Incidental Pulmonary Nodules and Lung Cancer Screening.

Incidental nodules and lung cancer screening nodules are causes of concern and anxiety for the patients. Both these require diligent follow up according to their respective guidelines.

Exploring the effects of racial and socioeconomic factors on timeliness of lung cancer diagnosis and treatment in Baltimore Veterans.

OBJECTIVES: To characterize the effect of racial and socioeconomic factors on the timeliness of lung cancer diagnosis and treatment in a single-center Veterans Affair Medical Center (VAMC) pulmonary nodule clinic. METHODS: We conducted a single-center retrospective review of all patients seen at the Baltimore VAMC pulmonary nodule clinic between 2013 and 2019 to identify key demographic factors, measures of neighborhood socioeconomic disadvantage, cancer staging and histopathologic information, and time elapsed between diagnosis and treatment. We excluded patients with pulmonary nodules undergoing active surveillance, prior history of lung cancer, metastases of a different primary origin, insufficient followup, or who had received care outside the VHA system. RESULTS: Median times to diagnosis and treatment of lung cancer were 28 and 73 days. There were no statistically significant differences in overall timeliness of diagnosis and treatment when stratified by race or measures of neighborhood socioeconomic disadvantage. CONCLUSIONS: The authors found no differences in timeliness of lung cancer care by race and socioeconomic status within the system. Despite general adherence to national standards in timeliness of care, there continues to be a need for improvements in the operational workflows to reduce time to diagnosis and treatment for all Veterans.

Military exposures and lung cancer in United States veterans.

Lung cancer screening begins at age 50, with yearly low dose computed tomography (LDCT) scans until age 80, for patients determined to be high risk due to tobacco smoking. Veterans serving from World War II to the Gulf War are now at the age where LDCT is recommended. This recommendation from the United States Preventative Service Task Force includes patients who have a 20-pack year tobacco history and currently smoke or quit within the last 15 years. This recommendation does not consider additional risk factors such as exposures to lung carcinogens. We discuss unique operational and occupational exposures encountered while serving in the armed forces, which may potentially increase the risk of lung cancers in the Veteran population. The additional risk of lung cancer due to military exposure history is unclear and more work is needed to identify and quantify risk at an individual level. Increasing awareness at the provider level regarding the carcinogenic exposures encountered may allow a larger population of Veterans, not meeting traditional LDCT criteria, to benefit from lung cancer screening.

Spirometry testing for extracorporeal membrane oxygenation (ECMO) bridge to transplant patients.

PURPOSE: ECMO can provide a bridge to transplantation and improve survival for patients with advanced lung disease. Although pulmonary function testing (PFT) is an important component of the lung allocation score (LAS), it is not always feasible on patients requiring ECMO. While generally safe, PFT testing has contraindications and is not recommended in unstable patients. Currently there are no recommendations regarding the performance of spirometry in ECMO patients. STUDY DESIGN: and Methods: We reviewed data on five patients with advanced lung disease requiring ECMO-bridge to transplant. After careful consideration of the theoretical physiologic risks associated with forced expiratory maneuvers, bedside spirometry was performed in order to update the patients' LAS. RESULTS: All patients successfully completed three forced expiratory maneuvers in the seated position with a bedside spirometer. Vital signs and ECMO flow were stable during testing and without complication. In 2 patients who had both a LAS pre and post spirometry, the LAS increased by 3-5 points. CONCLUSION: Spirometry results are pivotal to organ allocation under current organ sharing protocols. This case series demonstrates that bedside spirometry testing may be performed safely in patients on ECMO awaiting lung transplantation without appreciable side effects, leading to a more accurate LAS score.

The Effect of Chaplain Patient Navigators and Multidisciplinary Family Meetings on Patient Outcomes in the ICU: The Critical Care Collaboration and Communication Project.

