A case controlled study of risk factors for metastatic squamous cell carcinoma in organ transplant recipients: single academic medical center.

Solid organ transplant recipients (SOTRs) are at high risk of cutaneous squamous cell carcinoma (cSCC) metastasis. Despite prior studies identifying risk factors, mortality remains high. Understanding additional risk factors may aid in reducing mortality in this population. This study aimed to investigate risk factors and predictive variables for metastatic cSCC in SOTRs. The primary goal was to accurately identify transplant patients at increased risk of metastatic cSCC. A retrospective case-control study in a single institution of 3576 cases of organ transplants were identified from January 1991 to July 2022. A cohort of metastatic cancer patients and two randomly generated age and organ matched control cohorts were identified. 16 SOTR patients developed metastatic cSCC. The majority were male, with high-risk tumor sites. Tumor depth varied and half exhibited perineural invasion. Cylex® (p = 0.05) and white blood cell counts (p = 0.04) were significantly lower in these patients compared to control. Lung transplants were at highest risk relative to other solid organ transplants. Voriconazole exposure was also associated with increased metastatic risk (p = 0.04). Small sample size at a single institution. Close monitoring of SOTR, especially those with lung transplants given their increased risk, reducing immunosuppression, and limiting exposure to voriconazole can improve outcomes in SOTRs with metastatic cSCC.

Implementing primary care follow-up for high-risk vascular surgery patients.

BACKGROUND: The Centers for Medicare and Medicaid Services consider the 30-day hospital readmission rate an outcome of care measure; a high rate is associated with high-cost and bed utilization. PURPOSE: The Division of Vascular Surgery at a large academic medical center implemented a 15-week quality improvement project in the fall of 2022 to reduce readmissions among patients deemed high-risk for readmission and discharged to home. METHODS: The discharging provider utilized the "HOSPITAL Score for Readmission" tool to identify patients at high-risk for unplanned 30-day readmission to receive the intervention, which included follow-up with a primary care provider (PCP) within two weeks of hospital discharge to address non-surgical medical conditions that may have been exacerbated during the hospital stay. A hospital based transitional care clinic bridged medical care for identified patients without an established PCP or whose PCP could not accommodate an appointment until PCP assumption of care. Discharging providers included 11 nurse practitioners and 2 surgery residents; each received a one-on-one educational teaching session and a weekly reminder e-mail through week 9. RESULTS: A total of 158 vascular surgery patients (low and high-risk) were discharged home over 15 weeks with 30 patients (19%) having an unplanned readmission within 30-days from discharge. Adherence issues with the intervention among staff allowed for the high-risk group to be divided into those who did not receive the intervention versus those who did. The high-risk patients who did not receive the intervention had a higher readmission rate (30.4%) than the high-risk patients who did receive the intervention (21.4%). CONCLUSIONS: Numerous acute and chronic medical problems were treated at the PCP/transitional care clinic visits, which may have contributed to the reduction in rate of readmissions occurring within 30-days for those patients. Increased usage of the transitional care clinic identified a gap that patients continue to require assistance with establishing care with a PCP and further process change in the future is needed to ensure successful transition for all patients.

Building Frontline Capability for Shared Decision-Making (SDM) in a Major Academic Oncology Center Caring for People With Non-Small Cell Lung Cancer: Performance Outcomes of a SDM Simulation Training Program.

BACKGROUND: There is a growing body of evidence on shared decision-making (SDM) training programs worldwide. However, there is wide variation in program design, duration, effectiveness, and evaluation in both academia (ie, medical school) and the practice setting. SDM training has been slow to integrate in practice settings. METHODS: A pilot study of 6 multidisciplinary clinicians was conducted using quantitative and qualitative methods to evaluate changes in participant understanding and implementation of SDM in the practice setting. A 2-rater criterion-based evaluation method was used to assess a simulation-based case study role-play program using 7 domains of SDM pre and post training. The authors assessed whether clinicians addressed each of the 7 domains or what fraction of each domain was addressed as part of their simulation case study role-play performance. Focus groups were conducted pre- and postintervention to provide feedback to participants and to understand the clinician experience in greater detail. RESULTS: The increase in improvement in SDM ranged from 17% to 37%, and 7 of 8 domains for which participants were rated showed significant improvement. The areas of greatest improvement were seen in determining a patient's goals/preferences, including risk tolerance regarding treatments (+37%) and values and self-efficacy (+37%). CONCLUSION: The results of this study reveal a significant shift in clinician awareness of a patient's goals, preferences, and values. Postintervention, clinicians began to understand the value of building a partnership with their patients whereby the patient becomes an active participant in their clinical care.

