Lessons in Truth-Telling From the Novels of Thomas Wolfe.

This essay describes the author's experience with learning about building trust with every patient and family interaction through literature.

COVID-19 convalescent plasma therapy decreases inflammatory cytokines: a randomized controlled trial.

IMPORTANCE: This study examined the role that cytokines may have played in the beneficial outcomes found when outpatient individuals infected with SARS-CoV-2 were transfused with COVID-19 convalescent plasma (CCP) early in their infection. We found that the pro-inflammatory cytokine IL-6 decreased significantly faster in patients treated early with CCP. Participants with COVID-19 treated with CCP later in the infection did not have the same effect. This decrease in IL-6 levels after early CCP treatment suggests a possible role of inflammation in COVID-19 progression. The evidence of IL-6 involvement brings insight into the possible mechanisms involved in CCP treatment mitigating SARS-CoV-2 severity.

Dynamics of inflammatory responses after SARS-CoV-2 infection by vaccination status in the USA: a prospective cohort study.

BACKGROUND: Cytokines and chemokines play a critical role in the response to infection and vaccination. We aimed to assess the longitudinal association of COVID-19 vaccination with cytokine and chemokine concentrations and trajectories among people with SARS-CoV-2 infection. METHODS: In this longitudinal, prospective cohort study, blood samples were used from participants enrolled in a multi-centre randomised trial assessing the efficacy of convalescent plasma therapy for ambulatory COVID-19. The trial was conducted in 23 outpatient sites in the USA. In this study, participants (aged ≥18 years) were restricted to those with COVID-19 before vaccination or with breakthrough infections who had blood samples and symptom data collected at screening (pre-transfusion), day 14, and day 90 visits. Associations between COVID-19 vaccination status and concentrations of 21 cytokines and chemokines (measured using multiplexed sandwich immunoassays) were examined using multivariate linear mixed-effects regression models, adjusted for age, sex, BMI, hypertension, diabetes, trial group, and COVID-19 waves (pre-alpha or alpha and delta). FINDINGS: Between June 29, 2020, and Sept 30, 2021, 882 participants recently infected with SARS-CoV-2 were enrolled, of whom 506 (57%) were female and 376 (43%) were male. 688 (78%) of 882 participants were unvaccinated, 55 (6%) were partly vaccinated, and 139 (16%) were fully vaccinated at baseline. After adjusting for confounders, geometric mean concentrations of interleukin (IL)-2RA, IL-7, IL-8, IL-15, IL-29 (interferon-λ), inducible protein-10, monocyte chemoattractant protein-1, and tumour necrosis factor-α were significantly lower among the fully vaccinated group than in the unvaccinated group at screening. On day 90, fully vaccinated participants had approximately 20% lower geometric mean concentrations of IL-7, IL-8, and vascular endothelial growth factor-A than unvaccinated participants. Cytokine and chemokine concentrations decreased over time in the fully and partly vaccinated groups and unvaccinated group. Log10 cytokine and chemokine concentrations decreased faster among participants in the unvaccinated group than in other groups, but their geometric mean concentrations were generally higher than fully vaccinated participants at 90 days. Days since full vaccination and type of vaccine received were not correlated with cytokine and chemokine concentrations. INTERPRETATION: Initially and during recovery from symptomatic COVID-19, fully vaccinated participants had lower concentrations of inflammatory markers than unvaccinated participants suggesting vaccination is associated with short-term and long-term reduction in inflammation, which could in part explain the reduced disease severity and mortality in vaccinated individuals. FUNDING: US Department of Defense, National Institutes of Health, Bloomberg Philanthropies, State of Maryland, Mental Wellness Foundation, Moriah Fund, Octapharma, HealthNetwork Foundation, and the Shear Family Foundation.

The Perceptions of Cancer Patients Regarding the Causes and Preventability of Unplanned Hospital Admissions.

