Neutrophil engulfing bacteria

Image by Volker Brinkmann

Developing blood cells are caught in a tug of war between competing gene regulatory networks before finally deciding what type of cell to become, according to a study published in Nature.

Researchers found that, as developing blood cells are triggered by a multitude of genetic signals firing on and off, they are pulled back and forth in fluctuating multi-lineage states before finally becoming specific cell types.

The team still doesn’t understand exactly what drives the cells to an eventual fate, but their work suggests that competing gene networks induce dynamic instability, resulting in mixed-lineage states that are necessary to prime newly forming cells for that decision.

“It is somewhat chaotic, but, from that chaos, results order,” said study author Harinder Singh, PhD, of Cincinnati Children’s Hospital Medical Center in Ohio.

“It’s a finding that helps us address a fundamental question of developmental biology: What are the nature of the intermediate states and the networks of regulatory genes that underlie cell-type specification?”

Although the finding requires additional study to better understand the back-and-forth nature of this process, the research may eventually provide new insights into developmental miscues that cause disease, according to study author H. Leighton Grimes, PhD, of Cincinnati Children’s.

“How do blood cells know to become neutrophils or monocytes?” Dr Grimes asked. “Two thirds of your bone marrow is taken up with this activity, and the number of cells has to be exquisitely balanced. Too many or too few of either can kill you.”

For this study, Dr Grimes and his colleagues looked specifically at the formation of neutrophils and macrophages. The researchers studied mouse cells as they developed in a natural state using single-cell RNA sequencing.

The team also used a bioinformatics computer program known as iterative clustering and guide-gene selection (ICGS). They used ICGS to process and analyze sequencing and biological data to identify the various transitioning or shifting genomic and cellular states of developing blood cells.

Dynamic instability

Researchers previously proposed that neutrophils and macrophages result from a bi-stable gene regulatory network—one that can manifest either of 2 stable states. But the different cellular transition states and underlying molecular dynamics of development have remained unknown.

Dr Grimes and his colleagues said their analysis of developing blood cells captured a prevalent mixed-lineage intermediate.

These intermediates expressed a combination of genes, including those typical of hematopoietic stem and progenitor cells and some genes that are specific for red blood cells, platelets, macrophages, and neutrophils. This seemed to reflect competing genetic programs.

The researchers also observed the developing cells moving through a rare state where they encountered turbulence known as dynamic instability. This was caused by 2 counteracting myeloid gene regulatory networks.

Two key components of the counteracting gene networks were Irf8 and Gfi1, genes that are involved in blood cell formation. When Irf8 and Gfi1 were eliminated from the picture, the rare cells could be trapped in an intermediate state.

As they continue this work, the researchers want to gain a clearer understanding of what finally causes cells in intermediate states of dynamic instability to assume specific fates.

The team suggests the influence of 2 simultaneous and counteracting gene networks generates internal oscillations that are eventually stabilized by unknown mechanisms to generate 1 of 2 different cell fates.

Neutrophil engulfing bacteria

Image by Volker Brinkmann

Developing blood cells are caught in a tug of war between competing gene regulatory networks before finally deciding what type of cell to become, according to a study published in Nature.

Researchers found that, as developing blood cells are triggered by a multitude of genetic signals firing on and off, they are pulled back and forth in fluctuating multi-lineage states before finally becoming specific cell types.

The team still doesn’t understand exactly what drives the cells to an eventual fate, but their work suggests that competing gene networks induce dynamic instability, resulting in mixed-lineage states that are necessary to prime newly forming cells for that decision.

“It is somewhat chaotic, but, from that chaos, results order,” said study author Harinder Singh, PhD, of Cincinnati Children’s Hospital Medical Center in Ohio.

“It’s a finding that helps us address a fundamental question of developmental biology: What are the nature of the intermediate states and the networks of regulatory genes that underlie cell-type specification?”

Although the finding requires additional study to better understand the back-and-forth nature of this process, the research may eventually provide new insights into developmental miscues that cause disease, according to study author H. Leighton Grimes, PhD, of Cincinnati Children’s.

