tbuckley/cabot-search huggingface dataset:
Steroid tapering for patients with spinal cord compression or symptomatic brain metastases at Jackson Memorial Hospital.
Authors: David Asher, Benjamin Farnia, Stephen Ramey, Sarah Francis, Shahil Mehta, Angela Richardson, Glen Manzano, Stuart Samuels, Raphael Yechieli
Journal: Journal of Clinical Oncology (2018)

238 Background: Metastases to the spinal column and brain for patients with cancer are common occurrences seen in oncology practices. Steroids play a critical role in symptom management upon patient presentation and proper tapering of steroids is necessary to minimize risk of recurrent symptoms. Within our institution, which is a tertiary care facility primarily for the poor and near-poor of a large urban environment, 78% of patients with spinal cord compression or symptomatic brain metastases do not receive appropriate tapering of steroids following completion of radiation treatment. This leads to unnecessary side effects from continued steroid use, ultimately leading to an inefficient use of resources, including time and money. Methods: Through the guidance of American Society of Clinical Oncology (ASCO) Quality Training Program, we created a process map, cause and effect diagram, and acquired preliminary diagnostic data. This data was acquired via electronic medical record (EMR) review including evaluation of inpatient notes, discharge summaries, medication orders and prescriptions, and outpatient clinic visit notes. We then completed several PDSA cycles including grand round presentation, tapering template incorporation into clinic, and template creation within our EMR. Results: We identified that a single physician primarily was responsible for the patients that appropriately received steroids. We utilized this physician's expertise to help create meaningful interventions. By the complete of our last PDSA cycle, we have reduced the percentage of patients who do not receive an adequate steroid taper form 78% to 20%. Conclusions: Practitioner education and incorporation of steroid tapering templates into an outpatient radiation oncology clinic can reduce the percentage of patients with spinal cord compression or symptomatic brain metastases, who do not receive and adequate steroid tapering regimen.
Antibiotic Treatment for Uncomplicated Urinary Tract Infections—Reply
Authors: Angela Huttner, Leonard Leibovici, Stephan Harbarth
Journal: JAMA (2018)

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A focus on culturally sensitive communication to transform institutional awareness of health care disparities.
Authors: William James Maples, Sandra L Argenio, Linda Scaz, Jennifer Krippner
Journal: Journal of Clinical Oncology (2018)

69 Background: Healthcare organizations can cultivate the strength of a diverse workforce in creating a culture of excellence. Enabling the team to understand how personal and cultural beliefs affect our decision making and how we interact with patients and colleagues is integral. Gaps in care exist in cancer diagnoses and treatment in many minority groups. A need for education in the nature of assumptions, unconscious biases, and awareness around the existence of healthcare disparities, was identified through culture transformation work within multiple healthcare institutions. Methods: An experiential course was designed for multi-disciplinary groups of providers. Designed to meet the evolving demographics in the country and help participants recognize how their own cultural beliefs and values affect their decision making. Topics include cultural awareness, assumptions and unconscious bias, effective use of interpreters, and skills to recognize when cultural differences may be playing a role and how to successfully navigate these situations. Raising awareness of healthcare disparities is highlighted, including disparities in cancer care diagnosis, treatment and outcomes for different ethnicities and socioeconomic groups. Examples include disparities in diagnosis, treatment and outcomes of lung cancer, colon cancer and breast cancer in minorities. Results: Participants engage in skills-based work. Participants develop a plan how they can take this information and education back to help create an awareness of disparities and skills to successfully navigate these situations. After this program, participants will be cognizant of the nature of assumptions and unconscious bias and understand the strength of diversity as an asset rather than a hindrance. Conclusions: Healthcare disparities can have a significant impact on patient experience, quality and outcomes. Specific inequities in cancer diagnosis and treatment in minorities is highlighted. Participants are provided with information and skills that can be introduced to their home institutions to have all caregivers recognize and successfully navigate culturally sensitive situations.
Abstract 15463: Very Early Tissue Coverage After Drug-eluting Stent Implantation
Authors: Masayuki Takahara, Takashi Nakayama, Yoshihide Fujimoto, Yoshio Kobayashi
Journal: Circulation (2015)