PREVALENCE OF DIDANOSINE-RELATED RETINAL TOXICITY AT AN URBAN ACADEMIC CENTER AS DIAGNOSED WITH ULTRA-WIDEFIELD IMAGING.

PURPOSE: Antiretroviral therapy has revolutionized HIV treatment with didanosine (DDI) as a pioneering drug. However, DDI has been associated with retinal toxicity, characterized by peripheral chorioretinal degeneration with macular sparing. Despite its clinical recognition, the prevalence and risk factors for didanosine-induced retinopathy are not well described. METHODS: This retrospective case series analyzed 127 DDI-treated patients at Weill Cornell Medicine Department of Ophthalmology. Inclusion criteria included at least 6 months of DDI use and available ultra-widefield imaging. Patients were categorized as affected or unaffected based on retinal imaging assessed by two reviewers. The affected group was further divided into "probable" or "possible" retinopathy. Patient demographics, DDI usage characteristics, and imaging findings were analyzed with statistical comparisons drawn between affected and unaffected cohorts. RESULTS: Of the 127 patients, 9 (7%) showed signs of didanosine-induced retinal toxicity. On average, the affected group was older compared with the unaffected group (65.1 vs. 56.5 years, P = 0.025), with lower BMI (23.2 vs. 27.4, P = 0.04), and older at the start of the treatment (51.6 vs. 40.8 years, P = 0.026). Mild phenotypes with peripheral pigmentary changes were also identified using ultra-widefield imaging. CONCLUSION: This pioneering academic study highlighted a notable prevalence of DDI-induced retinal toxicity. Statistical analysis demonstrated age, BMI, and age at treatment initiation as potential risk factors. Ultra-widefield autofluorescence emerged as a valuable tool in detecting and delineating findings. Follow-up studies are needed to determine the necessity of regular screening for individuals on or with a history of didanosine use.

Multiple Lactobacillus Infections Caused by Probiotics at Pediatric and Adult Academic Medical Centers.

BACKGROUND: Probiotics are synthetic oral supplements containing live bacterial and fungal species hypothesized to help with various gastrointestinal conditions. However, they can cause infection if the organism spreads outside of the gastrointestinal tract. The aim of this study was to identify and describe patients who experienced systemic infections caused by probiotic use. METHODS: This study was a retrospective chart review of pediatric and adult patients at academic medical centers who received probiotics and subsequently developed positive cultures from a sterile site for probiotic-related species. Two individuals completed the chart reviews to determine if the probiotic was the true cause of the infection. RESULTS: Lactobacillus, Bifidobacterium, and Saccharomyces cultures were reviewed, with a total of 71, 8, and 2 cultures isolated from sterile sites for each organism, respectively. Further review revealed 23 Lactobacillus cultures from 13 unique patients who were taking Lactobacillus-containing probiotics. Four patients without gastrointestinal tract compromise were included in the final analysis, including 1 patient whose culture was confirmed as identical to the probiotic. Types of infections included meningitis and bacteremia. Targeted antimicrobial therapy included ampicillin, ampicillin-sulbactam, and piperacillin-tazobactam, with total durations of therapy ranging from 10 to 22 days. No patients had mortality attributed to Lactobacillus infection. CONCLUSIONS: Probiotics are not harmless supplements as they come with risk of serious infection as demonstrated in this review. Before use, the risks of probiotics should be considered carefully for each individual patient. Clinicians should consider avoiding probiotics in hospitalized patients, especially those with vascular or extra-ventricular access devices.

Implementation and evaluation of an electronic consult program at a large academic health system.

