Academic Medical Community Research Articles

Comparative analysis of vitamin K antagonists and direct oral anticoagulants for left ventricular thrombus management: a retrospective study utilising TriNetX

Abstract Introduction Despite progress in cardiovascular medicine, guidelines for addressing left ventricular thrombus (LVT) remain limited. Furthermore, incorporating oral anticoagulants into dual antiplatelet therapy for acute myocardial infarction (MI) adds complexity to treatment decisions. While conventional guidance favors vitamin K antagonists (VKAs), emerging evidence suggests favorable outcomes with direct oral anticoagulants (DOACs). Purpose This study aims to assess the safety and efficacy of DOACs versus VKAs in managing LVT among patients with and without recent acute coronary syndrome (ACS). Methods This was a retrospective observational study conducted within TriNetX, a global federated health research network with access to electronic medical records (EMRs) from participating health care organizations including academic medical centres and community hospitals covering approximately 70 million individuals, mainly in the United States. The search was conducted on 26th Februrary 2024 with a study cohort comprising patients with LV thrombus treated with either DOAC or VKA between 1st December 2013 to 1st December 2023. Subgroup analyses were conducted for patients with ACS within one month and those without ACS within a month of treatment. Cohort data were subject to propensity matching (PSM) for age, gender, ethnicities, medical and drug history. Risk analysis and Kaplan-Meier survival analysis were computed for each subgroup at 90 days since the indexed event. Results Following PSM, a total of 39,770 patients were included and 14,302 were in the ACS group and 24,162 in the non-ACS group. DOAC treatment exhibited favourable outcomes for stroke, bleeding, and systemic embolism (p<0.05) compared to VKA in the overall cohort (Table 1). In the ACS group, DOAC was linked to a reduced risk of stroke and systemic embolism (p<0.05) but not bleeding (p=0.066). In the non-ACS group, DOAC was associated with a decreased risk of stroke and bleeding (p<0.05) but not systemic embolism (p=0.113). Across all groups, there were no disparities in overall all causes of mortalities. Conclusion DOACs demonstrated better safety and efficacy outcomes when compared to VKAs in LVT treatment. Interestingly, DOACs utilisation within the ACS context resulted in a diminished risk of embolic complications without the benefit of reduced bleeding risk seen in patients without ACS, suggesting potential implications of triple therapy within first month of ACS treatment, removing the bleeding risk reduction of DOACs. This shows a fundamental difference in LVT between the 2 groups of patients so future studies should aim to differentiate between the 2.

Nudging Towards Sleep-Friendly Hospitalizations: A Multifaceted Approach on Reducing Unnecessary Overnight Interventions.

Choice architecture refers to the design of decision environments, which can influence healthcare decision-making. Nudges are subtle adjustments in these environments that guide decisions toward desired outcomes. For example, Computerized Provider Order Entry (CPOE) within Electronic Health Records (EHR) recommends frequencies for interventions such as nursing assessments and medication administrations, but these can link to around-the-clock schedules without clinical necessity. This study aimed to evaluate an intervention to promote sleep-friendly practices by optimizing choice architecture and employing targeted nudges on inpatient order frequencies. We employed a quasi-experimental interrupted time series analysis of a multifaceted, multiphase intervention to reduce overnight interventions in a hospital system. Our intervention featured EHR modifications to optimize the scheduling of vital sign checks, neurological checks, and medication administrations. Additionally, we used targeted secure messaging reminders and education on an inpatient neurology unit (INU) to supplement the initiative. Significant increases in sleep-friendly medication orders were observed at the academic medical center (AMC) and community hospital affiliate (CHA), particularly for acetaminophen and heparin at the AMC. This led to a reduction in overnight medication administrations, with the most substantial decrease observed with heparin at all locations (CHA: 18%, AMC: 10%, INU: 10%, p<0.05). Sleep-friendly vital sign orders increased significantly at all sites (AMC: 6.7%, CHA 4.3%, INU: 14%, p<0.05), and sleep-friendly neuro check orders increased significantly at the AMC (8.1%, p<0.05). There was also a significant reduction in overnight neurological checks at the AMC. Tailoring EHR modifications and employing multifaceted nudging strategies emerged as promising approaches for reducing unnecessary overnight interventions. The observed shifts in sleep-friendly ordering translated into decreases in overnight interventions. Multifaceted nudges can effectively influence clinician decision-making and patient care. The varied impacts across nudge types and settings emphasize the importance of thoughtful nudge design and understanding local workflows.

