Interdisciplinary Working Group Research Articles

Final Analysis of a Noninterventional Study on Cabozantinib in Patients With Advanced Renal Cell Carcinoma After Prior Checkpoint Inhibitor Therapy of the German Interdisciplinary Working Group on Renal Tumors (IAG-N)

BackgroundEfficacy of treatment after failure of check point inhibitors (ICI) therapy remains ill-defined in metastatic renal cell carcinoma (mRCC). ObjectiveTo evaluate the safety and effectiveness of cabozantinib after failure of ICI-based therapies. Design, setting and participantsPatients with mRCC who concluded cabozantinib treatment directly after an ICI-based therapy were eligible. Data was collected retrospectively from participating sites in Germany. InterventionsCabozantinib was administered as a standard of care. Outcome measurements and statistical analysisAdverse events (AE) were reported according to CTCAE v5.0. Objective response rate according to RECIST 1.1 and Progression Free Survival (PFS) were collected from medical records. Descriptive statistics and Kaplan-Meyer-plots were utilized. Results and limitationsAbout 56 eligible patients (71.4% male) with median age of 66 years and clear cell histology in 66.1% (n = 37) were analyzed. 87.5% (n = 49) had ≥ 2 previous lines. IMDC risk was intermediate or poor in 17 patients (30.4%) and missing in 66.1%. 20 patients (35.7%) started with 60 mg. 55.4% (n = 31) required dose reductions, 26.8% (n = 15) treatment delays and 1.8% (n = 1) treatment discontinuation. Partial response was reported in 10.7% (n = 6), stable and progressive disease were reported in 19.6% (n = 11) and in 12.5% (n = 7). 32 patients were not evaluable (57.1%). Median treatment duration was 6.1 months. Treatment related AE were reported in 76.8% (n = 43) and 19.6% (n = 11) had grade 3-5. Fatigue (26.8%), diarrhea (26.8%) and hand-foot-syndrome (25.0%) were the 3 most frequent AEs of any grade and causality. SAE were reported in 21.4% (n = 12), 2 were fatal. Major limitation was the retrospective data capture in our study. ConclusionsCabozantinib followed directly after ICI-based therapy was safe and feasible. No new safety signals were reported. A lower starting dose was frequently utilized in this real-world cohort, which was associated with a favorable tolerability profile. Our data supports the use of cabozantinib after ICI treatment.

Ensuring best practice in genomics education: A scoping review of genomics education needs assessments and evaluations.

A health workforce capable of implementing genomic medicine requires effective genomics education. Genomics education interventions developed for health professions over the last two decades, and their impact, are variably described in the literature. To inform an evaluation framework for genomics education, we undertook an exploratory scoping review of published needs assessments for, and/or evaluations of, genomics education interventions for health professionals from 2000 to 2023. We retrieved and screened 4,659 records across the two searches with 363 being selected for full-text review and consideration by an interdisciplinary working group. 104 articles were selected for inclusion in the review-60 needs assessments, 52 genomics education evaluations, and eight describing both. Included articles spanned all years and described education interventions in over 30 countries. Target audiences included medical specialists, nurses/midwives, and/or allied health professionals. Evaluation questions, outcomes, and measures were extracted, categorized, and tabulated to iteratively compare measures across stages of genomics education evaluation: planning (pre-implementation), development and delivery (implementation), and impact (immediate, intermediate, or long-term outcomes). They are presented here along with descriptions of study designs. We document the wide variability in evaluation approaches and terminology used to define measures and note that few articles considered downstream (long-term) outcomes of genomics education interventions. Alongside the evaluation framework for genomics education, results from this scoping review form part of a toolkit to help educators to undertake rigorous genomics evaluation that is fit for purpose and can contribute to the growing evidence base of the contribution of genomics education in implementation strategies for genomic medicine.

A Rough Guide to the Oil Archive

Abstract The omnipresence of petroleum makes it an essential part of a history of the modern world. However, this ubiquity also presents a challenge as to which archival materials historians should use to tell this story. By using material gathered during fieldwork in the Colombian oil city of Barrancabermeja, this article aims to investigate the nature of the oil archive. Situated within the broader field of literature on the history of petroleum and archives, the investigation touches upon records in diverse archives, the urban fabric, and repositories of oil’s history to be found underground. By pinpointing such materials across Barrancabermeja, the article argues that the oil archive is not just found in historical documents but embedded in the landscape, in social practices, in human bodies, and even in the geology of the earth. To understand the deep-seated influence of oil, the article argues for the establishment of an interdisciplinary working group of the oil archive. Faced with the impending challenge of climate change and the long-lasting legacy of the fossil fuel age, such a group could provide evidence for how humanity got to this stage, point to different imaginaries of past and future, and clarify issues surrounding climate justice and responsibility.

Asking those who know their needs best: A framework for active engagement and involvement of childhood cancer survivors and parents in the process of psychosocial research-A workshop report.

Patient and public involvement and engagement (PPIE) in healthcare research is crucial for effectively addressing patients' needs and setting appropriate research priorities. However, there is a lack of awareness and adequate methods for practicing PPIE, especially for vulnerable groups like childhood cancer survivors. This project aimed to develop and evaluate engagement methods to actively involve pediatric oncological patients, survivors, and their caregivers in developing relevant research questions and practical study designs. An interdisciplinary working group recruited n = 16 childhood cancer survivors and their caregivers to work through the entire process of developing a research question and a practicable study design. A systematic literature review was conducted to gather adequate PPIE methods which were then applied and evaluated in a series of three workshop modules, each lasting 1.5 days. The applied methods were continuously evaluated, while a monitoring group oversaw the project and continuously developed and adapted additional methods. The participants rated the different methods with varying scores. Over the workshop series, the participants successfully developed a research question, devised an intervention, and designed a study to evaluate their project. They also reported increased expertise in PPIE and research knowledge compared to the baseline. The project resulted in a practical toolbox for future research, encompassing the final workshop structure, evaluated methods and materials, guiding principles, and general recommendations. These findings demonstrate that with a diverse set of effective methods and flexible support, actively involving patients, survivors, and caregivers can uncover patients' unmet disease-related needs and generate practical solutions apt for scientific evaluation. The resulting toolbox, filled with evaluated and adaptable methods (workbook, Supplement 1 and 2), equips future scientists with the necessary resources to successfully perform PPIE in the development of health care research projects that effectively integrate patients' perspectives and address actual cancer-related needs. This integration of PPIE practices has the potential to enhance the quality and relevance of health research and care, as well as to increase patient empowerment leading to sustainable improvements in patients' quality of life.

Recommendations for optimal interdisciplinary management and healthcare settings for patients with rare neurological diseases

BackgroundIn 2017, the German Academy for Rare Neurological Diseases (Deutsche Akademie für Seltene Neurologische Erkrankungen; DASNE) was founded to pave the way for an optimized personalized management of patients with rare neurological diseases (RND) in all age groups. Since then a dynamic national network for rare neurological disorders has been established comprising renowned experts in neurology, pediatric neurology, (neuro-) genetics and neuroradiology. DASNE has successfully implemented case presentations and multidisciplinary discussions both at yearly symposia and monthly virtual case conferences, as well as further educational activities covering a broad spectrum of interdisciplinary expertise associated with RND. Here, we present recommendation statements for optimized personalized management of patients with RND, which have been developed and reviewed in a structured Delphi process by a group of experts.MethodsAn interdisciplinary group of 37 RND experts comprising DASNE experts, patient representatives, as well as healthcare professionals and managers was involved in the Delphi process. First, an online collection was performed of topics considered relevant for optimal patient care by the expert group. Second, a two-step Delphi process was carried out to rank the importance of the selected topics. Small interdisciplinary working groups then drafted recommendations. In two consensus meetings and one online review round these recommendations were finally consented.Results38 statements were consented and grouped into 11 topics: health care structure, core neurological expertise and core mission, interdisciplinary team composition, diagnostics, continuous care and therapy development, case conferences, exchange / cooperation between Centers for Rare Diseases and other healthcare partners, patient advocacy group, databases, translation and health policy.ConclusionsThis German interdisciplinary Delphi expert panel developed consented recommendations for optimal care of patients with RND in a structured Delphi process. These represent a basis for further developments and adjustments in the health care system to improve care for patients with RND and their families.

Development of low back pain curriculum content standards for entry-level clinical training

BackgroundThe management of low back pain (LBP) is highly variable and patients often receive management that is not recommended and/or miss out on recommended care. Clinician knowledge and behaviours are strongly influenced by entry-level clinical training and are commonly cited as barriers to implementing evidence-based management. Currently there are no internationally recognised curriculum standards for the teaching of LBP content to ensure graduating clinicians have the appropriate knowledge and competencies to assess and manage LBP. We formed an international interdisciplinary working group to develop curriculum content standards for the teaching of LBP in entry-level clinical training programs.MethodsThe working group included representatives from 11 countries: 18 academics and clinicians from healthcare professions who deal with the management of LBP (medicine, physiotherapy, chiropractic, osteopathy, pharmacology, and psychology), seven professional organisation representatives (medicine, physiotherapy, chiropractic, spine societies), and one healthcare consumer. A literature review was performed, including database and hand searches of guidelines and accreditation, curricula, and other policy documents, to identify gaps in current LBP teaching and recommended entry-level knowledge and competencies. The steering group (authors) drafted the initial LBP Curriculum Content Standards (LBP-CCS), which were discussed and modified through two review rounds with the working group.ResultsSixty-two documents informed the draft standards. The final LBP-CCS consisted of four broad topics covering the epidemiology, biopsychosocial contributors, assessment, and management of LBP. For each topic, key knowledge and competencies to be achieved by the end of entry-level clinical training were described.ConclusionWe have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to inform or benchmark the content of curricula related to LBP in new or existing entry-level clinical training programs.

Interdisciplinary optimisation of injection methods in the construction lot H52 BBT

AbstractFor the excavation of a hydrogeologically important section of the Brenner Base Tunnel (BBT), intensive injection works before excavation are necessary. The main objective of an interdisciplinary working group is to optimise these injections during the construction phase. The so‐called Hochstegen zone comprises two water‐bearing zones. The first zone, consisting of porous, metamorphic Triassic rocks, requires fine granular injection mediums, injections with maximum rates of 20 l/min and cementitious and chemical injection materials. The second zone, a water‐bearing zone in the Jurassic Hochstegen marble with micro‐karstic solution elements, requires a high volume injection method with maximum rates of approximately 500 l/min and an injection mortar with high density (2.3 t/m3).

Digital competencies in medical studies: results of an interdisciplinary course

Digital medicine has become increasingly important, especially with the growing use of artificial intelligence (AI) and telemedicine. The COVID19 pandemic has accelerated this trend and emphasized the need for digital competencies in healthcare. However, digital competencies have been insufficiently taught in medical school to date. The introduction of an elective course in digital competencies in medicine fills acurricular gap at the Medical Faculty of the University of Freiburg. The elective course was developed by an interdisciplinary working group and includes seven modules on topics such as e‑health, telemedicine, AI, hospital information systems, and data literacy. Each module consists of apreparatory self-study unit, atheoretical part, and apractical part. An evaluation was conducted to assess the effectiveness of the elective. Six students participated in the elective course in the summer semester of 2022. The evaluation shows that the goals of the course were achieved. The participants were able to acquire theoretical knowledge and deepen it through practical exercises. The interdisciplinary design of the course promotes exchange between students and teachers and creates synergies. The modular format of the course also allows for current topics, such as generative AI, to be addressed. In order to promote digital competencies among all students of human medicine, it is necessary to integrate the topics into the mandatory curriculum.

Medical Child Abuse - A Guideline to Detecting this Particular Form of Child Maltreatment

The term Medical Child Abuse (MCA) describes a form of child abuse in which the medical system is "abused" by carrying out unnecessary medical procedures on a child. This abuse of the medical system occurs through misrepresentation, non-disclosure, fabrication, misinterpretation or active causation of symptoms by a parent. In this article, the construct ofmedical child abuse is defined and predisposing and motivational factors are examined. It also provides an overview of terms that are used synonymously or comparably in the literature and discusses the connection between MCA and Munchausen-by-proxy-syndrome.The core of the article is the presentation of an internal guideline, which was created by the interdisciplinary working group on MCA of the Clinics for Paediatric and Adolescent Medicine, the Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, the Child Protection Outpatient Clinic and the Social Services at the Charité. It also outlines possible interventions.

Comparing some plant communities in a region of Türkiye via fuzzy similarity

Abstract In this study, the results obtained from forest vegetation via the research project on plant sociology which was conducted in the Black Sea region of Türkiye is evaluated with the help of a fuzzy similarity measures approach. Via this project, the plant sociology in an area which has not been studied in the Black Sea region of Türkiye is performed to investigate the plant communities and ecological and sociological relationships with each other. The similarity relations among the plant communities and relevés (sampling areas) which they covered are investigated. The issue of fuzzy similarity of sets and elements in sets is studied. According to this point of view, the fuzzy similarity among the plant communities and among the relevés is introduced. This joint study is carried out in a fuzzy environment, considering the classical results found in the project in question to be obtained in more detail for application. It is also understood that such studies can only be best performed with an interdisciplinary working group.

Digital transformation of an academic hospital department: A case study on strategic planning using the balanced scorecard.

Digital transformation has a significant impact on efficiency and quality in hospitals. New solutions can support the management of data overload and the shortage of qualified staff. However, the timely and effective integration of these new digital tools in the healthcare setting poses challenges and requires guidance. The balanced scorecard (BSC) is a managerial method used to translate new strategies into action and measure their impact in an institution, going beyond financial values. This framework enables quicker operational adjustments and enhances awareness of real-time performance from multiple perspectives, including customers, internal procedures, and the learning organization. The aim of this study was to adapt the BSC to the evolving digital healthcare environment, encompassing factors like the recent pandemic, new technologies such as artificial intelligence, legislation, and user preferences. A strategic mapping with identification of corresponding key performance indicators was performed. To achieve this, we employed a qualitative research approach involving retreats, interdisciplinary working groups, and semi-structured interviews with different stakeholders (administrative, clinical, computer scientists) in a rheumatology department. These inputs served as the basis for customizing the BSC according to upcoming or already implemented solutions and to define actionable, cross-level performance indicators for all perspectives. Our defined values include quality of care, patient empowerment, employee satisfaction, sustainability and innovation. We also identified substantial changes in our internal processes, with the electronic medical record (EMR) emerging as a central element for vertical and horizontal digitalization. This includes integrating patient-reported outcomes, disease-specific digital biomarker, prediction algorithms to increase the quality of care as well as advanced language models in order save resources. Gaps in communication and collaboration between medical departments have been identified as a main target for new digital solutions, especially in patients with more than one disorder. From a learning institution's perspective, digital literacy among patients and healthcare professionals emerges as a crucial lever for successful implementation of internal processes. In conclusion, the BSC is a helpful tool for guiding digitalization in hospitals as a horizontally and vertically connected process that affects all stakeholders. Future studies should include empirical analyses and explore correlations between variables and above all input and user experience from patients.

Enhancing Safety in AI-Driven Cone Beam CT-based Online Adaptive Radiation Therapy: Development and Implementation of an Interdisciplinary Workflow

PurposeThe emerging online adaptive radiotherapy (OART) treatment strategy based on cone-beam computed tomography allows for real-time replanning according to a patient's current anatomy. However, implementing this procedure requires a new approach across the patient's care path and monitoring of the "black box" adaptation process. This study identifies high-risk failure modes (FMs) associated with AI-driven OART and proposes an interdisciplinary workflow to mitigate potential medical errors from highly automated processes, enhance treatment efficiency, and reduce the burden on clinicians. Materials and MethodsAn interdisciplinary working group was formed to identify safety concerns in each process step using failure mode and effects analysis (FMEA). Based on the FMEA results, the team designed standardized procedures and safety checklists to prevent errors and ensure successful task completion. The Risk Priority Numbers (RPNs) for the top twenty FMs were calculated before and after implementing the proposed workflow to evaluate its effectiveness. Three hundred seventy-four adaptive sessions across five treatment sites were performed, and each session was evaluated for treatment safety and FMEA assessment. ResultsThe OART workflow has four components, each with 4, 8, 13, and 4 sequentially executed tasks and safety checklists. Site-specific template preparation, which includes disease-specific physician directives and Intelligent Optimization Engine template testing, is one of the new procedures introduced. The interdisciplinary workflow significantly reduced the RPNs of the high-risk FMs, with an average decrease of 110 (maximum reduction of 305.5 and minimum reduction of 27.4). ConclusionThis study underscores the importance of addressing high-risk FMs associated with AI-driven OART and emphasizes the significance of safety measures in its implementation. By proposing a structured interdisciplinary workflow and integrated checklists, the study provides valuable insights into ensuring the safe and efficient delivery of OART while facilitating its effective integration into clinical practice.

Streamlining urgent, same day oncology admissions from an ambulatory clinic and patient safety, patient experience, and team communication.

394 Background: The urgent, same-day, admission process for an ambulatory oncology patient is complex. Between January 1, 2021 and November 8, 2022, at least 35 safety reports were filed relating to urgent, same-day admissions yielding a rate of 1.72% of direct admissions resulting in a safety report. Issues included communication breakdowns (e.g. insufficient handoff, insufficient updates on patient condition, incorrect mode of communication which led to delays in care), admissions to incorrect teams, and admissions to locations ill-equipped to manage the patient’s acuity. Another challenge is the ambulatory facility, Dana-Farber Cancer Institute, and the admitting facility, Brigham and Women’s Hospital (BWH), are two different hospitals further complicating the admissions process. The goal was to streamline the urgent, same-day admission process, set expectations for the interdisciplinary teams involved, and determine a process to triage high acuity patients to the emergency department (ED) when warranted. Methods: The interdisciplinary workgroup identified gaps and pain points in the current state process. This collaborative effort led to new, streamlined workflows for key stakeholders in the process. New workflows were created for outpatient nurses, outpatient providers, and inpatient nurses. An important step in the new workflows revolves around establishing the rule that patients will be routed to the ED at 5pm if no bed will become available by clinic closing. This allows the patient to receive care quicker and triages the patient to the inpatient bed queue at an earlier point in the day. These workflows were posted in clinic and inpatient areas, distributed electronically, and presented in multiple team meetings. A new safety report event type, “Admissions from Clinic,” was created in the system to identify issues related to these processes. Results: From the date of implementation of the new workflows to the time of reporting (approximately 2.5 months), there have been 4 safety reports yielding a rate of 1.68% of direct admissions leading to safety reports. Most of these reports pertained to the bed tracking system not functioning properly leading to patients showing up to the inpatient floor before their bed was ready. Overall, the new workflows are functioning efficiently with no increase in the number of patients sent to the ED due to communication of bed availability at 5pm. Conclusions: Interdisciplinary collaboration involving key stakeholders in the direct admissions process from a cancer clinic to the inpatient setting, led to a reduction in safety reports generated regarding communication, patient safety and patient experience. There was no increase in patients being triaged to the ER at the end of the day.

Best practices for interdisciplinary care of uncontrolled severe asthma patients (TEAM project)

As one of the most prevalent chronic respiratory diseases, asthma imposes a heavy health and socioeconomic burden on society, particularly in the case of patients who fail to appropriately control the disease. For this reason, improving the clinical management of patients with severe uncontrolled asthma should be a priority for any healthcare system.At a time when healthcare models for chronic disease management and personalized medicine are undergoing a major overhaul, the project presented in this study seeks to lay the foundations for an interdisciplinary care model for patients with severe uncontrolled asthma. The work carried out reinforces the general perception that it is paramount to optimize coordination between different levels of care, encourage collaboration and an interdisciplinary approach, and promote an integrated care model that makes it possible to adapt the care of patients with severe uncontrolled asthma in a more personalized manner. Under this project, a series of interdisciplinary working groups were created, made up of specialist hospital pharmacists, pneumologists and allergists, to identify and prioritize a number of best practices, and classify them in terms of their potential impact on the improvement of the quality of care and the health outcomes of patients with severe uncontrolled asthma, and their feasibility. The authors’ ambition is that the conclusions drawn from this study should help other interdisciplinary teams improve the care provided to patients suffering from severe uncontrolled asthma.

Mental health promotion in the elderly in Slovenian local communities

Abstract Issue/problem Key issues in the elderly's mental health are: growing trends in mental disorders (dementia, depression), social exclusion with consequent lack of information, awareness and poorer access to prevention and assistance programs, discrimination, and high risk of poverty after retirement (especially in women). The public health challenge is to cope with these issues, as the share of the elderly population rapidly increases, also across European countries. Description of the problem According to the Resolution of the National Mental Health Program 2018-2028, and Action Plan 2021-2023, an interdisciplinary working group for mental health promotion among the elderly was established. Basic goals were prepared through regular meetings: adequately providing necessary information for the target population and enabling better networking of key actors in the field of mental health, including cooperation with existing networks. Specific activities ( >>Open hours for elderly << and >>Longevity society fairs <<) were implemented in the local communities. Results Twenty-one events, broadly promoted in the local communities, were realized. Different stakeholders were supported with developed materials (brochures, leaflets). A national conference on decreasing loneliness and social exclusion in the elderly was organized. Lessons Supportive environment for the empowerment of key actors and their continuous cooperation, could improve information flow, competencies, and inclusion of the target population in the local community and consequently decrease stigma. Despite pandemic measures, activities were realized, as recognized to be necessary. Regular financial support of less developed communities is a precondition for preventing inequities between communities. Key messages • A sensitized, empowered, connected, proactive and supported local community is a key for improving elderly's quality of life. • A connected and empowered local community is a precondition to prevent further stigmatization of the elderly.

Creation and Expansion of a Mixed Patient Intermediate Care Unit to Improve ICU Capacity.

ICU capacity strain is associated with worsened outcomes. Intermediate care units (IMCs) comprise one potential option to offload ICUs while providing appropriate care for intermediate acuity patients, but their impact on ICU capacity has not been thoroughly characterized. The aims of this study are to describe the creation of a medical-surgical IMC and assess how the IMC affected ICU capacity. Descriptive report with retrospective cohort review. Six hundred seventy-three-bed tertiary care academic medical center with 77 ICU beds. Adult inpatients who were admitted to the IMC. An interdisciplinary working group created an IMC which was located on a general ward. The IMC was staffed by hospitalists and surgeons and supported by critical care consultants. The initial maximum census was three, but this number increased to six in response to heightened critical care demand. IMC admission criteria also expanded to include advanced noninvasive respiratory support defined as patients requiring high-flow nasal cannula, noninvasive positive pressure ventilation, or mechanical ventilation in patients with tracheostomies. The primary outcome entailed the number of ICU bed-days saved. Adverse outcomes, including ICU transfer, intubation, and death, were also recorded. From August 2021 to July 2022, 230 patients were admitted to the IMC. The most frequent IMC indications were respiratory support for medical patients and post-operative care for surgical patients. A total of 1023 ICU bed-days were made available. Most patients were discharged from the IMC to a general ward, while 8% of all patients required transfer to an ICU within 48 hours of admission. Intubation (2%) and death (1%) occurred infrequently within 48 hours of admission. Respiratory support was the indication associated with the most ICU transfers. Despite a modest daily census, an IMC generated substantial ICU bed capacity during a time of peak critical care demand.

Nivolumab Switch Maintenance Therapy After Tyrosine Kinase Inhibitor Induction in Metastatic Renal Cell Carcinoma: A Randomized Clinical Trial by the Interdisciplinary Working Group on Renal Tumors of the German Cancer Society (NIVOSWITCH; AIO-NZK-0116ass)

BackgroundThe role of immune checkpoint inhibitor (ICI) maintenance therapy in metastatic renal cell carcinoma (mRCC) is undefined. ObjectiveTo determine whether switch maintenance therapy with nivolumab improves clinical outcomes in patients with mRCC with tyrosine kinase inhibitor (TKI) sensitivity. Design, setting, and participantsThis open-label phase 2 trial randomized patients with a partial response or stable disease after 10–12-wk TKI induction therapy to either TKI or nivolumab maintenance. Key inclusion criteria were measurable disease, clear cell histology, Eastern Cooperative Oncology Group performance status (ECOG PS) 0–2, and adequate organ function. InterventionIntravenous nivolumab 8 × 240 mg every 2 wk, followed by 480 mg every 4 wk or sunitinib 50 mg (4–2 regimen) or pazopanib 800 mg once daily orally. Outcome measurements and statistical analysesThe primary endpoint was overall survival (OS). Secondary endpoints were the objective response rate (ORR; Response Evaluation Criteria in Solid Tumors v1.1), progression-free survival (PFS), safety (Common Terminology Criteria for Adverse Events v4.03), and patient-reported outcomes (Functional Assessment of Cancer Therapy Kidney Symptom Index). The Kaplan-Meier method, two-sided log-rank tests, and Cox regression models were used for statistical analysis. Results and limitationsMaintenance therapy was nivolumab for 25 patients (51.0%) and TKI for 24 (48.9%). The median age was 65 yr (range 35–79). Nine patients (18.4%) were female, 31 (63.3%) had ECOG PS of 0, and 15 (30.6%) had favorable risk. OS data are immature (17 deaths, 34.7%). The ORR was 20.0% (n = 5) for nivolumab and 52.2% (n = 12) for TKI. PFS was worse with nivolumab (hazard ratio 2.57, 95% confidence interval 1.36–4.89; p = 0.003). Grade ≥3 adverse events occurred in 14 patients (56.0%) with nivolumab and 17 (70.8%) with TKI. A major limitation is early termination of our study. ConclusionsTKI treatment achieved superior ORR and PFS in comparison to nivolumab maintenance therapy. Our data do not indicate a role for nivolumab switch maintenance in mRCC. Patient summaryPatients with metastatic kidney cancer who experienced a tumor response or disease stabilization after a short period of targeted treatment with a tyrosine kinase inhibitor did not benefit from a switch to the immunotherapy drug nivolumab. Patients who continued their original treatment achieved better responses and a longer time without disease progression.This trial is registered on EudraCT as 2016-002170-13 and on ClinicalTrials.gov as NCT02959554.

An Integrated Process for Co-Developing and Implementing Written and Computable Clinical Practice Guidelines.

The goal of this article is to describe an integrated parallel process for the co-development of written and computable clinical practice guidelines (CPGs) to accelerate adoption and increase the impact of guideline recommendations in clinical practice. From February 2018 through December 2021, interdisciplinary work groups were formed after an initial Kaizen event and using expert consensus and available literature, produced a 12-phase integrated process (IP). The IP includes activities, resources, and iterative feedback loops for developing, implementing, disseminating, communicating, and evaluating CPGs. The IP incorporates guideline standards and informatics practices and clarifies how informaticians, implementers, health communicators, evaluators, and clinicians can help guideline developers throughout the development and implementation cycle to effectively co-develop written and computable guidelines. More efficient processes are essential to create actionable CPGs, disseminate and communicate recommendations to clinical end users, and evaluate CPG performance. Pilot testing is underway to determine how this IP expedites the implementation of CPGs into clinical practice and improves guideline uptake and health outcomes.

Improving the quality of the fracture liaison service through the implementation of a structured health record

ObjectiveAccording to the best practice framework for secondary fracture prevention, all patients aged ≥50 years with a fracture should be assessed for osteoporosis within the fracture liaison service (FLS). The...

Reduction of Chest Drain Overuse Through Implementation of a Pleural Drainage Order Set.

Small chest drains are used in many centers as the default drainage strategy for various pleural effusions. This can lead to drain overuse, which may be harmful. This study aimed to reduce chest drain overuse. We studied consecutive pleural procedures performed in the radiology department before (August 1, 2015, to July 31, 2016) and after intervention (September 1, 2019, to January 31, 2020). Chest drains were deemed indicated or not based on criteria established by a local interdisciplinary work group. The intervention consisted of a pleural drainage order set embedded in electronic medical records. It included indications for chest drain insertion, prespecified drain sizes for each indication, fluid analyses, and postprocedure radiography orders. Overall chest drain use and proportion of nonindicated drains were the outcomes of interest. We reviewed a total of 288 procedures (pre-intervention) and 155 procedures (post-intervention) (thoracentesis and drains). Order-set implementation led to a reduction in drain use (86.5% vs 54.8% of all procedures, P < .001) and reduction in drain insertions in the absence of an indication (from 45.4% to 29.4% of drains, P = .01). The need for repeat procedures did not increase after order-set implementation (22.0% pre vs 17.7% post, P = .40). Complication rates and length of hospital stay did not differ significantly after the intervention. More pleural infections were treated with drain sizes of 12Fr and greater (31 vs 70%, P < .001) after order-set deployment, and direct procedural costs were reduced by 27 CAN$ per procedure. Implementation of a pleural drainage order-set reduced chest drain use, improved procedure selection according to clinical needs, and reduced direct procedural costs. In institutions where small chest drains are used as the default drainage strategy for pleural effusions, this order set can reduce chest drain overuse.