Utilization of Discharge Checklist and Improved Education Reduces Hospital Readmission Rates in Childhood Leukemia Patients Receiving Induction Therapy.

OBJECTIVE: The aim is to identify preventable cause for hospital readmissions during induction and implement interventions to decreased preventable treatment-associated complications. BACKGROUND: Multiple factors contribute to patients with acute lymphoblastic leukemia (ALL) requiring readmissions during induction. MATERIALS AND METHODS: A dashboard monitored features of newly diagnosed patients with ALL. Readmission causes were stratified as preventable, possibly preventable, or unpreventable. A discharge checklist, including standardized education, and change of discharge date were implemented. RESULTS: Initially, there were 57 hospital readmissions of 98 patients (9 intensive care unit admissions and 2 deaths). Sixteen preventable (28.1%) and 32 unpreventable (56.1%) readmissions. After the interventions were initiated, including improved education, discharge checklist utilization, and standardized discharge date, there were 23 readmissions (78.3% were unpreventable, 6 intensive care unit admissions). CONCLUSION: Intervention implementation reduced readmission rates of induction patients with ALL by 20%.

Creation of a chemotherapy-induced nausea/vomiting dashboard to improve outcomes for pediatric cancer patients.

PURPOSE: Two of the most common acute side effects of chemotherapy are nausea and vomiting. Nausea and vomiting impact quality of life, nutritional status, and ability to tolerate further chemotherapy. Parents of pediatric oncology patients rank nausea as one of the most bothersome treatment-related symptoms. METHODS: Utilizing Quality Improvement methodology, we developed a dashboard interface to facilitate extraction of data from the electronic medical record (EMR), which is presented via a visual display that summarizes the type of chemotherapy and antiemetic medications, use of as needed medications, and number of episodes of emesis. RESULTS: This dashboard interface allows for rapid and efficient identification of patients whose antiemetic regimen is mismatched for the emetogenicity of ordered chemotherapy, thus providing a timely opportunity to modify the antiemetic regimen based on published guidelines before administration of chemotherapy drugs. It also allows measurement of the effectiveness of the antiemetic regimen in terms of the number of break through emesis and the need for as needed medications. CONCLUSIONS: A novel CINV dashboard was created, which visually conveys complex information about antiemetics, chemotherapy emetogenicity, as needed medications, and breakthrough vomiting for inpatient pediatric oncology patients.

Design and Implementation of a Curriculum for Emergency Medicine Residents to Address Medications and Treatment Referral for Opioid Use Disorder.

Background: Medications for Opioid Use Disorder (MOUD) are recognized as successful treatments for Opioid Use Disorder (OUD). The Emergency Department is well situated to initiate MOUD and begin the referral process. Unfortunately, uptake of this practice among Emergency Medicine (EM) physicians has been slow. EM physicians may feel inadequately prepared to provide MOUD and addiction referral services due to lack of previous training and experience. The goal of this pilot study was to create, implement, and evaluate an OUD management curriculum for EM residents and measure impact on knowledge, practice, and empathy. Methods: A 4.5-hour curriculum was developed, incorporating the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment mission statement as well as the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine resident physician milestones. The curriculum was inserted into an existing EM residency didactic block at an urban, tertiary care, residency program. Surveys were obtained pre- and post-intervention. Results: Post curriculum surveys demonstrated improved knowledge of buprenorphine/naloxone including indications, clinical effects and side-effects (p < 0.05). Surveys also noted increased comfort prescribing buprenorphine/naloxone for opioid withdrawal and misuse and instructing patients on home induction (p < 0.05). Additionally, residents responded positively regarding the impact of the curriculum on their understanding of the topic and their subsequent confidence in managing patients with OUD in the ED setting. Conclusion: A dedicated brief MOUD and referral curriculum can be effectively integrated into EM resident education to provide valuable clinical knowledge that may affect clinical practice.

Ultrasound is superior to palpation for thyroid cancer detection in high-risk childhood cancer and BMT survivors.