BACKGROUND: Although the benefits of eConsults in increasing access and lowering unnecessary utilization have been well described, the development of a successful program can be challenging. OBJECTIVE: We sought to share the experiences of a large academic health system in implementing and evaluating a high-volume electronic consultation (eConsult) program across 34 adult and pediatric medical and surgical specialties. METHODS: Using a multi-method approach, we collected qualitative and quantitative data on operational and process outcomes to describe adoption of eConsults, and survey data to capture satisfaction and experience among referring and specialist clinicians. RESULTS AND CONCLUSIONS: Data evaluating this eConsult program demonstrated robust uptake of the eConsult workflow as well as high satisfaction amongst primary care and specialty clinicians. Effective implementation strategies included engaging leadership, building a dedicated team, and developing quality assurance mechanisms. These experiences and findings may inform implementation at health systems interested in eConsult programs.

The Growth and Development of a Research Division in the Plastic Surgery Department of a Large Urban Academic Medical Center.

INTRODUCTION: Research is a critical component of academic medicine that may or may not be prioritized in centers with high clinical volumes. The benefits of research expansion go beyond notoriety and industry partnerships, expanding into resident training and preparation of the next generation of physician-scientists. Improving a division or department's research portfolio requires a commitment to reorganizing structure, personnel, resources, and a dedication to innovative funding models. To improve research productivity and quality, our group placed several initiatives into motion beginning in August 2017 that we have outlined and evaluated in the present study. Some of these initiatives included restructuring leadership, resourcing both bench and clinical outcomes research, providing initial funding directly from clinical profits and rewarding research fiscally. METHODS: Reviews of hiring records, publications, grant allocations, and interviews with key personnel were used to generate a road map of initiatives. Average impact factor was calculated by averaging journal impact factors for all publications from the department each year, excluding any publications with greater than 5 times the raw average, and creating a corrected average that more accurately represented the work. Student t tests were used to compare mean number of publications and impact factors from 2010 to 2017 to those from 2018 to 2022. RESULTS: Prior to restructuring (2010-2017), the department published an average of 9 articles annually, which increased to an average of 42 articles since that time (P < 0.01). Average impact increased from 0 in 2010 to 4.02 in 2022, with the number of publications in top 10 plastic surgery journals following a similar trajectory with 1 publication in 2010 and 31 in 2023. Following an initial $1 million investment to create an institutionally directed fund in 2018, the department leveraged its research to earn $3 million in endowments, $1.25 million in industry partnerships, $3.23 million in Department of Defense funding, and $1.65 million from a multi-institutional National Institutes of Health grant. CONCLUSION: Deliberate prioritization of research initiatives as noted above has led to remarkable growth in academic output.

Adopting academic rank in a rural community practice affiliated with an academic medical center.

BACKGROUND: United States rural community-based practices are increasingly participating in undergraduate and graduate medical education to train the workforce of the future, and are required or encouraged to provide academic appointments to physicians who have typically not held an academic appointment. Mechanisms to identify faculty and award academic appointments across an entire health system have not been reported. METHODS: Our rural community regional practice identified academic appointments as important for participating in medical education. Over a three-year period, our regional leadership organized a formal education committee that led a variety of administrative changes to promote the adoption of academic rank. Data on attainment of academic appointments was obtained from our Academic Appointment and Promotion Committee, and cross referenced with data from our regional human resources department using self-reported demographic data. RESULTS: We describe a successful adoption strategy for awarding academic rank in a rural regional practice in which the percentage of physician staff with academic rank increased from 41.1 to 92.8% over a 3-year period. CONCLUSIONS: Our experience shows that process changes can rapidly increase and then sustain academic appointments for physicians over time. More rural health systems may want to consider the use of academic rank to support educational programs while enhancing physician satisfaction, recruitment and retention.

How An Academic Direct Primary Care Clinic Served Patients from Vulnerable Communities.

PURPOSE: Direct primary care (DPC) critics are concerned that the periodic fee precludes participation from vulnerable populations. The purpose is to describe the demographics and appointments of a, now closed, academic DPC clinic and determine whether there are differences in vulnerability between census tracts with and without any clinic patients. METHODS: We linked geocoded data from the DPC's electronic health record with the social vulnerability index (SVI). To characterize users, we described their age, sex, language, membership, diagnoses, and appointments. Descriptive statistics included frequencies, proportions or medians, and interquartile ranges. To determine differences in SVI, we calculated a localized SVI percentile within Harris County. A t test assuming equal variances and Mann-Whitney U Tests were used to assess differences in SVI and all other census variables, respectively, between those tracts with and without any clinic patients. RESULTS: We included 322 patients and 772 appointments. Patients were seen an average of 2.4 times and were predominantly female (58.4%). More than a third (37.3%) spoke Spanish. There was a mean of 3.68 ICD-10 codes per patient. Census tracts in which DPC patients lived had significantly higher SVI scores (ie, more vulnerable) than tracts where no DPC clinic patients resided (median, 0.60 vs 0.47, p-value < 0.05). CONCLUSION: This academic DPC clinic cared for individuals living in vulnerable census tracts relative to those tracts without any clinic patients. The clinic, unfortunately, closed due to multiple obstacles. Nevertheless, this finding counters the perception that DPC clinics primarily draw from affluent neighborhoods.

