Clinician Perspectives Regarding the Impact of Information Technology on Multidisciplinary Tumor Boards: A National Comprehensive Cancer Network Survey.

PURPOSE: Multidisciplinary tumor boards (MTBs) support high-quality cancer care. Little is known about the impact of information technology (IT) tools on the operational and technical aspects of MTBs. The National Comprehensive Cancer Network EHR Oncology Advisory Group formed a workgroup to investigate the impact of IT tools such as EHRs and virtual conferencing on MTBs. METHODS: The workgroup created a cross-sectional survey for oncology clinicians (eg, pathology, medical, surgical, radiation, etc) participating in MTBs at 31 National Comprehensive Cancer Network member institutions. A standard invitation e-mail was shared with each EHR Advisory Group Member with a hyperlink to the survey, and each member distributed the survey to MTB participants at their institution or identified the appropriate person at their institution to do so. The survey was open from February 26, 2022, to April 26, 2022. Descriptive statistics were applied in the analysis of responses, and a qualitative thematic analysis of open-ended responses was completed. RESULTS: Individuals from 27 institutions participated. Almost all respondents (99%, n = 764 of 767) indicated that their MTBs had participants attending virtually. Most indicated increased attendance (69%, n = 514 of 741) after virtualization with the same or improved quality of discussion (75%, n = 557 of 741) compared with in-person MTBs. Several gaps between the current and ideal state emerged regarding EHR integration: 57% (n = 433 of 758) of respondents noted the importance of adding patients for MTB presentation via the EHR, but only 40% (n = 302 of 747) reported being able to do so most of the time. Similarly, 87% (n = 661 of 760) indicated the importance of documenting recommendations in the EHR, but only 53% (n = 394 of 746) reported this occurring routinely. CONCLUSION: Major gaps include the lack of EHR integration for MTBs. Clinical workflows and EHR functionalities could be improved to further optimize EHRs for MTB management and documentation.

Increasing clinician participation in tobacco cessation by an implementation science-based tobacco cessation champion program.

BACKGROUND: We designed a process to increase tobacco cessation in an academic center and its widely distributed network community sites using clinical champions to overcome referral barriers. METHODS: In 2020 a needs assessment was performed across the City of Hope Medical Center and its 32 community treatment sites. We reviewed information science strategies to choose elements for our expanded tobacco control plan, focusing on distributed leadership with tobacco cessation champions. We analyzed smoking patterns in patients with cancer before and following program implementation. We evaluated the champion experience and measured tobacco abstinence after 6 months of follow-up. RESULTS: Cancer center leadership committed to expanding tobacco control. Funding was obtained through a Cancer Center Cessation Initiative (C3I) grant. Multi-disciplinary leaders developed a comprehensive plan. Disease-focused clinics and community sites named cessation champions (a clinician and nurse) supported by certified tobacco treatment specialists. Patient, staff, clinician, and champion training/education were developed. Roles and responsibilities of the champions were defined. Implementation in pilot sites showed increased tobacco assessment from 80.8 to 96.6%, increased tobacco cessation referral by 367%, and moderate smoking abstinence in both academic (27.2%) and community sites (22.5%). 73% of champions had positive attitudes toward the program. CONCLUSION: An efficient process to expand smoking cessation in the City of Hope network was developed using implementation science strategies and cessation champions. This well-detailed implementation process may be helpful to other cancer centers, particularly those with a tertiary care cancer center and community network.

Establishing a research informatics program in a public healthcare system: a case report with model documents.

While much is known about governance models for research informatics programs in academic medical centers and similarly situated cancer centers, community and public health systems have been less well-characterized. As part of implementing an enterprise research governance framework, leaders in the Los Angeles County Department of Health Services established a research informatics program, including research data warehousing. The strategy is focused on high-priority, patient-centered research that leverages the investment in health IT and an efficient, sustained contribution from 2 affiliated Clinical Translational Sciences Institutes. This case study describes the foundational governance framework and policies that were developed. We share the results of several years of planning, implementation, and operations of an academically funded research informatics service core embedded in a large, multicenter county health system. We include herein a Supplementary Appendix of governance documents that may serve as pragmatic models for similar initiatives.

Patient generated health data and electronic health record integration in oncologic surgery: A call for artificial intelligence and machine learning.

