US Academic Medical Centers Research Articles

Outcomes and Treatment Patterns in Patients with Aggressive B-Cell Lymphoma after Failure of Anti-CD19 CAR T-Cell Therapy

Outcomes and Treatment Patterns in Patients with Aggressive B-Cell Lymphoma after Failure of Anti-CD19 CAR T-Cell Therapy

Analysis of Outcomes and Predictors of Response in Patients with Relapsed Mantle Cell Lymphoma Treated with Brexucabtagene Autoleucel

Analysis of Outcomes and Predictors of Response in Patients with Relapsed Mantle Cell Lymphoma Treated with Brexucabtagene Autoleucel

Impact of Molecular Features of Diffuse Large B-Cell Lymphoma on Treatment Outcomes with Anti-CD19 Chimeric Antigen Receptor (CAR) T-Cell Therapy

Impact of Molecular Features of Diffuse Large B-Cell Lymphoma on Treatment Outcomes with Anti-CD19 Chimeric Antigen Receptor (CAR) T-Cell Therapy

Factors Associated With Adherence to Outpatient Follow-Up in Patients With Idiopathic Intracranial Hypertension (IIH).

Idiopathic intracranial hypertension (IIH) is a chronic condition characterized by raised intracranial pressure of undetectable origin, that causes morbidity due to debilitating headaches and vision loss. Continuity of outpatient care is important to monitor for permanent vision loss, manage symptoms and limit emergency care. The purpose of this retrospective study was to identify factors associated with neuro-ophthalmology follow-up appointment completion among patients with IIH at a US academic medical center in order to establish evidence-based interventions to improve adherence patterns. Included are 111 completed or no-show neuro-ophthalmology return outpatient appointments by 23 subjects with IIH. Generalized estimating equation models were used to assess association between appointment completion status and factors previously shown to be associated with appointment adherence. Appointments were more likely to be completed during the summer (p=0.08) and by subjects with headache symptoms (p=0.06), however none of the patient factors reached statistical significance. Completed and no-show appointments did not differ by subject demographic or insurance factors. Further studies are needed to identify risk factors for lack of appointment adherence by patients with IIH, particularly those amenable to intervention, in order to improve continuity of care for IIH.

Cirrhosis Inpatients Receive More Opioids and Fewer Nonopioid Analgesics Than Patients Without Cirrhosis.

Pain is common among cirrhosis patients, particularly those hospitalized with acute illness. Managing pain in this population is challenging due to concern for adverse events and lack of guidelines for analgesic use. We sought to characterize analgesic use among inpatients with cirrhosis compared with matched noncirrhosis controls, as well as hospital-level variation in prescribing patterns. We utilized the Vizient Clinical Database, which includes clinical and billing data from hospitalizations at >500 US academic medical centers. We identified cirrhosis patients hospitalized in 2017-2018, and a matched cohort of noncirrhosis patients. Types of analgesic given-acetaminophen (APAP), nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and adjuvants (eg, gabapentinoids, antidepressants) were defined from inpatient prescription records. Conditional logistic regression was used to associate cirrhosis diagnosis with analgesic use. Of 116,363 cirrhosis inpatients, 83% received at least 1 dose of an analgesic and 58% had regular inpatient analgesic use, rates that were clinically similar to noncirrhosis controls. Cirrhosis inpatients were half as likely to receive APAP (26% vs. 42%, P <0.01) or NSAIDs (3% vs. 7%, P <0.01), but were more likely to receive opioids (59% vs. 54%, P <0.01), particularly decompensated patients (60%). There was notable variation in analgesic prescribing patterns between hospitals, especially among cirrhosis patients. Analgesic use was common among inpatients, with similar rates among patients with and without cirrhosis. Cirrhosis patients-particularly decompensated patients-were less likely to receive APAP and NSAIDs and more likely to receive opioid analgesics. Because of lack of evidence-based guidance for management of cirrhosis patients with pain, providers may avoid nonopioid analgesics due to perceived risks and consequently may overutilize opioids in this high-risk population.