“How do blood cells know to become neutrophils or monocytes?” Dr Grimes asked. “Two thirds of your bone marrow is taken up with this activity, and the number of cells has to be exquisitely balanced. Too many or too few of either can kill you.”

For this study, Dr Grimes and his colleagues looked specifically at the formation of neutrophils and macrophages. The researchers studied mouse cells as they developed in a natural state using single-cell RNA sequencing.

The team also used a bioinformatics computer program known as iterative clustering and guide-gene selection (ICGS). They used ICGS to process and analyze sequencing and biological data to identify the various transitioning or shifting genomic and cellular states of developing blood cells.

Dynamic instability

Researchers previously proposed that neutrophils and macrophages result from a bi-stable gene regulatory network—one that can manifest either of 2 stable states. But the different cellular transition states and underlying molecular dynamics of development have remained unknown.

Dr Grimes and his colleagues said their analysis of developing blood cells captured a prevalent mixed-lineage intermediate.

These intermediates expressed a combination of genes, including those typical of hematopoietic stem and progenitor cells and some genes that are specific for red blood cells, platelets, macrophages, and neutrophils. This seemed to reflect competing genetic programs.

The researchers also observed the developing cells moving through a rare state where they encountered turbulence known as dynamic instability. This was caused by 2 counteracting myeloid gene regulatory networks.

Two key components of the counteracting gene networks were Irf8 and Gfi1, genes that are involved in blood cell formation. When Irf8 and Gfi1 were eliminated from the picture, the rare cells could be trapped in an intermediate state.

As they continue this work, the researchers want to gain a clearer understanding of what finally causes cells in intermediate states of dynamic instability to assume specific fates.

The team suggests the influence of 2 simultaneous and counteracting gene networks generates internal oscillations that are eventually stabilized by unknown mechanisms to generate 1 of 2 different cell fates.

Neutrophil engulfing bacteria

Image by Volker Brinkmann

Developing blood cells are caught in a tug of war between competing gene regulatory networks before finally deciding what type of cell to become, according to a study published in Nature.

Researchers found that, as developing blood cells are triggered by a multitude of genetic signals firing on and off, they are pulled back and forth in fluctuating multi-lineage states before finally becoming specific cell types.

The team still doesn’t understand exactly what drives the cells to an eventual fate, but their work suggests that competing gene networks induce dynamic instability, resulting in mixed-lineage states that are necessary to prime newly forming cells for that decision.

“It is somewhat chaotic, but, from that chaos, results order,” said study author Harinder Singh, PhD, of Cincinnati Children’s Hospital Medical Center in Ohio.

“It’s a finding that helps us address a fundamental question of developmental biology: What are the nature of the intermediate states and the networks of regulatory genes that underlie cell-type specification?”

Although the finding requires additional study to better understand the back-and-forth nature of this process, the research may eventually provide new insights into developmental miscues that cause disease, according to study author H. Leighton Grimes, PhD, of Cincinnati Children’s.

“How do blood cells know to become neutrophils or monocytes?” Dr Grimes asked. “Two thirds of your bone marrow is taken up with this activity, and the number of cells has to be exquisitely balanced. Too many or too few of either can kill you.”

For this study, Dr Grimes and his colleagues looked specifically at the formation of neutrophils and macrophages. The researchers studied mouse cells as they developed in a natural state using single-cell RNA sequencing.

The team also used a bioinformatics computer program known as iterative clustering and guide-gene selection (ICGS). They used ICGS to process and analyze sequencing and biological data to identify the various transitioning or shifting genomic and cellular states of developing blood cells.

Dynamic instability

Researchers previously proposed that neutrophils and macrophages result from a bi-stable gene regulatory network—one that can manifest either of 2 stable states. But the different cellular transition states and underlying molecular dynamics of development have remained unknown.

Dr Grimes and his colleagues said their analysis of developing blood cells captured a prevalent mixed-lineage intermediate.