Identifying Barriers to Timely Follow-up After Elevated PSA Screening: A Retrospective Analysis of a Large Healthcare System

ObjectivesTo examine elevated PSA follow-up within our system and identify areas for improvement in the timely diagnosis of prostate cancer. MethodsWe queried the Mass General Brigham’s Enterprise Data Warehouse from 2018-2021, identifying patients with elevated PSA and documented time to follow-up. Timely follow-up was defined as having a urologist appointment, prostate biopsy, or prostate magnetic resonance imaging within 6 months from diagnosis. We stratified the location of elevated PSA diagnosis to academic medical centers vs. community sites. Univariable and multivariable analyses were performed to identify factors impacting follow-up. ResultsWe included 28,346 patients, with 50.30%, 15.02%, and 34.69% receiving timely, untimely, and no follow-up during the study period, respectively. In multivariable analysis, patients seen at academic medical centers were more likely to receive follow-up care (OR=1.39, 95%CI 1.30-1.48). In a sensitivity analysis including two of our largest community hospitals as part of academic medical facilities, those following up at our main sites showed even higher odds of timely follow-up (OR=1.61, 95%CI 1.51-1.73). ConclusionOur study observed variations in follow-up rate between our academic medical centers and community sites. This finding highlights the need for efforts to improve consistency and timeliness of prostate cancer follow-up care across all facilities. By addressing interfacility disparities, we can facilitate the delivery of timely care to all patients.

Heterogeneity in Antidepressant Treatment and Major Depressive Disorder Outcomes Among Clinicians

While abundant work has examined patient-level differences in antidepressant treatment outcomes, little is known about the extent of clinician-level differences. Understanding these differences may be important in the development of risk models, precision treatment strategies, and more efficient systems of care. To characterize differences between outpatient clinicians in treatment selection and outcomes for their patients diagnosed with major depressive disorder across academic medical centers, community hospitals, and affiliated clinics. This was a longitudinal cohort study using data derived from electronic health records at 2 large academic medical centers and 6 community hospitals, and their affiliated outpatient networks, in eastern Massachusetts. Participants were deidentified clinicians who billed at least 10 International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) diagnoses of major depressive disorder per year between 2008 and 2022. Data analysis occurred between September 2023 and January 2024. Heterogeneity of prescribing, defined as the number of distinct antidepressants accounting for 75% of prescriptions by a given clinician; proportion of patients who did not return for follow-up after an index prescription; and proportion of patients receiving stable, ongoing antidepressant treatment. Among 11 934 clinicians treating major depressive disorder, unsupervised learning identified 10 distinct clusters on the basis of ICD codes, corresponding to outpatient psychiatry as well as oncology, obstetrics, and primary care. Between these clusters, substantial variability was identified in the proportion of selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, and tricyclic antidepressants prescribed, as well as in the number of distinct antidepressants prescribed. Variability was also detected between clinician clusters in loss to follow-up and achievement of stable treatment, with the former ranging from 27% to 69% and the latter from 22% to 42%. Clinician clusters were significantly associated with treatment outcomes. Groups of clinicians treating individuals diagnosed with major depressive disorder exhibit marked differences in prescribing patterns as well as longitudinal patient outcomes defined by electronic health records. Incorporating these group identifiers yielded similar prediction to more complex models incorporating individual codes, suggesting the importance of considering treatment context in efforts at risk stratification.

A Virtual Interprofessional Death Café to Increase Comfort With End-Of-Life Conversations

The Death Café model has been adopted in lay and professional communities world-wide to foster agenda-free discussion about death. To address the discomfort discussing death common among healthcare trainees and professionals, the authors coordinated a virtual, interprofessional Death Café within an academic medical community. Students and faculty affiliated with Schools of Nursing, Medicine, and Public Health at a United States academic center were invited by email to participate in a virtual Death Café. Participants were asked to complete an anonymous postevent survey about their level of comfort discussing death. Forty-six of 69 Death Café attendees completed the survey. About 77.8% agreed that this event positively impacted their perspective on end-of-life discussion and 80% reported feeling more comfortable talking about death and dying after the event. These preliminary findings suggest this virtual Death Café model provides a feasible, acceptable platform to increase comfort discussing death among healthcare trainees and professionals.