Comparison of one-year survival prediction tools in patients with advanced heart failure

Abstract Background Predicting survival in patients with advanced heart failure (HF) remains difficult and prognostic scores such as the Seattle Heart Failure Model (SHFM) are cumbersome to use. Alternative approaches like the Surprise Question (SC) or the number of HF hospitalisations within the last year (NoH) could simplify prognostication. Purpose We assessed the prognostic utility of the SHFM, SC and NoH for predicting one-year survival status in patients with advanced HF. Methods A secondary analysis of a multisite, single-blinded cluster-randomized, controlled trial to test whether a structured intervention of educational content and automated reminders increased the likelihood of ICD deactivation conversations and ICD deactivation. The study was performed within the advanced HF practices at six US academic medical centers, between September 2011 to February 2016. Patient eligibility criteria included advanced HF, an implantable cardiac defibrillator and a high risk of death, with complete data on SHFM, SC, NoH and one-year survival status. SHFM survival was calculated from baseline variables; the SC (“Would you be surprised if the patient were to die within one year?”) was answered by cardiologists; and the NoH was extracted from medical records. For prediction of survival status, cut-offs for predicted survival per SHFM and NoH were chosen empirically by means of receiver operating characteristic (ROC) curve analysis maximising Youden's index. The resulting binary prediction models were assessed based on area under the ROC curve (AUC), sensitivity and specificity. Results Of the 535 subjects in our sample, 82 (15.3%) had died after one-year of follow-up. For the SHFM and the NoH, optimal cut-offs were found to be a predicted survival &amp;lt;86% and ≥2 hospitalisations, respectively. Performance metrics of prognostic models are detailed in Table 1. The SHFM yielded an AUC of 0.65 (0.60–0.71 95% confidence interval [CI]), a sensitivity of 0.76 (0.65–0.84 95% CI), and a specificity of 0.55 (0.50–0.60 95% CI). The SC demonstrated a comparable AUC 0.58 (0.54–0.63 95% CI), similar sensitivity 0.84 (0.74–0.91 95% CI), but lower specificity 0.33 (0.28–0.37 95% CI) compared to the SHFM. The NoH demonstrated a comparable AUC 0.56 (0.50–0.62 95% CI), similar sensitivity 0.56 (0.45–0.67 95% CI), and similar specificity 0.56 (0.51–0.61 95% CI) compared to the SHFM. The combination of positive SC and NoH ≥2 showed significantly higher specificity compared to the SHFM (0.68 [0.64–0.73 95% CI]). Conclusion The SC and NoH are clinically feasible bedside alternatives to the more complex SHFM model, yet yield similar overall prognostic utility for one-year survival status among advanced HF patients. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart, Lung, and Blood Institute

8.4 OUTCOMES OF YOUTH TREATED WITH ECT

The use of ECT in children and adolescents is based on a limited evidence base in the medical literature. Our objective is to review the available evidence for the safety and efficacy of ECT in pediatric patients with refractory mental health disorders. In this session, we review the available high-quality literature of ECT use in pediatric patients. We emphasize a recent study of youth treated with ECT at a single US academic medical center. Using a retrospective chart review, clinical outcomes from all patients aged 18 years and younger who received ECT at the University of Utah from 1985 through 2016 were assessed. For each patient record, 3 short-term clinical outcomes were evaluated: 1) response on the Clinical Global Impression-Improvement (CGI-I) scale; 2) number of treatments administered; and 3) reported side effects. Baseline characteristics were tested as predictors of clinical outcomes. A total of 107 youth (ages 10-18 years; 46% female) received ECT for a mood disorder, psychotic disorder, catatonia, or neuroleptic malignant syndrome. Mood disorders represented the most common diagnoses (DSM-IV-TR or DSM-5), including MDD (76 patients, 71% of the sample) and bipolar disorder (23 patients, 21% of the sample). The rate of response (much improved or very much improved) for the entire cohort was 77%. The mean number of treatments administered was 10.5. The most commonly reported side effects were headache (75%) and memory problems (65%). Although one patient experienced tardive seizures, there were no deaths or serious injuries. Clinical response was not predicted by age, sex, or clinical features. These data suggest that ECT is a safe and effective treatment for children and adolescents with certain severe mental illnesses. ECT outcomes and side effects were similar to those reported in adults, particularly for patients aged 15 to 18 years, for whom there are the most data. Despite its utility, ECT continues to suffer from considerable stigma, and access to ECT for pediatric patients is often challenging. Important areas for future development include increased dissemination of ECT outcomes, examination of predictors of treatment response in larger cohorts, and public advocacy to improve timely and equitable access to care for pediatric patients in need.