OBJECTIVE: The objective of this study was to determine the attitudes of oncology patients regarding the causes and preventability of unplanned hospitalizations. METHODS: Convenience sample using a 36-question survey instrument adapted from prior studies of hospital readmissions. RESULTS: A total of 95 evaluable patients answered >75% of survey items. Majorities (64%) agreed that they desired to avoid the admission, but disagreed (79%) that their own admission was preventable. Patients did not generally express lack confidence in their overall self-management abilities (only 36% agreed) or dissatisfaction with the level of home support, emotional or equipment (only 11% to 26% agreed). Patients did not complain of an inability to access their oncology care team (only 14% agreed), yet a strong majority (79%) endorsed the idea that emergency department visits represent the "quickest and easiest way to get needed care" and that the "hospital is the best place for me when I am sick" (60%). Overall, 79% indicated that their oncology care team directed them to visit the emergency department for evaluation. Most results did not differ by demographic factors. CONCLUSIONS: These results differ from previous results that use methods other than a direct patient survey to determine the preventability or root causes of unplanned hospital admissions/ or readmissions. Accordingly, patient support programs may not address the root causes of unplanned admissions. The use of the emergency department for unplanned care may represent local culture and institutions planning reduction efforts should include patent perceptions to plan a holistic solution.

Final outcomes of escalated melphalan 280 mg/m2 with amifostine cytoprotection followed autologous hematopoietic stem cell transplantation for multiple myeloma: high CR and VGPR rates do not translate into improved survival.

The most common preparative regimen for autologous transplantation (ASCT) in myeloma (MM) consists of melphalan 200 mg/m2 (MEL 200). Higher doses of melphalan 220-260 mg/m2, although relatively well tolerated, have not shown significant improvement in clinical outcomes. Several approaches have been pursued in the past to improve CR rates, including poly-chemotherapy preparative regimens, tandem ASCT, consolidation, and/or maintenance therapy. Since there is a steep dose-response effect for intravenous melphalan, we evaluated an alternative single ASCT strategy using higher-dose melphalan at 280 mg/m2 (MEL 280) with amifostine as a cytoprotectant as the maximum tolerated dose determined in an earlier phase I dose escalation trial. We report the final long-term outcomes of MM patients who underwent conditioning with MEL 280 with amifostine cytoprotection followed by ASCT. Although the complete response rate was quite high in the era pre-dating the routine use of novel therapies (proteasome inhibitors, immunomodulatory agents) (49%), the progression-free survival was a disappointing 22 months. The implications of this dichotomy between the excellent depth of ASCT response and progression-free survival are discussed.

Lung Cancer Screening in the Community Setting.

BACKGROUND: Lung cancer has high incidence and high mortality burden, particularly because it is typically diagnosed in later stages. The National Lung Screening Trial demonstrated a lung cancer-specific mortality benefit in high-risk current and former smokers with yearly low-dose chest computed tomography (CT). Lung cancer screening is thus recommended, but it is unclear whether the results of the National Lung Screening Trial can be replicated in community settings. METHODS: A retrospective review was performed of the lung screening program over its first 5 years, 2012 to 2016. Patients' demographics, initial screening results, follow-up, and management results were analyzed in relation to the National Lung Screening Trial results. Annual adherence was defined as returning for imaging within 1 year + 90 days. RESULTS: A total of 1,241 persons underwent initial screening over the 5-year period; 78.6% of findings were benign, and only annual repeat low-dose chest CT was recommended. A total of 29 cancers were identified in 26 participants (2%), of which 72% were stage I. The annual adherence rate to repeat imaging after a low-risk baseline scan was 37%, and the any follow-up rate was 51% despite programmatic efforts to follow screening recommendations. When positive findings required more intensive evaluation, most commonly by repeat chest CT scan, adherence was 88%. A total of 1.1% of all participants had invasive biopsies for benign results. Complications of biopsy were minimal. CONCLUSIONS: This review demonstrates that a community-based program can approximate the results of the National Lung Screening Trial in detecting early lung cancers. Further study of the adherence phenomenon is essential.

