Hoag Memorial Hospital Presbyterian Research Articles

The impact of COVID-19 on pharmacy transitions of care services.

COVID-19 has necessitated alterations to the delivery of healthcare services. Modifications include those made to improve patient and healthcare worker safety such as the use of personal protective equipment. Pharmacy services, specifically pharmacy transitions of care services have not been immune to change which have brought along their own set of unique challenges to consider. This paper discusses how COVID-19 has impacted the delivery of pharmacy transitions of care services with real world examples from Sharp Grossmont Hospital and Hoag Memorial Hospital Presbyterian. Procedures implemented to minimize the spread and contraction of COVID-19 such as minimized patient contact and altered visitor policies have made it more challenging to obtain a best possible medication list the patient was taking prior to arrival to the hospital which has lead to an increased reliance on secondary sources to complete medication histories. Regarding discharge prescriptions, preference has shifted to the use of electronic vs. hard copy prescriptions, mail order, and utilization of med to bed programs and other hospital medication delivery services to limit patient contact in outpatient pharmacies. An improved effort to resolve medication acquisition issues prior to discharge utilizing patient assistance programs and other hospital programs to cover the cost of medications for COVID positive patients under certain circumstances has been seen. This paper highlights the important role pharmacists can play in providing effective communication, supporting continuity of care, and advocating for patient engagement and empowerment during transitions of care in the COVID-19 pandemic.

Acute and Chronic Complications in Breast Cancer Patients Treated with Intraoperative Radiation Therapy.

Intraoperative radiation therapy (IORT) permits the delivery of radiation therapy directly to the tumor bed at the time of surgery. Minimal data are available about the complications associated with this modality of treatment using the Xoft(®) Axxent Electronic Brachytherapy (Axxent) System. A total of 702 patients who received IORT using the Xoft(®) Axxent System at Hoag Memorial Hospital Presbyterian between June 2010-February 2016 were accrued in an IORT data registry study. The prospective and retrospective protocols were approved by the institutional review board and met the guidelines of their responsible governmental agency. Data were collected at 1week, 1month, 3months, 6months, 1year, and thereafter yearly. Acute complications were defined as those occurring within the first month. Chronic complications were those that persisted beyond 6months. Acute complications were observed in 21% of patients and included hematomas that required drainage, seromas requiring drainage more than 3 times, infections treated with antibiotics or surgery, necrosis requiring surgery, and erythema. Chronic complications were observed in 13% of patients and included seromas, fibrosis, and hyperpigmentation. The majority of acute and chronic problems from IORT were mild. If grade I erythema, fibrosis, and hyperpigmentation were removed, only 32 of 702 (4.6%) had significant complications. Our complication rates were comparable to those of the TARGIT trial. IORT is a modality that safely delivers radiation therapy to patients diagnosed with breast cancer. This technique allows women who cannot (or decline to) undergo whole breast radiation to consider breast-conserving therapy rather than mastectomy.

Risk of recurrence of ductal carcinoma in situ by oncotype Dx technology: Some concerns

Predicting which patients with ductal carcinoma in situ (DCIS) will develop local disease recurrence: we have been trying to do that for 30 years. But now we can. The Holy Grail has been recovered in the form of Oncotype Dx, or so we have been told.1 A single genetic test capable of identifying the risk of local disease recurrence after breast conservation in patients with mammographically detected DCIS would obviate the need to factor in DCIS grade, size, and margin width, and patient age. The Oncotype Dx DCIS gene signature assay was validated in a registration trial2 that strictly defined a permissible size of ≤25 mm for low-to-intermediate grade tumors and ≤10 mm for high-grade tumors and those with margin widths of ≥3 mm. Unfortunately, most medical oncologists ordering the Oncotype Dx DCIS assay do not appreciate the limitations of the validated results. They order the $4000 test for patients with DCIS of all sizes and all margin widths. The test, if valid, is only valid if the strict protocol required of the Eastern Cooperative Oncology Group (ECOG) E5194 trial is adhered to. A transected DCIS is likely to recur in spite of a low score on the Oncotype Dx assay. A recent example of a 46-year-old woman with a low-risk Oncotype Dx score had 42 mm of disease and 3-mm margins. Her DCIS grade was intermediate with focal necrosis. A Van Nuys Prognostic Index calculation3 results in a total score of 9 (grade score of 2, size score of 3, margin score of 2, and age score of 2). Oncotype Dx provided a 10-year risk of disease recurrence of 15%, whereas the University of Southern California/Van Nuys Prognostic Index projects a local recurrence risk of 40% to 50% without irradiation. The Oncotype Dx assay is in essence a grading system based on gene expression, and is comparable to histologic grading of DCIS. Because it does not factor in a variety of important predictive factors such as age, margin width, extent of DCIS, nuclear grade, and necrosis, it is not likely to be accurate for the majority of patients. No single test, especially one in which other prognostic factors are ignored, can validly estimate the risk of local recurrence among patients with DCIS. The authors made no disclosures. Michael D. Lagios, MD1 Melvin J. Silverstein, MD2 1The Breast Cancer Consultation Service, Tiburon, California 2Department of Breast Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, California