In this review, we aim to assess the current state of science in relation to the integration of patient-generated health data (PGHD) and patient-reported outcomes (PROs) into routine clinical care with a focus on surgical oncology populations. We will also describe the critical role of artificial intelligence and machine-learning methodology in the efficient translation of PGHD, PROs, and traditional outcome measures into meaningful patient care models.

Association of CT perfusion and postoperative cognitive dysfunction after off-pump coronary artery bypass grafting.

OBJECTIVE: To investigate the relationship between an abnormal CT perfusion scan and postoperative cognitive dysfunction, as measured by changes in MoCA and MMSE scores, after off-pump coronary artery bypass grafting (OPCABG). METHODS: Eight hundred and thirteen patients were selected who underwent OPCABG between August 2010 and September 2013. Cognitive function was assessed before operation and at seven days post-op. CT perfusion scan was obtained preoperatively and was used to divide patients into two groups: abnormal perfusion and normal perfusion groups. RESULTS: (1) Logistic regression analysis showed that perfusion abnormalities (OR, 3.012; 95% CI, 1.660-5.463; P < 0.05) were an independent risk factor for postoperative cognitive dysfunction (POCD). (2) 556 patients with CT perfusion scans were divided into normal perfusion and abnormal perfusion groups: incidence of POCD in the abnormal perfusion group is significantly higher than the control group (21.6 vs 8.6%, P < 0.05); MMSE scores were significantly lower in patients with abnormal perfusion before and after surgery. MoCA scores demonstrated a significant drop after surgery for all patients with abnormal perfusion (P < 0.05). The abnormal perfusion group had a significant reduction in the visuospatial/executive and naming scores in the MoCA as compared to normal perfusion (P < 0.05). CONCLUSION: Abnormal CT perfusion is a significant risk factor for postoperative cognitive dysfunction, and has the most impact on visuospatial/executive and naming functions.

The threshold of cortical electrical stimulation for mapping sensory and motor functional areas.

This study aimed to investigate the threshold of cortical electrical stimulation (CES) for functional brain mapping during surgery for the treatment of rolandic epilepsy. A total of 21 patients with rolandic epilepsy who underwent surgical treatment at the Beijing Institute of Functional Neurosurgery between October 2006 and March 2008 were included in this study. Their clinical data were retrospectively collected and analyzed. The thresholds of CES for motor response, sensory response, and after discharge production along with other threshold-related factors were investigated. The thresholds (mean ± standard deviation) for motor response, sensory response, and after discharge production were 3.48 ± 0.87, 3.86 ± 1.31, and 4.84 ± 1.38 mA, respectively. The threshold for after discharge production was significantly higher than those of both the motor and sensory response (both p<0.05). A negative linear correlation was found between the threshold of after discharge production and disease duration. Using the CES parameters at a stimulation frequency of 50 Hz and a pulse width of 0.2 ms, the threshold of sensory and motor responses were similar, and the threshold of after discharge production was higher than that of sensory and motor response.

Anatomical study of endoscope-assisted far lateral keyhole approach to the ventral craniocervical region with neuronavigational guidance.

BACKGROUND: Image-guided neurosurgery, endoscopic-assisted neurosurgery and the keyhole approach are three important parts of minimally invasive neurosurgery and have played a significant role in treating skull base lesions. This study aimed to investigate the potential usefulness of coupling of the endoscope with the far lateral keyhole approach and image guidance at the ventral craniocervical junction in a cadaver model. METHODS: We simulated far lateral keyhole approach bilaterally in five cadaveric head specimens (10 cranial hemispheres). Computed tomography-based image guidance was used for intraoperative navigation and for quantitative measurements. Skull base structures were observed using both an operating microscope and a rigid endoscope. The jugular tubercle and one-third of the occipital condyle were then drilled, and all specimens were observed under the microscope again. We measured and compared the exposure of the petroclivus area provided by the endoscope and by the operating microscope. Statistical analysis was performed by analysis of variance followed by the Student-Newman-Keuls test. RESULTS: With endoscope assistance and image guidance, it was possible to observe the deep ventral craniocervical junction structures through three nerve gaps (among facial-acoustical nerves and the lower cranial nerves) and structures normally obstructed by the jugular tubercle and occipital condyle in the far lateral keyhole approach. The surgical area exposed in the petroclival region was significantly improved using the 0° endoscope (1147.80 mm(2)) compared with the operating microscope ((756.28 ± 50.73) mm(2)). The far lateral retrocondylar keyhole approach, using both 0° and 30° endoscopes, provided an exposure area ((1147.80 ± 159.57) mm(2) and (1409.94 ± 155.18) mm(2), respectively) greater than that of the far lateral transcondylar transtubercular keyhole approach ((1066.26 ± 165.06) mm(2)) (P < 0.05). CONCLUSIONS: With the aid of the endoscope and image guidance, it is possible to approach the ventral craniocervical junction with the far lateral keyhole approach. The use of an angled-lens endoscope can significantly improve the exposure of the petroclival region without drilling the jugular tubercle and occipital condyle.

