tbuckley/cabot-search huggingface dataset:
A tale of 2,000 charts: Measuring provider response to patient-reported outcome measures.
Authors: Gillian Hurwitz, Zahra Ismail, Lesley Moody, Lisa Catherine Barbera
Journal: Journal of Clinical Oncology (2018)

157 Background: Patients undergoing cancer treatment often experience physical and psychosocial symptoms that go undetected by clinicians, which highlights the need to incorporate patient-reported outcome measures (PROMs) in routine care. Systematic symptom screening for cancer patients using the Edmonton Symptom Assessment System (ESAS) is standard practice in Ontario. However, provider response to PROMs is essential to addressing symptom burden. To measure provider response, Regional Cancer Centre (RCC) Leads and Cancer Care Ontario developed a chart audit process. The objective was to determine whether the clinical team acknowledged, assessed and/or addressed symptoms identified by ESAS screening. Methods: RCCs received a chart audit tool with preset options and a data dictionary. Sites audited at least 140 charts for seven of the ESAS symptoms. Sites used a business intelligence tool to access patient charts based on sampling parameters. RCCs were required to audit charts of patients whose ESAS symptom scores were moderate to severe (4-10), with at least five charts in the moderate range (4-6). Results: 2,380 charts from 13 RCCs were audited based on ESAS scores from September to December 2016. Symptoms were most often acknowledged when the intensity was severe (69.9%), regardless of symptom type. Acknowledgement (71.5%), assessment (67.7%) and intervention (55.8%) were most often offered to patients reporting pain. Patients reporting depression and anxiety were the least likely to have the symptom acknowledged (44.5%, 45.0%, respectively) and be offered assessments (45.8%, 50.1%, respectively) and interventions (35.7%, 36.6%, respectively). Patients reporting moderate to severe depression and anxiety most commonly declined interventions (7.8%, 7.7%, respectively). Conclusions: These data show that providers disproportionately respond to physical symptoms, which may be easiest to treat due to clear management plans and referral pathways. To truly offer person-centred care, the emotional burden related to cancer must also be addressed, and providers must be trained to properly respond to psychosocial symptoms. Chart audits identify gaps in symptom management and areas for quality improvement.
Improving informed breast cancer systemic treatment decision-making.
Authors: Sarah T. Hawley, Larry An, Yun Li, Reshma Jagsi, Steven J. Katz
Journal: Journal of Clinical Oncology (2018)

225 Background: Decision making for adjuvant chemotherapy is increasingly complicated for women with a new diagnosis of early stage breast cancer. Few decision tools are designed to help support informed systemic treatment decision-making, by improving knowledge and decision quality. Methods: We conducted a randomized controlled trial (RCT) of a tailored, comprehensive (locoregional and systemic treatment) and interactive decision tool (iCanDecide), compared with static online information. 537 newly diagnosed, early stage breast cancer patients were enrolled from 22 surgical practices. Participants were surveyed 5 weeks (N = 496; RR 92%) and those eligible for systemic treatment (N = 358) again at 9 months (N = 307; RR 88%). The main outcome for this analysis was knowledge about systemic treatment using 4 true/false items, categorized into high (3- 4 correct) vs. low (0-2 correct). We also assessed subjective decision quality (SDQ) for chemotherapy on a 5-point scale and dichotomized into high (4-5) vs. low (1-3) We evaluated the distribution of participants in each arm, and assessed the association between the study arm and the outcomes using bivariate and multivariable approaches. Results: Of the 358 respondents, 201 did not receive or intend to have chemotherapy. Significantly more intervention than control patients had high knowledge about systemic treatment (52.9% vs. 39.9%, p = 0.012). Overall SDQ for chemotherapy was slightly higher in intervention than control subjects (mean 4.8 vs. 4.6, p = 0.08). However, among women who did not receive chemotherapy, significantly more intervention subjects reported high SDQ than controls (87.1% vs. 75.2%, p = 0.06). Values significantly related to chemotherapy use included avoiding side effects, continuing to work, and being most extensive possible. Conclusions: We found that the interactive decision tool contributed significantly to higher knowledge about systemic treatment among eligible patients. We further found the tool shows promise for improving subjective decision quality, particularly in patients who choose not to have chemotherapy. Further work to integrate tools into the oncology clinical setting is needed. Clinical trial information: NCT01840163.
A Case of Radioactivity Concentrated in Orbital Implant in 99mTc-MDP Bone Scan and SPECT/CT
Authors: Min Cai, Guisheng Feng, Guangwei Zhang
Journal: Clinical Nuclear Medicine (2018)

