High Tumor Mutational Burden in Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the most common type of liver cancer and one of the leading causes of cancer-related deaths worldwide. Tumor mutational burden (TMB) in a cancer specimen represents the number of mutations within a pre-determined length of genetic material. This value is increasingly investigated as it may correlate with both prognosis and cancer response to developing immunotherapies. Its role in HCC, however, is still unclear as it tends to exist in a lower range. We present the case of a 72-year-old female diagnosed with HCC that was diffusely spread throughout the liver without evidence of metastatic disease. Genetic analysis of a liver biopsy revealed a TMB of 87 mutations per megabase which is extremely high for HCC. The patient was treated with tremelimumab and durvalumab but passed away shortly afterward due to decompensation from her disease. This case highlights the importance of continuing to research TMB and its correlation with this cancer. An HCC case with an exceptionally high TMB that progressed rapidly, like this one, indicates the continued need to study markers such as TMB, especially in outlier cases, for prognostication and appropriate stratification of immunotherapy response. This case shows an instance of a non-metastatic but still aggressive HCC that was diagnosed too late for assessing therapy response. In this instance, the high TMB would point toward a worse prognosis, but further study of high-TMB cases is necessary to support a correlation. Given the prevalence of HCC worldwide, any potential avenues that could help guide clinical decision-making should be explored.

Oxygen extraction fraction (OEF) values and applications in neurological diseases.

One of the goals of this systematic review is to provide a meta-analysis-derived mean OEF of healthy volunteers. Another aim of this study is to indicate the OEF ranges of various neurological pathologies. Potential clinical applications of OEF metrics are presented. Peer-reviewed studies reporting OEF metrics derived from computed tomography (CT)/positron emission tomography (PET) and/or magnetic resonance imaging (MRI) were considered. Databases utilized included MEDLINE, PubMed, EMBASE, Web of Science, and Google Scholar. The Newcastle-Ottawa scoring system was used for evaluating studies. R Studio was utilized for the meta-analysis calculations when appropriate. The GRADE framework was utilized to assess additional findings. Of 2267 potential studies, 165 met the inclusion criteria. The healthy volunteer meta-analysis included 339 subjects and found a mean OEF value of 38.87 (37.38, 40.36), with a prediction interval of 32.40-45.34. There were no statistical differences in OEF values derived from PET versus MRI. We provided a GRADE A certainty rating for the use of OEF metrics to predict stroke occurrence in patients with symptomatic carotid or cerebral vessel disease. We provided a GRADE B certainty rating for monitoring treatment response in Moyamoya disease. Use of OEF metrics in diagnosing and/or monitoring other conditions had a GRADE C certainty rating or less. OEF might have a role in diagnosing and monitoring patients with symptomatic carotid or cerebral vessel disease and Moyamoya disease. While we found insufficient evidence to support measuring OEF metrics in other patient populations, in many cases, further studies are warranted.

A narrative review of how infection preventionist (IP) staffing and outcome metrics are assessed by health care organizations and factors to consider.

BACKGROUND: Infection Preventionist to date are experiencing staffing shortages, the purpose of this narrative review is to understand how heath care organizations track staffing and outcome metrics in relation to Infection Preventionists. METHODS: Databases utilized included MEDLINE, PubMed, EMBASE, Web of Science, and Google Scholar. RESULTS: The initial search included 668 studies. After excluding duplicates, the title and abstract review yielded 50 articles. After screening full texts, 37 studies met the inclusion criteria. Significant variability exists within infection prevention staffing metrics. Common metrics to account for IP staffing levels include the ratio of IPs per facility and IPs per inpatient bed. Frequently tracked outcomes in relation to infection preventionists include Catheter-associated urinary tract infections and central line bloodstream infection incidence rates and standardized infection ratios, as well as Clostridioides difficile incidence rates. Metrics and outcomes from included studies are available in our supporting tables. CONCLUSIONS: This review highlights the need for a new IP staffing model that focuses on a granular assessment of each program and care setting. Additional studies can then be conducted to examine how ideal staffing impacts outcome metrics.

Simulating for Quality: A Centralized Quality Improvement and Patient Safety Simulation Curriculum for Residents and Fellows.

PROBLEM: Requirements for experiential education in quality improvement and patient safety (QI/PS) in graduate medical education (GME) have recently expanded. Major challenges to meeting these requirements include a lack of faculty with the needed expertise, paucity of standardized curricular models allowing for skill demonstration, and inconsistent access to data for iterative improvement. APPROACH: In October 2017, the authors began development of a centralized QI/PS flipped-classroom simulation-based medical education (SBME) curriculum for GME trainees across multiple disciplines at Oregon Health & Science University (OHSU). The curriculum development team included OHSU and Veterans Affairs faculty with experience in QI/PS and SBME, as well as house officers. The curriculum consisted of a preassessment and prework readings and videos (sent 3 weeks before the simulation day) and an 8-hour simulation day, with introductory activities, 4 linked simulation sessions, and concluding activities. The 4 linked sessions followed the same medication error from disclosure and reporting to root cause analysis, iterative implementation of an action plan, and consolidation of lessons learned into routine operations with Lean huddles. OUTCOMES: In academic year 2018-2019, 71 residents and fellows of various postgraduate years from 23 training programs enrolled in 2 pilot sessions. Learners reacted favorably to the simulation curriculum. Learner attitudes, confidence, knowledge, and skills significantly increased across all QI/PS domains studied. NEXT STEPS: This approach focuses a small cadre of educators toward the creation of a centralized resource that, owing to its experiential SBME foundation, can accommodate many learners with data-driven practice-based learning and improvement cycles in a shorter time frame than traditional QI initiatives. Next steps include the addition of a control group, assessment of the sustainability of learner outcomes, translation of learning to behavior change and improvements in patient and health system outcomes, and adapting the materials to include learners from different professions and levels.