PURPOSE: Thyroid cancer is a common subsequent malignant neoplasm in childhood cancer survivors (CCS). Patients who received radiotherapy (RT) to the head, neck, upper thorax, or total body irradiation (TBI) are considered to be at risk for subsequent thyroid cancer. Current Children's Oncology Group screening guidelines recommend annual neck palpation. Our objective was to determine if ultrasound (US) is more sensitive and specific than palpation to detect thyroid cancer in high-risk CCS and bone marrow transplant (BMT) survivors. METHODS: Electronic medical records of patients followed in a longitudinal survivorship clinic from January 1, 2010 to December 31, 2017 were reviewed. Inclusion criteria included history of RT to the head, neck, upper thorax, or TBI for primary therapy or preparation for BMT prior to the age of 20 years. RESULTS: Two hundred and twenty-five patients had documented palpation and 144 (64%) also had US evaluation. Mean radiation dose was 28.6 Gy. Sixteen of 225 patients (7.1%) developed a subsequent thyroid cancer at a mean of 9.7 years from the completion of RT. Sensitivity of US was 100% compared with 12.5% for palpation. US demonstrated higher accuracy, with a receiver operating characteristic (ROC) area under the curve (AUC) of 0.87 versus 0.56 for palpation (P < 0.0001). CONCLUSION: Routine screening with US was more sensitive than palpation for detection of subsequent thyroid cancer after high-risk RT in CCS and BMT survivors. Screening US may lead to earlier detection of thyroid cancer in this population. Earlier diagnosis has the potential to decrease operative complexity, and earlier definitive therapy reduces the likelihood of metastatic disease.

Prevalence of work-related musculoskeletal pain in masonry apprentices.

The construction industry, specifically masonry, reports more work-related musculoskeletal disorders (WMSD) rates than the general industry. Masonry apprentices are assumed to be healthy, yet may have WMSDs. The purpose of this study was to evaluate the prevalence of musculoskeletal symptoms (MSS), time loss, and healthcare use among apprentices. 183 brick and block masonry apprentices completed surveys on demographics, work history, MSS, and functional well-being. The prevalence of MSS was calculated by body region, time loss, and healthcare use. The relationship between MSS, and perceived global physical and mental health was assessed. Approximately 78% of apprentices reported MSS, most in several body regions. Low back and wrists/hands were most prevalent, although few missed work or sought healthcare. Lower functional health and well-being was reported. Apprentices reported MSS comparable to previous studies of journey-level masons. Apprenticeship programmes could integrate ergonomics education to help apprentices develop safety culture early in their careers. Practitioner Summary: New masonry workers (apprentices) are assumed to be healthy yet work-related musculoskeletal symptoms (MSS) may be common early in their career. The prevalence of MSS was assessed among apprentices. Approximately 78% of apprentices reported MSS, most in several body regions, comparable to journey-level masons. Abbreviations: WMSD: work-related musculoskeletal disorders; MSS: musculoskeletal symptoms; SAVE: SAfety voice for ergonomics; MNQ: modified nordic questionnaire; FTE: full-time equivalent; SF-12: short from-12v2.

Successful treatment of severe refractory autoimmune hemolytic anemia after hematopoietic stem cell transplant with abatacept.

BACKGROUND: After hematopoietic stem cell transplantation (HSCT) autoimmune hemolytic anemia (AIHA) is a known and fairly common complication. It is often refractory to conventional therapies including corticosteroids, intravenous immunoglobulin, splenectomy, and the more recently described use of monoclonal antibodies. The high morbidity associated with these severe persistent cases elucidates the gaps in alternative therapies available for treatment. STUDY DESIGN AND METHODS: We described the successful use of abatacept for severe refractory AIHA after HSCT in three patients. RESULTS: Three pediatric patients with refractory AIHA after allogeneic stem cell transplantation were observed to be unresponsive to multitude immunosuppressive therapies, resulting in persistent transfusion dependency. Treatment with abatacept, a fusion protein that inhibits T-cell activation by binding to CD80/CD86 on antigen-presenting cells (APCs), thus blocking the required CD28 interaction between APCs and T cells, resulted in the resolution of hemolysis. CONCLUSION: Abatacept may provide significant clinical benefit in the management of AIHA after HSCT.