A 27-year-old woman, who has received a hydroxyapatite orbital implant in the right eye due to a trauma 6 years ago, was newly diagnosis with left breast invasive ductal carcinoma. Tc-MDP bone scan showed an increased radiotracer accumulation in the right orbit and SPECT/CT confirmed the focal accumulation at the site of the implant, without any sign of local malignant lesions or orbital infection. Radionuclide imaging could provide certain useful information in diagnosing or differential diagnosing orbital disease.
Abstract 18585: Differential Outcomes in Cardiac Resynchronization Therapy via Surgically Implanted Epicardial LV Leads in Patients With Ischemic and Dilated Cardiomyopathy
Authors: Haixia Fu, Lu CHEN, Heather Wiste, Victor Pretorius, Ulrika Birgersdotter-Green, Yong-Mei Cha
Journal: Circulation (2013)

Introduction: Surgically implanted epicardial left ventricular (eLV) lead has been used as an alternative approach when implantation of transvenous LV (tLV) lead in patients requiring cardiac resynchronization therapy (CRT) has failed. Recent literatures noted similarities in clinical response between tLV and eLV-CRT patients. However, comparison between CRT patients with ischemic (ICM) and dilated cardiomyopathy (DCM) is currently lacking in eLV-CRT patients. Hypothesis: We hypothesize that DCM patients respond better to eLV-CRT than ICM patients. Methods: Of 1038 patients who underwent tLV-CRT implantation at UCSD and Mayo Clinics between 2002 and 2013, 44 (Age 63±15, 28M) had failed tLV lead placement and received eLV-CRT. Electronic Medical Records of these patients were reviewed. NYHA class and echocardiograph were assessed before and after successful CRT implantation. Results: Following eLV-CRT implantation, improvements were noted in LVEF (26% vs. 31%, p &lt; 0.01), NYHA class (2.9 vs. 2.3, p &lt; 0.01) and LVESD (57mm vs. 52mm, p = 0.03) in the study cohort. In patients with DCM (n=19), the NYHA class (3.0 vs. 2.3, p = 0.01), LVEF (24% vs. 30%, p = 0.02) and LVESD (57mm vs. 52mm, p = 0.04) had significantly improved following CRT implantation compared to baseline (figures). No statistically significant changes in NYHA class, LVEF and LVESD were observed in patients with ICM (all p &gt; 0.05). Conclusion: In this two-center study, eLV-CRT patients with DCM benefited significantly after CRT, as compared to ICM patients. Although larger scaled studies are needed, eLV-CRT may be considered a viable alternative to tLV-CRT, especially in patients with DCM.
Utilizing a standardized order set to increase speech pathology referrals in head and neck cancer patients.
Authors: Carly Gerretsen, Corrine Jurgens
Journal: Journal of Clinical Oncology (2018)

324 Background: Treatment of head and neck cancers may include radiation, and side effects will result in short and long-term dysphagia. This can lead to feeding tube usage, malnutrition, loss of social interaction, and reduced quality of life. Rehabilitation therapies are available with speech pathologists to improve outcomes. Evidence supports initiating therapy prior to radiation. Computerized order entry systems (CPOE) support standardization of evidence- based order sets. The purpose of this study was to examine the effect of a standardized order set on referral rates to speech pathology in adult patients undergoing radiation treatment for head and neck cancer. Methods: A quality improvement project was implemented an outpatient oncology clinic within an academic hospital using the PDSA format. Approval was obtained through the hospitals quality assurance officer, and it was determined that IRB approval was not necessary. A chart review was completed to assess the rate of speech pathology consults. A brief education program targeting ordering providers was completed including demonstration of the order set. Post intervention chart review was performed to assess the change in referral rates. Results: A chi square analysis was used to compare the difference in referral rates and found to be statistically significant, x² (1, n = 56) = 17.147, p &lt; 0.01. Demographic data was analyzed using descriptive statistics. The sample was mostly Caucasian (82%), male (84%) with an average age of 63. The most common cancer diagnosis was larynx (36%). The percentage of referrals post intervention (82%) was significantly higher than pre-intervention (18%) consistent with the hypothesis that a standardized order set would increase speech referral rates. Conclusions: Use of a CPOE system with standardized order sets increased the rate of speech pathology referrals. The success of this order set has led to an expansion of the project, and creation of additional order sets. Standardized computerized order sets should be considered to increase referrals to underutilized ancillary services. Providers should be encouraged to create relationships with these services to improve patient’s quality of life and long- term outcomes.
Optimization of immune-related adverse event management in a thoracic oncology clinic.
Authors: Lexie Berwick, Deepa Rangachari, Daniel Botelho Costa, Kartik Sehgal, Meghan Shea
Journal: Journal of Clinical Oncology (2018)

