Virginia Commonwealth University Research Articles

“I Tell Heem Nothing!”: Education and the Americanization of Italian Immigrants at the Beginning of the Twentieth Century

Research Article| January 01 2021 “I Tell Heem Nothing!”: Education and the Americanization of Italian Immigrants at the Beginning of the Twentieth Century Cristina Stanciu Cristina Stanciu CRISTINA STANCIU, PhD, is an associate professor of English and director of the Humanities Research Center at Virginia Commonwealth University. She is co-editor of Laura Cornelius Kellogg: “Our Democracy and the American Indian” and Other Writings (Syracuse University Press, 2015) and of the MELUS special issue “Pedagogy in Anxious Times” (2017). Her work has appeared in American Indian Quarterly, Studies in American Indian Literatures, Multiethnic Literatures of the United States, Journal of the Gilded Age and Progressive Era, and College English, among others. She is a recipient of a Fulbright Scholar Award (2019-2020), an Obama Institute Fellowship (Germany), an NEH summer stipend, and an AAUW postdoctoral fellowship. She currently serves as book review editor of the journal MELUS. Her book from which this article is derived is forthcoming from Yale University Press. Search for other works by this author on: This Site Google Italian American Review (2021) 11 (1): 27–50. https://doi.org/10.5406/italamerrevi.11.1.0027 Cite Icon Cite Share Icon Share Facebook Twitter LinkedIn MailTo Permissions Search Site Citation Cristina Stanciu; “I Tell Heem Nothing!”: Education and the Americanization of Italian Immigrants at the Beginning of the Twentieth Century. Italian American Review 1 January 2021; 11 (1): 27–50. doi: https://doi.org/10.5406/italamerrevi.11.1.0027 Download citation file: Zotero Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All Scholarly Publishing CollectiveUniversity of Illinois PressItalian American Review Search Advanced Search The text of this article is only available as a PDF. Copyright 2021 by the Board of Trustees of the University of Illinois2021 Article PDF first page preview Close Modal You do not currently have access to this content.

The Job I Never Wanted Was Exactly What I Needed

The Job I Never Wanted Was Exactly What I Needed Stephanie G. Adams (bio) In march 2011, i accepted the offer to become the department head of the Engineering Education Department at Virginia Tech. In the history of the department, I would be the second, full-time department head and the first, permanent, woman of color. The fact that I was the first, permanent, woman of color department head should come as no surprise given the demographics of the engineering field. In 2017, there were 143 African American women engineering professors. This represents 0.5 percent of the 27,372 tenured/tenure-track faculty in engineering. Over the last forty-plus years, the percentage of underrepresented minority faculty in engineering has increased and according to the American Society for Engineering Education (ASEE) "By the Numbers," we make up 3.1 percent of all engineering faculty. Diversity and broadening participation in STEM have been a national priority for over forty years. Industry and academic leaders recognize that diversity, in all forms, is crucial to innovation and the development of new ideas. The presence of different perspectives and experiences improves productivity, creativity, and thus innovation. With a start date of August 10, I had a lot to do in five months: find a place to live; pack and move; close out my life at Virginia Commonwealth University (VCU); and most importantly, figure out what exactly a department head was supposed to do, as this was not a job I had ever hoped to have. I had been an assistant and associate dean at two institutions with my eye on becoming a dean. I had studied and interacted with deans for many years, and I had a strategy for what I would do when I finally became a dean. After a couple of unsuccessful attempts to become a dean and with the strong urging of a colleague, I applied for this position. Before I dive into the experience [End Page 196] of being the department head, I feel it is important to start with the preparation for the interview. I researched the department from top to bottom; I combed the website; I talked to some of the faculty in the department I had come to know through professional societies; I studied similar departments around the country; and I talked with friends who were or had been department heads/chairs. When I went for the interview, I had a pretty good handle on the department, the successes it had experienced, the challenges facing it, and the resources (people, money, space, and time) available to move it forward. The department was founded in 1967 as the Engineering Fundamentals Division within the College of Engineering. The objective was to provide incoming first-year students a better understanding of engineering. The unit was viewed as a service division in the college whose primary mission was teaching. The majority of the faculty had MS degrees and tenure was based on good teaching and conference presentations. In 2004, the division was renamed the Department of Engineering Education and a new doctoral program in engineering education was launched. In addition to the launch of the graduate program, an expectation was set that the department would shift its identity from a teaching-focused department to a research-focused department. A new type of faculty member was hired with a different set of expectations. Faculty were expected to have a PhD, conduct research on par with traditional engineering departments, develop and teach graduate level courses, and advise graduate students. When I arrived, the unit was operating structurally as a department with teaching faculty, research faculty, and a new doctoral program. But the shift in focus created a major challenge; one department with two disconnected camps. Our collective task was to provide a foundation from which to begin our work toward one unified department. As I began to understand the department, I came to realize that the decision to add a graduate program and attendant research expectations had been a topdown one, and that not all in the department bought into or understood how the new graduate program would or should be integrated. In my preparation stages, I also asked for the...