Introduction: Optical coherence tomography (OCT) have demonstrated neointimal coverage on drug-eluting stents (DES) struts at 6-12 month follow-up. However, there is little information about tissue coverage &lt;30 days after DES implantation. Methods: OCT was performed in patients who underwent staged percutaneous coronary intervention &lt;30 days (16.3±7.5 days) after DES implantation. Cross-sectional OCT images of DES were analyzed at 1-mm intervals. Results: A total of 6,054 struts of 29 stents (27 everolimus-eluting stents and 2 zotarolimus-eluting stents) in 24 lesions were analyzed. The stent length was 32.8±9.47 mm, mean stent area 7.50±2.17 mm2, mean lumen area 7.39±2.35 mm2, minimum lumen area 5.69±1.90 mm2, and minimum lumen diameter 2.41±0.39 mm. Stent coverage was observed in 73.5±20.4% of the struts, malapposition 0.85±1.53%, side branch orifice struts 1.37±2.16%, and protruding struts 1.01±4.08%. The tissue thickness was 36.9 ± 14.5 μm. The percentage of stent coverage was significantly lower in the overlapping segments than in the non-overlapping segments (Figure). Conclusions: Most of DES struts are covered by tissue &lt;30 days after EES implantation. However, the percentage of stent coverage is lower in the overlapping segments.
Abstract 19454: mmu_circ_008396 a Novel Circular RNA Involved in Myocardial Infarction
Authors: Venkata N Garikipati, Suresh K Verma, Zhongjian Cheng, Emily Nickoloff, Dongming Liang, Mohsin Khan, Cindy Benedict, Maria Cimini, Jessica Ibetti, Laurel A Grisanti, Sarah M Schumacher, Erhe Gao, Joseph E Rabinowitz, Jeremy E Wilusz, David Goukassian, Steven R Houser, Walter J Koch, Raj Kishore
Journal: Circulation (2016)

Introduction: Recent studies highlighted that circular RNAs (circRNA) can play an important role in cardiac hypertrophy. However, the role of circRNAs post myocardial infarction (MI) has not yet be...
Development of a nutrition-focused quality improvement program for new patients with cancer seen at the UTSW Simmons Comprehensive Cancer Center (SCCC) outpatient gastrointestinal (GI) oncology clinic.
Authors: Timothy J Brown, Heather R Wolfe, Shelli Hardy, Nizar Bhulani, Christine Hong, Leticia Khosama, Naga Cheedella, Stephanie Hobbs, Thomas W. Froehlich, Arif Kamal, Muhammad Shaalan Beg, Syed Mohammad Ali Kazmi
Journal: Journal of Clinical Oncology (2018)

143 Background: Patients with GI malignancies suffer from weight loss, sarcopenia and malnutrition contributing to poor outcomes and reduced survival. Early nutritional intervention in at-risk patients by a clinical dietitian can prevent or delay the onset of malnutrition. In the GI Oncology clinic at the UTSW SCCC, the rate of documented nutritional plan by a clinical dietitian within first 90 days of new patient encounter was low. Methods: We aimed to increase the rate of a documented nutrition assessment by a clinical dietitian to 65% within 90 days of a new patient encounter. Baseline data from the electronic medical record were obtained from Sep 2017-Oct 2018. Group sessions were arranged to apply QI methodologies to determine steps to a documented nutritional plan by a clinical dietitian. Patient advocates were interviewed to assess patient perspective. Sequential PDSA cycles were planned to improve rates of nutritional plan documentation and data were obtained every 2 weeks. Results: At baseline, 41.1% of new patients in the two-month data collection period had documented nutrition plans within 90 days of their first appointment. Most of these patients were on intravenous chemotherapy. EMR-based nutrition assessments identified 17% of all new patients at risk of malnutrition. Multiple causes for low baseline rates of nutrition plans were discovered, including patient or family characteristics and needs, clinical dietitian resources, physician limitations, process flaws, as well as difficulty with the EMR. Patient-centered PDSA cycles directed toward patients, and clinical staff to increase the rate of documented nutritional plan are ongoing. After the first PDSA cycle, early 2-week assessment shows documented rate of nutritional plan of 28%. Authors expect it to increase with longer follow-up and subsequent PDSA cycles. Conclusions: Malnutrition in GI cancer is prevalent and under-recognized in routine clinical encounters. Addressing malnutrition is important aspect from patient perspective. We are continuing ongoing efforts to increase the rate of nutritional assessments in these patients.
The Coming of Age of Drug-Susceptibility Testing for Tuberculosis
Authors: Helen Cox, Valerie Mizrahi
Journal: New England Journal of Medicine (2018)