OBJECTIVES: To assess the effectiveness of a chaplain patient navigator in improving outcomes and reducing costs in the ICU setting. DESIGN: A randomized controlled trial at a large, urban, academic community hospital in Baltimore, Maryland. SETTING/PATIENTS: All patients admitted to the Johns Hopkins Bayview Medical Center Cardiac and Medical ICUs between March 2015 and December 2015. INTERVENTIONS: Patients in the intervention group were assigned a chaplain patient navigator to facilitate communication, offer support, and setup multidisciplinary family meetings. MEASUREMENTS AND MAIN RESULTS: The primary outcomes were hospital and ICU length of stay. Secondary outcomes included total and ICU charges, 60- and 90-day readmission rates, and the number of palliative care consults. For all outcomes, patients were included in the intention-to-treat analyses only if they remained in the ICU greater than 24 hours. In total, 1,174 were randomly assigned to "usual care" (n = 573) or to the intervention (n = 601). In the intervention group, 44.8% (269/601) had meetings within 24 hours of admission and, of those patients, 32.8% (88/268) took part in the larger multidisciplinary family meeting 2-3 days later. The intervention group had longer mean adjusted hospital length of stay (7.78 vs 8.63 d; p ≤ 0.001) and mean ICU length of stay (3.65 vs 3.87 d; p = 0.029). In addition, they had greater total and ICU charges. There were no differences in other outcomes. Of note, only differences in total and ICU charges remained when controlling for case-mix index, which were greater in the intervention group. CONCLUSIONS: Although the chaplain patient navigator anecdotally enhanced communication, our study found an increase in hospital and ICU length of stay as well as cost. Since other studies have shown benefits in some clinical outcomes, projects focused on patient navigators may learn lessons from our study in order to better prioritize family meetings, gather indicators of communication quality, and identify the optimal patient navigator operational context.

A mixed-methods exploration of faith, spirituality, and health program interest among older African Americans with HIV.

BACKGROUND: Persons living with HIV (PLWH) are living into old age with more complex care needs that non-PLWH. Promoting quality of life should include advance care planning (ACP) education, particularly among African Americans. We explored faith/spirituality-related correlates of interest in a future quality of life program among African American PLWH. METHODS: Data were from the AFFIRM study. Participants were recruited from an HIV clinic and completed surveys, interviews, and focus groups. Quantitative analyses included Logistic regression. Qualitative data were coded using grounded theory. RESULTS: Nearly half of participants had less than a high school education (47.9%), and roughly 90% had heard of at least one ACP-related topic (86.6%; N = 315). Qualitative themes related to quality of life and faith/spirituality were: (1) Coping with life challenges; (2) Motivation to improve health for loved ones; and (3) Support programs for people with HIV (N = 39). Satisfaction with religion/spirituality was associated with greater interest in a future program (p < .05); discussing ACP before getting sick was associated with less interest (p < .05). CONCLUSIONS/PRACTICE IMPLICATIONS: Prioritizing skill-building and grounding in spirituality with input from faith leaders can reduce ACP inequities and improve health outcomes among African Americans.

The Association Between Neighborhood Socioeconomic Disadvantage and Readmissions for Patients Hospitalized With Sepsis.