261 Background: Improved awareness and management of immune checkpoint inhibitor (ICI) related adverse events (IRAEs) is a mandate for best practice given widespread use of ICIs in clinic. IRAE grading is standardized by the Common Terminology Criteria for Adverse Events (CTCAE); management has been standardized in recently published consensus guidelines. In the thoracic oncology clinic at the Beth Israel Deaconess Medical Center grading and management of IRAEs has been inconsistent. Methods: A retrospective review of 98 patients receiving ICIs in the thoracic oncology clinic from March 2015-April 2018 was conducted with a focus on IRAE grading and management. Oncologists were surveyed regarding barriers to grading, management, and subspecialty referral for IRAEs. We aimed to improve documentation of IRAE grading to 75% as well as the rate of specialist referral for grade 3-4 IRAEs. As an intervention we implemented a macro to document IRAE CTCAE grade and management. Additionally, our team created a pathway for specialist referral for patients with grade 3-4 IRAEs. Results: Upon review of 98 patient charts, 38 patients developed 58 IRAEs of which 36% were grade 1-2, 17% were grade 3, 0% were grade 4 and 47% were ungraded. The most commonly affected organs were skin (25%), thyroid (25%) and lung (11%). 53% of active IRAEs were formally graded in the oncologist’s assessment, only 6% of resolved IRAEs were documented in the subsequent oncologic history. A total of 11 patients were hospitalized for IRAEs, 7 of which had undocumented severity; 40% of grade 3 IRAEs were hospitalized. 14 specialist referrals were made, most with undocumented severity; 30% of patients with grade 3 IRAEs were referred. Overall, 18 patients required steroids, of these 40% were ungraded, and 19 had immunotherapy stopped or held, of these 45% were ungraded. Conclusions: While the presence of IRAEs is consistently documented, documentation of severity and subsequent management are inconsistent- including amongst those patients requiring hospitalization, specialty referral and/or treatment modification. Further data will be reported regarding utilization of the macro, documentation of IRAE grading and management as well as specialist referral rate.
National trends in end of life care for veterans with advanced cancer.
Authors: Claire Elizabeth Powers Smith, Pat Coke, Monica Kluger, Arif Kamal, Michael J. Kelley
Journal: Journal of Clinical Oncology (2018)

3 Background: It is imperative to provide quality end of life (EOL) care for cancer patients. This entails minimizing aggressive measures at the EOL. Although rates of hospice utilization within the Veteran’s Health Administration have improved, chemotherapy administration and intensive care unit (ICU) admission at the EOL, indicators of aggressive care, are not clearly declining over recent years. Methods: We identified 32,665 veterans diagnosed with stage IV lung, colorectal, or pancreatic cancer who died between 2009-2016 using VA cancer registry and Corporate Data Warehouse data through a novel EOL Dashboard Tool, which has been validated at multiple VA sites. This EOL tool reports three indicators; incidence of chemotherapy use in the last 14 days of life, ICU admission in the last 30 days of life and hospice admission or consult. Change over time, 2009-2016, was assessed using a repeated measures one-way ANOVA with post hoc test for linear trend of time for individual cancers and two-way ANOVA for all cancers combined. Results: Chemotherapy use in the last 14 days of life declined from 6.8% in 2009 to 4.4% in 2016 (p &lt; 0.05). ICU admission in the last 30 days did not change significantly, from 13.3% in 2009 to 14.7% in 2016. The exception was stage IV lung cancer patients in whom ICU admissions increased from 12.9% to 16.2% (p = 0.01). Patients utilizing hospice services increased from 32.4% to 52.6% (p &lt; 0.01). When combined for all years in an unadjusted analysis by VA regional network (VISN), chemotherapy use ranged geographically from 4.2% to 8.1% and for ICU admission from 8.4% to 18.0%. Conclusions: While chemotherapy administration at the EOL is declining for veterans with stage IV cancer, ICU admissions are unchanged and becoming more common in stage IV lung cancer despite increasing hospice utilization. Compared to prior Medicare reports, veterans have similar rates of EOL chemotherapy use and fewer EOL ICU admissions, adding to a growing body of literature showing that despite veterans having poorer health and utilizing more medical resources, the VA performs at or above non-veteran health care institutions on end of life cancer care. There is notable geographic variation in aggressive EOL care.
Cholesterol Efflux Capacity, High-Density Lipoprotein Particle Number, and Incident Cardiovascular Events
Authors: Amit V. Khera, Olga V. Demler, Steven J. Adelman, Heidi L. Collins, Robert J. Glynn, Paul M Ridker, Daniel J. Rader, Samia Mora
Journal: Circulation (2017)