Promoting Growth in Behavioral Neurology: A Path Forward.

Behavioral neurology & neuropsychiatry (BNNP) is a field that seeks to understand brain-behavior relationships, including fundamental brain organization principles and the many ways that brain structures and connectivity can be disrupted, leading to abnormalities of behavior, cognition, emotion, perception, and social cognition. In North America, BNNP has existed as an integrated subspecialty through the United Council for Neurologic Subspecialties since 2006. Nonetheless, the number of behavioral neurologists across academic medical centers and community settings is not keeping pace with increasing clinical and research demand. In this commentary, we provide a brief history of BNNP followed by an outline of the current challenges and opportunities for BNNP from the behavioral neurologist's perspective across clinical, research, and educational spheres. We provide a practical guide for promoting BNNP and addressing the shortage of behavioral neurologists to facilitate the continued growth and development of the subspecialty. We also urge a greater commitment to recruit trainees from diverse backgrounds so as to dismantle persistent obstacles that hinder inclusivity in BNNP-efforts that will further enhance the growth and impact of the subspecialty. With rapidly expanding diagnostic and therapeutic approaches across a range of conditions at the intersection of neurology and psychiatry, BNNP is well positioned to attract new trainees and expand its reach across clinical, research, and educational activities.

Workload Risk Factors for Pitching-Related Injuries in High School Baseball Pitchers

Background: Pitch counts are only one measure of the true workload of baseball pitchers. Newer research indicates that workload measurement and prevention of injury must include additional factors. Thus, current monitoring systems gauging pitcher workload may be considered inadequate. Purpose/Hypothesis: The purpose of this study was to develop a novel method to determine workload in baseball pitchers and improve processes for prevention of throwing-related injuries. It was hypothesized that our pitching workload model would better predict throwing-related injuries occurring throughout the baseball season than a standard pitch count model. Study Design: Cohort study; Level of evidence, 2. Methods: This prospective observational study was conducted at an academic medical center and community baseball fields during the 2019 to 2023 seasons. Pitchers aged 13 to 18 years were monitored for pitching-related injuries and workload (which included pitching velocity; intensity, using preseason and in-season velocity as a marker of effort; and pitch counts). Results: A total of 71 pitchers had 313 recorded pitcher outings, 11 pitching-related injuries, and 24,228 pitches thrown. Gameday pitch counts for all pitchers ranged from 19 to 219 (mean, 77.5 ± 41.0). Velocity ranged from 46.8 to 85.7 mph (mean, 71.3 ± 5.8 mph). Intensity ranged from 0.7 to 1.3 (mean, 1.0 ± 0.08). The mean workload was 74.7 ± 40.1 for all pitchers. Risk factors significant for injury included throwing at a higher velocity in game (P = .001), increased intensity (eg, an increase in mean velocity thrown from preseason to in-season; P < .001), and being an older pitcher (P = .014). No differences were found for workload between injured and noninjured pitchers because the analysis was underpowered. Conclusion: Our workload model indicated that throwing at a higher velocity, throwing at a higher intensity, and older age were risk factors for injury. Thus, this novel workload model should be considered as a means to identify pitchers who may be at greater risk for injury.

Reading between the lines: exploring the unwritten rules of letters of recommendation in the Canadian resident selection process

Background: Efforts to better understand and improve letters of recommendation (LORs) in the resident selection process have identified unwritten rules and hidden practices that may limit their effectiveness. The objective of our study is to explore these unwritten rules and hidden practices more fully in one Canadian academic medical community. Methods: We conducted semi-structured, discourse-based interviews with 18 faculty members from the departments of Internal Medicine and Psychiatry at the University of Manitoba, Canada. Interviews were guided by sample LORs and were focused on experiences with either writing or reading LORs. We analyzed interviews using key concepts from genre theory and Aristotle’s appeals to ethos, logos, and pathos. Results: Participants described how the practices surrounding LORs are guided by unwritten rules. These practices contributed to writers’ use of visible strategies and textual silence to establish credibility, build a strong case, and appeal to readers. Readers rely on similar strategies, but not always as intended by the writers. Conclusions: The unwritten rules of one academic community can impede a nationally-facilitated resident selection process. Our findings highlight how critiques and potential improvements to LORs could benefit from considering the use of visible and invisible rhetorical strategies in specific contexts.