Protecting workers in the home care industry: workers' experienced job demands, resource gaps, and benefits following a socially supportive intervention.

The Community of Practice and Safety Support (COMPASS) program is a peer-led group intervention for home care workers. In a randomized controlled trial, COMPASS significantly improved workers' professional support networks and safety and health behaviors. However, quantitative findings failed to capture workers' complex emotional, physical, and social experiences with job demands, resource limitations, and the intervention itself. Therefore, we conducted qualitative follow-up interviews with a sample of participants (n = 28) in the program. Results provided examples of unique physical and psychological demands, revealed stressful resource limitations (e.g., safety equipment access), and elucidated COMPASS's role as a valuable resource.

Presentation and Treatment of Histoplasmosis in Pediatric Oncology Patients: Case Series and Review of the Literature.

Histoplasmosis is an endemic fungus in several regions of the United States. The diagnosis and treatment of this infection can be challenging in pediatric oncology patients. We present 5 patients diagnosed with histoplasmosis while receiving treatment at a midsize pediatric oncology center in Iowa. Two cases occurred in patients with acute lymphoblastic leukemia and 3 cases in patients with solid tumors. All patients were treated with antifungal therapy and demonstrated excellent clinical response. Histoplasmosis should be considered as a potential cause of nonspecific febrile illness, pulmonary masses, and bone marrow suppression in immunocompromised patients in endemic regions. Prompt and accurate diagnosis can facilitate timely antifungal therapy and avoidance of prolonged hospital stays, invasive testing, unnecessary antibiotics, and unwarranted anticancer therapies.

Safety and Health Support for Home Care Workers: The COMPASS Randomized Controlled Trial.

OBJECTIVES: To determine the effectiveness of the COMmunity of Practice And Safety Support (COMPASS) Total Worker Health intervention for home care workers. METHODS: We randomized 16 clusters of workers (n = 149) to intervention or usual-practice control conditions. The 12-month intervention was scripted and peer-led, and involved education on safety, health, and well-being; goal setting and self-monitoring; and structured social support. We collected measures at baseline, 6 months, and 12 months, which included workers' experienced community of practice (i.e., people engaged in a common activity who interact regularly for shared learning and improvement). Implementation occurred during 2013 and 2014 in Oregon. RESULTS: In an intent-to-treat analysis, relative to control, the intervention produced significant and sustained improvements in workers' experienced community of practice. Additional significant improvements included the use of ergonomic tools or techniques for physical work, safety communication with consumer-employers, hazard correction in homes, fruit and vegetable consumption, lost work days because of injury, high-density lipoprotein cholesterol, and grip strength. Consumer-employers' reports of caregiver safety behaviors also significantly improved. CONCLUSIONS: COMPASS was effective for improving home care workers' social resources and simultaneously impacted both safety and health factors.

Pilot Study of Kano "Attractive Quality" Techniques to Identify Change in Emergency Department Patient Experience.

STUDY OBJECTIVE: We describe the use of the Kano Attractive Quality analytic tool to improve an identified patient experience gap in perceived compassion by emergency department (ED) providers. METHODS: In phase 1, point-of-service surveying assessed baseline patient perception of ED provider compassion. Phase 2 deployed Kano surveys to predict the effect of 4 proposed interventions on patient perception. Finally, phase 3 compared patients receiving standard care versus the Kano-identified intervention to assess the actual effect on patient experience. RESULTS: In phase 1, 193 of 200 surveys (97%) were completed, showing a baseline median score of 4 out of 5 (interquartile range [IQR] 3 to 5), with top box percentage of 33% for patients' perception of receiving compassionate care. In phase 2, 158 of 180 surveys (88%) using Kano-formatted questions were completed, and the data predicted that increasing shared decisionmaking would cause the greatest improvement in the patient experience. Finally, in phase 3, 45 of 49 surveys (92%) were returned and demonstrated a significant improvement in perceived concern and sensitivity, 5 (IQR 5 to 5) versus 4 (IQR 3 to 5) with a difference of 1 (95% CI 0.1-1.9) and a top box rating of 79% versus 35% with a difference of 44% (95% CI 12-66) by patients who received dedicated shared decisionmaking interventions versus those receiving standard of care. CONCLUSION: Kano analysis is likely predictive of change in patient experience. Kano methods may prove as useful in changing management of the health care industry as it has been in other industries.