Assessment of Opioid Prescribing Practices Before and After Implementation of a Health System Intervention to Reduce Opioid Overprescribing.

Importance: Overprescribing of opioids has generated and sustains the opioid overdose epidemic. Health systems have a responsibility to lead the effort to reduce overprescribing. Objective: To measure the effects of multilevel interventions on opioid prescribing within a health system. Design, Setting, and Participants: Quality improvement study comparing a 6-month preintervention baseline with a 16-month postintervention period ending in April 2018. Inpatient and outpatient clinical activity within a regional health system including an acute care hospital, same-day surgery, and outpatient clinics. Opioid prescribing activity by hundreds of clinicians involving over a million clinical encounters was measured using a health system's electronic medical record. Interventions: Multiple parallel interventions in different domains, including prescriber education and accountability, enhanced oversight via measurement of individual prescribers, tools to right-size postoperative discharge prescriptions, reduction of default amounts on standard opioid prescription orders, and professionally written patient and public education about opioid risks and alternatives. Main Outcomes and Measures: Morphine milligram equivalents (MME) per encounter per month, MME per opioid prescription, and rate of opioid prescriptions (opioid prescriptions per encounter per month). Results: More than 44 000 clinical encounters per month were recorded. All baseline trends were not significantly different from 0. Total health system MME per encounter decreased 1.0 MME per encounter per month. At the end of the postintervention observation period, the monthly MME per encounter was 58% lower than the average of the 6-month baseline, the MME per opioid prescription per month was 34% less than the average of the baseline, and the opioid prescription rate was 38% lower than the average of the baseline. Conclusions and Relevance: Opioid overprescribing was reduced with multifocal interventions targeting patient and public demand, creating prescriber awareness and accountability, and creating tools for clinical leadership accountability. The interventions described are adoptable by most organized health systems. Reducing total opioid supply within communities should be given high priority by those with a mission to protect and improve public health.

End-of-Life Care Patterns at a Community Hospital: The Rest of the Story.

We undertook a retrospective review of a subset of expired patients at our community hospital to evaluate end-of-life care patterns and the use of advanced care planning tools among patients who died in the hospital. These 162 expired patients fell into 1 of the 3 diagnosis-related groups of cardiac, respiratory, or infectious disease. Seventy-nine percent of patients arrived to the hospital with no requested limitations in the extent of resuscitative efforts, even though 98% of all patients had major or extreme severity of illness and risk of mortality scores. The presence of an advance directive requesting a limitation of resuscitative efforts modestly impacted resources and procedures, even though utilization in this group was high. Among the 21% of patients with preexisting limits, 21% requested more aggressive support during their course. Critical care unit utilization was seen in 69% of patients for a median of 48 hours. A request for palliative care consultation was received in 44% of patients but only occurred in 30% of all patients due to the short period between the consultation request and patient death (median 37 hours). Among this group of dying patients, engagement of the palliative care team came too late in the course of many patients, suggesting that automated tools embedded in the electronic medical record might be helpful in the identification of appropriate patients earlier.

ReCAP: Insights Into the Potential Preventability of Oncology Readmissions.

PURPOSE: The role of multidisciplinary care (MDC) on cancer care processes is not fully understood. We investigated the impact of MDC on the processes of care at cancer centers within the National Cancer Institute Community Cancer Centers Program (NCCCP). METHODS: The study used data from patients diagnosed with stage IIB to III rectal cancer, stage III colon cancer, and stage III non­small-cell lung cancer at 14 NCCCP cancer centers from 2007 to 2012. We used an MDC development assessment tool­with levels ranging from evolving MDC (low) to achieving excellence (high)­to measure the level of MDC implementation in seven MDC areas, such as case planning and physician engagement. Descriptive statistics and cluster-adjusted regression models quantified the association between MDC implementation and processes of care, including time from diagnosis to treatment receipt. RESULTS: A total of 1,079 patients were examined. Compared with patients with colon cancer treated at cancer centers reporting low MDC scores, time to treatment receipt was shorter for patients with colon cancer treated at cancer centers reporting high or moderate MDC scores for physician engagement (hazard ratio [HR] for high physician engagement, 2.66; 95% CI, 1.70 to 4.17; HR for moderate physician engagement, 1.50; 95% CI, 1.19 to 1.89) and longer for patients with colon cancer treated at cancer centers reporting high 2MDC scores for case planning (HR, 0.65; 95% CI, 0.49 to 0.85). Results for patients with rectal cancer were qualitatively similar, and there was no statistically significant difference among patients with lung cancer. CONCLUSION: MDC implementation level was associated with processes of care, and direction of association varied across MDC assessment areas.