A service-oriented approach to clinical trial recruitment for dementia and brain health: Methods and case examples of MyAlliance for Brain Health.

Recruitment of sufficient and diverse participants into clinical research for Alzheimer's disease and related dementias remains a formidable challenge. The primary goal of this manuscript is to provide an overview of an approach to diversifying research recruitment and to provide case examples of several methods for achieving greater diversity in clinical research enrollment. The University of Kansas Alzheimer's Disease Research Center (KU ADRC) developed MyAlliance for Brain Health (MyAlliance), a service-oriented recruitment model. MyAlliance comprises a Primary Care Provider Network, a Patient and Family Network, and a Community Organization Network, each delivering tailored value to relevant parties while facilitating research referrals. We review three methods for encouraging increased diversity in clinical research participation. Initial outcomes reveal an increase in underrepresented participants from 17% to 27% in a research registry. Enrollments into studies supported by the research registry experienced a 51% increase in proportion of participants from underrepresented communities. MyAlliance shifts power, resources, and knowledge to community advocates, promoting brain health awareness and research participation, and demands substantial financial investment and administrative commitment. MyAlliance offers valuable lessons for building sustainable, community-centered research recruitment infrastructure, emphasizing the importance of localized engagement and cultural understanding. MyAlliance led to a significant increase in the representation of underrepresented racial and ethnic groups and individuals from rural areas.The service-oriented approach facilitated long-term community engagement and trust-building, extending partnerships between an academic medical center and community organizations.While effective, MyAlliance required substantial financial investment, with costs including infrastructure development, staff support, partner organization compensation, and promotional activities, underscoring the resource-intensive nature of inclusive research recruitment efforts.

Implementation of clopidogrel pharmacogenetic clinical decision support for a preemptive return of results program.

To describe our experiences implementing and iterating CYP2C19 genotype-guided clopidogrel pharmacogenetic clinical decision support (CDS) tools over time in the setting of a large health system-wide, preemptive pharmacogenomics program. Clopidogrel-treated patients who are genetically predicted cytochrome P450 isozyme 2C19 (CYP2C19) intermediate or poor metabolizers have an increased risk of atherothrombotic events, some of which can be life-threatening. The Clinical Pharmacogenetics Implementation Consortium provides guidance for the use of clopidogrel based on CYP2C19 genotype in patients with cardiovascular and cerebrovascular diseases. Our multidisciplinary team implemented an automated, interruptive alert that fires when clopidogrel is ordered or refilled for biobank participants with structured CYP2C19 intermediate or poor metabolizer genomic indicators in the electronic health record. The implementation began with a narrow cardiovascular indication and setting and was then scaled in 4 primary dimensions: (1) clinical indication; (2) availability across health-system locations; (3) care venue (e.g., inpatient vs outpatient); and (4) provider groups (eg, cardiology and neurology). We iterated our approach over time based on evolving clinical evidence and proactive strategies to optimize CDS maintenance and sustainability. A key facilitator of expansion was socialization of the broader pharmacogenomics initiative among our academic medical center community, accompanied by clinician acceptance of pharmacogenetic alerts in practice. A multidisciplinary collaboration is recommended to facilitate the use of CYP2C19 genotype-guided antiplatelet therapy in patients with cardiovascular and cerebrovascular diseases. Evolving clopidogrel pharmacogenetic evidence necessitates thoughtful iteration of implementation efforts and strategies to optimize long-term maintenance and sustainability.

Assessing clinicians' and trainees' knowledge and practice of the IDSA guidelines for asymptomatic bacteriuria in older adults.

A survey of advanced practice clinicians (APCs), physicians, residents, and medical students at an academic medical center and community practices in southeastern Texas revealed a gap in knowledge and practice related to testing and treatment for asymptomatic bacteriuria (ASB) in older adults.