Safety voice for ergonomics (SAVE) project: protocol for a workplace cluster-randomized controlled trial to reduce musculoskeletal disorders in masonry apprentices.

BACKGROUND: Masons have the highest rate of overexertion injuries among all construction trades and rank second for occupational back injuries in the United States. Identified ergonomic solutions are the primary method of reducing exposure to risk factors associated with musculoskeletal disorders. However, many construction workers lack knowledge about these solutions, as well as basic ergonomic principles. Construction apprentices, as they embark on their careers, are greatly in need of ergonomics training to minimize the cumulative exposure that leads to musculoskeletal disorders. Apprentices receive safety training; however, ergonomics training is often limited or non-existent. In addition, apprenticeship programs often lack "soft skills" training on how to appropriately respond to work environments and practices that are unsafe. The SAVE program - SAfety Voice for Ergonomics - strives to integrate evidence-based health and safety training strategies into masonry apprenticeship skills training to teach ergonomics, problem solving, and speaking up to communicate solutions that reduce musculoskeletal injury risk. The central hypothesis is that the combination of ergonomics training and safety voice promotion will be more effective than no training or either ergonomics training alone or safety voice training alone. METHODS/DESIGN: Following the development and pilot testing of the SAVE intervention, SAVE will be evaluated in a cluster-randomized controlled trial at 12 masonry training centers across the U.S. Clusters of apprentices within centers will be assigned at random to one of four intervention groups (n = 24 per group): (1) ergonomics training only, (2) safety voice training only, (3) combined ergonomics and safety voice training, or (4) control group with no additional training intervention. Outcomes assessed at baseline, at the conclusion of training, and then at six and 12 months post training will include: musculoskeletal symptoms, general health perceptions, knowledge of ergonomic and safety voice principles, and perception and attitudes about ergonomic and safety voice issues. DISCUSSION: Masons continue to have a high rate of musculoskeletal disorders. The trade has an expected increase of 40 % in the number of workers by 2020. Therefore, a vetted intervention for apprentices entering the trade, such as SAVE, could reduce the burden of musculoskeletal disorders currently plaguing the trade. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02676635 , 2 February 2016.

Forb, insect, and soil response to burning and mowing Wyoming big sagebrush in greater sage-grouse breeding habitat.

Wyoming big sagebrush (Artemisia tridentata wyomingensis A. t. Nutt. ssp. wyomingensis Beetle and Young) communities provide structure and forbs and insects needed by greater sage-grouse (Centrocercus urophasianus) for growth and survival. We evaluated forb, insect, and soil responses at six mowed and 19 prescribed burned sites compared to 25, paired and untreated reference sites. Sites were classified by treatment type, soil type, season, and decade of treatment (sites burned during 1990-1999 and sites burned or mowed during 2000-2006). Our objective was to evaluate differences in ten habitat attributes known to influence sage-grouse nesting and brood rearing to compare responses among treatment scenarios. Contrary to desired outcomes, treating Wyoming big sagebrush through prescribed burning or mowing may not stimulate cover or increase nutrition in food forbs, or increase insect abundance or indicators of soil quality compared with reference sites. In some cases, prescribed burning showed positive results compared with mowing such as greater forb crude protein content (%), ant (Hymenoptera; no./trap), beetle (Coleoptera/no./trap), and grasshopper abundance (Orthoptera; no./sweep), and total (%) soil carbon and nitrogen, but of these attributes, only grasshopper abundance was enhanced at burned sites compared with reference sites in 2008. Mowing did not promote a statistically significant increase in sage-grouse nesting or early brood-rearing habitat attributes such as cover or nutritional quality of food forbs, or counts of ants, beetles, or grasshoppers compared with reference sites.

Translating an Intervention to Address Chronic Pain among Home Care Workers: The COMPASS-NP Pilot.