Patient Attitudes Regarding the Cost of Illness in Cancer Care.

BACKGROUND AND PURPOSE: The cost of illness in cancer care and the subsequent distress has attracted scrutiny. Guidelines recommend enhanced discussion of costs, assuming this will reduce both stress and costs. Little is known about patient attitudes about cost considerations influencing treatment decisions. METHODS: A convenience-sample survey of patients currently receiving radiation and/or intravenous chemotherapy at an outpatient cancer center was performed. Assessments included prevalence and extent of financial burden, level of financial distress, attitudes about using costs to influence treatment decisions, and frequency or desirability of cost discussions with oncologists. RESULTS: A total of 132 participants (94%) responded. Overall, 47% reported high financial stress, 30.8% felt well informed about costs prior to treatment, and 71% rarely spoke to their oncologists about cost. More than 71% of patients did not want either society's or personal costs to influence treatment, and this result did not change based on degree of financial stress. Even when asked to assume that lower cost regimens were equally effective, only 28% would definitely want the lower cost regimen. Patients did not believe it was the oncologist's duty to perform cost discussions. CONCLUSION: Even insured patients have a high degree of financial distress. Most, including those with the highest levels of distress, did not speak often with oncologists about costs and were strongly adverse to having cost considerations influence choice of regimen. The findings suggest that patients are not cost sensitive with regard to treatment decisions. Oncologists will require improved tools to have meaningful cost discussion, as recommended by the American Society of Clinical Oncology.

Measuring end-of-life care in oncology practices: learning from the care of the dying.

BACKGROUND: There is increased interest among oncology and palliative professionals in providing appropriately timed hospice services for cancer patients. End of life (EoL) metrics have been included in oncology quality programs, but accurate EoL data and benchmarks are hard to obtain. OBJECTIVE: To improve EoL care by measuring patterns of care among recently deceased patients. METHODS: Care utilization among deceased patients was analyzed by using software integrated with patient electronic health records. The data was verified by chart review. RESULTS: Of 179 cancer deaths, tumor registry data differed from chart review in 7% of cases with regard to dates and/or location of death. Institutional EoL metrics were significantly affected by a large number of patients (37%) with advanced illnesses who had clinical diagnoses of cancer made at the end of life, but who had not been managed by oncologists. This population of patients who had not been managed by oncologists was older, less likely to use hospice, and more likely to use the intensive care unit than were oncologist-managed cancer patients. Among the patients of individual oncologists, the median stay in hospice ranged from 6-28 days. Data collection and chart review took an average of 27 minutes per case with combined efforts by a data analyst and oncology practitioner. LIMITATIONS: Single institution with comprehensive electronic medical record; some patients were treated outside of the system. CONCLUSION: Acquiring accurate data on EoL metrics is time consuming. Compared with chart review, other data sources have inaccuracies and include some patients who have not been managed by oncologists. Accurate attribution to individual physicians requires chart review by an experienced clinician.

The political use of the cancer metaphor: negative consequences for the public and the cancer community.