Anticoagulation practices for continuous renal replacement therapy: a survey of physicians from the United States

Background During continuous renal replacement therapy (CRRT), anticoagulants are recommended for patients at low risk of bleeding and not already receiving systemic anticoagulants. Current anticoagulants used in CRRT in the US are systemic heparins or regional citrate. To better understand use of anticoagulants for CRRT in the US, we surveyed nephrologists and critical care medicine (CCM) specialists. Methods The survey contained 30 questions. Respondents were board certified and worked in intensive care units of academic medical centers or community hospitals. Results 150 physicians (70 nephrologists and 80 CCM) completed the survey. Mean number of CRRT machines in use increased ∼30% from the pre-pandemic era to 2022. Unfractionated heparin was the most used anticoagulant (43% of estimated patients) followed by citrate (28%). Respondents reported 29% of patients received no anticoagulant. Risk of hypocalcemia (52%) and citrate safety (42%) were the predominant reasons given for using no anticoagulant instead of citrate in heparin-intolerant patients. 84% said filter clogging was a problem when no anticoagulant was used, and almost 25% said increased transfusions were necessary. Respondents using heparin (n = 131) considered it inexpensive and easily obtainable, although of moderate safety, citing concerns of heparin-induced thrombocytopenia and bleeding. Anticoagulant citrate dextrose solution was the most used citrate. Respondents estimated that 37% of patients receiving citrate develop hypocalcemia and 17% citrate lock. Conclusions Given the increased use of CRRT and the lack of approved, safe, and effective anticoagulant choices for CRRT in the US, effective use of current and other anticoagulant options needs to be evaluated.

1275. Impact of a bundled antimicrobial stewardship intervention leveraging frontline pharmacist response to rapid blood culture diagnostics at an academic medical center and community hospital

Abstract Background Rapid Blood Culture Identification (BCID) panels have been shown to improve patient outcomes, including mortality and length of stay, when paired with antimicrobial stewardship (ASP) intervention. We report the results of a quality improvement initiative to expand to 24/7 pharmacist response to BCID results in a large academic medical center and a community hospital within the same health system. Methods A pre/post review was performed following a bundled stewardship intervention. Prior to the intervention, BCID results were addressed by the antimicrobial stewardship team Monday through Friday between 8am and 4pm. The bundled ASP intervention consisted of standardized treatment guidance, clinical education on result interpretation, frontline pharmacist evaluation of BCID results during off-peak hours to provide 24/7 response, and electronic health record documentation at each site. Clinical and microbiological data were collected for all patients. The primary outcome was time to optimal therapy (TTOT) for patients with a positive BCID within the first 72 hours of hospital admission. The secondary outcome assessed observed to expected length of stay (O/E LOS) ratios based on Vizient® Clinical Database estimates. The pre-intervention period included patients with a positive BCID between 1/1/2021 and 10/14/2022. The post-intervention period included patients with a positive BCID between 1/3/2023 and 3/31/2023. Results Clinical data and outcomes are reported in Table 1. During the first three months following ASP intervention, TTOT decreased at the academic medical center (15.0 to 6.4 hours) but did not change at the community hospital (25.9 to 25.1 hours). The O/E LOS ratio decreased for the academic medical center from 0.92 to 0.78 while the O/E LOS remained similar (0.85 to 0.83) for the community hospital. Conclusion A bundled ASP intervention utilizing frontline, non-ASP pharmacist review and prescriber outreach of BCID results quickly adopted. The intervention demonstrated benefit in the academic medical center, including quicker time to appropriate therapy and reduced length of hospitalization. Additional interventions may be needed for community sites depending on existing resources, staffing models and pharmacist/physician experience. Disclosures Nathaniel J. Rhodes, PharmD MS, Third Pole Therapeutics: Advisor/Consultant

Medical School Rankings: Time to End or Time to Amend?

