53–71 yr). ICU admission rates declined from 38.5% (95% CI, 31.6–45.8%) in 2018 to 16.4% in 2023 (95% CI, 13.5–19.7%; p < 0.0001). Cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome was the reason for ICU admission in 87.9%. In 2023 vs. 2018, ICU patients were older (median, 65 yr [IQR, 55–73 yr] vs. 58 yr [48–67 yr]; p = 0.003) with higher comorbidity indices (4 [4–6] vs. 3 [2–4]; p = 0.005) and more severe toxicities (≥ grade 3: 90.1% vs. 69.9%; p = 0.004). Corticosteroid use for less severe toxicities (≤ grade 2 toxicity: 73.8% vs. 40.6%; p = 0.0001) and anakinra use (56% vs. 5.5%; p < 0.0001) increased throughout the years. Mortality from cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome remained low (5.5%). Age, Sequential Organ Failure Assessment greater than or equal to 10 at ICU admission, and ICU admission for noncytokine release/neurotoxicity syndrome reasons were associated with hospital mortality (odds ratios, 1.02 [95% CI, 1–1.04; p = 0.046], 4.69 [2.44–9.01; p < 0.0001], and 3.74 [1.91–7.3; p = 0.0001], respectively). Conclusions: ICU admission rates after CAR T-cell treatment are declining. Although ICU patients are older with higher severity of illness and toxicity grades, ICU mortality after CAR T-cell therapy remains low.

Background While rapid response teams (RRT) are widely implemented to address clinical deterioration in hospitalized patients, their impact on goals of care (GOC) discussions remains underexplored. Aims We aimed to evaluate whether RRT activations were associated with subsequent goals of care discussions, code status changes, and clinical outcomes. Methods We conducted a retrospective single-center review of hospitalized adult patients admitted to medicine services who had RRT activations between January and December 2023. The primary outcome was GOC discussion within 72 h of RRT. GOC discussions were identified through EMR documentation of conversations, code status changes, and ACP notes. Secondary outcomes included code status change, transition to comfort care, and 30- and 90-day mortality. Analyses were adjusted using inverse probability of treatment weighting. Results 1823 RRTs among 1677 patients were analyzed; 47% of patients were female and 88% identified as white. Those transferred to the ICU had higher odds of goals of care discussions (OR 1.52, P < 0.001), code status change (OR 2.43, P < 0.001), and transition to comfort care (OR 1.47, P = 0.026) compared to those who remained on the floor. ICU transfer was also associated with increased 30- (OR 1.39, P = 0.006) and 90-day mortality (OR 1.30, P = 0.014). Conclusions ICU transfer following RRT activation is strongly associated with downstream goals of care discussions, changes in code status, comfort-focused care, and higher mortality. This demonstrates the importance of initiating goals of care discussions early and often, regardless of whether clinical decompensation is anticipated.

Abstract Rationale: The Deterioration Index (DTI) may serve as a crucial tool for predicting adverse patient outcomes; however, there is a paucity of literature attempting to externally validate this tool in specific clinical scenarios. In this study, we analyzed the relationship between DTI scores during rapid response team (RRT) activations and subsequent ICU transfer, initiation of goals of care (GOC) conversations, and 90-day mortality. Methods: This was a retrospective single-center review of adult patients who had an RRT activation while hospitalized between January 1, 2023 and December 31, 2023. This study was approved by our hospital institutional review board. Deterioration scores (0-100) were recorded every 15 minutes during the RRT event, and the highest score of each encounter was selected for analysis. The primary outcome was transfer to the ICU as a direct result of the RRT activation. Secondary outcomes included GOC discussions following RRT activation and 90-day mortality. GOC discussions, defined as physician-led conversations that specifically addressed code status, treatment priorities, or broader goals of care, met criteria only if initiated within 72 hours of the analyzed RRT activation. Logistic regression was used to assess the relationship between DTI scores during RRT activations and the aforementioned variables. Results: A total of 1643 patients were included in the analysis. For every 1-point increase in the deterioration score, the odds of ICU transfer increased by 2.7% (OR: 1.027, CI: 1.021-1.034, p&lt;0.0001), the odds of a goals of care discussion within 72 hours increased by 3.3% (OR: 1.033, CI: 1.025-1.040, p&lt;0.0001), and the likelihood of mortality within 90 days increased by 2.6% (OR: 1.026, CI: 1.019-1.033, p&lt;0.0001). Conclusion: Our findings contribute to external validation of DTI predictive value during RRT events. DTI scores were associated with key clinical outcomes, including ICU transfer and 90-day mortality. There was also an association between DTI scores and the likelihood of physician-led GOC discussions, suggesting that DTI may demonstrate predictive value not only of patient outcomes, but also the likelihood of specific non-medical physician actions. Further validation of these scores in prospective studies, specifically in the context of acute decompensation events, could help facilitate the integration of DTI-based RRT interventions into routine hospital practice.

Abstract Rationale: Medical trainees are often involved in the care of hospitalized patients, yet there are minimal data about correlation of trainee involvement with outcomes for patients with rapid response team (RRT) activations. Methods: This was a retrospective single-center review of adult patients on a primary medicine service who had an RRT activation between January 1, 2023 and December 31, 2023. This study was approved by our hospital institutional review board. Patients were included if they were at least 18 years old and had a hospitalization with an RRT activation. Outcomes analyzed included transfer to the ICU, 90-day mortality, and goals of care discussions. A subset analysis was performed of patients who remained on the floor after RRT. Statistical analysis was performed with Pearson's chi-square and Kruskal-Wallis tests. Results: We analyzed 1686 adult patients who had an RRT activation within the study timeframe. Mean age was 67.3 years (SD 16.8), 792 (47.0%) were female, and 1489 (88.3%) identified as white. Trainees were involved with 1016 (60.3%) patients; 935 of these were on an internal medicine team and 81 were on a family medicine team. Patients were more likely to transfer to the ICU if they were on a primary floor team with trainee involvement (p = 0.006). There was no difference in goals of care discussion occurrence prior to RRT (p = 0.257) or 90-day mortality (p = 0.877). Subset analysis of patients who remained on the floor after RRT was performed. There was no difference in occurrence of goals of care discussions after RRT (p = 0.169), code status change (p = 0.237), or transition to comfort care (p = 0.381) for patients on teams with trainee involvement and those without. Of the 925 patients who remained on the floor after RRT, goals of care discussion occurred after RRT in 210 (22.7%). Conclusions: In this study, we demonstrate that trainee involvement does not correlate with occurrence of goals of care discussions either before or after RRT activations. Trainee involvement also does not correlate with 90-day mortality for patients with decompensation events. However, patients on teams with trainee involvement are more likely to transfer to the ICU as the result of an RRT activation. It is possible that this reflects the increased complexity of patients who are admitted to teaching services; however, further investigation is needed.

Abstract Introduction: Differentiation syndrome (DS) is a life-threatening adverse drug reaction caused by differentiating agents, including all-trans retinoic acid, arsenic trioxide, inhibitors of mutant isocitrate dehydrogenase (e.g., enasidenib), and the FLT3 inhibitor gilteritinib. The proliferation of differentiated leukemic cells can alter cytokine balance, leading to tissue inflammation, but the pathogenesis remains incompletely understood. We present a case of severe DS in a patient with AML and multi-organ failure. Case: An 80-year-old female with a history of polycythemia vera and newly diagnosed AML, on decitabine, venetoclax, and enasidenib. She was admitted after her first treatment cycle with weakness, altered mental status, and neutropenic fever. Enasidenib was discontinued due to suspected DS, and she was treated with dexamethasone for five days. Three days after discontinuing steroids, her respiratory and mental status deteriorated, leading to a rapid response call and transfer to the ICU for acute hypoxemic respiratory failure. Point of care ultrasound revealed underfilled ventricles and collapsible IVC on inhalation. She became hypotensive and unresponsive, requiring intubation. Initial P/F was 72. PV tool with recruitment showed no low inflexion point but recruitable lung. Laboratory results revealed a WBC of 68.7 x 10⁹/L with 89% blasts which was increased from prior days and acute liver injury with hyperbilirubinemia. A CT scan revealed bilateral consolidations and pleural effusions with interlobular septal thickening. Despite initial oxygenation improvement with prone positioning, she remained hypotensive requiring norepinephrine, vasopressin, angiotensin II, and hydrocortisone. Methylene blue was administered with a favorable response. Leukocytosis worsened, and decitabine and hydroxyurea were initiated due to concern for uncontrolled acute leukemia. She was started on continuous renal replacement therapy (CRRT) for oliguric renal failure. After the fourth dose of decitabine, her shock resolved, urinary output improved, and leukocytosis decreased. However, in the following days, her oxygen requirements escalated, WBC again increased to 120 x 10⁹/L with 80% blasts, and she became hypotensive with signs of myocardial ischemia. She was ultimately transitioned to comfort care. Discussion: This case highlights severe DS following enasidenib administration, which progressed to multi-organ failure. Prompt initiation of systemic glucocorticoids is critical in the management of DS, and this condition should be considered in patients receiving active treatment for acute leukemia who require ICU-level care. Risk factors for DS development and the role of prophylaxis remain areas requiring further research in the context of acute leukemia treatment.

Abstract Rationale: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of cancer. They are also associated with life-threatening immune-related adverse events (irAEs), including the rare, poorly understood, and potentially fatal triad of myasthenia gravis, myocarditis, and myositis(triple M syndrome). We aimed to describe the management, intensive care unit (ICU)utilization, and outcomes of patients with irAEs with a specific focus on triple M syndrome. Methods: We conducted a retrospective chart review of patients with irAEs admitted to three quaternary care hospitals between December 2018 and 2023. We aimed to collect data on demographics, cancer type, treatment, ICU resource utilization, and outcomes including mortality. Results: Over this 5-year period, 140 patients were admitted for irAEs. Forty-nine percent were male, median age was 73 (IQR 64-80) years, 7% were of African American or Asian descent, and 32%required ICU admission. Median ICU and hospital length of stay (LOS) were 1.5 (IQR 0.7-2.9)and 7.2 (IQR 4.1-13.4) days, respectively. Among ICU patients, 14/140 (10%) had myositis,22/140 (16%) myocarditis, and 9/140 (6.4%) myasthenia gravis. Triple-M syndrome was diagnosed in 7/140 (5%) patients, including 3 with metastatic melanoma, 2 with genitourinary malignancies, 1 with metastatic lung and 1 with colon cancer. Four had received pembrolizumab and 3 nivolumab. Median ICU and hospital LOS were 3 (IQR 1-6) and 10 (IQR 8-21) days in this group. Three patients required mechanical ventilation, one required tracheostomy, and one required vasopressor support. Triple-M management included corticosteroids, IVIG, pyridostigmine, mycophenolate mofetil, and rituximab. Patients with triple-M syndrome were significantly older than other patients with ICI toxicity (P &lt;0.009) and had higher mortality (57%vs 25%, p = 0.07). Patients discharged from the ICU had a median survival of 67 (IQR 26-201)days. Conclusions: Patients with irAEs frequently require ICU level of support with significant morbidity and mortality, especially with triple M syndrome. Clinicians should always consider the possibility of triple-M syndrome in patients with multiple irAEs as symptoms can be subtle and easily overlooked. Corticosteroids remain the primary treatment of irAEs and can be combined with other immunosuppressive agents such as infliximab, anti-thymocyte globulin, or pyridostigmine. Unfortunately, mortality due to triple-M syndrome remains high underscoring the importance of early recognition and prompt multidisciplinary management of these toxicities.

Identifying the mechanisms of ventilator/ventilation-induced lung injury requires an understanding of the pulmonary physiology involved in the mechanical properties of the lung along with the involvement of the inflammatory cascade. Accurately measuring parameters that represent physiologic lung stress and lung strain at the bedside can be clinically challenging. Although surrogates for lung stress and strain have been proposed, such as plateau pressure and driving pressure, these values only represent a static variable in the ventilator breath. It has been proposed that a single variable could be used as a unifying parameter to identify a threshold for the safe application of mechanical ventilation. The concept of “mechanical power” applies an energy load transfer designation to the ventilator settings and output of tidal volume, airway pressures, and flow. However, there is a potential disconnect between the use of “absolute” mechanical power and the variability of body weight throughout a mixed medical population. Using ideal body weight as an influential factor to express mechanical power can potentially allow for a more accurate depiction of energy applied to the lungs and a potentially reliable injurious mechanical ventilation threshold indicator.