Why Opportunities for Tenure Matter for Minoritized Faculty in Academic Medicine.

Academic medicine continues to characterize the experiences of Black and other minoritized faculty in medicine to enhance their careers and promote their advancement. An issue of discussion is tenure and its role in the advancement and retention of this group. Tenure is a sign of national presence, command of an area of study, and can demonstrate support from the institution in terms of permanent employment, eligibility to apply for awards, sit or vote on certain committees or qualify for certain leadership opportunities. Anecdotally there have been reports that tenure is a thing of the past that has lost relevance prompting some to end tenure in their institutions. Reasons for this are complex, however the literature does not include minoritized faculty as a reason for the need to revise or eliminate tenure and tenure earning tracks. The authors discuss 3 reasons why Black and other minoritized faculty should be afforded the opportunity to achieve permanent status in their academic health centers. They include histories of being denied freedom, having information concealed or being giving false information, and being denied permanent academic employment status.

A lay of the land: a description of academic acute care surgery models in Canada.

BACKGROUND: Patients who require emergency general surgery (EGS) are at a substantially higher risk for perioperative morbidity and mortality than patients undergoing elective general surgery. The acute care surgery (ACS) model has been shown to improve EGS patient outcomes and cost-effectiveness. A recent systematic review has shown extensive heterogeneity in the structure of ACS models worldwide. The objective of this study was to describe the current landscape of ACS models in academic centres across Canada. METHODS: We sent an online questionnaire to the 18 academic centres in Canada. The lead ACS physicians from each institution completed the questionnaire, describing the structure of their ACS models. RESULTS: In total, 16 institutions responded, all of which reported having ACS models, with a total of 29 ACS services described. All services had resident coverage. Of the 29, 18 (62%) had dedicated allied health care staff. The staff surgeon was free from elective duties while covering ACS in 17/29 (59%) services. More than half (15/29; 52%) of the services described protected ACS operating room time, but only 7/15 (47%) had a dedicated ACS room all 5 weekdays. Four of 29 services (14%) had no protected ACS operating room time. Only 1/16 (6%) institutions reported a mandate to conduct ACS research, while 12/16 (75%) found ACS research difficult, owing to lack of resources. CONCLUSION: We saw large variations in the structure of ACS models in academic centres in Canada. The components of ACS models that are most important to patient outcomes remain poorly defined. Future research will focus on defining the necessary cornerstones of ACS models.

Promoting professionalism through humanities-based transformation.

INTRODUCTION: In the last two decades, academic medical centers in the United States have faced a new challenge, dealing with breaches of medical professionalism in their staff, house staff, and medical students. Medical education settings have largely directed their professionalism efforts toward responding reactively to negative outliers. DISCUSSION: This paper contends that the warrant of medical education mandates a transformative path forward. While negative behavior must be responded to meaningfully, so, too, must positive role models of professional behavior be publicly lauded for their consequential culture change in their institutions, and promoted as positive role models. Further, the promotion of medical professionalism must be part of this culture by proactively engaging all learners and health care providers with medical ethics and humanities-based knowledge, critical thinking skills, and role modeling. CONCLUSION: Professionalism programs should be vested with the authority to implement an affirmative educational program intended to nurture and promote medical professionalism in each medical student, resident, fellow, and attending and utilize methods to that end employing both virtue and care ethics.

Medical professionalism is the foundational concept grounded upon scientific- and humanities-based knowledge and skills, directed toward the promotion of patient benefit with the rejection of self-interest, delivered with excellence in comportment, and the adherence to a covenant of trust with society.Medical educators who solely emphasize the detection and punishment of negative outliers are missing essential elements in promoting medical professionalism.Medical professionalism should be comprehensively addressed through a systematic addressing of teaching fundamental knowledge, skills, and virtue, promote excellence in role modeling and mentorship, and the redress of those lacking insight in their professional conduct.