The recent decisions of several medical schools to no longer participate in the rankings published annually by U.S. News & World Report have added greater visibility to the issues surrounding medical school rankings than ever before. While these announcements garnered significant attention in academic medicine and from the lay public, the authors believe these events are unlikely to eliminate rankings in medical education. In this article, the authors outline the potential harms of rankings in higher education, provide a rationale for why they will likely endure despite recent scrutiny, and offer suggestions for prospective students and the academic medical community to engage with rankings in a more productive way. Criticisms of medical school rankings have been noted for decades, including their use of subjective information and data with questionable relevance to the quality of students' education or the outcomes of their educational experience, methodological concerns, and the potential harms of ranking systems (such as schools diverting their focus and resources away from initiatives that benefit students to improve their ranking). At the same time, rankings are ubiquitous in today's culture and are powerful in human decision-making, so there is reason to believe that medical school rankings may weather the current storm. Given these concerns, the authors suggest students continue to use a variety of resources to obtain information about medical schools and consider how each school fits with their own educational needs. The authors also encourage medical schools, medical education organizations, and governing medical bodies to suggest different metrics that reflect quality in medical education and that are of importance to applicants.

Cancer Treatment Decision-Making for People Living With HIV: Physician-Reported Barriers, Facilitators, and Recommendations.

Compared with the general cancer population, people living with HIV (PLWH) and cancer are less likely to receive treatment and have significantly elevated cancer-specific mortality for many common cancer types. Physician recommendations drive the cancer therapy that patients receive, yet there is limited information assessing how cancer treatment decisions are made for people living with HIV and cancer. We sought to understand oncologist decision-making in PLWH and cancer by eliciting barriers, facilitators, and recommendations for enhancing care delivery. Participants were recruited between May 2019 and May 2021 from one academic medical center in the western United States (n = 13), another in the southeastern United States (n = 7), and community practices nationwide (n = 5). Using an inductive qualitative approach, we conducted in-depth interviews with 25 oncologists from two academic medical centers and community practices. Facilitators of cancer care delivery included readily available information regarding HIV status and stage, interdepartmental communication, and antiviral therapy adherence. Barriers included a lack of formal education on HIV malignancies, perceptions of decreased life expectancy, fear of inadvertent disclosure, and drug-drug interactions. Recommendations included improved provider communication, patient social and mental health resources, and continuing education opportunities. The study revealed drivers of cancer treatment decision-making, highlighting physician-reported barriers and facilitators, and recommendations to support treatment decision-making. This is the first known study examining oncologists' perceptions of caring for PLWH. Given that cancer is a leading cause of death among PLWH, there is an urgent need to improve care and outcomes.

Safety and clinical activity of autologous RNA chimeric antigen receptor T-cell therapy in myasthenia gravis (MG-001): a prospective, multicentre, open-label, non-randomised phase 1b/2a study

Chimeric antigen receptor (CAR) T cells are highly effective in treating haematological malignancies, but associated toxicities and the need for lymphodepletion limit their use in people with autoimmune disease. To explore the use of CAR T cells for the treatment of people with autoimmune disease, and to improve their safety, we engineered them with RNA (rCAR-T)-rather than the conventional DNA approach-to target B-cell maturation antigen (BCMA) expressed on plasma cells. To test the suitability of our approach, we used rCAR-T to treat individuals with myasthenia gravis, a prototypical autoantibody disease mediated partly by pathogenic plasma cells. MG-001 was a prospective, multicentre, open-label, phase 1b/2a study of Descartes-08, an autologous anti-BCMA rCAR-T therapy, in adults (ie, aged ≥18 years) with generalised myasthenia gravis and a Myasthenia Gravis Activities of Daily Living (MG-ADL) score of 6 or higher. The study was done at eight sites (ie, academic medical centres or community neurology clinics) in the USA. Lymphodepletion chemotherapy was not used. In part 1 (phase 1b), participants with Myasthenia Gravis Foundation of America (MGFA) disease class III-IV generalised myasthenia gravis received three ascending doses of Descartes-08 to determine a maximum tolerated dose. In part 2 (phase 2a), participants with generalised myasthenia gravis with MGFA disease class II-IV received six doses at the maximum tolerated dose in an outpatient setting. The primary objective was to establish safety and tolerability of Descartes-08; secondary objectives were to assess myasthenia gravis disease severity and biomarkers in participants who received Descartes-08. This trial is registered with clinicaltrials.gov, NCT04146051. We recruited 16 individuals for screening between Jan 7, 2020 and Aug 3, 2022. 14 participants were enrolled (n=3 in part 1, n=11 in part 2). Ten participants were women and four were men. Two individuals did not qualify due to low baseline MG-ADL score (n=1) or lack of generalised disease (n=1). Median follow-up in part 2 was 5 months (range 3-9 months). There was no dose-limiting toxicity, cytokine release syndrome, or neurotoxicity. Common adverse events were headache (six of 14 participants), nausea (five of 14), vomiting (three of 14), and fever (four of 14), which resolved within 24 h of infusion. Fevers were not associated with increased markers of cytokine release syndrome (IL-6, IL-2, and TNF). Mean improvements from baseline to week 12 were -6 (95% CI -9 to -3) for MG-ADL score, -7 (-11 to -3) for Quantitative Myasthenia Gravis score, -14 (-19 to -9) for Myasthenia Gravis Composite score, and -9 (-15 to -3) for Myasthenia Gravis Quality of Life 15-revised score. In this first study of an rCAR-T therapy in individuals with an autoimmune disease, Descartes-08 appeared to be safe and was well tolerated. Descartes-08 infusions were followed by clinically meaningful decreases on myasthenia gravis severity scales at up to 9 months of follow-up. rCAR-T therapy warrants further investigation as a potential new treatment approach for individuals with myasthenia gravis and other autoimmune diseases. Cartesian Therapeutics and National Institute of Neurological Disorders and Stroke of the National Institutes of Health.