Tuberculosis is the leading infectious cause of death worldwide, claiming 1.6 million lives annually.1 Antimicrobial resistance is undermining efforts to curb the global tuberculosis epidemic: among the 10.6 million cases of tuberculosis that occurred in 2016, less than a quarter of the estimated 600,000 patients with multidrug-resistant (MDR) or rifampin-resistant tuberculosis received diagnoses and were treated. Although rollout of the Xpert MTB/RIF molecular test has enabled the rapid detection of resistance to the first-line tuberculosis drug rifampin, a diagnostic test that can accurately determine the complete drug-susceptibility profile of the infecting strain or strains of Mycobacterium tuberculosis would make it . . .
Abstract 473: Differential Regulation of Sk Channels by CamKII and Pyk2 Under Adrenergic Stimulation
Authors: Radmila Terentyeva, Iuliia Polina, Shanna Hamilton, Karim Roder, Gideon Koren, Jin O-Uchi, Dmitry Terentyev
Journal: Circulation Research (2017)

Introduction: Small conductance calcium (Ca)-activated K (SK) channels present in the plasmalemma of ventricular cardiomyocytes (VCMs) are dormant in health and become functional in cardiac disease. We recently showed that SK channels contribute to VCM repolarization in a rat model of hypertrophy induced by thoracic aortic banding (TAB), despite reduced expression levels, suggestive of increased activity of the channels. However, the mechanisms responsible for disease-associated functional upregulation of the channels are yet to be defined. Hypothesis: Functional recruitment of SK channels in cardiac hypertrophy is caused by enhancement of adrenergic signaling cascades. Methods: The effects of α1 adrenergic stimulation by phenylephrine (10 μM) + propranolol (100 μM) were studied in patch-clamped rat VCMs overexpressing rat SK2 after 48 hrs in culture. Calcium transients were recorded simultaneously using confocal microscopy and were used as a ramp [Ca] to assess possible changes in Ca sensitivity of the channel. Phosphorylation of SKs by Ser/Thr and tyrosine kinases, phosphorylation of Calmodulin at Thr-79, expression levels and phosphorylation of CaMKII and tyrosine kinase Pyk2 were assessed in cultured rat VCMs and freshly isolated VCMs from TABs and Shams using Western blot analysis. Results: WB analysis showed increased Ser/Thr and Tyr phosphorylation of SK2 in TABs. Alpha1 stimulation of rat VCMs overexpressing rat SK2 mimicked this pattern, increasing I SK at high voltages in parallel with the increase in Ca transient amplitude and reduction in Ca sensitivity of the channels. Overexpression of Pyk2 inhibitor CRNK did not restore I SK despite reduction in Ca transient amplitude because of attenuating α1-agonist mediated decrease in Ca sensitivity of SKs. Application of CaMKII inhibitor KN93 fully reversed α1-mediated I SK increase at high voltages without affecting Ca sensitivity of the channel. Conclusion: Upregulation of SKs in hypertrophic hearts is likely caused by CaMKII-dependent phosphorylation which reduces voltage-dependent block of the channels. Pyk2 inhibition may present therapeutic potential by attenuating negative effects on SK Ca sensitivity thereby increasing repolarization reserve diminished in cardiac disease.
Burdensome transitions on cancer decedents treated in different health care systems at the end of life.
Authors: Risha Gidwani
Journal: Journal of Clinical Oncology (2018)