Mentorship effect for PAs at an academic medical center and its healthcare system.

PURPOSE: Mentorship has many notable benefits. Research about mentorship for physician associates/assistants (PAs) is limited. This study sought to uncover more detailed information on mentorship and its effect on PAs. METHODS: A survey was sent via email to all PAs and advanced practice registered nurses at our institution. Subgroup analysis was performed on PA respondents, including satisfaction and independent predictors associated with mentorship. RESULTS: Of the 295 PAs, 63 (21.4%) identified having a mentor. Those with a mentor were statistically more likely to function as a mentor (OR 2.7 [95% CI 1.5-4.9], P = .001), have an academic rank of assistant professor or higher (OR 2.7 [95% CI 1.3-5.5], P = .007), be under age 45 years (OR 6.1 [95% CI 2.1-17.4], P = .008), be less than 10 years into their career (OR 3.1 [95% CI 1.7-5.7], P = .002), and be satisfied with mentorship (88.9% versus 23.9%, P < .001). CONCLUSIONS: Mentorship for PAs is crucial and can boost academic promotion and career satisfaction.

A case study of inclusion of rural populations in research: Implications for science and health equity.

Prior research highlights that rural populations have been historically underrepresented/excluded from clinical research. The primary objective of this study was to describe the inclusion of rural populations within our research enterprise using Clinical Research Management System demographic information at a large academic medical center in the Southeast. This was a cross-sectional study using participant demographic information for all protocols entered into our Clinical Research Management System between May 2018 and March 2021. Descriptive statistics were used to analyze the representation of rural and non-rural participants and demographic breakdown by age, sex, race, and ethnicity for our entire enterprise and at the state level. We also compared Material Community Deprivation Index levels between urban and rural participants. Results indicated that 19% of the research population was classified as rural and 81% as non-rural for our entire sample, and 17.5% rural and 82.5% urban for our state-level sample. There were significant differences in race, sex, and age between rural and non-rural participants and Material Community Deprivation Indices between rural and non-rural participants. Lessons learned and recommendations for increasing the inclusion of rural populations in research are discussed.

Improving Lung Cancer Screening at an Academic Medical Center.

INTRODUCTION: Lung cancer ranks as the third most prevalent cancer in the United States. The use of low-dose computed tomography (LDCT) screening significantly reduces mortality from this disease. Unfortunately, Texas lags in completing lung cancer screening (LCS) for high-risk patients, ranking 48th among all states. It is crucial to implement quality improvement (QI) initiatives in Texas. In collaboration with the American Cancer Society, the primary care center (PCC) at our institution led a multidisciplinary QI project aimed at enhancing LCS through LDCT for eligible PCC patients. METHODS: The study included patients eligible for screening and who fall into the following categories: established patients with Medicaid, low-income or uninsured established patients, and established patients with either Medicare or commercial insurance. Enhancements to electronic medical records, education for clinical staff and patients, and a coordinated, multidisciplinary effort were implemented. RESULTS: The study revealed a substantial 40.2% improvement in LCS rates. CONCLUSION: The US Preventive Services Task Force guidelines rely on an accurate history of patient's tobacco use to identify patients eligible for LCS. This QI project achieved success in improving the thoroughness of tobacco use history documentation and surpassed our target for increasing LCS by more than 10%.

Factors Associated With Nasogastric Tube Placement-Related Complications in a Single Academic Medical Center.

OBJECTIVE: At our 710-bed academic medical center, nine (9) patients sustained injuries during nasogastric (NG) tube insertion attempts over a 16-month period (March 2021-July 2022). No injuries were reported during the comparable period before these events. This increase in reported events prompted an in-depth analysis to determine the root causes and implement a process improvement plan. METHODS: Root cause analysis (RCA) of these events failed to identify risk factors or actionable themes. The RCAs demonstrated wide variation in the number of insertion attempts and techniques. RESULTS: A standard process was created to provide team members with guidance for escalation when NG tube placement was difficult. CONCLUSIONS: Although the complication rate for NG tube insertion was comparable with the criterion standard for large tertiary care institutions, we focused on minimizing risk and improving outcomes by creating a standard process for NG tube placement.