These intermediates expressed a combination of genes, including those typical of hematopoietic stem and progenitor cells and some genes that are specific for red blood cells, platelets, macrophages, and neutrophils. This seemed to reflect competing genetic programs.

The researchers also observed the developing cells moving through a rare state where they encountered turbulence known as dynamic instability. This was caused by 2 counteracting myeloid gene regulatory networks.

Two key components of the counteracting gene networks were Irf8 and Gfi1, genes that are involved in blood cell formation. When Irf8 and Gfi1 were eliminated from the picture, the rare cells could be trapped in an intermediate state.

As they continue this work, the researchers want to gain a clearer understanding of what finally causes cells in intermediate states of dynamic instability to assume specific fates.

The team suggests the influence of 2 simultaneous and counteracting gene networks generates internal oscillations that are eventually stabilized by unknown mechanisms to generate 1 of 2 different cell fates.

A once-daily inhaled combination of fluticasone furoate and vilanterol was associated with an 8% lower rate of exacerbations in chronic obstructive pulmonary disease (COPD) than was usual care, with no increase in adverse effects, according to a multicenter trial designed to reflect real-world practice.

“Future effectiveness studies [like this one] are likely to influence clinical guidelines, not only for COPD but [also] for many other chronic diseases,” said Jørgen Vestbo, MD, of University Hospital of South Manchester NHS Foundation Trust, Manchester, England, and his associates, for the Salford Lung Study investigators. The findings were presented at the annual congress of the European Respiratory Society and published simultaneously in the New England Journal of Medicine.

©designer491/Thinkstock

Current COPD guidelines are based on clinical trials of carefully selected and monitored patients, which substantially limits their usefulness in everyday practice, the researchers said. To help address that problem, their 12-month, prospective, open-label, parallel-group, randomized study enrolled 2,799 COPD patients in 75 general practices within a single urban area in the United Kingdom. Patients received 100 mcg of fluticasone furoate and 25 mcg of vilanterol or usual care. The primary outcome was the rate of moderate or severe exacerbations among patients who had experienced an exacerbation within 1 year before enrollment. Patients received all treatment from their usual providers and were monitored remotely for safety through electronic health records (N Engl J Med. 2016 Sep 4. doi: 10.1056/NEJMoa1608033).

Fluticasone furoate/vilanterol was associated with 1.74 moderate or severe exacerbations per year, compared with 1.9 events per year with usual-care group, for a statistically significant difference of 8.4% (95% confidence interval, 1.1%-15.2%; P = .02). The trial arms had similar rates of COPD-related health care visits and first moderate or severe exacerbations. They also did not notably differ in terms of serious adverse events of special interest, such as cardiovascular events (which affected 8% of patients in each group) or pneumonia (which affected 7% of fluticasone furoate/vilanterol patients and 6% of usual-care patients). Thirteen patients in each group developed fatal pneumonia, of which one case was considered related to usual care. The only other treatment-related death involved of deep-vein thrombosis and pulmonary embolism in a patient receiving fluticasone furoate/vilanterol.

Medication switches were about twice as common (22%) in the intervention group than in the usual care group (11%), perhaps because of the open-label nature of the trial, the researchers said. Only 4% of patients receiving fluticasone furoate/vilanterol needed better disease control, half the rate of the usual care group.

GlaxoSmithKline funded the trial. Dr. Vestbo reported personal fees from GlaxoSmithKline while the study was conducted.

A once-daily inhaled combination of fluticasone furoate and vilanterol was associated with an 8% lower rate of exacerbations in chronic obstructive pulmonary disease (COPD) than was usual care, with no increase in adverse effects, according to a multicenter trial designed to reflect real-world practice.

“Future effectiveness studies [like this one] are likely to influence clinical guidelines, not only for COPD but [also] for many other chronic diseases,” said Jørgen Vestbo, MD, of University Hospital of South Manchester NHS Foundation Trust, Manchester, England, and his associates, for the Salford Lung Study investigators. The findings were presented at the annual congress of the European Respiratory Society and published simultaneously in the New England Journal of Medicine.