OBJECTIVE: To pilot test the COMmunity of Practice And Safety Support for Navigating Pain (COMPASS-NP) intervention for home care workers experiencing chronic pain. METHODS: Home care workers with chronic pain participated (n = 19; 2 groups) in a 10-week online group program focused on workplace safety and pain self-management. Primary outcomes were changes in pain interference with work and life. Other outcomes related to ergonomics, pain levels, opioid misuse risk, mental health, sleep, and physical activity. RESULTS: The intervention produced a large reduction in pain interference with life ( d = -0.85) and a moderate reduction in pain interference with work time demands ( d = -0.61). Secondary outcomes showed favorable effect sizes, including a substantial increase in the use of ergonomic tools and techniques ( d = 1.47). CONCLUSION: Findings were strongly encouraging. The effectiveness of COMPASS-NP will be evaluated in a future randomized controlled trial.

Characteristics and Health Care Utilization of Patients With Housing Insecurity in the ED.

Importance: Unstable housing and homelessness can exacerbate adverse health outcomes leading to increased risk of chronic disease, injury, and disability. However, emergency departments (EDs) have no universal method to identify those at risk of or currently experiencing homelessness. Objective: To describe the extent of housing insecurity among patients who seek care in an urban ED, including chief concerns, demographics, and patterns of health care utilization. Design, Setting, and Participants: This cross-sectional study included all adult patients presenting to the ED at Vanderbilt University Medical Center (VUMC), an urban tertiary care, level I trauma center in the Southeast US, from January 5 to May 16, 2023. Main Outcomes and Measures: The primary outcome was the proportion of ED visits at which patients screened positive for housing insecurity. Secondary outcomes included prevalence of insecurity by chief concerns, demographics, and patterns of health care utilization. Results: Of all 23 795 VUMC ED visits with screenings for housing insecurity (12 465 visits among women [52%]; median age, 47 years [IQR, 32-48 years]), in 1185 (5%), patients screened positive for current homelessness or housing insecurity (660 unique patients); at 22 610 visits (95%), the screening result was negative. Of visits with positive results, the median age of patients was 46 years (IQR, 36-55 years) and 829 (70%) were among male patients. Suicide and intoxication were more common chief concerns among visits at which patients screened positive (132 [11%] and 118 [10%], respectively) than among those at which patients screened negative (220 [1%] and 335 [2%], respectively). Visits with positive results were more likely to be among patients who were uninsured (395 [33%] vs 2272 [10%]) and had multiple visits during the study period. A higher proportion of positive screening results occurred between 8 pm and 6 am. The social work team assessed patients at 919 visits (78%) with positive screening results. Conclusions and Relevance: In this cross-sectional study of 23 795 ED visits, at 5% of visits, patients screened positive for housing insecurity and were more likely to present with a chief concern of suicide, to be uninsured, and to have multiple visits during the study period. This analysis provides a call for other institutions to introduce screening and create tailored care plans for patients experiencing housing insecurity to achieve equitable health care.

Prospective External Validation of the Esbenshade Vanderbilt Models Accurately Predicts Bloodstream Infection Risk in Febrile Non-Neutropenic Children With Cancer.

PURPOSE: The optimal management of fever without severe neutropenia (absolute neutrophil count [ANC] ≥500/µL) in pediatric patients with cancer is undefined. The previously proposed Esbenshade Vanderbilt (EsVan) models accurately predict bacterial bloodstream infections (BSIs) in this population and provide risk stratification to aid management, but have lacked prospective external validation. MATERIALS AND METHODS: Episodes of fever with a central venous catheter and ANC ≥500/µL occurring in pediatric patients with cancer were prospectively collected from 18 academic medical centers. Variables included in the EsVan models and 7-day clinical outcomes were collected. Five versions of the EsVan models were applied to the data with calculation of C-statistics for both overall BSI rate and high-risk organism BSI (gram-negative and Staphylococcus aureus BSI), as well as model calibration. RESULTS: In 2,565 evaluable episodes, the BSI rate was 4.7% (N = 120). Complications for the whole cohort were rare, with 1.1% (N = 27) needing intensive care unit (ICU) care by 7 days, and the all-cause mortality rate was 0.2% (N = 5), with only one potential infection-related death. C-statistics ranged from 0.775 to 0.789 for predicting overall BSI, with improved accuracy in predicting high-risk organism BSI (C-statistic 0.800-0.819). Initial empiric antibiotics were withheld in 14.9% of episodes, with no deaths or ICU admissions attributable to not receiving empiric antibiotics. CONCLUSION: The EsVan models, especially EsVan2b, perform very well prospectively across multiple academic medical centers and accurately stratify risk of BSI in episodes of non-neutropenic fever in pediatric patients with cancer. Implementation of routine screening with risk-stratified management for non-neutropenic fever in pediatric patients with cancer could safely reduce unnecessary antibiotic use.

