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Transfers are high-risk events, and outside hospital admissions lack standardized processes to ensure timely delivery of essential clinical information. We piloted a novel, standardized process for outside admissions to a single academic medical center’s resident- and hospital medicine-attending-based medicine services. Following literature review, Epic UserWeb review, and frontline physician input, a workflow and templated electronic health record accept note were developed to centralize outside admission documentation. Completed by physicians during real-time communication with outside physicians, the template captures key clinical data and incorporates a communication checklist. Physician education was delivered electronically and in person. Subjective attending and resident perceptions were assessed via electronic prepost surveys administered 1 week before and 90 days after implementation. Secondarily, exploratory patient clinical outcomes were assessed through 90-day prepost manual retrospective chart review. Survey responses were obtained from 60/38 residents and 12/7 attendings (pre/post). Documentation sufficiency on patient arrival was directionally promising among residents (21.7% vs 39.5%, P = 0.062). Satisfaction with the admission process and perceived patient safety improved significantly among residents and attendings ( P ≤ 0.036). Most respondents rated the note as useful or very useful (84% residents; 86% attendings), and attendings reported reduced time managing outside admissions. The intervention was associated with exploratory, nonsignificant reductions in rapid response team activation, intensive care unit transfer, 30-day readmission, mortality, and length of stay compared with preintervention patients. A standardized documentation and communication process improved physician satisfaction and perceived patient safety, with promising exploratory patient outcomes. Further study is warranted to assess impact at scale.

Objectives: To evaluate the association of a templated interhospital transfer (IHT) note on transfer appropriateness and clinical outcomes. Methods: We conducted a retrospective, single-center study of 100 IHTs to the Department of Medicine services between May and June 2023. The exposure was the type of documentation at the time of transfer, categorized as templated note, nontemplated note, or no note. The primary outcome was appropriateness of transfer, determined by 2 independent adjudicators using a standardized framework developed as part of the POINT Study. Documentation type by clinical specialty and reason for transfer were assessed, with statistical analyses of clinical outcomes limited to those with an incidence >5% (ie, escalation/downgrade in level of care within 24 h of transfer and 30 d mortality). Results: Among 100 transfers, 81 (81%) were deemed appropriate and 19 (19%) were deemed inappropriate. Documentation was present in 59%, including templated (35%) and nontemplated notes (24%). IHTs without documentation had the highest appropriateness rate (87.8%, 36/41), compared with templated notes (29/35, 82.9%; P =0.15) and nontemplated notes (66.7%, 16/24; P =0.042). Downgrades were more common in inappropriate transfers with nontemplated notes (50.0%, 4/8) than in appropriate transfers with templated notes (10.3%, 3/29; P =0.012). Conclusions: Structured IHT documentation was inconsistently used and did not predict the appropriateness of transfer. Transfers without documentation were most often appropriate, suggesting straightforward cases may not require formal notes. In contrast, nontemplated notes in inappropriate transfers showed high downgrade rates, implying that unstructured documentation may inflate perceived acuity. Further evaluation of documentation strategies is needed to support appropriate transfer decision-making.

Abstract Genetic studies have significantly advanced our understanding of tauopathies, yet the genetic aetiology of Pick’s disease, a rare 3-Repeat tauopathy, remains unclear. The MAPT p.A152T variant has been identified as a risk factor for Alzheimer’s disease and progressive supranuclear palsy, but its role in Pick’s disease is unknown. In this study, we examined the prevalence of MAPT p.A152T in the largest series of neuropathologically confirmed Pick’s disease cases to date (n = 401). Through genotyping, we identified a single mutation carrier in the Pick’s disease cohort (minor allele frequency = 0.12%). We previously reported MAPT p.A152T at a 0.20% frequency in healthy controls (n = 2456), suggesting that it does not associate with 3-Repeat tauopathy risk. To further investigate the effect of the variant on MAPT transcript expression, we used bulk RNA sequencing in Alzheimer’s disease and progressive supranuclear palsy A152T mutation carriers. We did not detect significant differences in 4-Repeat tau levels, though preliminary trends may indicate more nuanced effects that need to be examined with long-read sequencing in a larger series. Overall, our study suggests that MAPT p.A152T does not increase Pick’s disease risk and may instead be linked to 4-Repeat or mixed tau pathologies, warranting further functional investigation.