©designer491/Thinkstock

Current COPD guidelines are based on clinical trials of carefully selected and monitored patients, which substantially limits their usefulness in everyday practice, the researchers said. To help address that problem, their 12-month, prospective, open-label, parallel-group, randomized study enrolled 2,799 COPD patients in 75 general practices within a single urban area in the United Kingdom. Patients received 100 mcg of fluticasone furoate and 25 mcg of vilanterol or usual care. The primary outcome was the rate of moderate or severe exacerbations among patients who had experienced an exacerbation within 1 year before enrollment. Patients received all treatment from their usual providers and were monitored remotely for safety through electronic health records (N Engl J Med. 2016 Sep 4. doi: 10.1056/NEJMoa1608033).

Fluticasone furoate/vilanterol was associated with 1.74 moderate or severe exacerbations per year, compared with 1.9 events per year with usual-care group, for a statistically significant difference of 8.4% (95% confidence interval, 1.1%-15.2%; P = .02). The trial arms had similar rates of COPD-related health care visits and first moderate or severe exacerbations. They also did not notably differ in terms of serious adverse events of special interest, such as cardiovascular events (which affected 8% of patients in each group) or pneumonia (which affected 7% of fluticasone furoate/vilanterol patients and 6% of usual-care patients). Thirteen patients in each group developed fatal pneumonia, of which one case was considered related to usual care. The only other treatment-related death involved of deep-vein thrombosis and pulmonary embolism in a patient receiving fluticasone furoate/vilanterol.

Medication switches were about twice as common (22%) in the intervention group than in the usual care group (11%), perhaps because of the open-label nature of the trial, the researchers said. Only 4% of patients receiving fluticasone furoate/vilanterol needed better disease control, half the rate of the usual care group.

GlaxoSmithKline funded the trial. Dr. Vestbo reported personal fees from GlaxoSmithKline while the study was conducted.

A once-daily inhaled combination of fluticasone furoate and vilanterol was associated with an 8% lower rate of exacerbations in chronic obstructive pulmonary disease (COPD) than was usual care, with no increase in adverse effects, according to a multicenter trial designed to reflect real-world practice.

“Future effectiveness studies [like this one] are likely to influence clinical guidelines, not only for COPD but [also] for many other chronic diseases,” said Jørgen Vestbo, MD, of University Hospital of South Manchester NHS Foundation Trust, Manchester, England, and his associates, for the Salford Lung Study investigators. The findings were presented at the annual congress of the European Respiratory Society and published simultaneously in the New England Journal of Medicine.

©designer491/Thinkstock

Current COPD guidelines are based on clinical trials of carefully selected and monitored patients, which substantially limits their usefulness in everyday practice, the researchers said. To help address that problem, their 12-month, prospective, open-label, parallel-group, randomized study enrolled 2,799 COPD patients in 75 general practices within a single urban area in the United Kingdom. Patients received 100 mcg of fluticasone furoate and 25 mcg of vilanterol or usual care. The primary outcome was the rate of moderate or severe exacerbations among patients who had experienced an exacerbation within 1 year before enrollment. Patients received all treatment from their usual providers and were monitored remotely for safety through electronic health records (N Engl J Med. 2016 Sep 4. doi: 10.1056/NEJMoa1608033).

Fluticasone furoate/vilanterol was associated with 1.74 moderate or severe exacerbations per year, compared with 1.9 events per year with usual-care group, for a statistically significant difference of 8.4% (95% confidence interval, 1.1%-15.2%; P = .02). The trial arms had similar rates of COPD-related health care visits and first moderate or severe exacerbations. They also did not notably differ in terms of serious adverse events of special interest, such as cardiovascular events (which affected 8% of patients in each group) or pneumonia (which affected 7% of fluticasone furoate/vilanterol patients and 6% of usual-care patients). Thirteen patients in each group developed fatal pneumonia, of which one case was considered related to usual care. The only other treatment-related death involved of deep-vein thrombosis and pulmonary embolism in a patient receiving fluticasone furoate/vilanterol.