Accuracy of the Veterans Health Administration COVID-19 (VACO) Index for predicting short-term mortality among 1307 US academic medical centre inpatients and 427 224 US Medicare patients

BackgroundThe Veterans Health Administration COVID-19 (VACO) Index predicts 30-day all-cause mortality in patients with COVID-19 using age, sex and pre-existing comorbidity diagnoses. The VACO Index was initially developed and validated...

Effect of Whole-Genome Sequencing on the Clinical Management of Acutely Ill Infants With Suspected Genetic Disease

Whole-genome sequencing (WGS) shows promise as a first-line genetic test for acutely ill infants, but widespread adoption and implementation requires evidence of an effect on clinical management. To determine the effect of WGS on clinical management in a racially and ethnically diverse and geographically distributed population of acutely ill infants in the US. This randomized, time-delayed clinical trial enrolled participants from September 11, 2017, to April 30, 2019, with an observation period extending to July 2, 2019. The study was conducted at 5 US academic medical centers and affiliated children's hospitals. Participants included infants aged between 0 and 120 days who were admitted to an intensive care unit with a suspected genetic disease. Data were analyzed from January 14 to August 20, 2020. Patients were randomized to receive clinical WGS results 15 days (early) or 60 days (delayed) after enrollment, with the observation period extending to 90 days. Usual care was continued throughout the study. The main outcome was the difference in the proportion of infants in the early and delayed groups who received a change of management (COM) 60 days after enrollment. Additional outcome measures included WGS diagnostic efficacy, within-group COM at 90 days, length of hospital stay, and mortality. A total of 354 infants were randomized to the early (n = 176) or delayed (n = 178) arms. The mean participant age was 15 days (IQR, 7-32 days); 201 participants (56.8%) were boys; 19 (5.4%) were Asian; 47 (13.3%) were Black; 250 (70.6%) were White; and 38 (10.7%) were of other race. At 60 days, twice as many infants in the early group vs the delayed group received a COM (34 of 161 [21.1%; 95% CI, 15.1%-28.2%] vs 17 of 165 [10.3%; 95% CI, 6.1%-16.0%]; P = .009; odds ratio, 2.3; 95% CI, 1.22-4.32) and a molecular diagnosis (55 of 176 [31.0%; 95% CI, 24.5%-38.7%] vs 27 of 178 [15.0%; 95% CI, 10.2%-21.3%]; P < .001). At 90 days, the delayed group showed a doubling of COM (to 45 of 161 [28.0%; 95% CI, 21.2%-35.6%]) and diagnostic efficacy (to 56 of 178 [31.0%; 95% CI, 24.7%-38.8%]). The most frequent COMs across the observation window were subspecialty referrals (39 of 354; 11%), surgery or other invasive procedures (17 of 354; 4%), condition-specific medications (9 of 354; 2%), or other supportive alterations in medication (12 of 354; 3%). No differences in length of stay or survival were observed. In this randomized clinical trial, for acutely ill infants in an intensive care unit, introduction of WGS was associated with a significant increase in focused clinical management compared with usual care. Access to first-line WGS may reduce health care disparities by enabling diagnostic equity. These data support WGS adoption and implementation in this population. ClinicalTrials.gov Identifier: NCT03290469.