Does the Type and Frequency of Palliative Care Services Received by Patients with Advanced Heart Failure Impact Symptom Burden?

JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 1, 2014 a Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0231 Brief Reports Does the Type and Frequency of Palliative Care Services Received by Patients with Advanced Heart Failure Impact Symptom Burden? Lorraine S. Evangelista, PhD, RN, FAHA, FAAN, 1 Solomon Liao, MD, FAAHPM, 2 Marjan Motie, PhD, 3 Nathalie De Michelis, RN, BSN, 4 Jennifer Ballard-Hernandez, MSN, NP, AACC, 5 and Dawn Lombardo, MD 4 pies, organ and tissue donation, and medical device donation), and worked with participants to develop a treat- ment plan that listed the goals of care. The treatment plan was presented to the interdisciplinary PC team during their weekly meetings, in order to support a team-based approach to providing patient-family centered care that encouraged active involvement of patients and their families in decision making involving their care. Introduction P atients with heart failure (HF) experience a myriad of symptoms that are associated with marked distress and impaired quality of life. 1–3 In light of their high symptom burden and poor prognosis, patients with symptomatic HF are an appropriate population in whom to introduce pallia- tive care (PC). 4–6 However, PC referral early in the course of symptomatic HF is a relatively new practice and few data exist that describe the nature of these encounters. 7 The current study was conducted to describe the nature of outpatient PC services (i.e., type of services and care received, duration, and frequency of visits) used by patients discharged from the hospital with acute HF exacerbation, i.e., New York Heart Association (NYHA) Functional Class II–III, and to describe levels of symptom burden during the initial PC consultation and three months thereafter. Data collection methods The study was approved by the appropriate institutional review board. Participants provided informed consent prior to completing the modified Edmonton Symptom Assessment Scale (ESAS), 8 a nine-item, self-reported visual analog scale numerically rated from 0 (no symptom at all) to 10 (worst possible symptom) at baseline and three months, to assess ratings of each symptom at the time that the survey was completed. 9 The severity of each individual item was cate- gorized as none (0), mild (1–4), moderate (5–7), and severe (8– 10). The reliability (Cronbach’s a) of the ESAS for the current study was 0.86. Data on types of PC services received, the focus of care for each encounter, and medication use over three months were abstracted from the medical records. Methods Study design, setting, and participants This descriptive-exploratory study was conducted at a single university affiliated medical center. Participants were recruited from the inpatient setting through HF provider referrals. Data analyses Palliative care intervention Descriptive summaries of demographic and clinical data, symptom burden scores, and duration and frequency of PC encounters were computed using SPSS 18.0 (SPSS Inc., Chi- cago, IL). The paired Wilcoxon signed-rank test was used to compare symptom burden scores immediately after discharge and three months postdischarge. A symptom response rate (i.e., percentage of participants presenting a reduction of ‡ 2 points on an individual symptom of the ESAS) was computed to determine efficacy of PC in reducing symptom burden; a two-point change in individual symptom scores has been Participants met within seven days of hospital discharge with a PC specialist (e.g., physician or advanced practice nurse) who retained primary responsibility for their PC needs over three months. The PC specialist performed a compre- hensive physical and psychosocial assessment, initiated dis- cussions about advance care planning (e.g., completion of advance directives, options to take in the event of worsening health, family involvement, pain management, hydration is- sues, artificial nutrition, blood transfusions, advanced thera- Program of Nursing Science, University of California Irvine, Irvine, California. Palliative Care Services and Department of Medicine, 4 Clinical Heart Failure Program, University of California Irvine Medical Center, Irvine, California. Pro-HEART, Program of Nursing Science, University of California Irvine, Irvine, California. Hoag Memorial Hospital Presbyterian, Newport Beach, California. Accepted August 30, 2013.