The disconcerting differences in pancreatic cancer care among races

Presenter: Catalina Mosquera MD | Virginia Commonwealth University Massey Cancer Center Background: Racial disparities in surgical access and post-operative outcomes following pancreatic resection for pancreatic cancer, continues to be a concern and target for improvement. Unfortunately, studies that investigate the independent impact of race in cancer treatment and post-operative outcomes are lacking. The goal of our study was to investigate the impact of race on oncologic treatment and surgical outcomes following pancreatico-duodenectomy for pancreatic adenocarcinoma using a large national database. We hypothesize that the non-white patients will have lower rates of adjuvant therapy and worse postoperative outcomes. Methods: A retrospective survey was performed utilizing the National-Surgical-Quality-Improvement-Program (NSQIP), data from 2014-2019 for patients undergoing pancreatico-duodenectomy for pancreatic adenocarcinoma. Preoperative characteristics, tumor factors and postoperative outcomes were compared between race groups in all patients. Distributions of each race in the database was calculated relative to the estimated number of patients with resectable pancreatic cancer in the US. Multivariate logistic regression was conducted to assess the independent impact of race on outcomes following pancreatico-duodenectomy. Results: A total of 6562 patients undergoing pancreatic resection for pancreatic adenocarcinoma were evaluated. There was similar gender distribution (52% male) with a median age of 66 years of age. Majority of the patients were classified as white 84%, followed by African American 7.9%, Asian 4.5% and Hispanic 3.0%. Only 20% were categorized as ASA 1-2. In terms of tumor characteristics, 58% of patients had T3 disease followed by T2 in 25%, and T1 in 12% of the cases. Nodal positivity was common (65%). Less than half of the patients received chemotherapy (39.6%) and only a quarter received radiation therapy (16.9%). Regarding outcomes, Majority of patients were discharged home (87.7%) There was a 30-day readmission rate of 14.7% and a 30-day mortality rate of 1.7%. On univariate analysis Asians and Hispanics were healthier compared to their counterparts (ASA1-2 30% and 23% vs. 19.1% and 14.3%, p<0.05). There were no significant differences in tumor characteristics between races. Asians and Hispanics were less likely to receive chemotherapy or radiation therapy compared to African Americans and whites [(chemotherapy: Asian:31.2%, Hispanic 30.4%, African American 41.4% and white 40.2%), (Radiation therapy: Asian: 11.1%, Hispanic 12.3%, African American 19.7% and white 17%, p<0.008)]. Disparities played a significant role in postoperative complications; African Americans were more likely to develop sepsis and return to the operating room (p<0.005) whereas Asians and Hispanics were more likely to require transfusions, have a prolonged ventilator wean and longer hospital stay. Discharge destination, readmissions and 30 day mortality were similar between racial groups. On multivariate analysis race persisted as an independent predictor of oncologic care and postoperative complications. Conclusion: In this large national-level surgical database, a significant interaction between race and postoperative outcomes was found. Disparities were noted in access to oncologic therapy. Race was independently associated with postoperative complications

Experiences in outpatient parenteral antimicrobial therapy (OPAT): Barriers and challenges from the front lines.

Outpatient parenteral antimicrobial therapy (OPAT) is now the standard of care for managing patients who no longer need inpatient care but require prolonged intravenous antimicrobial therapy. OPAT increases patient satisfaction, reduces the lengths of hospital stay, lowers emergency department readmission rates, and decreases total healthcare spending. To investigate Virginia Commonwealth University Health System's experience with OPAT and to highlight the obstacles patients and clinicians face when navigating and utilizing this program. We conducted this descriptive study at a large, academic, tertiary-care hospital in Central Virginia. We performed manual reviews of electronic medical records of 602 patient, and we evaluated the records of those receiving OPAT between 2017 and 2020. Reviews included antimicrobial agents, diagnoses requiring OPAT, adverse effects related to antimicrobials, adverse effects related to peripherally inserted central catheters (PICC), readmission rate, discharge destination, and death. We evaluated our program with descriptive statistics. Among 602 patients who received OPAT, most were diagnosed with bacteremia or musculoskeletal infections. Patients were either discharged home or to another healthcare facility, with the former comprising most of the rehospitalizations. Ertapenem and vancomycin were associated with the most adverse drug events among our cohort. Elevated transaminase levels were noted in 23% of patients. The rate of PICC-line adverse events in this study population was 0.05%. Our findings highlight the barriers and challenges that patients and providers face when receiving OPAT, and they can inform efforts to improve patient clinical outcomes.