Multicenter analysis of geriatric fitness and real-world outcomes in older patients with classical Hodgkin lymphoma

AbstractWe performed a multicenter retrospective analysis across 10 US academic medical centers to evaluate treatment patterns and outcomes in patients age ≥60 years with classic Hodgkin lymphoma (cHL) from 2010-2018. Among 244 eligible patients, median age was 68, 63% had advanced stage (III/IV), 96% had Eastern Cooperative Oncology Group performance status (PS) 0-2, and 12% had documented loss of ≥1 activity of daily living (ADL). Medical comorbidities were assessed by the Cumulative Illness Rating Scale–Geriatric (CIRS-G), where n = 44 (18%) had total scores ≥10. Using multivariable Cox models, only ADL loss predicted shorter progression-free (PFS; hazard ratio [HR] 2.13, P = .007) and overall survival (OS; HR 2.52, P = .02). Most patients (n = 203, 83%) received conventional chemotherapy regimens, including doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD; 56%), AVD (14%), and AVD with brentuximab vedotin (BV; 9%). Compared to alternative therapies, conventional regimens significantly improved PFS (HR 0.46, P = .0007) and OS (HR 0.31, P = .0003). Survival was similar following conventional chemotherapy in those ages 60-69 vs ≥70: PFS HR 0.88, P = .63; OS HR 0.73, P = .55. Early treatment discontinuation due to toxicity was more common with CIRS-G ≥10 (28% vs 12%, P = .016) or documented geriatric syndrome (28% vs 13%, P = .02). A competing risk analysis demonstrated improved disease-related survival with conventional therapy (HR 0.29, P = .02) and higher mortality from causes other than disease or treatment with high CIRS-G or geriatric syndromes. This study suggests conventional chemotherapy regimens remain a standard of care in fit older patients with cHL, and highlights the importance of geriatric assessments in defining fitness for cHL therapy going forward.

Critical Success Factors for Addressing Discharge Inefficiency at a Large Academic Medical Center: A Lean Six Sigma Approach.

Delayed discharges can be a systemic issue. Understanding the systemic factors that contribute to discharge inefficiencies is essential to addressing discharge inefficiencies. This article reports on a Lean Six Sigma approach and the process to identifying inefficiencies and systemic barriers to early discharge in a large US academic medical center. A qualitative methodology guided this project. In particular, direct observation methods were used to help the project team identify factors contributing to discharge inefficiencies. Overall, findings suggest that establishing consistent multidisciplinary team communication processes was a contributing factor to reducing the inefficiencies around discharges. On a more granular level, key barriers included disparate communication systems, disruptors (specifically Kaizen bursts), and unique role challenges. This article provides a framework for addressing discharge inefficiencies. Because the output of the process, a critical contributor to the overall outcome, is often not analyzed, this analysis provides value to others contemplating the same or similar process toward discharge efficiency.

Characteristics and Outcomes of Women With COVID-19 Giving Birth at US Academic Centers During the COVID-19 Pandemic

Prior studies on COVID-19 and pregnancy have reported higher rates of cesarean delivery and preterm birth and increased morbidity and mortality. Additional data encompassing a longer time period are needed. To examine characteristics and outcomes of a large US cohort of women who underwent childbirth with vs without COVID-19. This cohort study compared characteristics and outcomes of women (age ≥18 years) who underwent childbirth with vs without COVID-19 between March 1, 2020, and February 28, 2021, at 499 US academic medical centers or community affiliates. Follow-up was limited to in-hospital course and discharge destination. Childbirth was defined by clinical classification software procedural codes of 134-137. A diagnosis of COVID-19 was identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis of U07.1. Data were analyzed from April 1 to April 30, 2021. The presence of a COVID-19 diagnosis using ICD-10. Analyses compared demographic characteristics, gestational age, and comorbidities. The primary outcome was in-hospital mortality. Secondary outcomes included hospital length of stay, intensive care unit (ICU) admission, mechanical ventilation, and discharge status. Continuous variables were analyzed using t test, and categorical variables were analyzed using χ2. Among 869 079 women, 18 715 (2.2%) had COVID-19, and 850 364 (97.8%) did not. Most women were aged 18 to 30 years (11 550 women with COVID-19 [61.7%]; 447 534 women without COVID-19 [52.6%]) and were White (8060 White women [43.1%] in the COVID-19 cohort; 499 501 White women (58.7%) in the non-COVID-19 cohort). There was no significant increase in cesarean delivery among women with COVID-19 (6088 women [32.5%] vs 273 810 women [32.3%]; P = .57). Women with COVID-19 were more likely to have preterm birth (3072 women [16.4%] vs 97 967 women [11.5%]; P < .001). Women giving birth with COVID-19, compared with women without COVID-19, had significantly higher rates of ICU admission (977 women [5.2%] vs 7943 women [0.9%]; odds ratio [OR], 5.84 [95% CI, 5.46-6.25]; P < .001), respiratory intubation and mechanical ventilation (275 women [1.5%] vs 884 women [0.1%]; OR, 14.33 [95% CI, 12.50-16.42]; P < .001), and in-hospital mortality (24 women [0.1%] vs 71 [<0.01%]; OR, 15.38 [95% CI, 9.68-24.43]; P < .001). This retrospective cohort study found that women with COVID-19 giving birth had higher rates of mortality, intubation, ICU admission, and preterm birth than women without COVID-19.