Acute hyponatremia is an uncommon complication of percutaneous cholecystostomy drainage with minimal literature to date. We present a case of a patient with necrotizing pancreatitis causing perforated cholecystitis, requiring percutaneous cholecystostomy that was complicated by acute hyponatremia. High biliary solute and volume loss led to the hyponatremia and elucidated downstream biliary obstruction. Fluid resuscitation, biliary stenting, and endoscopic drainage corrected the patient's sodium and symptoms in this multidisciplinary case.

Abstract Background Dementia with Lewy Bodies (DLB) is often misdiagnosed or conflated with Alzheimer’s Disease (AD) due to overlapping clinical presentations and neuropathological features. The presence of AD‐like features correlates with accelerated cognitive decline and a worse overall prognosis. Compared to AD, studies suggest that amyloid uptake in DLB may spare the occipital lobe. This project aims to investigate whether amyloid PET could be leveraged to differentiate between AD and DLB patients, with the goal of improving diagnostic accuracy and supporting patient stratification and safety in anti‐amyloid trials. Method This study involves collaboration across six centres (University of Geneva, BioFINDER, AMPLE, AMYPAD PNHS, MCSA, GEHC), each contributing amyloid PET imaging data from patients diagnosed with DLB based on clinical or neuropathological assessments. Moreover, each center provided an additional subset of AD and healthy controls, then matched to DLB samples based on age/sex/APOE genotype/education for comparison. A sub analysis will be performed on patients with evidence of both DLB and AD markers. Given the relatively small sample size, key aspect of the methodological approach is to reduce technical sources of variability. The processing workflow includes rigorous quality control, formatting, normalisation to MNI space, harmonisation (differential smoothing), and MRI‐based segmentation. Result The dataset currently includes amyloid PET scans (acquired using [ 11 C]PiB, [ 18 F]Flutemetamol or [ 18 F]Florbetapir) and MRI scans from ∼130 DLB patients, along with ∼150 AD patients and ∼150 controls. In addition, 99 patients positive for the CSF α‐Synuclein Seeding Amplification Assay were included. Patient data were anonymized, and a harmonised database was created, including demographic characteristics, clinical history, and results from neuropsychological assessments. Conclusion The creation of a standardized, multi‐centre amyloid PET dataset for DLB will enable the study of amyloid PET patterns at the global, regional and voxel level, in comparison with uptake in AD patients and controls. This dataset will serve as a valuable resource for investigating the neuropathological underpinnings of DLB, improving diagnostic accuracy, and potentially guiding patient stratification in anti‐amyloid trials. Efforts to integrate [ 18 F]Florbetaben and additional data are ongoing.