74. Interrupted Time Series Analysis of the Impact of Fluoroquinolone Cascade Reporting

BackgroundCascade reporting is a form of selective reporting where antibiotic susceptibility results are revealed in a sequential order to optimize antibiotic use. On May 1, 2019, Virginia Commonwealth University Health implemented cascade reporting for ciprofloxacin and levofloxacin for E. coli from urine cultures. We hypothesize that suppressing fluoroquinolone (FQ) results for urine isolate E. coli susceptibility panels using cascade reporting led to a decrease in the overall rate of inpatient FQ use.MethodsWe compared inpatient FQ use (in days of therapy (DOT)/1000 patient days (PD)) for the one-year pre-cascade period (May 2018-April 2019) to the one-year post cascade period (May 2019-April 2020). Inpatient FQ use for May 2018-April 2020 was modeled as an interrupted time series (ITS) using ordinary least squares regression. The regression model followed the form of Y = B0 +B1T + B2 X + B3 XT with Y = (DOT/1,000 PD), T = time in months, X = cascade reporting represented with a binary digit, and XT= time since cascade reporting was implemented. Results were examined for autocorrelation and lag effects. Analysis conducted using Microsoft Excel and Python Statsmodel library v0.11.1.ResultsA segmented regression model was successfully fitted with R^2 = 0.73 (Figure 1). The pre-intervention slope (T), intervention change (X), and post-intervention slope (XT) were -3.9, -2.3, and 3.8 DOT respectively. A significant positive change in pre versus post intervention slope was detected (p = 0.01). ConclusionResults showed no significant change in FQ DOT/1000 PD when cascade reporting was implemented in May 2019. This may be due to empiric prescribing of FQs in the inpatient setting, due to the fact the rate of FQ use was already decreasing prior to cascade reporting adoption, or due to other factors.We detected a significant positive change in the slope of FQ from -4 to 4 DOT/1000 PD each month post-cascade reporting. Our hospital has had a decrease in FQ use over the past 8 years so this may be due to a ‘floor’ effect where the true minimum of necessary FQ use was reached; further investigation is warranted. We believe our data will be of interest to other Antimicrobial Stewardship Programs considering cascade reporting.Disclosures All Authors: No reported disclosures

858. Inter-rater Reliability of Hand Hygiene Observers with an Electronic Monitoring System

BackgroundHand hygiene (HH) is the bedrock of infection prevention. Knowing the limitations of hand hygiene observers, Virginia Commonwealth University Health System invested in technology to remotely monitor health care workers’s (HCW) HH. Each hand sanitizer and soap dispenser in the patient care areas has a sensor, as well as each patient’s bed and each HCW. As the HCW moves around the environment, the sensors detect whether or not HH was performed for each opportunity.MethodsWhile monitoring HH via observations, we compared the manual observations and the technologic hand hygiene observations.ResultsOf 31 witnessed and manually recorded HH observations, 30 were noted in the electronic system (96.7% correspondence). There was only one witnessed opportunity that the technology failed to capture, when the staff member was performing hand hygiene while standing in the doorway talking to the nurse inside the room. There were multiple missed opportunities for HH while in patient rooms, as defined by the WHO’s Five Moments.ConclusionThere was excellent correspondence between the manual observations and the HH technology in this study. There is significant limitation in what an observer can do, while the HH technology will average around 35,000 ‘observations’ on a daily basis and is capable of capturing more of the 5 moments of HH. We have previously noted interference in the wireless technology in the healthcare environment. However, failure of providers to perform HH when indicated overshadow the failures of technology to capture HH that is performed. Better understanding of the indications for HH in accordance with the WHO 5 Moments may improve provider trust in the technology.Disclosures All Authors: No reported disclosures

The 2013 Clinical Course Descriptors for Multiple Sclerosis: A Clarification.

In the Views & Reviews article “The 2013 Clinical Course Descriptors for Multiple Sclerosis: A Clarification” by Lublin et al.,1 the contributions of Dr. Myla Goldman, Virginia Commonwealth University, were previously omitted from the author contributions section. Dr. Goldman was a committee member, and she reviewed the manuscript. The authors regret the error.

How We Do It: Implementing a Virtual, Multi-Institutional Collaborative Education Model for the COVID-19 Pandemic and Beyond

ObjectiveTo describe the implementation of a virtual, multi-institutional educational collaboration involving over 50 general surgery residency programs during the COVID-19 pandemic that enabled enhanced learning for surgical residents despite social-distancing requirements.DesignDescription of Virginia Commonwealth University's virtual educational augmentation program and the development of a collaborative teaching network during the coronavirus pandemic.SettingThis collaboration was initiated by Virginia Commonwealth University's Department of Surgery, Richmond, VA, and grew to include general surgery residency programs from across the nation.ParticipantsGeneral surgery residents and faculty from Departments of General Surgery were recruited locally via direct emails and nationally via the Association of Program Directors’ listserv and Twitter. In total, 52 institutions participated from every part of the country.ResultsA virtual, multi-institutional collaborative lecture series was initiated that grew to involve over 50 general surgery residency programs, allowing for daily didactics by experts in their fields during the initial surge of the COVID-19 pandemic, while maintaining social distancing and the provision of essential clinical care.ConclusionA multi-institutional collaboration enabled continued didactic education during the coronavirus pandemic, vastly broadening the expertise, scope and variety available to residents, while decreasing burden on faculty. We believe this can serve as a framework for future multi-institutional collaborations that extend beyond the COVID-19 era.