7 Background: Cancer decedents often experience intensive and unnecessary medical care in the months prior to death. We evaluated whether cancer patients treated by a purchasing system with fee-for-service incentives (Medicare) experience a greater number of burdensome transitions in the last 6 months of life compared to those treated by a system in which care is directly provided by salaried clinicians (Veterans Health Administration, or VA). Methods: We evaluated Fee-for-Service (FFS) Medicare and VA data from FY 2010-2014 for the population of veteran cancer decedents who died from solid tumor, as assessed by National Death Index data (n = 97,955). Burdensome transitions were defined as ED visits or hospital admission in the last 6 months of life. Veterans were allocated to the system (i.e., Medicare, VA) in which they received the most overall healthcare. We modeled outcomes using hierarchical logistic regression, with month nested within patient. Models adjusted for variables previously shown to influence veteran selection into Medicare versus VA, comorbidity burden, and time trends. Results: In adjusted analyses, veterans treated by Medicare were significantly more likely to experience an ED visit in the last 6 months of life compared to veterans treated by VA (aOR = 1.37, 95% CI 1.26-1.49, p &lt; 0.001). Adjusted analyses also revealed veterans treated by Medicare were significantly more likely to experience a hospital stay in the last 6 months of life compared to veterans treated by VA (aOR 1.28, 95% CI 1.17-1.40, p &lt; 0.001). Conclusions: Patients dying of metastatic solid tumor who were treated under FFS Medicare were more likely to have ED visits or hospital stays in the last six months of life those treated by VA. As VA shifts more towards purchasing care in the community for its veterans, they may be at greater risk of experiencing burdensome transitions in the last months of life.[Table: see text]
Improving start-up times in oncology clinical trials: An ASCO quality improvement project.
Authors: Leslie Byatt, Kaylee Deutsch, Zoneddy R. Dayao
Journal: Journal of Clinical Oncology (2018)

297 Background: With the increasing complexity of clinical trials, the UNMCCC and NMCCA are seeing increased delays in study activation. Currently, the average time from protocol receipt to trial activation is 33 weeks. Creating strategies to shorten the timeline where the longest delays occur will expedite patient access to novel therapies and improve patient care. Aims: Define the average activation timelines; Identify the timeline where an intervention will make the most impact in shortening start-up time; Implement an intervention, beginning February 2018; Identify strategies to decrease the longest timeline by 50% by December 2018. Methods: Timelines of 81 clinical trials opened in 2017 were analyzed. Data showed that the longest timeline is IRB approval to activation (12 weeks) and identified this as the focus of intervention to decrease our overall activation time by 50% (6 weeks). Two focus group meetings with involved staff were organized and completed. Interventions were identified. The time to complete activation tasks cannot be shortened due to staffing resources. However, shifting these tasks forward in our timeline could decrease the time to activation by at least 6 weeks. A sponsor survey was created to identify logistical concerns earlier. Regulatory coordinators were provided an email template to request systems access early. Site initiation visits are scheduled earlier. Results: Our data shows that our interventions have had a strong positive impact on our timelines. Conclusions: Since implementation, we have seen an improvement in our study timeline. We will continue to track and analyze our timeline data to determine if these strategies are effective across trials with varying startup complexities.[Table: see text]
Reducing inappropriate rasburicase use to promote cost-effective care.
Authors: Arjun Gupta, Komal Patel, Taylor Roberts, Eileen M. Marley, Hsiao Ching Li, Navid Sadeghi
Journal: Journal of Clinical Oncology (2018)

312 Background: Rasburicase is recommended for treating established Tumor lysis syndrome (TLS) and patients at high-risk for TLS. Unfortunately, it is an expensive medication and unnecessary use contributes to expenses. Methods: A multidisciplinary quality improvement team reviewed the process of ordering rasburicase and its prescription patterns at Parkland Heath and Hospital System, Dallas, TX between 10/2015-9/2017. Use was determined as appropriate/ inappropriate based on internally approved indications (laboratory TLS, at-risk for TLS, acute kidney injury and hyperuricemia, failure of or inability to administer allopurinol). Quality improvement interventions were implemented based on weaknesses identified. Results: 65 doses of rasburicase were administered during the 2-year baseline period; 21 (32.3%) of these were grossly inappropriate. The most common ordering providers were oncologists (23 orders, 35%), hospitalists (16 orders, 25%), intensivists (11 orders, 17%), and emergency physicians (8 orders, 12%). Ordering process review identified several pitfalls: one-click ready to sign order, auto-population of dosage, no hard-stop requiring providers to review rasburicase indications, and no pharmacy oversight. We aimed to reduce the percentage of inappropriate rasburicase orders from a baseline of 32.3% to 10% over 3 months. In 2/2018, we implemented PDSA cycle 1 including introducing a best practice advisory requiring providers to select an approved indication for medication use and changed auto-population of rasburicase dosage to 3 mg. A mandatory secondary review by pharmacy prior to dispensing the medication was implemented. Over a 3-month period post-change (2/2018- 5/2018), 11 of 11 rasburicase administered doses have been appropriate (0% inappropriate). Conclusions: A multidisciplinary team and classic quality improvement methodology was able to reduce inappropriate rasburicase use from 32.3% to 0%, with significant cost savings. Straightforward electronic medical record interventions and increased pharmacy oversight are effective interventions in curbing medication overuse. We will periodically re-assess utilization patterns and refine PDSA cycles as needed.
Abstract 18724: Coronary Angiography After Out-of-hospital Cardiac Arrest is Associated With Improved Neurologically Intact Survival
Authors: Tasha Hanuschak, Steven Brooks, Laurie Morrison, Paul Peng, Cathy Zhan
Journal: Circulation (2015)

