Citations

Abstract Rationale: Ongoing healthcare staffing shortages have prompted new care paradigms that incorporate remote care delivery to support timely detection of patient physiological deterioration through mechanisms other than clinician bedside evaluations. In partnership with institutional Information Technology, our team has developed a unique clinical informatics environment, known as the Advanced Medical Practice (AMP) platform, that incorporates data from multiple sources and platforms and supports remote observation of patients from the electronic intensive care unit(eICU). AMP takes advantage of technologies outside of vendor-supported EHRs, and its advanced user-interface design reduces information overload while incorporating real-time data from novel devices and sensors. We partnered with the hospital practice to co-develop a score within the AMP platform(Clinical Events Detection and Response[CEDAR]) that incorporates heart rate, blood pressure, respiratory rate, and SpO2 to stratify patient risk and generate deterioration alerts for the electronic ICU(eICU) team. This formative evaluation employed an implementation science approach to refine CEDAR and ensure it is acceptable to users and can be feasibly implemented in practice. Methods: The study team conducted this pilot work in the eICU at Mayo Clinic (Rochester, MN). We observed the eICU workflow and documented feedback from eICU staff in fieldnotes. eICU staff were asked to log issues in a tracking file during shifts. Issues were reviewed daily and discussed at multidisciplinary team meetings weekly. Observation and tracking data were coded to constructs in the Consolidated Framework for Implementation Research(CFIR 2.0) framework and mapped to Expert Recommendations for Implementation Change(ERIC) strategies that targeted key determinants. Results: Between 9/23/24 and 10/25/24 we completed 25 days of observations. Most identified issues related to technical/design issues like unclear vital trigger alerts (CFIR: Innovation trialability and design); staff knowledge of CEDAR functionality and attitudes about functionality, complexity, or relative advantage compared to current systems (CFIR: Inner setting access to knowledge and information and relative advantage); and difficulties incorporating CEDAR into workflow(CFIR: Inner setting/compatibility). Implementation strategies mapped to CFIR determinants included promoting adaptability of customized interface features; staging implementation scale-up with iterative improvements; providing local technical assistance; assessing for readiness and identifying facilitators and barriers; and conducting educational outreach visits. Conclusions: Formative evaluation during pilot studies are a critical step in the process of intervention development and testing. User engagement and frameworks from implementation science can identify issues of feasibility and inform strategies to ensure acceptability prior to intervention scale-up in clinical practice and readiness for conducting larger implementation studies.

Abstract Rationale : Interprofessional providers (IPPs), such as nurses, pharmacists, and respiratory therapists, teaching physician trainees (“interprofessional teaching” [IPT]), may improve teamwork and quality of care in the intensive care unit (ICU). However, the role that IPPs play in physician trainee education in the ICU and their attitudes about IPT have not been well described. In this study, we explored the impact of IPPs on education for Pulmonary and Critical Care fellows and their perceptions regarding IPPs as teachers for medical trainees. Methods: Fellows from eight large academic medical centers with pulmonary and critical care fellowship programs located in the Northeast, Mid-Atlantic, Midwest and West Coast were invited to participate. Eligible participants included Internal Medicine-trained Pulmonary and Critical Care or Critical Care Medicine fellows in the first, second, or third year of fellowship training. All focus groups were led by a single study team member who facilitated sessions in-person at four sites and virtually at four sites. Focus group transcripts were analyzed using a framework approach, and inter-rater reliability testing was performed prior to coding each manuscript in full (Cohen's kappa = 0.77). Results: Focus groups were held at eight sites between March and July 2023. A total of 50 fellows participated, including 13 first year, 21 second year, and 12 third year fellows, all of whom had completed at least 8 weeks of medical ICU rotations during fellowship. Several themes emerged. Fellows identified the relevance of IPP teaching content, fellow bandwidth to learn from IPPs, and the perceived benefit of relationship building with IPPs as factors that made them ideal learners for IPT among medical trainees. Fellows described distinct teaching content from each IPP group, with nurses revealing the “hidden curriculum,” pharmacists providing specific concrete learning points and incorporating primary literature, and respiratory therapists teaching at the bedside. Identified barriers to IPT included fellows’ competing roles as both teacher and learner in limited time, IPPs having difficulty identifying learner needs at varying levels, and fellows’ uncertainty about whether IPPs view themselves as educators. Conclusions: Fellows are uniquely situated to learn from IPPs in the ICU. Perceived benefits include expansion of their knowledge base and fostering relationships with the interprofessional team. The unique teaching profiles of each IPP group could be leveraged to enhance IPT in the ICU.