Partnerships Connecting Healthcare and Community-Based Organizations in Virginia

The Virginia Geriatric Education Center (VGEC)’s Geriatrics Workforce Enhancement Program (GWEP) partners with two programs, Senior Strong at Eastern Virginia Medical School in Norfolk, VA and the Richmond Health and Wellness Program at Virginia Commonwealth University in Richmond VA to support their age-friendly initiatives. These programs enhance primary care for an older population experiencing adverse social determinants of health by providing screening around the 4Ms pillars of age-friendly healthcare and connecting participants with healthcare and community-based organizations. These programs offer a rich learning environment for interprofessional students. The VGEC GWEP strengthens these programs by developing faculty and student training in collaboration with the programs and facilitating program participation in the GWEP-CC Age-Friendly Action Community to develop and refine age-friendly practice workflows, referral pathways and documentation.

Addressing Alzheimer’s Risk in Racially Diverse, Low-Income Older Adults Through Telephone Health Coaching

Preclinical Alzheimer’s disease (AD) behavioral risk reduction needs to be more fully explored at the community-level. Connecting behavior change to AD can reduce individual-level helplessness for the disease. However, behavior change targeting AD prevention factors (e.g., alcohol, depression, physical inactivity, smoking, isolation, medication management) is extremely challenging for multiple reasons, including failures in connecting AD and health behavior risk, and due to individual-level motivational, self-efficacy, and knowledge barriers. Methods: As part of the Virginia Commonwealth University iCubed Health and Wellness in Aging Population Core, 20 diverse older adults (aged 60+) living in Richmond, VA, with incomes below $12,000/year and managing either diabetes/cardiovascular symptoms, were offered weekly telephone-based health coaching for 12-weeks, providing education, motivations, self-efficacy skills, and referral services, for AD behavioral risk factors. A patient preference health coaching behavioral change strategy was implemented, where the person decides which behavioral practices to target. All study subjects completed a behavioral-psychosocial baseline and 3-month follow-up assessment. Findings: The study demonstrated feasibility for implementing health coaching within low-income racially-diverse older adults. The study sample (n=20, mean age 69 years (range: 61-77 years) was 90% African American (n=18), and 55% males (n=11). Improvement in AD knowledge (F=4.19;p=.0565); cognitive functioning (memory (F=4.19;p=.0556); delayed memory (F=2.85;p=.1086); TrailsA (F=5.60;p=.0294)), alcohol-risk (F=3.33;p=.1108) and social isolation (F=4.11;p=.0569) trends were found at 3-month follow-up. Conclusions: The findings from this study exhibit positive trends in reducing AD risk. This study creates the impetus for future large-scale investigations and dissemination of findings to improve the lives of at-risk low-income aging adults.

Roadmap: one anesthesiology department's strategic approach to COVID-19.

The COVID-19 pandemic has driven transformation in every aspect of the healthcare delivery system. The unpredictable onset and magnitude of COVID-19 infections resulted in wide gaps in preparedness for healthcare systems. The development of protocols to address both scarcity of resources and staff protection continues to be essential for risk mitigation. The northeast region of the United States had a rapid early surge of COVID-19 infections leading to the exhaustion of critical care capacity. In addition, northeastern hospitals experienced decrease in elective surgical interventions, including organ transplantation. Limited availability of COVID-19 testing and personal protective equipment further fueled the pandemic. This commentary highlights a comprehensive innovative approach to addressing the operating room and hospital demands, as well as the shortages in resources and staffing during the pandemic. The VCU Department of Anesthesiology operated at 40% of its regular operating room volume throughout the COVID-19 pandemic because of the increased demand from emergency cases. The delay in the peak surge allowed Virginia Commonwealth University, Department of Anesthesiology to develop a comprehensive infrastructure resulting in resulting is maximal workforce risk mitigation.

On the intersection of molecular bioelectronics and biosensors: 20 Years of C3B

Formed in 2000 at Virginia Commonwealth University, the Center for Bioelectronics, Biosensors and Biochips (C3B®) has subsequently been located at Clemson University and at Texas A&M University. Established as an industry-university collaborative center of excellence, the C3B has contributed new knowledge and technology in the areas of i) molecular bioelectronics, ii) responsive polymers, iii) multiplexed biosensor systems, and iv) bioelectronic biosensors. Noteworthy contributions in these areas include i) being the first to report direct electron transfer of oxidoreductase enzymes enabled by single walled carbon nanotubes and colloidal clays, ii) the molecular level integration of inherently conductive polymers with bioactive hydrogels using bi-functional monomers such as poly(pyrrole-co-3-pyrrolylbutyrate-conj-aminoethylmethacrylate) [PyBA-conj-AEMA] and 3-(1-ethyl methacryloylate)aniline to yield hetero-ladder electroconductive hydrogels, iii) the development of a multi-analyte physiological status monitoring biochip, and iv) the development of a bioanalytical Wien-bridge oscillator for the fused measurement to lactate and glucose. The present review takes a critical look of these contributions over the past 20 years and offers some perspective on the future of bioelectronics-based biosensors and systems. Particular attention is given to multiplexed biosensor systems and data fusion for rapid decision making.

Barriers to Attendance of Prenatal and Well-Child Visits.