OBJECTIVES: To evaluate associations between a readily availvable composite measurement of neighborhood socioeconomic disadvantage (the area deprivation index) and 30-day readmissions for patients who were previously hospitalized with sepsis. DESIGN: A retrospective study. SETTING: An urban, academic medical institution. PATIENTS: The authors conducted a manual audit for adult patients (18 yr old or older) discharged with an International Classification of Diseases, 10th edition code of sepsis during the 2017 fiscal year to confirm that they met SEP-3 criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The area deprivation index is a publicly available composite score constructed from socioeconomic components (e.g., income, poverty, education, housing characteristics) based on census block level, where higher scores are associated with more disadvantaged areas (range, 1-100). Using discharge data from the hospital population health database, residential addresses were geocoded and linked to their respective area deprivation index. Patient characteristics, contextual-level variables, and readmissions were compared by t tests for continuous variables and Fisher exact test for categorical variables. The associations between readmissions and area deprivation index were explored using logistic regression models. A total of 647 patients had an International Classification of Diseases, 10th edition diagnosis code of sepsis. Of these 647, 116 (17.9%) either died in hospital or were discharged to hospice and were excluded from our analysis. Of the remaining 531 patients, the mean age was 61.0 years (± 17.6 yr), 281 were females (52.9%), and 164 (30.9%) were active smokers. The mean length of stay was 6.9 days (± 5.6 d) with the mean Sequential Organ Failure Assessment score 4.9 (± 2.5). The mean area deprivation index was 54.2 (± 23.8). The mean area deprivation index of patients who were readmitted was 62.5 (± 27.4), which was significantly larger than the area deprivation index of patients not readmitted (51.8 [± 22.2]) (p < 0.001). In adjusted logistic regression models, a greater area deprivation index was significantly associated with readmissions (ß, 0.03; p < 0.001). CONCLUSIONS: Patients who reside in more disadvantaged neighborhoods have a significantly higher risk for 30-day readmission following a hospitalization for sepsis. The insight provided by neighborhood disadvantage scores, such as the area deprivation index, may help to better understand how contextual-level socioeconomic status affects the burden of sepsis-related morbidity.

Granulomatosis with Polyangiitis Manifesting as a Symptomatic Sellar Mass in a Young Woman.

A pituitary mass is a rare and poorly understood complication of granulomatosis with polyangiitis (GPA). Here we describe the case of a young woman with GPA who presented with signs and symptoms initially suggestive of meningitis but was ultimately found to have hypopituitarism and an enlarging sellar mass. She underwent transsphenoidal biopsy, which revealed an abundance of sterile inflammation and necrosis consistent with GPA-related inflammation. This case demonstrates a rare complication of GPA, i.e., a pituitary mass, initially mimicking meningitis. GPA-related pituitary involvement has an unknown pathogenesis and can have debilitating long-term consequences including chronic hypopituitarism and vision impairment, highlighting the need for further research.

Chronic Pain, Functional Status, and Life Satisfaction Are Associated With Patients Living With HIV Discussing Advance Care Planning With Their Family or Friends.

CONTEXT: In the era of effective antiretroviral therapy, persons living with HIV/AIDS (PLWHA) are living longer, transforming HIV from a universally fatal disease to a serious chronic illness, warranting discussions between patients and their loved ones about advance care planning (ACP). Evidence is needed on factors associated with patients' likelihood to discuss ACP with loved ones. OBJECTIVES: To further characterize factors associated with successful ACP in PLWHAs with their loved ones, we examined associations between patients having ACP discussions with the need for assistance with personal care, chronic pain, life satisfaction, prior family disagreements over health care decisions, sex, age, and interference in daily routines due to memory problems. METHODS: Data were from the Affirm Care study (N = 370), which examined social and environmental factors associated with health outcomes among PLWHAs and their informal caregivers. RESULTS: Slightly more than half of respondents discussed ACP with loved ones (57%). In adjusted analysis, higher levels of chronic pain (odds ratio [OR] = 2.09, P = 0.045), needing assistance with personal care (OR = 1.63, P = 0.023), greater life satisfaction (OR = 1.02, P = 0.002), prior family arguments over health care decisions (OR = 2.80, P < 0.001), and female sex (OR = 2.22, P = 0.001) were associated with higher odds of discussing ACP with loved ones, whereas age, drug use, education level, depression, and memory problems were nonsignificant. CONCLUSION: These results suggest that interventions to increase ACP among PLWHAs and their loved ones should target males. The findings also suggest PLWHAs with chronic pain, the need for assistance with personal care, and those with a history of prior family arguments over health care decisions may be primed for ACP.