Abstract Introduction: T-PLL is a rare, aggressive leukemia with poor prognosis and limited therapies. Previous studies on T-PLL patients receiving an allogeneic stem cell transplant (alloSCT) are limited by small numbers with limited data on disease and transplant characteristics. Further, recent data from our large national cohort of patients demonstrated significant survival difference between TCL1A+ and TCL1A- T-PLL, and CD8+ T-PLL vs CD8- T-PLL. In this large multi-center series, utilizing comprehensive disease subtype and alloSCT clinical data, we evaluated prognostic and survival therapeutic outcomes in T-PLL patients that had an alloSCT with a particular focus on T-PLL disease subtypes. Methods: We retrospectively evaluated 572 diagnosed with T-PLL at 21 academic cancer centers throughout the USA between 2000-2023, of which we performed a further evaluation on the169 that proceeded with alloSCT. Overall survival (OS) and progression-free survival (PFS) were assessed using Kaplan-Meier methods and Cox proportional hazard models. Results: Among n=169 alloSCT recipients with T-PLL, the median follow-up time was 20.9 months post-alloSCT (range: 0.2-182.9), the median age at transplant was 59 years (range: 35-77) and 52% were male. In evaluated patients (n=109), TCL1A was positive by cytogenetics or FISH in 69%. As our recent analysis demonstrated significant differences in survival among specific subtypes of T-PLL, we evaluated outcomes in patients with CD4+CD8- T-PLL (n=90, 53%), CD4-CD8+ (n=17, 10%) T-PLL, and CD4+CD8+ T-PLL (n=52, 31%). 53% (87/164) had known nodal involvement at diagnosis identified by PET or CT scan and 45% (43/96) of known patients had minimal residual disease (MRD) at the time of transplant [defined as <5% T-PLL in marrow by flow, or +cytogenetics (e.g. TCL1A)] prior to alloSCT. At the time of alloSCT, 136 (80%) patients were in CR and 23 (14%) patients were in PR. Forty-nine (30%) had a myeloablative (MAC)conditioning regimen and 114 (70%) had a reduced intensity chemotherapy (RIC) conditioning regimen. Eighty (49%) patients had TBI as part of their regimen. The most common regimens were fludarabine (flu)/melphalan based regimens (n=44; 26.0%), flu/cyclophosphamide (cy) based regimens (n=33; 19.5%), flu/busulfan based regimens (n=22; 13.0%), flu/total body irradiation (TBI) (n=8; 4.7%), and cy/TBI (n=4; 2.4%). Across the whole cohort, the median OS and PFS post-alloSCT was 32.6 months (95% CI: 21.0-41.9) and 20.8 months (95% CI: 14.4-30.5) months while the 1-year cumulative incidences (CI) of NRM and relapse were 17% and 20%, respectively. The incidences of grade II-IV acute GVHD and cGVHD were 19% and 23%. There was no difference between patients with myeloablative conditioning (MAC) (n=49, 29%) when compared to patients that received reduced intensity conditioning (RIC) (n=114, 67%) in OS (33.1 vs 29.2; p=0.68) and PFS (20.2 vs 20.8; p=0.97). Patients that were MRD+ (n=31) had worse OS (22.2 vs 48.6; p=0.1) and PFS (14.1 vs 32.5; p=0.04) and higher rates of relapse (1-year relapse 20% vs 8%; p=0.08) than patients that were MRD- (n=50). PFS was improved in those who received alloSCT though only trended towards significance due to low numbers (HR 0.76, p=0.09). In subtype analysis, TCL1A+ T-PLL had significantly worse outcomes compared to TCL1A negative T-PLL. TCL1A+ disease had significantly worse OS (21.6 vs 63.1; p=0.01) and PFS (12.4 vs 50.7; p=0.01) compared to TCL1A-. Additionally, in TCL1A+ disease CI of NRM (24% vs 3%; p=0.02) and relapse (25% vs 12%; p=0.86) was higher vs TCL1A- PLL. CD4+CD8-, CD4-CD8+, and CD4+CD8+ disease had no difference in survival via either OS (28.0 vs 34.4 vs 21.0; p=0.17) or PFS (29.4 vs 23.5 vs 13.6; p=0.09) as well as no difference 1-year CI of NRM ( 11.6 vs 23.5 vs 26.2; p=0.35) and relapse (18.5 vs 23.5 vs 20.0; p=0.67).Conclusions: AlloSCT significantly improved outcomes for patients with T-PLL compared to those who did not proceed to alloSCT and remains he only curative therapy for those with T-PLL. OS, PFS, and CI relapse were significantly worse for patients with TCL1A+ subtype of T-PLL, or those with MRD positivity or PR prior to alloSCT. Novel strategies to decrease relapse such as post-alloSCT maintenance therapy to improve outcomes are urgently needed in these patients.

AbstractSecure messaging platforms were designed to optimize healthcare communication by providing asynchronous, bidirectional, Health Insurance Portability and Accountability Act‐compliant text messaging options. Proponents argue that these platforms streamline workflows, foster coordination across multidisciplinary teams, and improve patient safety. However, critics highlight their potential to disrupt workflows through overwhelming message volumes and task interruptions, increased risk for miscommunication, and possible detrimental impacts on patient care. While secure messaging shows promise for modernizing hospital communication, it requires institutional guidelines and thoughtful use to mitigate inefficiencies and risks.