Abstract RATIONALE: Community engagement is critical in the conduct of research seeking to address healthcare disparities. Indigenous peoples (American Indians and Alaskan Natives) have the highest prevalence of cigarette smoking and commercial tobacco use among all racial and ethnic groups in the United States. Including Indigenous people as partners in the research process is critical for moving interventions to improve health forward. Engagement in the research process should be considerate of the time, travel, and ease of use for research participants and advisors. Based on feedback from community members, we launched social media pages with deidentified study updates for past participants and any interested community members to receive updates on a prospective mixed methods study designed to inform a pilot smoking cessation intervention. METHODS: Facebook and Instagram were the social media platforms identified for this study. Prior themes identified from the principal investigator's previous work and results of current study informed the development of posts. Institutional Review Board approval was granted for this community engagement method. There were no recruitment activities conducted on these pages, and all information was presented in a deidentified, thematic fashion to protect research participants. There were two social media moderators monitoring interaction with social media pages. An Indigenous artist created accompanying images to enhance engagement with posts. The content covered discussions on smoking cessation identified from the primary study along with profiles highlighting team members and allies. Posts were made at non-fixed, variable intervals from May to September 2024, and were checked bi-weekly to ensure respectful conduct. RESULTS: Between May and September 2024, ten posts were shared, including three highlighting Indigenous team members and allies and seven focused on smoking cessation discussions. Instagram had more engagement when compared to Facebook. Posts that featured Indigenous team members and allies received higher interaction when compared to those on smoking cessation alone, contributing to Instagram's overall success. CONCLUSION: Instagram was the more effective platform demonstrating higher engagement and follower growth when compared to Facebook. Of note, on both platforms, posts that highlighted team members and allies resonated well, and generated the most interaction. This not only emphasizes social media as an effective tool to engage underserved populations in the research process, but also suggests that emphasizing representation and ally-ship among research teams is impactful when engaging Indigenous audiences. This outcome exemplifies the importance of integrating cultural relevance in public health messaging when discussing thoughts and attitudes surrounding smoking cessation.

Abstract RATIONALE: Hypereosinophilic syndrome (HES) is a group of rare diseases characterized by persistent hypereosinophilia causing organ damage/dysfunction. Idiopathic and lymphocytic HES (I-HES/L-HES) subgroups exclude clonal and reactive HES. We evaluated real-world clinical outcomes of patients with I-HES/L-HES. METHODS: This retrospective observational cohort study of patients with I-HES/L-HES collected data from the TriNetX Linked Network of de-identified Electronic Health Records plus Claims in the US. Patients had a HES diagnosis (ICD-10-CM: D72.11) between 10/01/2020–09/12/2023, with ≥12 months continuous enrollment before their first HES diagnosis record (index date [ID]). Patients with myeloproliferative/reactive HES, or a diagnosis of eosinophilic granulomatosis with polyangiitis after HES diagnosis, were excluded. Baseline was defined as 12 months prior to ID. Year 1 was defined as 12 months after ID. Patients were followed up until either 09/12/2023, disenrollment from insurance, death, or 24 months after ID, whichever came first. Clinical response was defined as ≥3 months without HES symptoms and a blood eosinophil (bEOS) count ≤750 cells/µL. Complete hematological remission was defined as a bEOS count ≤500 cells/µL. Partial remission was defined as a bEOS count <50% of baseline value, but >500 cells/µL. Kaplan-Meier curves estimated time to first HES flare and hematological remission. Analyses were descriptive. RESULTS: At ID, patients with I-HES/L-HES (N=110) had a mean (standard deviation [SD]) age of 43.8 (21.3) years; 66 (60.0%) were male, 58 (52.7%) were White and 30 (27.3%) were Black or African American. Mean (SD) follow-up was 15.1 (7.7) months. Median (95% confidence interval [CI]) time from ID to first flare (n=47) was 18.0 (11.0, not estimated) months (Table 1). Median (95% CI) time to first complete or partial hematological remission (n=52) was 15.3 (10.8, 21.6) months. The proportion of patients with a definite or probable HES flare was lower at Year 1 (10/69 [14.5%]) versus baseline (40/110 [36.4%]). Few patients achieved clinical response at baseline (10/110 [9.1%]) and Year 1 (5/69 [7.2%]). Among patients with bEOS data, mean (SD) bEOS count was 2235.3 (4351.7) cells/µL at baseline (n=51) and 833.6 (1396.0) cells/µL at Year 1 (n=11). The proportion of patients with a bEOS count <500 cells/µL was 20/51 (39.2%) at baseline and 7/11 (63.6%) at Year 1. CONCLUSION: Despite a reduced proportion of patients experiencing flares within a year after diagnosis, many did not experience hematological remission or clinical response by Year 1; suggesting high disease burden with existing treatment and the need for novel therapies to better manage I-HES/L-HES.