Medication switches were about twice as common (22%) in the intervention group than in the usual care group (11%), perhaps because of the open-label nature of the trial, the researchers said. Only 4% of patients receiving fluticasone furoate/vilanterol needed better disease control, half the rate of the usual care group.

GlaxoSmithKline funded the trial. Dr. Vestbo reported personal fees from GlaxoSmithKline while the study was conducted.

Purpose: Develop ordersets that seamlessly enter chemotherapy and biologics orders from CPRS to Pharmacy’s VISTA program (pVista) and CPRS notes within the VISN.

Background: Hematology/Oncology orders ranged from paper to CPRS within the VISN. CPRS orders must be reentered into pVistA by the pharmacist, a safety issue. Commercial proprietary programs were expensive and didn’t translate to pVistA. The COEMS program isn’t available within the VA may not interface seamlessly with pVistA. Therefore, VISN 09 Medicine Service Line’s Oncology Committee (MSLOC) decided to develop ordersets in CPRS that enter treatment notes and orders into pVistA.

Methods: Ordersets development was MSLOC highest priority (2015). MSLOC met monthly by phone identifying resources, reviewing available ordersets, and translating into pVistA. MSLOC developed a timeline for orderset implementation. Progress was discussed monthly and documented with screen shots. Site visits will be completed before 2017.

Data Analysis: Flowsheets included: 1. facility resources: treatment area, providers, staffing, oncology pharmacy, ADPACs, and CACs; 2. Mechanisms of orders and notes entering/ recording; 3. Dosing and safety checks; 4. Available ordersets.

Results: In 2016 our ordersets were established as a “best practice”. VISN issued a suspense to implement electronic ordersets by 2017. The timeline included: 1. team development (fall 2015)-providers, pharmacists, pharmacy ADPAC, CACs; 2. Review of available ordersets (winter 2016); 3. Orderset development (winter-spring 2016); 4. Progress assessment (spring 2016); 5. Site visits (summer 2016). Results varied by VISN site: 2/5 of VAs were already paperless; 4/5 are now paperless; 2/5 have completely updated ordersets; 1/5 still uses paper and have only begun implementing ordersets. 1/5 ordersets completed chemotherapy notes; this will be implemented at all sites.

Implications: Using limited VA resources, ordersets can seamlessly enter pVistA. Results vary within VISN sites; switching from paper to electronic requires a paradigm shift. In approximately 18 months ordersets have been revised and updated. Chemotherapy ordersets now are generated electronically in 4/5 VAs. A team of MSLOC, providers, and staff have implemented this. In 2017 MSLOC will quantify the effectiveness of the initiative to improve patient care, safety, and efficiency.

Purpose: Develop ordersets that seamlessly enter chemotherapy and biologics orders from CPRS to Pharmacy’s VISTA program (pVista) and CPRS notes within the VISN.

Background: Hematology/Oncology orders ranged from paper to CPRS within the VISN. CPRS orders must be reentered into pVistA by the pharmacist, a safety issue. Commercial proprietary programs were expensive and didn’t translate to pVistA. The COEMS program isn’t available within the VA may not interface seamlessly with pVistA. Therefore, VISN 09 Medicine Service Line’s Oncology Committee (MSLOC) decided to develop ordersets in CPRS that enter treatment notes and orders into pVistA.

Methods: Ordersets development was MSLOC highest priority (2015). MSLOC met monthly by phone identifying resources, reviewing available ordersets, and translating into pVistA. MSLOC developed a timeline for orderset implementation. Progress was discussed monthly and documented with screen shots. Site visits will be completed before 2017.

Data Analysis: Flowsheets included: 1. facility resources: treatment area, providers, staffing, oncology pharmacy, ADPACs, and CACs; 2. Mechanisms of orders and notes entering/ recording; 3. Dosing and safety checks; 4. Available ordersets.