Prenatal care (PNC) and well child visit (WCV) attendance are associated with improved health outcomes. We aimed to determine if the factors affecting maternal and child attendance are similar or different. We conducted a retrospective case control study at Virginia Commonwealth University Health System. We used the Adequacy of Prenatal Care Utilization Index and the American Academy of Pediatrics recommendations to assess the adequacy of PNC and WCV attendance, respectively. Mothers with less than 50% visit adherence or initiation after 5 months gestation were eligible as cases and those with 80% or more adherence and initiation before 5 months were eligible as controls. Children in the lowest quintile of adherence were eligible as cases and those with 80% or more adherence were eligible as controls. Cases and controls were randomly selected at a 1:2 ratio from the eligible subjects and frequency matched on birth month. In adjusted analyses, mothers and children who were publicly insured or who were uninsured had higher odds of poor preventive visit attendance. Mothers who experienced intimate partner violence and had more living children were more likely to have poor attendance. Children whose mothers had younger age, greater number of pregnancies and transportation difficulties had poorer attendance. While lack of insurance and public insurance remained significantly associated with both poor PNC and WCV attendance, other factors varied between groups. Expanding eligibility requirements and streamlining enrollment and renewal processes may improve two generations of preventive visit attendance.

Adverse Childhood Experiences, Maternal/Fetal Attachment, and Maternal Mental Health.

Background: This pilot study investigated the potential impact of exposure to childhood adversity on variables known to be related to posttraumatic stress (including attachment, mental health, and perceived stress) in a clinic sample of pregnant women.Materials and Methods: Participants consisted of 101 pregnant women recruited from the Virginia Commonwealth University Health System in Richmond, VA. All participants completed the Adverse Childhood Experience (ACE) questionnaire, Parental Bonding Instrument, Maternal Fetal Attachment Scale, Posttraumatic Stress Disorder (PTSD) Checklist, Symptom Checklist, and the Perceived Stress Scale.Results: Increased exposure to ACEs was negatively associated with retrospective report of viewing one's mother and father as caring and involved. ACE exposure was a statistically significant predictor of viewing one's mother and father as intrusive and controlling. ACEs were positively associated with self-reported PTSD symptoms, depressive and anxious symptomatology, and perceived stress. No direct effect of adverse childhood events on maternal/fetal attachment was found.Conclusions: ACE associations are discussed in terms of study methodology and needs for future research. Providers may consider incorporating the ACE questionnaire to identify exposure to childhood adversity and events that may increase an individual's risk for toxic stress and negative health outcomes.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

COVD-19. COGNITION, CANCER, AND COVID: DELIVERING DIRECT-TO-HOME TELE-NEUROPSYCHOLOGY SERVICES TO NEURO-ONCOLOGY PATIENTS

BACKGROUNDThe COVID-19 pandemic altered the delivery of healthcare services globally with a rapid adoption of telemedicine to meet patient’s needs. Telemedicine is critical for neuro-oncology patients who may be at an increased risk of infection, yet require continuity of care. An important aspect of neuro-oncology care includes neuropsychological assessment, which can be challenging to complete outside of a structured testing environment. Teleneuropsychology (TNP) has been explored under proctored conditions and proven feasible and reliable. Conducting TNP visits directly to the patients’ home (DTH-TNP) had minimal study prior to the pandemic, but was implemented to reduce COVID-19 exposure.METHODSWe used surveys to examine patient acceptance and clinician feasibility of DTH-TNP at two regionally diverse medical institutions routinely providing neuropsychological assessments services to neuro-oncology patients from April to August 2020, Massachusetts General Hospital (MGH) and Virginia Commonwealth University (VCU).RESULTS45 patients voluntarily responded (MGH=30, VCU=15) and 98 percent (MGH=100%, VCU=93%) of respondents were satisfied with the DTH-TNP experience. Nine percent (MGH=7%, VCU=13%) reported challenges (e.g., technological issues) during the appointment. Eighty-nine percent (MGH=90%, VCU=87%) would recommend the virtual visit to others. Patients perceived reduced risk of infection (MGH=77%, VCU=87%) and time traveling to clinic (MGH=87%, VCU=80%) as favorable aspects of DTH-TNP. 43 clinician surveys collected at MGH indicated that clinicians were able to achieve the goal of their appointment in 91% of clinical encounters. Common issues reported by clinicians included trouble connecting (7%) to the telemedicine platform and environmental disruptions (12%).DISCUSSIONThis preliminary data suggests neuro-oncology patients and clinicians find DTH-TNP to be an acceptable and feasible practice, while also recognizing its limitations. This study is limited in that voluntary patient surveys are subject to bias. These results suggest that further study of DTH-TNP (e.g., reliability, validity, and limitations) for neuro-oncology patients is warranted. Future directions are discussed.