Performance of ACR TI-RADS and the Bethesda System in Predicting Risk of Malignancy in Thyroid Nodules at a Large Children's Hospital and a Comprehensive Review of the Pediatric Literature.

While thyroid nodules are less common in children than in adults, they are more frequently malignant. However, pediatric data are scarce regarding the performance characteristics of imaging and cytopathology classification systems validated to predict the risk of malignancy (ROM) in adults and select those patients who require fine-needle aspiration (FNA) and possibly surgical resection. We retrospectively reviewed the electronic medical records of all patients 18 years of age or younger who underwent thyroid FNA at our institution from 1 July 2015 to 31 May 2022. Based on surgical follow-up from 74 of the 208 FNA cases, we determined the ROM for the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) ultrasound risk stratification system and The Bethesda System for Reporting Thyroid Cytopathology and added our results to those of pediatric cohorts from other institutions already published in the literature. We found the following ROMs for 1458 cases using ACR TI-RADS (TR): TR1. Benign: 2.2%, TR2. Not Suspicious: 9.3%, TR3. Mildly Suspicious: 16.6%, TR4. Moderately Suspicious: 27.0%, and TR5. Highly Suspicious 76.5%; and for 5911 cases using the Bethesda system: Bethesda I. Unsatisfactory: 16.8%, Bethesda II. Benign: 7.2%, Bethesda III: Atypia of Undetermined Significance: 29.6%, Bethesda IV. Follicular Neoplasm: 42.3%, Bethesda V. Suspicious for Malignancy: 90.8%, and Bethesda VI. Malignant: 98.8%. We conclude that ACR TI-RADS levels imply higher ROMs for the pediatric population than the corresponding suggested ROMs for adults, and, in order to avoid missing malignancies, we should consider modifying or altogether abandoning size cutoffs for recommending FNA in children and adolescents whose thyroid glands are smaller than those of adults. The Bethesda categories also imply higher ROMs for pediatric patients compared to adults.

COMMunity of Practice And Safety Support for Navigating Pain (COMPASS-NP): study protocol for a randomized controlled trial with home care workers.

BACKGROUND: Chronic pain is a prevalent and costly problem that often has occupational origins. Home care workers (HCWs) are at high risk for work-related injuries, pain, and disability. Current treatments for chronic pain emphasize medications, which are an inadequate stand-alone treatment and can produce significant adverse effects. METHODS: In this translational study, we will adapt an established work-based injury prevention and health promotion program (COMmunity of Practice And Safety Support: COMPASS) to address the needs of HCWs experiencing chronic pain. COMPASS employs peer-led, scripted group meetings that include educational content, activities, goal setting, and structured social support. The translated intervention, named COMPASS for Navigating Pain (COMPASS-NP), will be delivered in an online group format. Safety protections will be strengthened through an ergonomic self-assessment and vouchers for purchasing ergonomic tools. Educational content will integrate a self-management approach to chronic pain using proven cognitive-behavioral therapy (CBT) principles. We will use a mixed-methods hybrid type 2 evaluation approach to assess effectiveness and implementation. A cluster-randomized waitlist control design will involve 14 groups of 10 HCWs (n = 140) recruited from Washington, Oregon, and Idaho. Half of the groups will be randomly selected to complete the intervention during the first 10 weeks, while the waitlist groups serve as controls. During weeks 10-20, the waitlist groups will complete the intervention while the original intervention groups complete a follow-up period without further intervention. Our primary hypothesis is that COMPASS-NP will reduce pain interference with work and life. Secondary outcomes include injury and pain prevention behaviors, pain severity, changes in medication use, risk for opioid misuse, well-being, physical activity, and sleep. Qualitative data, including phone interviews with group facilitators and organizational partners, will evaluate the implementation and guide dissemination. DISCUSSION: The results will advance the use and knowledge of secondary prevention interventions such as ergonomic tools and cognitive behavior therapy, to reduce injury, pain, and disability and to encourage appropriate uses of analgesic medications among HCWs. TRIAL REGISTRATION: ClinicalTrials.gov NCT05492903. Registered on 08 August 2022.