Results: In 2016 our ordersets were established as a “best practice”. VISN issued a suspense to implement electronic ordersets by 2017. The timeline included: 1. team development (fall 2015)-providers, pharmacists, pharmacy ADPAC, CACs; 2. Review of available ordersets (winter 2016); 3. Orderset development (winter-spring 2016); 4. Progress assessment (spring 2016); 5. Site visits (summer 2016). Results varied by VISN site: 2/5 of VAs were already paperless; 4/5 are now paperless; 2/5 have completely updated ordersets; 1/5 still uses paper and have only begun implementing ordersets. 1/5 ordersets completed chemotherapy notes; this will be implemented at all sites.

Implications: Using limited VA resources, ordersets can seamlessly enter pVistA. Results vary within VISN sites; switching from paper to electronic requires a paradigm shift. In approximately 18 months ordersets have been revised and updated. Chemotherapy ordersets now are generated electronically in 4/5 VAs. A team of MSLOC, providers, and staff have implemented this. In 2017 MSLOC will quantify the effectiveness of the initiative to improve patient care, safety, and efficiency.

Purpose: Develop ordersets that seamlessly enter chemotherapy and biologics orders from CPRS to Pharmacy’s VISTA program (pVista) and CPRS notes within the VISN.

Background: Hematology/Oncology orders ranged from paper to CPRS within the VISN. CPRS orders must be reentered into pVistA by the pharmacist, a safety issue. Commercial proprietary programs were expensive and didn’t translate to pVistA. The COEMS program isn’t available within the VA may not interface seamlessly with pVistA. Therefore, VISN 09 Medicine Service Line’s Oncology Committee (MSLOC) decided to develop ordersets in CPRS that enter treatment notes and orders into pVistA.

Methods: Ordersets development was MSLOC highest priority (2015). MSLOC met monthly by phone identifying resources, reviewing available ordersets, and translating into pVistA. MSLOC developed a timeline for orderset implementation. Progress was discussed monthly and documented with screen shots. Site visits will be completed before 2017.

Data Analysis: Flowsheets included: 1. facility resources: treatment area, providers, staffing, oncology pharmacy, ADPACs, and CACs; 2. Mechanisms of orders and notes entering/ recording; 3. Dosing and safety checks; 4. Available ordersets.

Results: In 2016 our ordersets were established as a “best practice”. VISN issued a suspense to implement electronic ordersets by 2017. The timeline included: 1. team development (fall 2015)-providers, pharmacists, pharmacy ADPAC, CACs; 2. Review of available ordersets (winter 2016); 3. Orderset development (winter-spring 2016); 4. Progress assessment (spring 2016); 5. Site visits (summer 2016). Results varied by VISN site: 2/5 of VAs were already paperless; 4/5 are now paperless; 2/5 have completely updated ordersets; 1/5 still uses paper and have only begun implementing ordersets. 1/5 ordersets completed chemotherapy notes; this will be implemented at all sites.

Implications: Using limited VA resources, ordersets can seamlessly enter pVistA. Results vary within VISN sites; switching from paper to electronic requires a paradigm shift. In approximately 18 months ordersets have been revised and updated. Chemotherapy ordersets now are generated electronically in 4/5 VAs. A team of MSLOC, providers, and staff have implemented this. In 2017 MSLOC will quantify the effectiveness of the initiative to improve patient care, safety, and efficiency.

Purpose: To identify DEL amongst veteran patients with diffuse large B cell lymphoma (DLBCL) and its outcome.

Background: Molecular profile determines prognosis in DLBCL. Activated B-cell (ABC), a subtype of DLBCL, is associated with poor outcome compared to germinal center Bcell (GCB). Poor response to standard chemotherapy is seen with double-hit lymphomas as detected by FISH (5% -10% of DLBCL) and DELs that express both MYC and BCL-2 as detected by immunohistochemistry (IHC) (cutoffs—30% MYC, 40% BCL-2), with a median overall survival of <12 months.