Risk Stratified Tandem Vs Single Autologous Stem Cell Transplantation for Multiple Myeloma Yields Equivalent Survival

The standard of care for patients with newly diagnosed multiple myeloma who are transplant eligible is induction therapy followed by conditioning with high dose melphalan and autologous hematopoietic cell transplant (HCT). While the value of a single HCT (S-HCT) is established in standard-risk myeloma (SRM), there is controversy about whether tandem transplantation would improve outcomes such as progression-free survival (PFS) or overall survival (OS) in high-risk myeloma (HRM) patients. In this IRB approved retrospective study, the records of 343 multiple myeloma patients, who were referred by community oncologists and underwent HCT at Virginia Commonwealth University from 2008 to 2015, were reviewed. Patients were classified into different disease risk groups and OS and PFS determined. HRM was defined as including at least one of the following prognostic factors at diagnosis: t(4;14), t(14;16), t(14;20), del17p13, or gain of 1q by FISH; del 13 or aneuploidy by karyotyping; and ISS stage 3; patients without these features and with standard risk attributes were classified as SRM, while any patients with missing attribute information were classified as having undetermined risk myeloma (URM). In the study population, there were 135 SRM, 100 HRM, and 104 URM patients. Median age of the entire cohort was 60 years (76-34). The patients underwent hematopoietic cell mobilization and collection with filgrastim ± plerixafor and were conditioned with high-dose Melphalan (140-200 mg/m2). When possible, patients with SRM underwent single HCT (S-HCT) and those with HRM, tandem HCT (T-HCT) based on risk classification, response to prior therapy, insurance mandate and patient/physician preference. In those undergoing T-HCT, the median time to second HCT was 141 days. Evaluating the entire study population, and comparing patients who underwent a T-HCT (median follow up 82 mo.) vs. a S-HCT (85 mo.), there was no significant difference in OS (adjusted HR 1.1, 95% CI: 0.7-1.8; Cox proportional hazard model, adjusted for age, gender and risk group) (Figure 1) and PFS (HR 0.9, 95% CI: 0.6-1.2) between these two treatment groups. Of the 135 SRM patients, 20 underwent T-HCT; there was no significant difference in OS (HR = 1.2, 95% CI 0.5-2.9) and PFS (HR = 0.9, 95% CI = 0.5-1.7) in these patients compared to those undergoing S-SCT. Of the 100 HRM patients, 46 underwent T-HCT (P &amp;lt;0.01 c/w SRM &amp; URM for T-HCT assignment). Again, there was no significant difference observed in OS (HR = 1.3, 95% CI = 0.7 - 2.5) (Figure 2) and PFS (HR = 1.0, 95% CI = 0.6 - 1.8) in the T-HCT recipients as compared to S-SCT amongst the HRM patients. Similar outcomes were observed in the URM patients. There were no differences observed between S-HCT and T-HCT outcomes in patients with deletion of chromosome 17p or in those with ISS stage 3 disease in OS (HR = 1.7, 95% CI = 0.8 - 3.8) and PFS (HR = 1.0, 95% CI: 0.5, 1.9). Overall, HRM patients had a trend for worse, albeit not significantly different, OS (HR 1.4, 95% CI: 0.9-2.2), as well as PFS (HR 1.1, 95% CI 0.7-1.6) compared to SRM; URM demonstrated a similar trend vis a vis SRM. This retrospective review of survival in SRM and HRM transplanted at a single center demonstrates that in the era of induction and maintenance therapy with novel agents, tandem transplantation does not improve OS or PFS in either SRM or HRM patients compared to a single transplant. Standard of care for newly diagnosed multiple myeloma patients who are transplant eligible should remain induction therapy with novel agents followed by single autologous HCT and maintenance therapy. Disclosures No relevant conflicts of interest to declare.