PHarmacistavoidance or reductions in medical costs inCRITicallyill adults rounding with oneSERVICEcompared to two or more services:PHARM‐CRIT‐SERVICE

AbstractIntroductionIntensive care unit (ICU) pharmacists are integral members of the interdisciplinary health care team. Pharmacy staffing models vary by ICU and hospital, and clinical pharmacists may cover one ICU service or multiple services. It is presently unknown how covering or rounding on multiple services relative to one service impacts the quantity of interventions made or the acceptance rate of those interventions.MethodsExploratory analysis of the PHarmacist Avoidance or Reductions in Medical costs in CRITically ill adults (PHARM‐CRIT) study, a multicenter, prospective, observational study was performed between August 2018 and January 2019 in academic medical centers and community hospitals throughout the United States. ICU pharmacists documented recommendations and accepted interventions. Pharmacists that covered one service were compared to those who covered two or more services or no services.Results218 ICU pharmacists participated across 85 centers. There were 2905 shifts and the primary rounding structure was one service (n = 1766, 60.8%) compared to covering two or more services (n = 822, 28.3%), and no rounding (n = 317, 10.9%). The percent of pharmacists with accepted interventions was higher with one service compared to the other groups: one service (45.7% ± 1.8) vs. no rounding (12.7% ± 1) (odds ratio [OR] 4.92 [95% confidence interval (CI) 4.19–5.78]) and one service vs. two or more services (31.6% ± 1.6) (OR 1.81 [95% CI 1.67–1.95]). This was also observed when comparing two or more services to no rounding (OR 2.73 [95% CI 2.32–3.2]). The probability of an intervention being accepted was highest in pharmacists rounding on one service, followed by two or more services, and least likely without rounding. Increasing the patient load of the pharmacist in any of the rounding structures resulted in a decline in interventions being accepted.ConclusionsICU pharmacists rounding with one service relative to two or more or none had more interventions attempted and accepted.

Advancing Team-Based Care for Spinal Muscular Atrophy: A Multi-State Project ECHO Initiative and National Education Strategy (S2.002)