Synergetic neuroprotection of normobaric oxygenation and ethanol in ischemic stroke through improved oxidative mechanism.

BACKGROUND AND PURPOSE: Normobaric oxygenation (NBO) and ethanol both provide neuroprotection in stroke. We evaluated the enhanced neuroprotective effect of combining these 2 treatments in a rat stroke model. METHODS: Sprague-Dawley rats were subjected to middle cerebral artery occlusion for 2 hours. Reperfusion was then established and followed by treatment with either (1) an intraperitoneal injection of ethanol (1.0 g/kg), (2) NBO treatment (2-hour duration), or (3) NBO plus ethanol. The extent of brain injury was determined by infarct volume and motor performance. Oxidative metabolism was determined by ADP/ATP ratios, reactive oxygen species levels, nicotinamide adenine dinucleotide phosphate oxidase activity, and pyruvate dehydrogenase activity. Protein expression of major nicotinamide adenine dinucleotide phosphate oxidase subunits (p47(phox), gp91(phox), and p67(phox)) and the enzyme pyruvate dehydrogenase was evaluated through Western immunoblotting. RESULTS: NBO and ethanol monotherapies each demonstrated reductions as compared to stroke without treatment in infarct volume (36.7% and 37.9% vs 48.4%) and neurological deficits (score of 6.4 and 6.5 vs 8.4); however, the greatest neuroprotection (18.8% of infarct volume and 4.4 neurological deficit) was found in animals treated with combination therapy. This neuroprotection was associated with the largest reductions in ADP/ATP ratios, reactive oxygen species levels, and nicotinamide adenine dinucleotide phosphate oxidase activity, and the largest increase in pyruvate dehydrogenase activity. CONCLUSIONS: Combination therapy with NBO and ethanol enhances the neuroprotective effect produced by each therapy alone. The mechanism behind this synergistic action is related to changes in cellular metabolism after ischemia reperfusion. NBO plus ethanol is attractive for clinical study because of its ease of use, tolerability, and tremendous neuroprotective potential in stroke.

Changes in spinal cord met-enkephalin levels and mechanical threshold values of pain after pulsed radio frequency in a spared nerve injury rat model.

OBJECTIVES: The present study investigated changes in the met-enkephalin (M-ENK) levels in the spinal cord. We also determined the mechanical threshold value of pain in spared nerve injury (SNI) rats after applying pulsed radiofrequency (PRF) on L5 dorsal root ganglion (DRG). METHODS: Sixty-four rats were divided into four groups: the normal group (n = 16), the control group (n = 16), the sham intervention group (n = 16), and the PRF group (n = 16). With exception for the normal group, the other three groups were treated with an established SNI model. After 7 days, PRF or sham intervention was applied on the right L5 DRG. The M-ENK levels in the spinal cord were examined by radioimmunoassay 24 hours after applying PRF or sham operation. Mechanical threshold values of pain were also tested 1 day before SNI procedure, 1 and 2 days after SNI procedure, and 2 and 24 hours after applying PRF or sham operation. RESULTS: Twenty-four hours after treatment with PRF, M-ENK levels in spinal cord increased significantly, while no changes were detected in the sham intervention group. Hyperalgesia was found in rats 1-2 days after SNI procedure and was improved by PRF. This was demonstrated by an increased mechanical threshold of pain 2 and 24 hours after the PRF. The sham intervention group showed no change in the mechanical threshold of pain. CONCLUSION: This study demonstrates that applying PRF on the DRG can improve hyperalgesia and increase M-ENK levels in the spinal cord of SNI rats within 24 hours. These findings indicate that the endogenous M-ENK in the spinal cord is involved in the mechanism of PRF on the therapy of neuropathic pain.

