Automated patient selection and care coaches to increase advance care planning for cancer patients.

BACKGROUND: Advance care planning/serious illness conversations can help clinicians understand patients' values and preferences. There are limited data on how to increase these conversations, and their effect on care patterns. We hypothesized that using a machine learning survival model to select patients for serious illness conversations, along with trained care coaches to conduct the conversations, would increase uptake in cancer patients at high risk of short-term mortality. METHODS: We conducted a cluster-randomized stepped wedge study on the physician level. Oncologists entered the intervention condition in a random order over six months. Adult patients with metastatic cancer were included. Patients with <2 year computer-predicted survival and no prognosis documentation were classified as high-priority for serious illness conversations. In the intervention condition, providers received automated weekly emails highlighting high-priority patients and were asked to document prognosis for them. Care coaches reached out to these patients to conduct the remainder of the conversation. The primary endpoint was proportion of visits with prognosis documentation within 14 days. RESULTS: 6,372 visits in 1,825 patients were included in the primary analysis. The proportion of visits with prognosis documentation within 14 days was higher in the intervention condition than control condition: 2.9% vs 1.1% (adjusted odds ratio 4.3, p < .0001). The proportion of visits with advance care planning documentation was also higher in the intervention condition: 7.7% vs 1.8% (adjusted odds ratio 14.2, p < .0001). In high-priority visits, advance care planning documentation rate in intervention/control visits was 24.2% vs 4.0%. CONCLUSION: The intervention increased documented conversations, with contributions by both providers and care coaches.

Use of Machine Learning and Lay Care Coaches to Increase Advance Care Planning Conversations for Patients With Metastatic Cancer.

PURPOSE: Patients with metastatic cancer benefit from advance care planning (ACP) conversations. We aimed to improve ACP using a computer model to select high-risk patients, with shorter predicted survival, for conversations with providers and lay care coaches. Outcomes included ACP documentation frequency and end-of-life quality measures. METHODS: In this study of a quality improvement initiative, providers in four medical oncology clinics received Serious Illness Care Program training. Two clinics (thoracic/genitourinary) participated in an intervention, and two (cutaneous/sarcoma) served as controls. ACP conversations were documented in a centralized form in the electronic medical record. In the intervention, providers and care coaches received weekly e-mails highlighting upcoming clinic patients with < 2 year computer-predicted survival and no prior prognosis documentation. Care coaches contacted these patients for an ACP conversation (excluding prognosis). Providers were asked to discuss and document prognosis. RESULTS: In the four clinics, 4,968 clinic visits by 1,251 patients met inclusion criteria (metastatic cancer with no prognosis previously documented). In their first visit, 28% of patients were high-risk (< 2 year predicted survival). Preintervention, 3% of both intervention and control clinic patients had ACP documentation during a visit. By intervention end (February 2021), 35% of intervention clinic patients had ACP documentation compared with 3% of control clinic patients. Providers' prognosis documentation rate also increased in intervention clinics after the intervention (2%-27% in intervention clinics, P < .0001; 0%-1% in control clinics). End-of-life care intensity was similar in intervention versus control clinics, but patients with ≥ 1 provider ACP edit met fewer high-intensity care measures (P = .04). CONCLUSION: Combining a computer prognosis model with care coaches increased ACP documentation.

Toxicity of spike fragments SARS-CoV-2 S protein for zebrafish: A tool to study its hazardous for human health?

Despite the significant increase in the generation of SARS-CoV-2 contaminated domestic and hospital wastewater, little is known about the ecotoxicological effects of the virus or its structural components in freshwater vertebrates. In this context, this study evaluated the deleterious effects caused by SARS-CoV-2 Spike protein on the health of Danio rerio, zebrafish. We demonstrated, for the first time, that zebrafish injected with fragment 16 to 165 (rSpike), which corresponds to the N-terminal portion of the protein, presented mortalities and adverse effects on liver, kidney, ovary and brain tissues. The conserved genetic homology between zebrafish and humans might be one of the reasons for the intense toxic effects followed inflammatory reaction from the immune system of zebrafish to rSpike which provoked damage to organs in a similar pattern as happen in severe cases of COVID-19 in humans, and, resulted in 78,6% of survival rate in female adults during the first seven days. The application of spike protein in zebrafish was highly toxic that is suitable for future studies to gather valuable information about ecotoxicological impacts, as well as vaccine responses and therapeutic approaches in human medicine. Therefore, besides representing an important tool to assess the harmful effects of SARS-CoV-2 in the aquatic environment, we present the zebrafish as an animal model for translational COVID-19 research.

Juvenile Nile Tilapia Fish Avoid Red Shelters.

Shelters are frequently used for fish rearing to improve welfare conditions. In this study, whether Nile tilapia prefers specific shelter colors was evaluated. Thus, fish preference for white, red, blue, green or yellow shelters was tested. A high variation of individual preference responses for the shelter colors among fish was found. Even so, while red shelter was clearly avoided by Nile tilapia, a clear-cut preference could not be concluded. Thus, avoiding red shelters for rearing Nile tilapia is recommended, assuming fish preference, or non-preference, as important elements considering welfare conditions. Moreover, individual variability should also be considered whenever possible.

Welfare in Nile Tilapia Production: Dorsal Fin Erection as a Visual Indicator for Insensibility.

In aquaculture, to ensure animal welfare in pre-slaughter and slaughter stages, it is fundamental that fish are insensible. A method for evaluating fish insensibility is based on visual sensibility indicators (VSI) assessment (i.e., self-initiated behavior, responses to stimuli and reflexes). However, many stimuli used to assess fish responses are painful. Therefore, this study verifies whether the presence/absence of a dorsal fin erection (DFE) response can be used as a painless VSI in Nile tilapia (Oreochromis niloticus). Three stunning protocols were applied to fish: benzocaine anesthesia (40 mg/L and 80 mg/L), ice water immersion (0-1, 2-3 and 5-6 °C) and CO2 stunning. After these stunning methods were applied in fish, the time of loss and return of DFE was observed, along with the vestibulo-ocular reflex (VOR). All fish stunned using benzocaine and ice water immersion lose both VSIs, while 95% of fish stunned using CO2 lose these VSIs. In all treatments, DFEs return quicker than VOR. Therefore, DFE can be used as a VSI in Nile tilapia, which is simple for producers to assess and does not require a painful stimulus. However, the DFE alone does not totally ensure fish insensibility and must be used together with other well-established VSIs at fish farms.