COVID Symptoms and COVID Anxiety in Sickle Cell Disease

BackgroundEven before the US upswing of the current COVID pandemic, the number of sickle cell disease (SCD) patients coming to hospitals and EDs appeared to fall drastically. This happened despite SCD patients having often been heavy utilizers of the ED and hospital for their iconic vaso-occlusive crises (VOC). Though ambulatory SCD clinics quick converted largely to telehealth in order to comply with stay-at-home orders designed to suppress person-to-person transmission, some SCD patients appeared to avoid care, delay care, or refuse doctors' invitations for care. Presumably patients did so out of COVID fears, but this has not been confirmed in the literature. Further, whether these patients had COVID symptoms but stayed at home has not been studied. As part of quality improvement (QI) to conduct COVID surveillance in an adult sickle cell program, we sought to explain and predict SCD health care utilization patterns we were observing, as well as to determine urgent physical and mental health needs of patients who appeared to be avoiding care.MethodsFifteen staff in the Adult Sickle Cell Medical Home at Virginia Commonwealth University, a large urban academic medical center, conducted a telephone survey (“wellness check”was used when we talked to patients) of all known adults with SCD over 19 days in 2020. A staff member confirmed the patient had SCD, asked permission to proceed, then asked about symptoms consistent with COVID-19. At the end of the telephone survey, respondents wer invited to complete an email survey of sickle cell and COVID-19 utilization attitudes (19-33 items, depending on the response pattern, either drawn from the National Health Interview Survey, from the Adult Sickle Cell Quality of Life Measurement quality of care survey, or drafted by the authors), the Sickle Cell Stress Survey-Adult (SCSS-A, a 10-item previously validated survey), and anxiety and depression (PHQ9 of the PRIME-MD).ResultsOf 622 adults approached by phone call, 353 responded to the following yes/no screening questions regarding the prior 14 days: fever over 100 F 0/353 (0.00%); cough 3/353(0.01%); difficulty breathing 0/353(0.00%); unexplained shortness of breath 2/353(0.01%); sore throat 2/353 (0.01%); unexplained muscle soreness 2/353(0.01%);contact with anyone who tested positive for COVID-19 2/353(0.01%); testing for COVID 19 6/353(0.02%). For QI purposes, we set a threshold of three or more COVID-associated symptoms or the presence of fever as criteria requiring intense telephone or in-person staff monitoring for the following week. Only three patients met criteria. A total of 219/353 had email surveys sent. Of 63 patients (28.8%) who returned email surveys by June 10, 2020, 35.9% had already managed a “pain attack” at home 4 or more times in the prior 12 months, and 45.5% of these said their bad ER experiences were very or somewhat important in that decision. In the prior 14 days, although 30/64 reported a crisis for at least one day, only 4/64 had visited the Emergency Department for pain. On a 0-10 scale, 21/61 patients endorsed “0” for worry that they would be COVID-infected by going for medical care (weighted mean 3.9), but 18/59 endorsed “10” for worry they were more at risk of COVID because of SCD (weighted mean 6.31), and 22/60 endorsed “10” for worry they would fare worse than others if COVID infected (weighted mean 6.97). Many patients forwent “needed” care (16/62) or delayed “needed” care by at least a day (36/61). Eleven patients met criteria for moderately severe to severe depression on the PHQ-9, and 28/63 somewhat or strongly agreed with the statement “death is always on the back of my mind” on the SCSS-A.ConclusionsIn adolescents and adults with SCD, many were already reticent to come to the ED for pain, but a significant portion reported delays or avoidance of needed care during the early stages of the US COVID pandemic, and few reported using the ED despite over half reporting at least one crisis day in 14. Patients nonetheless reported very few COVID-associated symptoms. Fears of COVID infection/susceptibility may limit visits for needed sickle cell care among adults.Acknowledgements: Mica Ferlis RN, FNP, Caitlin McManus, RN, FNP, Emily Sushko, RN, FNP, Justin West, RN, Kate Osborne, RN, Stefani Vaughan-Sams, Marla Brannon, BS, Nakeiya Williams, BSDisclosuresSmith:GlycoMimetics, Inc.: Consultancy; Emmaeus Pharmaceuticals, Inc.: Consultancy; Novartis, Inc.: Consultancy, Other: Investigator, Research Funding; Global Blood Therapeutics, Inc.: Consultancy, Research Funding; Shire, Inc.: Other: Investigator, Research Funding; NHLBI: Research Funding; Patient-Centered Outcomes Research Institute: Other: Investigator, Research Funding; Health Resources and Services Administration: Other: Investigator, Research Funding; Incyte: Other: Investigator; Pfizer: Consultancy; Ironwood: Consultancy; Novo Nordisk: Consultancy; Imara: Research Funding; Shire: Research Funding.