Recent failures of drugs that raised high-density lipoprotein (HDL) cholesterol levels to reduce cardiovascular events in clinical trials have led to increased interest in alternative indices of HDL quality, such as cholesterol efflux capacity, and HDL quantity, such as HDL particle number. However, no studies have directly compared these metrics in a contemporary population that includes potent statin therapy and low low-density lipoprotein cholesterol.HDL cholesterol levels, apolipoprotein A-I, cholesterol efflux capacity, and HDL particle number were assessed at baseline and 12 months in a nested case-control study of the JUPITER trial (Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin), a randomized primary prevention trial that compared rosuvastatin treatment to placebo in individuals with normal low-density lipoprotein cholesterol but increased C-reactive protein levels. In total, 314 cases of incident cardiovascular disease (CVD) (myocardial infarction, unstable angina, arterial revascularization, stroke, or cardiovascular death) were compared to age- and gender-matched controls. Conditional logistic regression models adjusting for risk factors evaluated associations between HDL-related biomarkers and incident CVD.Cholesterol efflux capacity was moderately correlated with HDL cholesterol, apolipoprotein A-I, and HDL particle number (Spearman r= 0.39, 0.48, and 0.39 respectively; P<0.001). Baseline HDL particle number was inversely associated with incident CVD (adjusted odds ratio per SD increment [OR/SD], 0.69; 95% confidence interval [CI], 0.56-0.86; P<0.001), whereas no significant association was found for baseline cholesterol efflux capacity (OR/SD, 0.89; 95% CI, 0.72-1.10; P=0.28), HDL cholesterol (OR/SD, 0.82; 95% CI, 0.66-1.02; P=0.08), or apolipoprotein A-I (OR/SD, 0.83; 95% CI, 0.67-1.03; P=0.08). Twelve months of rosuvastatin (20 mg/day) did not change cholesterol efflux capacity (average percentage change -1.5%, 95% CI, -13.3 to +10.2; P=0.80), but increased HDL cholesterol (+7.7%), apolipoprotein A-I (+4.3%), and HDL particle number (+5.2%). On-statin cholesterol efflux capacity was inversely associated with incident CVD (OR/SD, 0.62; 95% CI, 0.42-0.92; P=0.02), although HDL particle number again emerged as the strongest predictor (OR/SD, 0.51; 95% CI, 0.33-0.77; P<0.001).In JUPITER, cholesterol efflux capacity was associated with incident CVD in individuals on potent statin therapy but not at baseline. For both baseline and on-statin analyses, HDL particle number was the strongest of 4 HDL-related biomarkers as an inverse predictor of incident events and biomarker of residual risk.URL: http://www.clinicaltrials.gov. Unique identifier: NCT00239681.
Could Brexit harm the NHS?
Authors: Anand Menon, Graham Gudgin
Journal: BMJ (2018)

Predictions of a smaller UK economy, at least in the short term, and fewer EU healthcare staff present challenges for the NHS after 29 March 2019, argues <b>Anand Menon</b>. But <b>Graham Gudgin</b> is unconvinced by what he believes are biased estimates promoted by a government pushing for a soft Brexit
Effect of a Positive Psychological Intervention on Pain and Functional Difficulty Among Adults With Osteoarthritis
Authors: Leslie R. M. Hausmann, Ada Youk, C. Kent Kwoh, Rollin M. Gallagher, Debra K. Weiner, Ernest R. Vina, D. Scott Obrosky, Genna T. Mauro, Shauna McInnes, Said A. Ibrahim
Journal: JAMA Network Open (2018)