Implementation of a text-based postpartum blood pressure monitoring program at 3 different academic sites

Up to 30% of patients with hypertensive disorders of pregnancy continue to have elevated blood pressures after delivery, often necessitating medication titration or hospital evaluation in the weeks following hospital discharge. A previous randomized controlled trial demonstrated that remote blood pressure monitoring programs led to an increase in the number of blood pressure measurements obtained and increased compliance with clinical guidelines regarding the monitoring of patients for persistent or worsening postpartum hypertension. The aims of this study were to measure the program participant response rates during the first 10 days after hospital discharge, to assess the replicability and scalability of the program, and to evaluate patient satisfaction at 3 distinct sites. We conducted a prospective observational cohort study across 3 US academic medical centers during which postpartum participants with hypertensive disorders of pregnancy were enrolled in a previously validated, remote, text message-based blood pressure monitoring program known as Heart Safe Motherhood. English-speaking patients with access to a text message-enabled cell phone and with a diagnosis of hypertensive disorders of pregnancy were candidates for enrollment in the study. Each study site planned to enroll approximately 66 participants in this pilot implementation phase. All the enrolled participants received a validated blood pressure cuff, education on proper use of the device, and were sent text messages as a reminder to check their blood pressures twice daily for 10 days after discharge. They were asked to reply via text message with their blood pressure readings. All blood pressure readings were reviewed via a web-based platform by a physician. Physicians communicated with patients whose blood pressure levels exceeded 160 mm Hg systolic or 100 mm Hg diastolic to determine the next management steps. Enrollees were texted a survey at the end of the 10 days and the responses were recorded. The proportion of eligible parturients who were enrolled, the number of measured blood pressure values, and the postprogram survey results were measured. We assessed the number of patients who reported elevated blood pressures, required antihypertensive medication, and were readmitted for blood pressure control during the program duration. A total of 199 participants were enrolled in the program: 66 at site A, 67 at site B, and 66 at site C. In the 10 days after hospital discharge, 192 (97%) participants submitted at least 1 blood pressure measurement via text message. More enrolled patients submitted a blood pressure measurement on postpartum days 7 to 10 (171, 86%) than on days 1 to 4 (134, 67%). A total of 126 (63%) participants submitted blood pressures during both time frames. Elevated blood pressures were recorded for 70 (35%) participants, 32 (16%) of whom were started on oral antihypertensives after discussing their blood pressure measurements with an on-call provider. A total of 10 participants (5%) required hypertension-related readmission after delivery. The end-of-program survey was completed by 98 (49%) of the participants. Of those who completed the survey, 93% agreed that the program helped them to monitor their blood pressure (89% at site A; 88% at site B, and 100% at site C), and 93% would recommend it to friends or family members (94% at site A, 96% at site, and 88% at site C). Postpartum participants are willing and capable of using the Heart Safe Motherhood program for remote blood pressure monitoring and reported high satisfaction with the program across multiple sites. Our study demonstrated that this remote blood pressure monitoring program can be implemented successfully and demonstrated replicable efficacy at diverse sites.