There has been an increase in the use of cancer as a political metaphor, most recently to describe the threat of international terrorism. The powerful cancer metaphor implies a particular political problem is serious, progressive and deadly. As such to use a cancer metaphor prepares the public for a set of serious, intense and prolonged actions. While politically useful for a governmental to communicate policy, there are negative consequences to the use of the cancer metaphor. It perpetuates among the public and patients old stereotypes of cancer prognosis and therapies that oncologists have tried to combat through education. These education efforts are designed to help patients avoid overly aggressive treatments, surveillance, monitoring and surgeries. It is hard to successfully educate the general public and patients when they continuously receive alternative messages from political leaders who use the cancer metaphor for a different purpose. Professional cancer educators and clinicians should be aware of this trend and redouble efforts to educate that the political metaphor is for politics only and misleading in the public health and clinical arenas.

Improving hospital performance in the treatment of febrile neutropenia.

PURPOSE: Febrile neutropenia (FN) remains a common and dangerous complication of cancer treatment. Guidelines from the Infectious Disease Society of America urge initiating antibiotics within 2 h of presentation. We reviewed our institution's performance to identify areas of needed improvement and to design performance improvement steps. METHODS: FN management was deconstructed into discrete tasks. Experienced practitioners estimated appropriate time allowance for each task. Cycle time analysis data on a baseline cohort (baseline group) identified causes and loci of delay. Based on these data, new processes to bypass roadblocks for timely therapy were introduced. Performance monitoring continued as these changes were implemented (the transitional group) and for 20 months thereafter (the post-intervention group). RESULTS: Sixty-nine episodes of FN were identified. Ten distinct improvement steps were implemented. Median time to antibiotics was reduced from 252 min, to 188 min and 118 min for the baseline, transitional, and post-intervention groups, respectively (p = 0.0002 for the baseline vs. the post-intervention group comparison). Variability was reduced with the inter-quartile range falling from 174 min (baseline) to 65 min (post-intervention). Despite improvement, there were persisting episodes of delays, due to competing priorities from other patients or decisions to postpone infusion of antibiotics until patients had been admitted. Standardized order sets eliminated improper antibiotic choices as a source of error. CONCLUSIONS: Improvements in the management of FN can be accomplished and sustained by the focused study of performance of individual tasks, the design of streamlined processes by practitioners, and the ongoing review of performance with feedback to clinical departments.

A supportive care clinic for cancer patients embedded within an oncology practice.

BACKGROUND: Most cancer patients have symptoms from their disease or treatment. Symptoms are not ideally managed in the context of busy clinics, resulting in potentially avoidable emergency department (ED) visits and hospitalizations. Adjunct supportive care clinics (SCCs) may more effectively address patient needs, but they contribute to fractionation of care if different personnel are involved. OBJECTIVE: We describe an SCC embedded within a physician practice in which an employed nurse practitioner delivered most of the care. We measured the disposition of patients from the SCC to the ED, and the effect on ED visits and admissions for symptom management. METHODS: We conducted a retrospective review of the patients attending the SCC over a period of 11 months. Demographics and disposition outcomes were tracked and compared with pre-intervention controls. RESULTS: In all, 340 visits were recorded from 330 unique patients. Same-day and next-day appointments with a nurse practitioner were arranged for 62% and 25% of patients, respectively. The most common complaints related to pain and gastrointestinal issues. Most of the patients were discharged home. A few needed hospitalization or ED-level care. Admissions for symptom-related care fell by 31%. An estimated 66 ED visits were avoided by patients accessing the SCC. LIMITATIONS: The study was retrospective. It did not include detailed fnancial data. Results may not be generalizable because of the high level of central planning and use of a shared electronic medical record system, which may be lacking in some practices. CONCLUSIONS: An embedded supportive care clinic allowed rapid access to experienced oncology care under supervision by the patient's own oncologists. The clinic was associated with less use of the ED and need for hospitalization. New methods of reimbursing medical care will increasingly require oncology practices to improve patient access to symptom-related care to avoid unnecessary admissions. An embedded SCC can accomplish these goals while avoiding further fractionation of care.