Preneoplastic liver cell foci expansion induced by thioacetamide toxicity in drug-primed mice.

Mice primed by feeding griseofulvin or diethyl 1,4-dihydro 1,4,6-trimethyl 3,5-pyridine decarboxylate for 5 months followed by drug withdrawal for 1 month (drug-primed mice) were given thioacetamide intraperitoneally, and the livers were subsequently studied at intervals up to 7 days. The hepatocellular proliferative response was measured by immunostaining for proliferative cell nuclear antigen. Necrosis was followed by measuring ALT. Mallory bodies were identified by immunoperoxidase stains for ubiquitin and cytokeratin. Preneoplastic foci were localized using immunofluorescence stain for glutathione S-transferase (GST mu) and histochemical stain for gamma glutamyl transpeptidase (GGT). The results showed that the preneoplastic foci selectively proliferated and expanded and formed nodules as indicated by quantitation of nuclei stained positive for proliferating cell nuclear antigen after thioacetamide treatment. Data support the hypothesis that the preneoplastic foci consisted of clones of hepatocytes which preferentially express GST mu, GGT and Mallory bodies. These preneoplastic cells selectively proliferate in response to the promoter effects of necrosis-induced liver cell regeneration ("chemical partial hepatectomy").

Combined use of computed tomography coronary calcium scores and C-reactive protein levels in predicting cardiovascular events in nondiabetic individuals.

BACKGROUND: The South Bay Heart Watch is a prospective cohort study designed to appraise the value of coronary calcium and risk factors for predicting outcomes in asymptomatic adults. Two factors that may be related to subsequent cardiovascular events are coronary calcium (CAC, a manifestation of subclinical atherosclerosis) and high-sensitivity C-reactive protein (CRP, a measure of chronic inflammation). METHODS AND RESULTS: Between December 1990 and December 1992, 1461 participants without coronary heart disease underwent baseline risk factor screening, computed tomography for CAC, and measurement of CRP. Participants were followed up for 6.4+/-1.3 years. Cox regression analyses were conducted for the 967 nondiabetics with CRP levels < or =10 mg/L to estimate the risk-factor-adjusted relative risks of CAC and CRP for the occurrence of (1) nonfatal myocardial infarction (MI) or coronary death and (2) any cardiovascular event (MI, coronary death, coronary revascularization, or stroke). CAC was a predictor of both end points (P<0.005), and CRP was a predictor of any cardiovascular event (P=0.03). Risk group analysis defined by tertiles for CAC (<3.7, 3.7 to 142.1, >142.1) and the 75th percentile for CRP (>4.05 mg/L) indicated that there was increasing risk with increasing calcium and CRP. Relative risks for the medium-calcium/low-CRP risk group to high-calcium/high-CRP risk group ranged from 1.8 to 6.1 for MI/coronary death (P=0.003) and 2.8 to 7.5 for any cardiovascular event (P<0.001). CONCLUSIONS: Participants without diabetes and those at intermediate risk may benefit from risk stratification based on high-sensitivity CRP levels and CAC, because both factors contribute independently toward the incidence of cardiovascular events.

The importance of cycling of blood alcohol levels in the pathogenesis of experimental alcoholic liver disease in rats.

BACKGROUND & AIMS: Rats fed ethanol at a constant rate through a permanent intragastric cannula have a regular fluctuation in blood alcohol level (BAL) and urine alcohol level (UAL). The level of ethanol peaks every 6-10 days. The question is how the liver differs at the peaks and troughs of the UAL cycle. Hypoxic injury is postulated to occur at the peaks. Therefore, liver injury may be different at the peaks and troughs. METHODS: Many parameters were measured at the peaks, troughs, and controls for comparison. RESULTS: Indicators of hypoxic injury at the peaks included ATP reduction, a shift to the reduced state in the NADH/NAD ratio, an increase in expression of vascular endothelial growth factor, an increase in the pathology score at the peaks, and an increase in adduct formation using pimonidazole. Liver nitrites, number of granulocytes, liver weight/body weight ratio, cytochrome P450 2E1 protein, and chymotrypsin-like activity changed in the same direction compared with control values. CONCLUSIONS: The results indicate that hypoxic injury occurs at the peaks. There was a marked shift in NADH/NAD redox state at the peaks caused by hypoxia. This shift could account for the reduced rate of ethanol elimination by alcohol dehydrogenase at the peaks.