Introduction: Evidence for the effectiveness of coronary angiography after out-of-hospital cardiac arrest (OHCA) is conflicting. Our objective was to evaluate the association between receiving coronary angiography within 72 hours of hospital arrival and survival with favorable neurologic outcome. Methods: This was a population-based retrospective cohort study of consecutive cases of adult OHCA transported to and treated at 28 hospitals in Southern Ontario between March 1, 2010 and December 31, 2014. We included patients with atraumatic OHCA, who achieved return of spontaneous circulation, and were alive 6 hours after hospital arrival. Multi-level logistic regression was used to measure the association between early coronary angiography and neurologically intact survival (Modified Rankin Score 0-2), while controlling for potential confounders and clustered data. We controlled for age, sex, initial cardiac rhythm, witness status, bystander resuscitation, EMS response time, prehospital return of spontaneous circulation, location of arrest, daytime presentation, neurologic status at hospital arrival, STEMI status, cardiac history, initiation of therapeutic hypothermia, hospital size and type, and hospital annual cardiac arrest volume. Results: During the period of study, 2678 consecutive OHCA patients met the inclusion criteria. The mean age was 66(±16), 31.7% were female, 54.1% had a bystander witnessed arrest, 35.2% received bystander CPR, 45.9% had a shockable initial rhythm, 30.1% had ST elevation on the first post arrest ECG, and 32.4% received coronary angiography. Receiving coronary angiography was strongly associated with neurologically intact survival (OR 2.30, CI95 1.69-3.15) and survival (OR 2.08, CI95 1.53-2.82). A similar association was observed in the subgroup of patients without STEMI (OR 3.24, CI95 2.16-4.87 and OR 2.66, CI95 1.78-3.99, respectively). Conclusions: Neurologically intact survival among post cardiac arrest patients may be improved with coronary angiography, particularly for patients without STEMI. This observation should be confirmed with future randomized controlled studies.
Current Status and Future Perspectives on Neoadjuvant Therapy in Lung Cancer
Authors: Gideon M. Blumenthal, Paul A. Bunn, Jamie E. Chaft, Caroline E. McCoach, Edith A. Perez, Giorgio V. Scagliotti, David P. Carbone, Hugo J.W.L. Aerts, Dara L. Aisner, Jonas Bergh, Donald A. Berry, Anthony Jarkowski, Nicholas Botwood, Darren A.E. Cross, Max Diehn, Nicole L. Drezner, Robert C. Doebele, Collin M. Blakely, Wilfried E.E. Eberhardt, Enriqueta Felip, Luca Gianni, Steven P. Keller, Patrick J. Leavey, Shakun Malik, Francesco Pignatti, Tatiana M. Prowell, Mary W. Redman, Naiyer A. Rizvi, Rafael Rosell, Valerie Rusch, Dirk de Ruysscher, Lawrence H. Schwartz, Rajeshwari Sridhara, Rolf A. Stahel, Stephen Swisher, Janis M. Taube, William D. Travis, Patricia Keegan, Jacinta R. Wiens, Ignacio I. Wistuba, Murry W. Wynes, Fred R. Hirsch, Mark G. Kris
Journal: Journal of Thoracic Oncology (2018)