Communication regarding adverse neonatal birth events: Experiences of parents and clinicians

ObjectivesCommunicating with parents about adverse birth outcomes is challenging. We sought to describe attitudes and experiences of parents and providers regarding communication about adverse newborn birth events.MethodsFrom 2011–2012, we conducted semi-structured in-depth interviews with parents who believed they had experienced an adverse birth-related neonatal outcome and focus groups with healthcare providers who have communicated with parents about adverse newborn birth events from three geographically diverse US academic medical centers. We conducted qualitative thematic analysis to identify key themes.ResultsParents and providers described unique communication challenges around adverse neonatal outcomes in six categories: 1) High expectations for a positive delivery experience and the view that birth is a life event, not a medical encounter; 2) Powerful emotions associated with birth, amplified when an adverse event occurs; 3) Rapid changes when expectations for a normal birth take a sudden negative turn; 4) Family involvement adding complexity to communication; 5) Multiple patients and providers complicating communication dynamics with inter-professional teams seeking to coordinate information and care; and, 6) Concerns about litigation surrounding the birth experience. Strategies to educate parents and enhance communication were identified by both parents and providers.ConclusionBoth parents and providers experience – and may suffer as a result of – communication challenges following adverse birth events affecting the newborn. Training and resources for this care environment are needed to meet parental, extended family, and provider expectations for communication when these events occur.

Anti-Racism and Anti-Colonialism Praxis in Global Health-Reflection and Action for Practitioners in US Academic Medical Centers.

ABSTRACT.The movement to decolonize global health and address power inequities among its actors is not new. Founded on the work of colonized and marginalized people themselves, initiatives at universities, schools of public health, and international development organizations have emerged to call for anti-racism and anti-colonialism within the field. US Academic Medical Centers (AMCs) have been less vocal in this wider discussion, despite their large engagement in the field through clinical, research, and medical education activities. As global health practitioners currently based at an AMC, we believe that it is important to critically evaluate our practices. We therefore propose three starting questions for our colleagues and students to consider and act upon as they adopt and navigate a praxis in anti-racism and anti-colonialism as foundational principles in global health. These questions call on us to closely examine the legacies of racism and colonialism in global health, the value placed on different ways of knowing in this field, and our motivations for engaging in this work. They are presented as a tool to reexamine global health, challenging the constructed binary of the “global South” and “global North,” and the perceived ideas of poverty and resource scarcity as the natural immutable reality of the global South.

Assessing the utility of deep neural networks in predicting postoperative surgical complications: a retrospective study

Early detection of postoperative complications, including organ failure, is pivotal in the initiation of targeted treatment strategies aimed at attenuating organ damage. In an era of increasing health-care costs and limited financial resources, identifying surgical patients at a high risk of postoperative complications and providing personalised precision medicine-based treatment strategies provides an obvious pathway for reducing patient morbidity and mortality. We aimed to leverage deep learning to create, through training on structured electronic health-care data, a multilabel deep neural network to predict surgical postoperative complications that would outperform available models in surgical risk prediction. In this retrospective study, we used data on 58 input features, including demographics, laboratory values, and 30-day postoperative complications, from the American College of Surgeons (ACS) National Surgical Quality Improvement Program database, which collects data from 722 hospitals from around 15 countries. We queried the entire adult (≥18 years) database for patients who had surgery between Jan 1, 2012, and Dec 31, 2018. We then identified all patients who were treated at a large midwestern US academic medical centre, excluded them from the base dataset, and reserved this independent group for final model testing. We then randomly created a training set and a validation set from the remaining cases. We developed three deep neural network models with increasing numbers of input variables and so increasing levels of complexity. Output variables comprised mortality and 18 different postoperative complications. Overall morbidity was defined as any of 16 postoperative complications. Model performance was evaluated on the test set using the area under the receiver operating characteristic curve (AUC) and compared with previous metrics from the ACS-Surgical Risk Calculator (ACS-SRC). We evaluated resistance to changes in the underlying patient population on a subset of the test set, comprising only patients who had emergency surgery. Results were also compared with the Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) calculator. 5 881 881 surgical patients, with 2941 unique Current Procedural Terminology codes, were included in this study, with 4 694 488 in the training set, 1 173 622 in the validation set, and 13 771 in the test set. The mean AUCs for the validation set were 0·864 (SD 0·053) for model 1, 0·871 (0·055) for model 2, and 0·882 (0·053) for model 3. The mean AUCs for the test set were 0·859 (SD 0·063) for model 1, 0·863 (0·064) for model 2, and 0·874 (0·061) for model 3. The mean AUCs of each model outperformed previously published performance metrics from the ACS-SRC, with a direct correlation between increasing model complexity and performance. Additionally, when tested on a subgroup of patients who had emergency surgery, our models outperformed previously published POTTER metrics. We have developed unified prediction models, based on deep neural networks, for predicting surgical postoperative complications. The models were generally superior to previously published surgical risk prediction tools and appeared robust to changes in the underlying patient population. Deep learning could offer superior approaches to surgical risk prediction in clinical practice. The Novo Nordisk Foundation.