A Graduate Medical Orientation Intervention Focused on Local Health Inequities.

Background: Residents must understand the social drivers of health in the communities they serve to deliver quality care. While resident orientation provides an opportunity to introduce residents to social and structural drivers of health, inequity, and care delivery relevant to the patient population in their new communities, many graduate medical education orientation curricula do not include this content. Objective: To report the development and implementation of a novel, patient-centered health equity orientation curriculum, including initial feasibility and acceptability data as well as preliminary self-reported outcomes. Methods: The curriculum was developed by academic faculty in collaboration with institutional and local health equity champions. Content centered on the history of inequities and racism within the local communities and included didactic presentations, asynchronous video, and virtual site visits to community resource groups. The curriculum was administered to all 2021 incoming Vanderbilt University Medical Center medical and surgical residents (N=270) over 2 half-days, both in-person and via Zoom. Data were collected anonymously via pre- and post-surveys. Results: A total of 216 residents (80% response rate) provided pre-survey response data, but only 138 residents (51.1%) provided post-survey data, including self-reported demographics (eg, underrepresented in medicine status) and level of agreement with 10 competency-based statements coded as pertaining to knowledge, skills, behaviors, or attitudes (KSBAs). Primary outcomes included improvement in residents' KSBAs from pre- to post-survey. The greatest increases in percentages occurred with content that was specific to local history and population. Conclusions: In a class of incoming residents, this study demonstrated feasibility, acceptability, and pre-post curriculum improvement in self-reported KSBAs when addressing health equity issues.

High Prevalence of Gene Fusions and Copy Number Alterations in Pediatric Radiation Therapy-Induced Papillary and Follicular Thyroid Carcinomas.

Background: Childhood cancer survivors and bone marrow transplant recipients treated with radiation therapy (RT) are at increased risk for subsequent thyroid cancer. However, the genetic landscape of pediatric thyroid cancer, both primary and RT-induced, remains poorly defined, as pediatric papillary thyroid carcinoma (PTC) has been understudied compared with adults and data on pediatric follicular thyroid carcinoma (FTC) are virtually nonexistent. The objective of this study was to characterize and compare the molecular profiles of pediatric RT-induced PTC and FTC cases with primary pediatric thyroid cancers. Methods: A total of 41 differentiated thyroid carcinomas (11 RT cases and 30 primary cases) from 37 patients seen at Phoenix Children's Hospital between January 1, 2010 and December 31, 2019 were evaluated by targeted next-generation sequencing and/or BRAF immunohistochemistry. Results: Eighty-six percent (6/7) of RT-PTC harbored a gene fusion (GF) compared with 56% (14/25) of primary PTC; 14% (1/7) of RT-PTC had a single-nucleotide variant (SNV; specifically, a point mutation in the DICER1 gene) compared with 44% (11/25) of primary PTC (all of the latter had the BRAFV600E mutation). An exceedingly rare ROS1 fusion was identified in a child with RT-PTC. With respect to FTC, copy number alterations (CNAs) were seen in 75% (3/4) of RT cases compared with 40% (2/5) of primary cases. None of the RT-FTC had SNVs compared with 100% (5/5) of primary FTC. Conclusions: In children, the molecular profile of subsequent RT-induced thyroid cancers appears to differ from primary (sporadic and syndromic) cases, with a high prevalence of GFs in RT-PTC (similar to PTC occurring after the Chernobyl nuclear reactor accident) and CNAs in RT-FTC. A better understanding of the molecular mechanisms underlying these cancers may lead to more accurate diagnosis, prognosis, and treatment, as some of the genomic alterations are potentially targetable.