Functional B Cell Reconstitution Following Allogeneic Stem Cell Transplantation

Immune reconstitution is critical to long term survivability in recipients of allogeneic hematopoietic cell transplantation (HCT), mitigating both relapse as well as infection risk. However, both graft versus host disease (GVHD) and post HCT immunosuppression used to prevent it impair immune recovery, particularly functional B cell reconstitution which may not happen for several months post-transplant. This is relevant for post-transplant vaccination which in some centers is delayed till immune cell recovery. In this retrospective, Virginia Commonwealth University institutional review board (IRB) approved study, T helper and B cell recovery for up to two years following HCT was evaluated in 212 patients transplanted between 2015 and 2019. There were 69 HLA matched related &amp; 143 unrelated donor transplant recipients. Median age of the patients was 56 years (range 19-74); conditioning regimens utilized were reduced intensity (RIC) in ~62% of the patients and rabbit anti-thymocyte globulin was used in ~72% of the patients. Blood stem cells were given in 183 patients and bone marrow in 29. Only patients with hematological malignancies were included in this study. Landmark analysis was carried out, with patients who did not survive the first 6 months post-transplant excluded. Of these patients, 85% are surviving. Median CD3+/4+ (Th) cell counts were 153 at 6 months, 228 at 1-year, 296 at 2 years, and corresponding B cell counts were 70, 175, &amp; 273. Plotting Th and B cell counts over time in each individual donor-recipient pair demonstrated close correspondence between Th and B cell recovery, with synchronous recovery observed in most patients, median R 0.76 (range: 0.01-0.99). The slope of the B/Th cell curves for each patient then were compared in a subset of patients, and demonstrated a significant difference between those patients who either did not develop GVHD or only had acute GVHD as opposed to those who developed both acute and chronic GVHD (1.3±1.4 B cells/Th cells and 1.1±1.2 vs. 0.5±1, P=0.02 and 0.06 respectively), suggesting poor B cell recovery in those with chronic GVHD. Different immune recovery kinetics were observed amongst patients (Figure 1); A) rapid B cell recovery, highest absolute B cell count between 30 and 180 days post-HCT, B) intermediate B cell recovery, days 180 and 455, C) delayed B cell recovery, days 455 and 725 days, and D) minimal to no B cell recovery. A higher relative risk for developing acute + chronic GVHD was seen in the intermediate B cell recovery group when compared to those with delayed recovery, RR = 2.38 (95% CI 1.08-5.25). Functional B cell studies were performed in a subset, by measuring IgG levels and anti-pneumococcal antibody titers. Correlation was observed between Th cell count and IgG levels over time in individual patients (median R = 0.57). Pneumococcal titers were also measured at approximately 6 months, 1- and 2-years post-transplant as patients were given a series of PCV13 &amp; PSV23 vaccinations 6 months after HCT. When the antibody titers against unique pneumococcal serotypes were analyzed in individual patients, these varied within each individual, following a declining trend in levels for antibodies against different serotypes; this decline occurred on a logarithmic scale suggesting differential immunogenicity of the pneumococcal antigens, and also mathematically ordered, rather than random Th and B cell responses (Figure 2A). When the serotypes with the highest titers in most patients were correlated with Th and B cell counts measured simultaneously, no association was observed. Further, when fold increase in pneumococcal titers beyond 1-year post transplant were compared across different groups of patients based on their GVHD status, no significant difference was observed in their antibody responses (Figure 2B). In conclusion, our data suggest synchronous Th and B cell reconstitution post allogeneic HCT, both in numeric and functional terms, and thus strategies to help promote T cell recovery, such as IL-7 administration post-transplant, are necessary to encourage optimal immune reconstitution. Vaccine responses beyond 6 months, as in the institutional practice reported here, are independent of GVHD status and numeric immune cellular recovery. These findings are consistent with the notion that immune recovery is a dynamical, rather than a stochastic process. Disclosures No relevant conflicts of interest to declare.

Improved Utilization Amongst Adult Sickle Cell Disease Patients: A Multi-Disciplinary Medical Home Approach

Background Worldwide, Sickle Cell Disease (SCD) is the most common monogenetic disorder. SCD is costly to the American health care system: $460,151 per patient for the 100,000 affected US patients. Biological and behavioral health comorbidities with limited hospital resources contributed to a cost increase in SCD readmissions at the Virginia Commonwealth University Health System (VCUHS) from 2012-2016, after a long history of decline. With increasing census, in FY16 the 30-day SCD readmission rate was 33.7%, up from 22.5% in FY14. The average SCD length of stay was 6.7 days, compared with an expected length of 4.2 days. The number of ED visits for SCD patients in FY17 was projected to be double that of FY14. The percent of ED returns in 3 days was projected to be triple that of FY14. Method The VCU Adult SCD Medical Home (ASCMH) was funded and launched to address this issue, based on the success of a pilot that showed cost savings of $333,000 for 5 patients in 12 months. The SCD ASCMH officially began January 1,2018 with a two-year pilot funding period. The ASCMH was structured and designed using quality improvement (QI) principles and consisted of multidisciplinary teams to coordinate inpatient care, emergency care, and ambulatory care respectively. Evaluation compared utilization during CY 2017 (pre-intervention) versus CY 2019 (2 years post intervention). For all patients we compared the average 30-day readmission rate, the average length of stay (ALOS), the average 3-Day ED return rate, the number of ED discharges, the numbers of inpatient days, inpatient discharges, and outpatient visits, the number of patients who used the ED, and total VCU charges. Results Among 541 (2017) and 592 (2019) SCD adults, including 40.6% males and 59.4% females, comparing pre-intervention to intervention, average utilization and VCU charges were either numerically or statistically significantly reduced. Mean 30-day readmission rates were reduced (31.60% vs 20.40%) ALOS was reduced (5.6 days vs 4.3 days), inpatient days were reduced (5313 days vs 3340 days), and total charges were significantly reduced ($15,664,895 vs $13,939,842). Conclusion At VCU, a multi-disciplinary ASCMH that featured intensive case management (CM) reduced annual utilization and cost savings for adult SCD patients. CM program elements that were most effective should be studied in the future and next steps should include a randomized controlled trial that can demonstrate evidence of their efficacy in strengthening and improving utilization Table Disclosures Smith: Emmaeus Pharmaceuticals, Inc.: Consultancy; GlycoMimetics, Inc.: Consultancy; Novartis, Inc.: Consultancy, Other: Investigator, Research Funding; Shire, Inc.: Other: Investigator, Research Funding; Imara: Research Funding; Novo Nordisk: Consultancy; Ironwood: Consultancy; Pfizer: Consultancy; Incyte: Other: Investigator; Health Resources and Services Administration: Other: Investigator, Research Funding; NHLBI: Research Funding; Patient-Centered Outcomes Research Institute: Other: Investigator, Research Funding; Global Blood Therapeutics, Inc.: Consultancy, Research Funding; Shire: Research Funding.