Multi-Level Stakeholder Perspectives on Determinants of Point of Care Ultrasound Implementation in a US Academic Medical Center.

There is growing interest from multiple specialties, including internal medicine, to incorporate diagnostic point of care ultrasound (POCUS) into standard clinical care. However, few internists currently use POCUS. The objective of this study was to understand the current determinants of POCUS adoption at both the health system and clinician level at a U.S. academic medical center from the perspective of multi-level stakeholders. We performed semi-structured interviews of multi-level stakeholders including hospitalists, subspecialists, and hospital leaders at an academic medical center in the U.S. Questions regarding the determinants of POCUS adoption were asked of study participants. Using the framework method, team-based analysis of interview transcripts were guided by the contextual domains of the Practical Robust Implementation and Sustainability Model (PRISM). Thirty-one stakeholders with diverse roles in POCUS adoption were interviewed. Analysis of interviews revealed three overarching themes that stakeholders considered important to adoption by clinicians and health systems: clinical impact, efficiency and cost. Subthemes included two that were deemed essential to high-fidelity implementation: the development of credentialing policies and robust quality assurance processes. These findings identify potential determinants of system and clinician level adoption that may be leveraged to achieve high-fidelity implementation of POCUS applications that result in improved patient outcomes.

Maintenance Rituximab or Observation after Frontline Treatment with Bendamustine-Rituximab (BR) for Follicular Lymphoma: A Real World Analysis Across 13 US Cancer Centers

Maintenance Rituximab or Observation after Frontline Treatment with Bendamustine-Rituximab (BR) for Follicular Lymphoma: A Real World Analysis Across 13 US Cancer Centers

Consolidation with Autologous Hematopoietic Cell Transplant in First Remission Improves Overall Survival in Younger Patients with Mantle Cell Lymphoma in the Rituximab Era