<h3>Objective:</h3> N/A <h3>Background:</h3> An academic medical center, medical education provider, and faculty experts developed a comprehensive, multicomponent initiative, with Project ECHO® serving as the primary delivery platform. The goal was to help multidisciplinary, community-based teams across the US enhance care of their patients with spinal muscular atrophy (SMA). <h3>Design/Methods:</h3> We conducted monthly group tele-mentoring sessions using the proven Project ECHO model as our primary educational framework. Project ECHO creates collaborative learning networks led by expert interprofessional teams and includes de-identified patient case discussion, mentoring, and didactic presentations using a web-based videoconferencing platform to conduct virtual sessions with learners. Sessions were accredited for physicians and nurses. We assessed changes in knowledge, competency, and performance pre-/post-initiative and gathered participant feedback using online surveys and phone interviews. We also created an accredited, online activity for clinicians across the country; its content aligned with that of the live ECHO sessions. <h3>Results:</h3> Clinicians from 7 sites participated in the Project ECHO portion of the initiative. Sites included academic medical centers, community hospitals, and private practices. The online national educational activity launched April 27, 2022, with over 350 participants thus far. Learners for this initiative included neurologists, pediatricians, nurses, NPs, PAs, and other professionals who collectively care for approximately 1,000 patients with SMA on a regular basis. Outcomes data and feedback revealed positive effects on learning and performance with statistically significant increases in knowledge and competency. However, persistent learning gaps remained post-education related to appropriate use of available and emerging treatments, suggesting areas for continued education. <h3>Conclusions:</h3> This initiative’s high level of interactivity allowed for in-depth exploration of challenges clinicians face in SMA management, which is not easily accomplished within traditional educational frameworks. In the setting of SMA management, where clinicians may feel professionally isolated, the ECHO model proved critical in improving quality of patient care and cultivating communities of practice. <b>Disclosure:</b> Mrs. Gabriel has nothing to disclose. Ana Carolina Tesi Rocha, MD has nothing to disclose. Dr. Klotz has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Genentech Roche. Dr. Adewuya has nothing to disclose. Ms. Hack has nothing to disclose. Whitney Hess has nothing to disclose.

Normative Values for the Inner EAR Scale.

To determine normative values for the Inner Effectiveness of Auditory Rehabilitation (Inner EAR) scale, a validated instrument utilized to study the impact of hearing loss and potential treatments. Observational outcomes study. Academic medical center and community care sites. We included patients who were at least 18 years of age and completed the Inner EAR scale, pure-tone audiometry, and word recognition score assessment. Based on audiometry results, patients were categorized as having: (1) normal bilateral hearing, (2) unilateral hearing loss, and (3) bilateral hearing loss. The distributions of Inner EAR scale scores were assessed within each category. Fisher's exact test was utilized to determine whether data-driven threshold values could discriminate among the 3 clinical groups. Two hundred and twenty-two consecutive patients with hearing-related complaints met inclusion criteria. Mean Inner EAR scores for patients with bilateral hearing loss (29.2, interquartile range [IQR] 10-41.5), unilateral hearing loss (38.9, IQR 23-49), and normal hearing (46.6, IQR 31-62) were significantly different (analysis of variance F < 0.0001). An Inner EAR score threshold of 50 supported the ability to statistically significantly discriminate between bilateral hearing loss and normal hearing (p = .003), as well as between unilateral hearing loss and normal hearing (p = .015). An Inner EAR score normative threshold value of 50 provides significant discriminatory ability between normal hearing and unilateral or bilateral hearing loss on audiometry. Normative values provide useful, frequently referenced data when assessing responses to treatment. Based on these data, this threshold may help distinguish patients with and without perceived functional impact from hearing loss.

Neoadjuvant Radiotherapy Facility Type Affects Anastomotic Complications After Esophagectomy

BackgroundEsophagectomy is a complex oncologic surgery that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons; however, limited data exists evaluating the importance of neoadjuvant radiotherapy delivery at high- versus low-volume centers. We sought to compare postoperative toxicity among patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC). MethodsConsecutive patients undergoing esophagectomy for locally advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Associations between patient factors and treatment-related toxicities were calculated in univariate (UVA) and multivariable analyses (MVA). ResultsOne hundred forty-seven consecutive patients were identified: 89 CMC and 58 AMC. Median follow-up was 30 months (0.33–124 months). Most patients were male (86%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Median radiation dose was 50.4 Gy between groups. Radiotherapy at CMCs resulted in higher rates of re-operation after esophagectomy (18% vs 7%, p = 0.055) and increased rates of anastomotic leak (38% vs 17%, p < 0.01). On MVA, radiation at a CMC remained predictive of anastomotic leak (OR 6.13, p < 0.01). ConclusionEsophageal cancer patients receiving preoperative radiotherapy had higher rates of anastomotic leaks when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted.