Large Academic Medical Institution Research Articles

Abstract 3888: TOP1 mutations mediate cross resistance to ADCs in metastatic breast cancer

Abstract Background: Antibody-drug conjugates (ADCs) have improved survival for patients with metastatic breast cancer (MBC). In patients with HER2 negative MBC, two ADCs have FDA approval: sacituzumab govitecan (SG) and trastuzumab deruxtecan (T-DXd), both with topoisomerase-I (topo-I) inhibitor payloads. Given the many other ADCs in development, there is great interest in using ADC after ADC to maximize treatment benefit for patients. However, there is limited understanding regarding resistance mechanisms to ADCs and impact on ADC sequencing. We conducted a translational study to address this, and here we report the incidence of TOP1 mutations and clinical impact on ADC sequencing. Methods: All patients with MBC treated with ADCs at a large academic medical institution (Massachusetts General Hospital) who had comprehensive plasma-based genotyping (500 gene GuardantOMNI panel) were included. Since both SG and T-DXd have topo-I inhibitor-based payloads, we particularly focused on TOP1 mutations, variant allele frequency (VAF), and germline/somatic characterization. Incidence of TOP1 mutations in the ADC cohort was compared to The Cancer Genome Atlas (TCGA). Clinical “cross-resistance” was defined as progressive disease (PD) as best response to second ADC (ADC2) or treatment time on ADC2 of less than 60 days. Results: Based on comprehensive plasma-based genotyping we identified 4 distinct TOP1 mutations: S57C, R364H, W401C, G359E, at a frequency of 6.0% (4/67) at the time of disease progression on ADC compared to a frequency of 0.5% described in primary breast cancer in TCGA. Two of the amino acids found to be mutated are known to form direct interactions with the DNA backbone (G359) or the topoisomerase inhibitor itself (R364). For clinical resistance, one patient was briefly on ADC2 but stopped after 1 dose for toxicity; among the other 3 patients, two had cross-resistance to ADC after ADC, with both ADCs containing topo-I inhibitor payloads. Median duration on first ADC was 455 days compared to a median of 52 days for ADC2. Finally, one patient treated sequentially with 3 ADCs (all with topo-I inhibitor payloads) was found to have rising TOP1 VAF with progressive ADC treatments. Conclusion: This is the first report describing emergence of TOP1 mutations under selective pressure from ADCs and the impact on mediating cross-resistance to ADC after ADC with topo-I inhibitor payloads. Novel ADCs with alternative payloads may potentially be more effective when used sequentially after an ADC with a topo-I inhibitor. Further biomarker research is needed to optimize ADC sequencing for patients with TOP1 mutant MBC. Citation Format: Rachel Occhiogrosso Abelman, Haley Barnes, Arielle J. Medford, Annika Putur, Bogang Wu, Caroline Weipert, Geoffrey Fell, Laura M. Spring, Seth A. Wander, Beverly Moy, Andreas Varkaris, Dejan Juric, Leif Ellisen, Ryan Corcoran, Aditya Bardia. TOP1 mutations mediate cross resistance to ADCs in metastatic breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3888.

Identification of Choroidal Vascular Abnormalities in Patients with Hereditary Hemorrhagic Telangiectasia (HHT)

Purpose: To evaluate the frequency of ocular imaging in patients with HHT at a large academic medical institution; characterize the choroidal vascular changes on indocyanine green angiography (ICGA) and optical coherence tomography (OCT); and explore the relationship of these ocular features with HHT genotypes and systemic manifestations. Methods: Retrospective review of patients with HHT who were seen in the Mayo Clinic ophthalmology department between 2011 to 2021. Results: Of the 71 patients with HHT identified, 7 (10%) individuals had qualifying imaging defined as radial or raster spectral-domain OCT scans and/or ICGA. 4 (57%) patients had enlarged choroidal vessels detected on OCT and/or ICGA. 3 (43%) patients had retinal telangiectasias. Patients with choroidal changes (mean age 67 years) had the endoglin gene mutation, gastrointestinal arteriovenous malformations (AVM), and facial and mucocutaneous telangiectasias. In contrast, patients without choroidal changes (mean age 45 years) included the activin A receptor type-like kinase 1 gene mutation. Conclusion: Only a small proportion of patients with HHT undergo ophthalmic imaging at our institution. The presence of choroidal abnormalities is associated with the endoglin gene mutation, older age, corroborating retinal vascular changes, and increased systemic manifestations.

Evaluation of an Advanced Practice Provider Onboarding and Development Program.

To evaluate the impact of implementing a comprehensive secondary onboarding and development program within a hospital medicine group at a large tertiary academic medical institution. This was a mixed-methods study with physician and advanced practice providers (APPs) at an academic medical institution. For quantitative methods, improvement in competencies was determined using a pre-and posttest for APPs and pre- and postevaluation scores from collaborating physicians. APPs also participated in a pre- and post-self-assessment. For qualitative methods, experiences in the secondary onbo.arding and development program were assessed using semistructured interviews. For quantitative results, there were a total of 25 APPs who completed the pre- and posttest and were evaluated by at least 9 physicians. The average pretest score for APPs was 71.7% and the average posttest score was 83.0%. The average score for physicians' evaluations of APPs was 4.24/5 and increased to 4.38/5 in the postprogram evaluations. The average score for APP self-assessment pretraining was 3.52/5 and after the 12-month onboarding training, average scores increased to 3.84/5. For qualitative results, 4 APPs and 6 physicians were interviewed. Three of the APPs reported having more confidence in treating patients, whereas 1 APP viewed the program as a refresher course. All of the APPs mentioned that they would recommend the program to other APPs. Physicians reported that the program was beneficial in standardizing the care provided among the different types of APPs (physician assistants and nurse practitioners). All of the physicians also would recommend the program to other physicians and APPs.

Factors influencing second victim experiences and support needs of OB/GYN and pediatric healthcare professionals after adverse patient events

There is growing recognition that clinical and nonclinical healthcare professionals may become “second victims” following adverse patient events, medical errors, or patient-related injuries. In addition to the trauma-associated symptoms experienced by second victims, unprocessed second victim experience (SVE) can lead to burnout and leaving the healthcare workforce. To better understand the risk factors and support needs of affected healthcare professionals after a SVE, we conducted in-depth qualitative interviews with twelve staff in obstetrics & gynecology and pediatrics at a large academic medical institution in the upper Midwest of the U.S. Several participants indicated that it was not the patient outcome itself that precipitated the SVE, but associated factors such as moral distress or communication challenges. Participants discussed the role of their work unit culture in post-SVE processing, expressing that units perceived as blame-seeking or where adverse events were not openly discussed, hindered their recovery. While desired support mechanisms were individualized, participants stressed the importance of immediate and proactive support, such as through a peer support program, and long-term support mechanisms for lingering symptoms. As attrition of the healthcare workforce continues to be a significant concern, it is essential that we understand and meet the post-SVE support needs of affected staff, to promote holistic care following adverse patient events.

Characteristics of Sexual Assault Among Men Receiving a Forensic Medical Examination

ABSTRACT Sexual assault is a form of violence disproportionately perpetrated against women by men; however, men also experience high rates of sexual victimization. While recent research exploring victimization of sexual assault among men does exist, little is known about situational characteristics and consequences surrounding men’s assault experiences. Therefore, the current study examines narratives of men’s sexual assault to further understand the unique experiences of men receiving a sexual assault medical forensic examination. To accomplish this, we conducted a retrospective medical chart review of sexual assault narratives from N = 45 men receiving a sexual assault medical forensic examination at a large academic medical institution in the southeastern United States. Three general constructs were identified within the records: a) Perpetrator use of coercive tactics, b) Memory loss, and c) Contextual factors. Nested within these constructs, five specific themes emerged, including: a1) Use of weapons and physical force; a2) Tactical administration of alcohol and drugs; b1) Difficulties remembering assault; c1) Consensual sexual activity turned non-consensual; c2) Incarceration. Findings from the present study common identified characteristics of sexual assaults among men receiving a sexual assault medical forensic examination, including coercive tactics used by perpetrators, consequences of sexual assault, and high-risk settings for male victimization.

Preferred Feedback Styles Among Different Groups in an Academic Medical Center

IntroductionFeedback is an essential component in complex work environments. Different generations have been shown to have different sets of values, derived from societal and cultural changes. We hypothesize that generational differences may be associated with preferred feedback patterns among medical trainees and faculty in a large academic institution. MethodsA survey was distributed to all students, residents/fellows, and faculty at a large academic medical institution from April 2020 through June 2020. Survey questions evaluated feedback methods for six domains: preparedness, performance, attitude, technical procedures, inpatient, and outpatient care. Participants selected a preferred feedback method for each category. Patient demographics and survey responses were described using frequency statistics. We compared differences in feedback preferences based on generation and field of practice. ResultsA total of 871 participants completed the survey. Preferred feedback patterns in the medical field do not seem to align with sociologic theories of generational gaps. Most participants preferred to receive direct feedback after an activity away from their team, irrespective of their age or medical specialty. Individuals preferred direct feedback during an activity in front of their team only for technical procedures. Compared to nonsurgeons, surgeons were more likely to prefer direct feedback in front of team members for preparedness, performance, and attitude. ConclusionsGenerational membership is not significantly associated with preferred feedback patterns in this complex medical academic environment. Variations in feedback preferences are associated with field of practice that may be due to specialty-specific differences in culture and personality traits present within certain medical specialties, particularly surgery.

Analysis of Incidentally Found Proliferative Lesions in Oncoplastic and Macromastia Breast Reductions.

Reduction mammaplasty pathologic specimens can reveal incidentally found proliferative lesions. However, there is a lack of data investigating the comparative incidences and risk factors for such lesions. A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single large academic medical institution in a metropolitan city by two plastic surgeons over a 2-year period. All reduction mammaplasties, symmetrizing reductions, and oncoplastic reductions performed were included. There were no exclusion criteria. A total of 632 breasts were analyzed-502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions-in 342 patients. Mean age was 43.9 ± 15.9 years, mean body mass index was 29.2 ± 5.7 kg/m 2 , and mean reduction weight was 610.0 ± 313.1 g. Patients who underwent reduction mammaplasty for benign macromastia had a significantly lower incidence (3.6%) of incidentally found breast cancers and proliferative lesions compared with patients with oncoplastic reductions (13.3%) and symmetrizing reductions (17.6%) ( P < 0.001). On univariate analysis, personal history of breast cancer ( P < 0.001), first-degree family history of breast cancer ( P = 0.008), age ( P < 0.001), and tobacco use ( P = 0.033) were all statistically significant risk factors. Using a backward elimination stepwise reduced multivariable logistic regression model for risk factors associated with breast cancer or proliferative lesions, age ( P < 0.001) was the only retained significant risk factor. Proliferative lesions and carcinomas of the breast found in reduction mammaplasty pathologic specimens may be more common than previously reported. The incidence of newly found proliferative lesions was significantly lower in cases of benign macromastia compared with oncoplastic and symmetrizing reductions. Risk, II.

Adjuvant trastuzumab and vinorelbine for early-stage HER2+ breast cancer.

The single-arm phase II APT trial established trastuzumab and paclitaxel (TH) as the standard adjuvant regimen for small human epidermal growth factor receptor 2 (HER2+) tumors. However, paclitaxel causes alopecia and has high rates of neuropathy and hypersensitivity reactions. In patients with metastatic HER2+ breast cancer (BC), the combination of trastuzumab and vinorelbine (TV) is effective and well tolerated. There is a need for alternative non-anthracycline/taxane-based regimens for patients with HER2+ early-stage BC, especially for those with contraindications or who wish to avoid side effects of taxane-based regimens. Here we describe our institutional experience with adjuvant TV for patients with early-stage HER2+ BC. Clinicopathological characteristics, treatment details, and outcomes of patients with localized HER2+ BC treated with adjuvant TV from 2007 to 2021 at a large academic medical institution were collected. Study endpoints included invasive disease-free survival (IDFS), overall survival (OS), and safety/tolerability. IDFS and OS were measured from start date of TV treatment to date of event/last follow-up and date of death/last follow-up, respectively. A total of 30 patients were treated with TV. All patients received trastuzumab at standard dosing and vinorelbine at a starting dose of 25 mg/m2 either on days 1/8 or on days 1/8/21 (weekly) of a 21-day cycle with four planned cycles. Median age at diagnosis was 59 years (range: 36-81). 90.3% of patients had anatomic pathologic stage IA BC and 9.7% stage IIA BC. Of the 30 patients, 24 of them opted to pursue TV due to concerns related to alopecia, neuropathy, and other toxicities, and 6 switched from treatment with TH to TV due to toxicities. Eight patients experienced neutropenia with no cases of febrile neutropenia. No patients experienced alopecia or long-term neuropathy. With a median follow-up of 68 months (5.7 years), the 5-year IDFS rate was 90.9%, with one local and one distant recurrence. The 5-year OS was 100%. Trastuzumab in combination with vinorelbine in the adjuvant, early-stage setting for low-risk HER2+ BC demonstrated clinical efficacy and appeared to be well tolerated. TV warrants further evaluation as an alternative regimen to TH for patients with early-stage HER2+ BC.

Correction to: Prevalence and predictors of inappropriate apixaban dosing in patients with non‑valvular atrial fibrillation at a large tertiary academic medical institution

Correction to: Prevalence and predictors of inappropriate apixaban dosing in patients with non‑valvular atrial fibrillation at a large tertiary academic medical institution

Educational assessment of intrathoracic and extrathoracic surgical stabilization of rib fractures

BackgroundSurgical stabilization of rib fractures (SSRF) is being done with increased frequency and new advances. Intrathoracic SSRF is a new less invasive approach compared to the traditional extrathoracic plating procedure. Educational assessment can be done through descriptive analysis of learning curves with operation time used as a proxy measurement for learning. The objective of this level 3 observational cohort study is to assess the learning curve of introducing the intrathoracic method of plating at a large academic medical institution. MethodsIntrathoracic surgical stabilization of rib fractures was introduced at a tertiary trauma center in March of 2019. All patients that received SSRF beginning 11/2017 were included. Patients with abbreviated injury scale score of the head, abdomen, extremity, or face greater than three and days from injury to SSRF greater than 4 were excluded. Operation time was determined from time of incision to completion of skin closure. Time per fracture and time per plate were calculated using total operation time. Learning curves and CUSUM graphs for individual surgeons that had completed in more than 3 SSRF cases were generated using and trended for statistical significance. ResultsAfter exclusions, there were 38 patients with extrathoracic SSRF between November 2017–September 2021 and 24 patients with intrathoracic plating between March 2019–Sept. 2021. There were 5 fellows and 6 residents that performed extrathoracic SSRF. Four fellows and 2 residents performed intrathoracic SSRF. Graphs of time per fracture and time per plate over time produced learning curves without an inflection point for extrathoracic or intrathoracic SSRF in any of the following categories: all surgeries (Figs. 1 and 2), academic year (July to June), individual attending surgeons, fellows, or residents. ConclusionThere was no discernible inflection point on the generated learning curves. Time per plate and time per fracture did not decrease as surgeons gained more experience. Introducing intrathoracic SSRF in a large academic hospital may not need to account for a learning curve adjustment period.

Adjuvant trastuzumab and vinorelbine (TV) for early-stage HER2+ breast cancer.

e12521 Background: The anti-HER2 antibody trastuzumab has vastly improved outcomes for women with early stage and advanced HER2+ breast cancer (BC) when used in combination with chemotherapy. Anthracycline and taxane-based regimens have historically made up the chemotherapy backbone for patients with localized HER2+ BC, though recent evidence suggests anthracyclines can be safely omitted. The single arm phase II APT trial established trastuzumab and paclitaxel as the standard adjuvant regimen for small HER2+ tumors. However, paclitaxel requires weekly treatment, causes alopecia, and has high rates of neuropathy and hypersensitivity reactions. In patients with metastatic HER2+ BC, the combination of trastuzumab and vinorelbine (TV) is effective and well tolerated. There is a need for alternative regimens for patients with HER2+ early-stage BC, especially for those with contraindications to anthracycline and taxane-based regimens. We conducted a retrospective study of patients with early stage HER2+ BC treated with adjuvant TV to evaluate a non-anthracycline/taxane-based, alopecia-sparing regimen. Methods: Clinicopathological characteristics, treatment details, and outcomes of patients with localized HER2+ BC treated with adjuvant TV for from 2007 to 2021 at a large academic medical institution were collected. Study endpoints included invasive disease-free survival (IDFS), overall survival (OS), and safety/tolerability. IDFS and OS were measured from start date of TV treatment to date of event or last follow-up, respectively. 5-year survival rates were generated in GraphPad Prism. Results: A total of 25 patients were treated with TV. All patients received trastuzumab at standard dosing and vinorelbine at a starting dose of 25 mg/m2 on days 1/8 of a 21-day cycle with 4 planned cycles. Median age at diagnosis was 61 years (range: 36-81). 88% of patients had anatomic pathologic Stage IA BC and 12% Stage IIA BC. Of the 25 patients, 24 of them opted to pursue TV due to concerns over alopecia, neuropathy, and other toxicities while 1 patient had received prior adriamycin and therefore opted for TV. With a median follow-up time of 68 months (5.7 years), the 5-year rate of survival from invasive disease was 90.9%, with 1 local and 1 distant recurrence. The 5-year overall survival was 100%. 76% of patients completed 4 cycles of TV without dose holds or delays and 92% completed 4 cycles without dose reductions. 2 patients required hospitalization during treatment with TV due to toxicity (diarrhea attributed to V, rigors/fever attributed to T). No patients experienced alopecia or long-term neuropathy. Conclusions: Trastuzumab in combination with vinorelbine in the adjuvant, early-stage setting for HER2+ BC is effective and well-tolerated and warrants further exploration as an alternative to taxane-based regimen.

Diagnoses per Encounter by Telephone, Televideo, and In-Office Visits.

We sought to determine if there are differences between number of International Classification of Disease-10 (ICD-10) codes per visit before and after COVID-19 when comparing in-office visits and between telemedicine vs in-office visits, toward the goal of determining value of telemedicine visits relative to in-office visits. We did a chart review study assessing the number of ICD-10 codes noted by providers at a large academic medical institution in 2019 and 2020. Only in-office visits were reviewed in 2019. The focus of analysis was on individual patient visits per visit type; however, a subset of patients who had visits in both 2019 and 2020 were also analyzed. We compared mean number of diagnoses for encounter types using encounter, billing and coding data. We analyzed 211,829 patient encounters. For 2020, 73% were in office. Mean number of diagnoses per encounter for 2019 was 2.65 (in office only), compared with 3.04 in office, 2.76 telephone, and 2.48 televideo for 2020. We found an increase in the number of diagnoses addressed during in-office visits from 2019 to 2020. When looking at diagnoses managed per visit, all 3 types of visits had similar complexity. These results may guide future reimbursement policy for telemedicine visits.

Use of provider education, intra-operative decision support, and an email-feedback system in improving compliance with sugammadex dosage guideline and reducing drug expenditures

Study objectiveDue to excessive sugammadex expenditures at our institution, we designed dosing guidelines that utilize adjusted body weight and informatics-based tools aimed at reducing variability in dosing practices. DesignWe retrospectively reviewed rates of high-dose sugammadex administration in three phases: Pre-intervention - May 2018 to November 2018; First intervention - November 2018 to April 2019; and Second intervention - April 2019 to July 2019. SettingAcademic medical center in the United States - Vanderbilt University Medical Center (VUMC) PatientsN/A InterventionsFirst, anesthesia providers were educated on adjusted body weight-based dosing guidelines. Providers also received intraoperative decision support displaying a patient's actual and adjusted body weight along with rates of high-dose (>200 mg) sugammadex administration for each respective provider. Second, we implemented an email-feedback system to remind providers of the new guidelines. MeasurementsWeekly rate of high-dose sugammadex cases. Main resultsDuring the pre-intervention stage, 1556 (12.3%) cases involved high-dose sugammadex. Comparatively, 550 (4.3%) and 187 (3.1%) high-dose sugammadex cases occurred during the first and second intervention stages, respectively. Segmented regression analysis demonstrated a significant rate change of −3.51% (95% CI: −5.64%, −1.38%) in sugammadex dosing practices after provider education and the implementation of digital improvement initiatives but failed to reveal a significant change after implementation of the email-feedback system. Overall, our interventions were associated with $2563.05 in estimated weekly savings of sugammadex expenditures. ConclusionsProvider education and digital quality improvement was associated with reduced rates of high-dose sugammadex administration, generating cost savings at a large academic medical institution.

Diversity Matters: A 21-Year Review of Trends in Resident Recruitment into Surgical Specialties.

Diversity within the healthcare workforce is essential to improve quality of care, although evaluation of diversity within surgical training remains limited. This study analyzed diversity in recruitment of residents into surgical subspecialties at a large academic medical institution and national trends. A 21-year cross-sectional study of medical school graduates accepted into all surgical subspecialty training programs was performed. The institutional cohort was divided into two groups (1997-2006, 2007-2017). Subspecialty acceptance rates were determined between 2011 and 2018. Data on candidate demographics including gender, race, ethnicity, citizenship, and origin of medical education at a single institution and nationally were extracted. Two thousand found hundred seventy-two residents were included in this study. From 1997 to 2018, female acceptances increased from 21.1% to 29.7% (p < 0.01), non-White increased from 27.9% to 31.8% (p = 0.01), and international medical graduates decreased from 28.8% to 25.5% (p = 0.02). There was no significant change in accepted Hispanic and Non-US candidates. Female subspecialty rates for subspecialties increased nationally and was comparable to our cohort, except in general surgery. Hispanic subspecialty acceptance rates were less than 10% and Black/African American acceptance rates remained less than 5% across subspecialties nationally and at our institution. Diversity in surgical training has modestly progressed over the last two decades, but the degree of positive change has not been universal and highlights the critical need for improvement and action. Continued institution driven and collaborative strategies are essential to promote diversity in recruitment across all surgical specialties that has implications on our future workforce and surgical leadership.

31.6 Burnout and Depression Among Residents and Faculty in a Single Academic Medical Institution: A Pilot Study

Burnout is defined as a long-term, unresolvable job stress leading to feelings of exhaustion, overwhelm, cynicism, detachment from job, and a lack of sense of personal accomplishment. Medscape Physician Burnout surveys have shown that over 40% of physicians report burnout. There is a scarcity of studies that investigated the association between physician burnout and depression. Our study aimed to investigate this association and to compare this association's changes by groups of interest. The Maslach Burnout Inventory (MBI) and Quick Inventory of Depressive Symptomatology–Self Report (QIDS-SR) were used to assess burnout (N = 168) and depression (N = 167) among faculty and trainees (residents and fellows) in Psychiatry and Pediatrics at a large academic medical institution in the Southeast. The 3 subscale scores of MBI (emotional exhaustion [EE], depersonalization [DP], and personal accomplishment [PA]) and QIDS-SR scores were analyzed between trainees vs faculty, race, gender, and specialty. χ2 and Fischer’s exact tests were used to determine statistical significance of categorical association. Approximately 28% of faculty and trainees had high EE, and trainees reported nearly twice as much moderate EE than faculty (18.75% vs 39.29%). Trainees had high DP compared to faculty (41.07% vs 12.5%), and more psychiatrists reported high DP than pediatricians (35.81% vs 12.87). Notably, African American physicians reported a higher rate of depression than White physicians and physicians of other races (14.29% vs 11.11% and 11.9%, respectively) with no difference in depression rates between faculty and residents, by specialty, or by gender. Eleven percent of trainees and 14% of faculty reported clinically significant depression. There was significant correlation between burnout and depression (p < 0.0001). Physicians in training were twice as likely to experience burnout. High burnout is a predictor of clinically significant depression. Although this is a pilot study with only 2 specialties, the rate of depression is found to be higher (11%-14%) than the general population (7.1%). Creating a better understanding of the interrelationships among these measures can increase awareness among the physician community, which may help identify burnout early, seek help, and prevent serious downstream effects such as anxiety, depression, and suicide.

Glycemic Variability With Insulin Glargine Versus Detemir in Hospitalized Patients With Diabetes

Background: Prior research has demonstrated increased mortality with increasing glycemic variability (GV) in hospitalized patients with diabetes. Objective: We aimed to compare glycemic variability (GV) of insulin glargine to detemir in the inpatient setting. Methods: This single-center, retrospective, cohort study evaluated noncritically ill patients with diabetes on long-acting insulin at a large academic medical institution between 2010 and 2017. This study was reviewed and approved by the Institutional Review Board. The formulary transitioned from insulin glargine to detemir in December 2013; therefore, patients were compared before and after transition. The primary endpoint was to compare coefficient of variation (CV), a measure of GV, between detemir and glargine. Secondary endpoints included GV measured by standard deviation (SD), CV within 72 hours of long-acting insulin initiation, length-of-stay (LOS), in-hospital mortality, and comparison between subgroups. Results: 2334 patients were included in the study, and there were 1167 in each group. CV was significantly less variable with detemir compared to glargine (33.7% versus 34.8%, difference = 1.09, p = 0.02) and remained significant after controlling for confounders. Similarly, SD was significantly less with detemir (p = 0.048). CV within 72 hours, LOS, and in-hospital mortality were not statistically different. Lastly, GV was higher in medical patients compared to surgical. Conclusion: Insulin detemir exhibited less GV than insulin glargine, although the small difference is unlikely to be clinically significant. Application of this data will aid in formulary decisions and support the use of either agent within the hospital setting.

Impact of Duration of N-Acetylcysteine in Non-Acetaminophen-Induced Acute Liver Failure.

Studies of the use of IV N-acetylcysteine in the management of non-acetaminophen-induced acute liver failure have evaluated various dosing regimens. The only randomized trial studying this application described a 72-hour regimen. However, observational studies have reported extended duration until normalization of international normalized ratio. This study seeks to compare differences in patient outcomes based on IV N-acetylcysteine duration. Retrospective cohort study. Medical ICU at a large quaternary care academic medical institution and liver transplant center. Adult patients admitted to the medical ICU who received IV N-acetylcysteine for the treatment of non-acetaminophen-induced acute liver failure. Patients were divided into cohorts based on duration; standard duration of IV N-acetylcysteine was considered 72 hours, whereas extended duration was defined as continuation beyond 72 hours. The primary outcome was time to normalization of international normalized ratio to less than 1.3 or less than 1.5; secondary outcomes included all-cause mortality and transplant-free survival at 3 weeks. In total, 53 patients were included: 40 in the standard duration cohort and 13 in the extended duration. There were no major differences in baseline characteristics. There was no significant difference in time to international normalized ratio normalization between cohorts. Transplant-free survival was higher with extended duration (76.9% extended vs 41.4% standard; p = 0.03). All-cause mortality at 3 weeks was numerically lower in the extended duration group (0% extended vs 24.1% standard; p = 0.08). Patients with non-acetaminophen-induced acute liver failure who received extended duration N-acetylcysteine were found to have significantly higher transplant-free survival than patients who received standard duration, although there was no significant difference in time to normalization of international normalized ratio or overall survival. Prospective, randomized, multicenter study is warranted to identify subpopulations of patients with non-acetaminophen-induced acute liver failure who could benefit from extended treatment duration as a bridge to transplant or spontaneous recovery.

Hemoglobin Monitoring in Acute Gastrointestinal Bleeding: Are We Monitoring Blood Counts Too Frequently?

BackgroundGastrointestinal hemorrhage is a common cause of hospital admission. However, there are little data to inform practice around blood count monitoring—a cornerstone of management. We hypothesized that more frequent testing leads to increased resource utilization without improvement in patient outcomes. MethodsThis retrospective observational cohort study examined all patients admitted to a large academic medical institution primarily for gastrointestinal bleeding between July 10, 2014, and January 1, 2018. We identified 1150 patients admitted for gastrointestinal hemorrhage. Patients under 18, who developed bleeding while hospitalized, or who were transferred were excluded. The primary outcome was the number of complete blood counts collected in the first 48 hours of admission. Propensity matched analysis was performed to assess blood transfusion, units of blood transfused, time-to-endoscopy, mortality, and 30-day readmission rate. ResultsOn average, 5.6 complete blood counts were collected in the first 48 hours; 67% of the cohort was transfused (average of 2.6 units of packed red blood cells). When matched for comorbidity, anticoagulant use, location (ward vs. intensive care unit), vital signs, hemoglobin level, and international normalized ratio, patients having more frequent monitoring had similar hospital length of stay and mortality rates, but were more likely to receive a blood transfusion (0.93 vs 0.76, P < .05), and if transfused, receive more blood (4 vs 2 units, P < .05). ConclusionsBlood count monitoring occurs more frequently than is likely necessary, is associated with a higher likelihood of blood transfusion, and does not affect patient outcomes, suggesting patient care may be improved by less frequent monitoring.

Corticosteroid Exposure in the Treatment of Severe COPD Exacerbations

Background: Recent literature and guidelines support treatment of severe acute exacerbation of COPD (AECOPD) with prednisone 40 mg (or equivalent) for 5 days. Objective: The purpose of this study was to determine whether systemic corticosteroids were being prescribed at the appropriate dose and duration in the treatment of severe AECOPD at a large academic medical institution. Methods: This was a single-center, retrospective, observational study conducted to evaluate corticosteroid prescribing patterns for adults admitted for severe AECOPD from March to May 2019 at a large academic medical institution. Appropriate therapy was defined as: prednisone 40 mg (or equivalent) for 5 days. The primary outcome was to determine the frequency of appropriate dose and duration. The secondary outcomes were to identify the frequency of appropriate dose or duration, compare the prevalence of adverse effects, such as new/worsening hyperglycemia or hypertension, and compare 30- and 90-day readmission rates. Results: Of the 190 patients included, 16 (8.4%) had an appropriate duration and 8 (4.2%) an appropriate dose. Only 4 patients (2.1%) had both appropriate corticosteroid dose and duration. New/worsening hyperglycemia occurred in 96 (50.5%), and hypertension developed in 13 (6.8%). Thirty-day readmission occurred in 46 (24.2%) and 90-day readmission in 78 (41.1%). These were more likely in those without appropriate dose and duration. Conclusion: Systemic corticosteroids for the treatment of severe AECOPD are not prescribed in accordance with evidence-based recommendations at this institution. This might result in a greater incidence of adverse effects and readmissions.

Secondary Traumatic Stress in Ob-Gyn: A Mixed Methods Analysis Assessing Physician Impact and Needs

This study aims to evaluate the incidence of secondary traumatic stress in Obstetrics and Gynecology physicians including symptoms, impact, and programmatic needs for support. This study used a mixed-methods approach comprised of an anonymous online survey and individual interviews/focus groups. IBM SPSS 24.0 generated statistical analysis: descriptive statistics, Fisher's exact test to compare nominal survey data and across groups, phi correlations (ϕ) and interitem reliability (Cronbach alpha). Constant comparative qualitative analysis determined cross-cutting themes. Research was approved by institutional IRB. This study was conducted at the Medical College of Wisconsin, Milwaukee, Wisconsin, a large academic medical institution. Participants were recruited from the Department of Obstetrics & Gynecology via email. Faculty, fellows, and residents participated in an anonymous online survey and were invited to complete individual interviews or focus groups. The online survey was distributed to 67 clinical faculty, residents, and fellows with a total of 27 individuals completing the reliable (alpha = 0.71) anonymous survey (40% response rate). Ten faculty participated in individual interviews or focus groups. Respondents to the quantitative survey identified involvement in adverse medical events (95%) and symptoms of traumatic stress (75%). Anxiety (81%), guilt (62%), and disrupted sleep (58%) were most frequently reported symptoms (mean number of symptoms = (3.4(±2.1)). Individuals reporting anxiety were more likely to seek support from colleagues (ϕ = 0.5, p < 0.006); those reporting guilt would go to friends (ϕ = 0.5, p < 0.007). Disrupted sleep more commonly led to seeking mental health services (ϕ = 0.5, p < 0.007). Desire for support varied. Those reporting anxiety were interested in peer-to-peer responders (ϕ = 0.6, p < 0.001); those reporting guilt would use debriefing sessions (ϕ = 0.4, p < 0.023). Qualitative data from individual interviews and focus groups yielded descriptions of physical and cognitive symptoms associated with second victim experiences included responsibility, guilt/shame, self-doubt, anxiety/rumination and sleep disturbance. Identified resources for coping: just culture, collegial support, peer-to-peer responders, and structured case conferences for emotional debriefing. Obstetrics and Gynecology providers are likely to experience symptoms of secondary traumatic stress following adverse patient events similar to other medical specialties. Comprehensive programs to address emotional well-being of physicians are important to promote collegiality and reduce symptoms of secondary traumatic stress. Safety and transparency with opportunities for group processing are identified as essentials for positive institutional culture, as well as peer support programs.