Abstract Background Time spent awaiting discharge after the acute need for hospitalization has resolved is an important potential contributor to hospital length of stay (LOS). Objective To measure the prevalence, impact, and context of patients who remain hospitalized for prolonged periods after completion of acute care needs. Design, Setting, and Participants We conducted a cross‐sectional “point‐in‐time” survey at each of 15 academic US hospitals using a structured data collection tool with on‐service acute care medicine attending physicians in fall 2022. Main Outcomes and Measures Primary outcomes were number and percentage of patients considered “medically ready for discharge” with emphasis on those who had experienced a “major barrier to discharge” (medically ready for discharge for ≥1 week). Estimated LOS attributable to major discharge barriers, contributory discharge needs, and associated hospital characteristics were measured. Results Of 1928 patients sampled, 35.0% ( n = 674) were medically ready for discharge including 9.8% ( n = 189) with major discharge barriers. Many patients with major discharge barriers (44.4%; 84/189) had spent a month or longer medically ready for discharge and commonly (84.1%; 159/189) required some form of skilled therapy or daily living support services for discharge. Higher proportions of patients experiencing major discharge barriers were found in public versus private, nonprofit hospitals (12.0% vs. 7.2%; p = .001) and county versus noncounty hospitals (14.5% vs. 8.8%; p = .002). Conclusions Patients experience major discharge barriers in many US hospitals and spend prolonged time awaiting discharge, often for support needs that may be outside of clinician control.

AbstractIntroductionOperationalized research criteria for mild cognitive impairment with Lewy bodies (MCI‐LB) were published in 2020. The aim of this systematic review and meta‐analysis was to review the evidence for the diagnostic clinical features and biomarkers in MCI‐LB set out in the criteria.MethodsMEDLINE, PubMed, and Embase were searched on 9/28/22 for relevant articles. Articles were included if they presented original data reporting the rates of diagnostic features in MCI‐LB.ResultsFifty‐seven articles were included. The meta‐analysis supported the inclusion of the current clinical features in the diagnostic criteria. Evidence for striatal dopaminergic imaging and meta‐iodobenzylguanidine cardiac scintigraphy, though limited, supports their inclusion. Quantitative electroencephalogram (EEG) and fluorodeoxyglucose positron emission tomography (PET) show promise as diagnostic biomarkers.DiscussionThe available evidence largely supports the current diagnostic criteria for MCI‐LB. Further evidence will help refine the diagnostic criteria and understand how best to apply them in clinical practice and research.Highlights A meta‐analysis of the diagnostic features of MCI‐LB was carried out. The four core clinical features were more common in MCI‐LB than MCI‐AD/stable MCI. Neuropsychiatric and autonomic features were also more common in MCI‐LB. More evidence is needed for the proposed biomarkers. FDG‐PET and quantitative EEG show promise as diagnostic biomarkers in MCI‐LB.

ABSTRACT Background Multiple System Atrophy is a rare neurodegenerative disease with alpha‐synuclein aggregation in glial cytoplasmic inclusions and either predominant olivopontocerebellar atrophy or striatonigral degeneration, leading to dysautonomia, parkinsonism, and cerebellar ataxia. One prior genome‐wide association study in mainly clinically diagnosed patients with Multiple System Atrophy failed to identify genetic variants predisposing for the disease. Objective Since the clinical diagnosis of Multiple System Atrophy yields a high rate of misdiagnosis when compared to the neuropathological gold standard, we studied only autopsy‐confirmed cases. Methods We studied common genetic variations in Multiple System Atrophy cases (N = 731) and controls (N = 2898). Results The most strongly disease‐associated markers were rs16859966 on chromosome 3, rs7013955 on chromosome 8, and rs116607983 on chromosome 4 with P ‐values below 5 × 10 −6 , all of which were supported by at least one additional genotyped and several imputed single nucleotide polymorphisms. The genes closest to the chromosome 3 locus are ZIC1 and ZIC4 encoding the zinc finger proteins of cerebellum 1 and 4 (ZIC1 and ZIC4). Interpretation Since mutations of ZIC1 and ZIC4 and paraneoplastic autoantibodies directed against ZIC4 are associated with severe cerebellar dysfunction, we conducted immunohistochemical analyses in brain tissue of the frontal cortex and the cerebellum from 24 Multiple System Atrophy patients. Strong immunohistochemical expression of ZIC4 was detected in a subset of neurons of the dentate nucleus in all healthy controls and in patients with striatonigral degeneration, whereas ZIC4‐immunoreactive neurons were significantly reduced inpatients with olivopontocerebellar atrophy. These findings point to a potential ZIC4‐mediated vulnerability of neurons in Multiple System Atrophy. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society