Image-guided helical Tomotherapy for treatment of spine tumors

Objectives One of the most common indications for radiotherapy is treatment of the spine. The vast majority of cases are related to metastatic disease with primary tumors of the spine being rare. Conventional radiation therapy often plays an important role in the management of spine tumors although at times with significant side effects and disadvantages. Furthermore, retreatment of spine tumors is a challenge due to concerns over spinal cord toxicity. In this series, we examine the efficacy of using image-guided helical Tomotherapy and the possible advantages offered by this new technology. Patients and methods Eight patients at Hoag Memorial Hospital Presbyterian were treated between November 2005 and November 2006. The median age was 66 years. Of the eight patients, seven had metastatic disease with one patient having a primary neuroendocrine tumor of the spine. Five patients were previously treated to the spine with conventional radiation planning. Two patients received single fraction stereotactic radiosurgery (15 Gy) while the remaining patients received hypofractionated stereotactic radiotherapy to a median total dose of 2500 cGy in 500 cGy fractions. Results At the time of last follow-up, radiographic control was seen in all eight patients with a median local control rate of 2.5 months (range of 1–5.8 months). Four of the eight patients are still alive with median overall survival of 5.1 months (range 1.4–6.9 months). Acute toxicity ranged from Radiation Therapy Oncology Group (RTOG) score 0–2 and no patients experienced late complications of radiation myelitis. Conclusions The TomoTherapy Hi-ART system can be an alternative treatment option for upfront or retreatment of spine tumors. Minimal acute and late toxicity were seen in patients treated with Tomotherapy. Intensity-modulated radiation delivery combined with megavoltage CT image guidance offered by the TomoTherapy Hi-ART system allows for set-up and delivery accuracy that is required for stereotactic treatment of spine tumors and eliminates the need for any internal or external fiducial marker placement.

Impact of Gynecologic Oncologists on Referral Patterns and Care of Patients with Uterine Malignancies at a Community Hospital

Objective: The purpose of this study was to assess the impact of the introduction of gynecologic oncology services at a community hospital on patterns of referral and responsibility for management of patients with uterine malignancies. The number of patients treated at, and referred from, the study hospital over a 19-year period is reported. The increase in the utilization of the gynecologic oncologist by the general gynecologist over the study period is detailed. Methods: From January 1981 to December 1999, 543 patients were diagnosed and received total or partial treatment for uterine malignancy at Hoag Memorial Hospital Presbyterian in Newport Beach, CA. Patients were categorized according to the type of treatment (surgery, radiotherapy) administered, stage of disease, and degree of gynecologic oncologist involvement with patient care. Results: Utilization of a gynecologic oncologist as a primary surgeon, assistant surgeon, or postoperative consultant increased gradually to more than 90%. The number of...

Cutting edge discussions of management, policy, and program issues in emergency care

Cutting edge discussions of management, policy, and program issues in emergency care

Hoag Memorial Hospital Presbyterian

Hoag Memorial Hospital Presbyterian

Imaging techniques

MB-Z: Director of MRI, Hoag Memorial Hospital Presbyterian, Newport Beach, California, Clinical Professor of Radiology, University of California—San Francisco, San Francisco, California, and Loma Linda University, Loma Linda, California. Reprints: M. Brant-Zawadzki, 355 W. Placentia, Suite 207, Newport Beach, CA 92625.

LETTERS TO THE EDITOR-IN-CHIEF

Senior Technologist Pulmonary Physiology Laboratory Hoag Memorial Hospital Presbyterian Newport Beach, CA 92663