ASCO Guidelines provide recommendations with comprehensive review and analyses of the relevant literature for each recommendation, following the guideline development process as outlined in the ASCO Guidelines Methodology Manual . ASCO Guidelines follow the ASCO Conflict of Interest Policy for Clinical Practice Guidelines . Clinical Practice Guidelines and other guidance (“Guidance”) provided by ASCO is not a comprehensive or definitive guide to treatment options. It is intended for voluntary use by clinicians and should be used in conjunction with independent professional judgment. Guidance may not be applicable to all patients, interventions, diseases or stages of diseases. Guidance is based on review and analysis of relevant literature and is not intended as a statement of the standard of care. ASCO does not endorse third-party drugs, devices, services, or therapies and assumes no responsibility for any harm arising from or related to the use of this information. See complete disclaimer in Appendix 1 and 2 (online only) for more. PURPOSE To develop a clinical practice guideline and recommendations for symptom management of patients with well-differentiated grade 1 to grade 3 metastatic gastroenteropancreatic neuroendocrine tumors. METHODS ASCO convened an Expert Panel to develop a clinical practice guideline by reviewing the literature for relevant guidelines, systematic reviews, randomized controlled trials (RCTs), and observational studies to develop recommendations for clinical practice. RESULTS The literature review identified eight guidelines, 19 systematic reviews, and three RCTs that informed the development of guideline recommendations. RECOMMENDATIONS Recommendations are included for carcinoid syndrome, carcinoid heart disease and carcinoid crisis, and functional pancreatic neuroendocrine tumor syndromes. Recommendations are provided for surgical management, liver-directed therapy, and systemic therapy options, as well as palliative care. Limited guidance is provided for sequencing of interventions. Additional information is available at www.asco.org/gastrointestinal-cancer-guidelines .

Importance Many older adults with advanced cancer never communicate goals of care or treatment preferences to their clinicians, raising the risk that care received will not match their values. Scalable models of care may help surmount this barrier. Objective To test whether a combined patient and clinician intervention increased the rate of advance care planning (ACP) documentation in large health care systems. Design, Setting, and Participants This stepped-wedge cluster randomized clinical trial using an open cohort design included patients aged 65 years or older with advanced cancer seen at oncology clinics in 3 health care systems located in the US South, Midwest, and Mid-Atlantic regions from April 1, 2020, to November 30, 2022. Data collection ended in 2024. Intervention The intervention involved delivering brief evidence-based patient-facing video decision aids available in 25 languages as well as goals-of-care communication training to oncology clinicians. Patients in the control period received usual care. Main Outcomes and Measures The primary outcome was ACP documentation, which included any electronic health record documentation of a goals-of-care conversation, palliative care, hospice, or limitation of life-sustaining treatments, identified via a validated natural language processing program. Analysis was performed on an intention-to-treat basis. Results Twenty-nine practices, comprising 13 800 unique eligible patients with a total of 29 357 repeated measurements, were included (mean [SD] age, 74.5 [6.6] years; 52.3% men [15 344 of 29 357 measurements]). The proportion of patients with ACP documentation was greater in the intervention phase compared with the usual care phase (adjusted rate difference, 6.8% [95% CI, 2.8%-10.8%]; P < .001). ACP documentation in the intervention phase occurred among 3980 of 15 754 patients (25.3%) (goals-of-care conversation, 21.4% [3377 of 15 754]; palliative care, 9.6% [1517 of 15 754]; hospice, 5.4% [847 of 15 754]; and limitation of life-sustaining treatments, 7.2% [1128 of 15 754]). In comparison, ACP documentation in the usual care phase occurred among 2834 of 13 603 patients (20.8%) (goals-of-care conversation, 16.8% [2281 of 13 603]; palliative care, 9.5% [1287 of 13 603]; hospice, 5.3% [724 of 13 603]; and limitation of life-sustaining treatments, 8.4% [1149 of 13 603]). Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial for older adults with advanced cancer, a bundled evidence-based decision aid and communication training intervention increased the proportion of older patients with ACP documentation. This approach offers an innovative paradigm with a clinically meaningful increase in ACP documentation, a widely used quality metric that reflects high-quality patient-centered care delivery. Trial Registration ClinicalTrials.gov Identifier: NCT03609177

Despite advances in cardiovascular care and improved outcomes, fragmented healthcare systems, nonequitable access to health care, and nonuniform and unbiased collection and access to healthcare data have exacerbated disparities in healthcare provision and further delayed the technological-enabled implementation of precision medicine. Precision medicine relies on a foundation of accurate and valid omics and phenomics that can be harnessed at scale from electronic health records. Big data approaches in noncardiovascular healthcare domains have helped improve efficiency and expedite the development of novel therapeutics; therefore, applying such an approach to cardiovascular precision medicine is an opportunity to further advance the field. Several endeavors, including the American Heart Association Precision Medicine platform and public-private partnerships (such as BigData@Heart in Europe), as well as cloud-based platforms, such as Terra used for the National Institutes of Health All of Us, are attempting to temporally and ontologically harmonize data. This state-of-the-art review summarizes best practices used in cardiovascular genomic and precision medicine and provides recommendations for systems’ requirements that could enhance and accelerate the integration of these platforms.

Objective To develop and validate classification criteria for pediatric chronic nonbacterial osteomyelitis (CNO) jointly supported by EULAR and the American College of Rheumatology (ACR). Methods This international initiative had 4 phases: (1) candidate items were proposed in a survey of pediatric rheumatologists, (2) criteria definition and reduction by Delphi and nominal group technique exercises, (3) criteria weighting using multicriteria decision analysis, and (4) refinement of weights and threshold score in a development cohort of 441 patients and validation in another cohort of 514 patients. Results The new EULAR/ACR classification criteria for CNO require typical radiographic or magnetic resonance imaging findings and bone pain as an obligatory entry criterion and exclusion criteria of malignancy, infection, vitamin C deficiency, and hypophosphatasia, followed by additive weighted criteria in 5 clinical (site of bone lesions, pattern of bone lesions, age at onset, coexisting conditions, fever) and 4 pathology/laboratory domains (bone biopsy findings if done, anemia, C‐reactive protein level, and erythrocyte sedimentation rate). A total score ≥55 is required for classification as CNO. The new criteria had a sensitivity of 82% and specificity of 98% in the validation cohort. Conclusion These new classification criteria for pediatric CNO developed with international input reflect current views about CNO, have high specificity and good sensitivity, and provide a key foundation for future CNO research.

ImportanceMetastatic cutaneous Crohn disease (MCD) is a rare condition for which there are currently no published diagnostic criteria. Formal MCD diagnostic criteria will expand clinical care and research by enabling future diagnostic code validation, crystallizing a more uniform disease entity for the purposes of translational research, and allowing the development of more formalized outcome measures aimed at treatment response.ObjectiveTo define a set of criteria for the diagnosis of MCD.Evidence ReviewIn this consensus statement, a panel of experts on MCD and related conditions was assembled. Their opinions were gathered regarding the clinical and histologic findings that are sufficient, necessary, and highly suggestive of MCD through serial survey. Subsequent surveys were continued until consensus was achieved. Sufficient was defined as a feature that, if noted, would enable diagnosis of MCD without any other signs, symptoms, or testing. Necessary was defined as a feature that must be present to establish a diagnosis of MCD. Highly suggestive referred to any other features that were indicative of MCD but did not qualify as sufficient or necessary to diagnose MCD.FindingsOf 24 experts invited, 19 agreed to participate, with a 79% to 100% response rate across 5 rounds conducted. Five patients were also invited to participate, but none opted to participate, citing lack of clinical expertise and time concerns. The experts were all from the US; 5 (26%) have practiced medicine for 0 to 5 years, 5 (26%) practiced for 6 to 10 years, 6 (32%) practiced for 11 to 15 years, and 3 (16%) practiced for more than 20 years. A total of 18 experts (95%) worked in an academic practice setting. There was consensus agreement that MCD could present as oral disease, genital disease, or, rarely, in another location. Consensus was achieved on 2 major and 5 minor criteria for genital/other subtypes of MCD and 5 minor criteria for oral MCD. There was consensus that, while there are some pathological findings that are highly suggestive of MCD, histologic criteria are not necessary for diagnosis.Conclusions and RelevanceA panel of experts reached consensus on the diagnostic criteria for MCD described in this study. These criteria include major and minor clinical criteria, along with histopathological criteria for the diagnosis of genital and oral MCD. This consensus is a crucial step in the diagnosis of and future treatment development for MCD, a rare and clinically understudied condition.