Abstract Introduction: Mantle cell lymphoma (MCL) is a CD5+ B-cell lymphoma characterized by cyclin D1 expression. The disease has heterogeneous clinical outcomes: in a subset of patients, it is indolent but many others have an aggressive course with poor outcome. Consolidative autologous hematopoietic cell transplant (HCT) in 1st remission is often employed for fit patients ≤65; however the benefit of this approach remains uncertain without prospective validation in the rituximab era. Herein we retrospectively assessed the impact of HCT consolidation following induction therapy on survival in a large multicenter cohort of transplant eligible patients aged ≤65. Methods: We retrospectively studied adults with newly diagnosed MCL, aged ≤65, transplant eligible at diagnosis, and treated with induction chemotherapy from 2000-2015. Eligibility for transplant was determined by the institutional chart reviewer. 22 US and Canadian academic medical centers contributed. Information on prognostic markers, treatment, response to induction, and survival was collected. The primary objective was to assess for an overall survival (OS) benefit of HCT consolidation in first remission. A landmark survival analysis was restricted to patients surviving >6 months who achieved ≥partial response (PR) after induction, with OS and progression-free survival (PFS) defined as time from diagnosis to event (death or relapse). Cox multivariate regressions were performed to evaluate the effect of HCT consolidation on OS and PFS after adjusting for confounders (age, sex, MIPI, stage, induction regimen, blastoid/pleomorphic phenotype, response to induction (complete response (CR) vs. PR), and maintenance therapy. Due to the differential times of HCT, this was included in the model as a time-varying covariate. Ki67 was excluded from regression models as it was available in Results: Data was collected for 1113 patients, and 921 patients met inclusion criteria. HCT was performed in 595 patients (64%). The two most common reasons for not performing HCT were physician (46%) or patient preference (23%). Three centers, who contributed a combined 135 patients, performed HCT in Conclusion: In this large cohort of younger transplant eligible patients with MCL, HCT consolidation in first remission was associated with significantly improved OS and PFS after adjusting for prognostic factors and differences in initial treatment. Within the limitations of retrospective analysis and inherent selection bias, our findings support the benefit of HCT consolidation following induction therapy for fit patients ≤65 in the rituximab era. Download : Download high-res image (148KB) Download : Download full-size image Disclosures Barta: Janssen: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Research Funding; Merck: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Research Funding. Villa: Roche: Consultancy, Honoraria, Other: Travel, Research Funding; Lundbeck: Consultancy, Honoraria, Other: Travel; Seattle Genetics: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Janssen: Honoraria; Abbvie: Other: Travel. Gerrie: Roche: Research Funding; Seattle Genetics: Honoraria, Membership on an entity's Board of Directors or advisory committees; Lundbeck: Honoraria; Janssen: Membership on an entity's Board of Directors or advisory committees. Fenske: Celgene: Consultancy; Sanofi: Consultancy; Pharmacyclics: Consultancy. Maddocks: Merck: Research Funding; Pharmacylics: Research Funding; BMS: Research Funding; Novartis: Research Funding. Lansigan: Spectrum Pharmaceuticals: Consultancy, Research Funding; Seattle Genetics: Consultancy. Reddy: Abbvie: Consultancy; BMS: Consultancy; Celgene: Consultancy; Gilead: Speakers Bureau. Landsburg: Curis: Consultancy, Research Funding; Takeda: Research Funding. Karmali: Celgene: Speakers Bureau. Kaplan: Takeda: Research Funding; Millennium: Research Funding; Seattle Genetics: Research Funding; Janssen: Research Funding. Caimi: Celgene: Speakers Bureau; Abbvie: Equity Ownership; Seattle Genetics: Equity Ownership; Incyte: Equity Ownership. Cohen: Takada: Research Funding; Bristol Myers Squibb: Research Funding; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Genentech: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bioinvent: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; LAM Therapeutics, Inc: Research Funding; Infinity: Consultancy, Membership on an entity's Board of Directors or advisory committees. Calzada: Seattle Genetics: Research Funding. Handorf: Pfizer: Research Funding. Bachanova: Seattle-Genetics: Consultancy, Membership on an entity's Board of Directors or advisory committees; Juno: Membership on an entity's Board of Directors or advisory committees; Oxis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Zymogen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis Pharmaceuticals Corporation: Membership on an entity's Board of Directors or advisory committees, Research Funding.

Cognitive impairment and functional change in COVID-19 patients undergoing inpatient rehabilitation.

Cognitive impairment is increasingly recognized as a sequela of COVID-19. It is unknown how cognition changes and relates to functional gain during inpatient rehabilitation. We administered the Montreal Cognitive Assessment (MoCA) at admission to 77 patients undergoing inpatient rehabilitation for COVID-19 in a large US academic medical center. Forty-five patients were administered the MoCA at discharge. Functional gain was assessed by change in the quality indicator for self-care (QI-SC). In the full sample, 80.5% of patients exhibited cognitive impairment on admission, which was associated with prior delirium. Among 45 patients with retest data, there were significant improvements in MoCA and QI-SC. QI-SC score gain was higher in patients who made clinically meaningful changes on the MoCA, an association that persisted after accounting for age and delirium history. Cognitive impairment is frequent among COVID-19 patients, but improves over time and is associated with functional gain during inpatient rehabilitation.