Positive psychological interventions for improving health have received increasing attention recently. Evidence on the impact of such interventions on pain, and racial disparities in pain, is limited.To assess the effects of a positive psychological intervention on pain and functional difficulty in veterans with knee osteoarthritis.The Staying Positive With Arthritis Study is a large, double-blinded randomized clinical trial powered to detect race differences in self-reported pain in response to a positive psychological intervention compared with a neutral control intervention. Data were collected from 2 urban Veterans Affairs medical centers. Participants included non-Hispanic white and non-Hispanic African American patients aged 50 years or older with a diagnosis of osteoarthritis. Mailings were sent to 5111 patients meeting these criteria, of whom 839 were fully screened, 488 were eligible, and 360 were randomized. Enrollment lasted from July 8, 2015, to February 1, 2017, with follow-up through September 6, 2017.The intervention comprised a 6-week series of evidence-based activities to build positive psychological skills (eg, gratitude and kindness). The control program comprised similarly structured neutral activities. Programs were delivered via workbook and weekly telephone calls with interventionists.The primary outcomes were self-reported pain and functional difficulty measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range 0-100). Secondary outcomes included affect balance and life satisfaction.The sample included 180 non-Hispanic white patients and 180 non-Hispanic African American patients (mean [SD] age, 64.2 [8.8] years; 76.4% were male). Mean (SD) baseline scores for WOMAC pain and functional difficulty were 48.8 (17.6) and 46.8 (18.1), respectively. Although both decreased significantly over time (pain: χ23 = 49.50, P < .001; functional difficulty: χ23 = 22.11, P < .001), differences were small and did not vary by treatment group or race. Exploratory analyses suggested that the intervention had counterintuitive effects on secondary outcomes.The results of this randomized clinical trial do not support the use of positive psychological interventions as a stand-alone treatment for pain among white or African American veterans with knee osteoarthritis. Adaptations are needed to identify intervention components that resonate with this population, and the additive effect of incorporating positive psychological interventions into more comprehensive pain treatment regimens should be considered.ClinicalTrials.gov Identifier: NCT02223858.
Using standardized electronic pathology data to identify practice variation, potential impact to patient outcomes, and quality improvement initiatives.
Authors: Jessica Kitchen, Shaalee Sone, Shaheena Mukhi, Mary Argent-Katwala, John Srigley
Journal: Journal of Clinical Oncology (2018)

45 Background: Practice variation in diagnosis and treatment exists between clinicians and regions across Canada. This variation can impact the quality of care that patients receive and affect patient outcomes. We aimed to gain a better understanding of the scale and type of variation between clinicians and provinces within the cancer system. Methods: Fifty pathologists, surgeons, and medical oncologists from 10 regions were convened to leverage literature and the College of American Pathologists data standards to create 48 indicators related to five cancers: breast, lung, colorectal, endometrial and prostate. Six months of synoptic pathology data were used to generate the indicators, which were reviewed by 65 clinicians to identify practice variation and potential quality improvement areas. Results: Five provinces generated 48 indicator data analyses. Practice and performance variation across five cancer sites and jurisdictions was found. For example, guidelines recommend examining at least 12 lymph nodes in colorectal cancer resections as this directly impacts staging, treatment and patient prognosis. Only one province met this guideline in 90% of cases. Another example is Lynch syndrome testing, a hereditary condition that increases the risk of developing multiple primary cancers – particularly colorectal and endometrial. The data showed unequitable access to screening with 0-70% of colorectal cancer patients aged ≤70 years and only 10-40% of endometrial cancer cases being screened for Lynch syndrome. The value of these indicators is enormous to inform potential training opportunities and set standards of care at the local or broader clinical governance level so that consistent, high-quality care is delivered in accordance with evidence-based guidelines. Conclusions: Practice variation exists between clinicians and jurisdictions. In two jurisdictions (200 pathologists), comparative pathology indicator data are being used to self-reflect and converse with peers with the goal of reducing practice variation and improving patient care.