Methods: Sixty-nine DLBCL patients diagnosed at DC VAMC from 1/1996-4/2016 were identified utilizing cancer registry. IHC stains were reviewed for CD3, CD10, CD20, BCL-2, BCL-6, C-MYC, MUM-1, MIB1, and p53. DLBCL were sub-classified as GCB and ABC based on CD10, BCL6 and MUM1 stains. Demographic data, diagnosis, treatment and outcome in terms of relapse and death are analyzed and will be presented at the meeting.

Results: Of the 69 DLBCL cases, only 37 met inclusion criteria; 32 were excluded due to unavailable blocks (20, mostly sent to outside institutions), tissue exhaustion with incomplete IHC data (6), T-cell rich B cell lymphoma (5) and pending (1). 20 cases are GCB and 17 ABC. All cases are CD20 positive with high mib1. MYC is positive in 17 cases (46%) and 15 of them double positive for BCL-2 (40%).

Implications/Future Directions: DLBCL veterans at the DC VAMC have a high percentage of double expressors when compared to the literature. It will be important to examine clinical data, treatment, and outcome to develop better treatment guidelines for double-expressor DLBCL. Future studies are in plan to compare double hit lymphomas to double expressors.

Purpose: To identify DEL amongst veteran patients with diffuse large B cell lymphoma (DLBCL) and its outcome.

Background: Molecular profile determines prognosis in DLBCL. Activated B-cell (ABC), a subtype of DLBCL, is associated with poor outcome compared to germinal center Bcell (GCB). Poor response to standard chemotherapy is seen with double-hit lymphomas as detected by FISH (5% -10% of DLBCL) and DELs that express both MYC and BCL-2 as detected by immunohistochemistry (IHC) (cutoffs—30% MYC, 40% BCL-2), with a median overall survival of <12 months.

Methods: Sixty-nine DLBCL patients diagnosed at DC VAMC from 1/1996-4/2016 were identified utilizing cancer registry. IHC stains were reviewed for CD3, CD10, CD20, BCL-2, BCL-6, C-MYC, MUM-1, MIB1, and p53. DLBCL were sub-classified as GCB and ABC based on CD10, BCL6 and MUM1 stains. Demographic data, diagnosis, treatment and outcome in terms of relapse and death are analyzed and will be presented at the meeting.

Results: Of the 69 DLBCL cases, only 37 met inclusion criteria; 32 were excluded due to unavailable blocks (20, mostly sent to outside institutions), tissue exhaustion with incomplete IHC data (6), T-cell rich B cell lymphoma (5) and pending (1). 20 cases are GCB and 17 ABC. All cases are CD20 positive with high mib1. MYC is positive in 17 cases (46%) and 15 of them double positive for BCL-2 (40%).

Implications/Future Directions: DLBCL veterans at the DC VAMC have a high percentage of double expressors when compared to the literature. It will be important to examine clinical data, treatment, and outcome to develop better treatment guidelines for double-expressor DLBCL. Future studies are in plan to compare double hit lymphomas to double expressors.

Purpose: To identify DEL amongst veteran patients with diffuse large B cell lymphoma (DLBCL) and its outcome.

Background: Molecular profile determines prognosis in DLBCL. Activated B-cell (ABC), a subtype of DLBCL, is associated with poor outcome compared to germinal center Bcell (GCB). Poor response to standard chemotherapy is seen with double-hit lymphomas as detected by FISH (5% -10% of DLBCL) and DELs that express both MYC and BCL-2 as detected by immunohistochemistry (IHC) (cutoffs—30% MYC, 40% BCL-2), with a median overall survival of <12 months.

Methods: Sixty-nine DLBCL patients diagnosed at DC VAMC from 1/1996-4/2016 were identified utilizing cancer registry. IHC stains were reviewed for CD3, CD10, CD20, BCL-2, BCL-6, C-MYC, MUM-1, MIB1, and p53. DLBCL were sub-classified as GCB and ABC based on CD10, BCL6 and MUM1 stains. Demographic data, diagnosis, treatment and outcome in terms of relapse and death are analyzed and will be presented at the meeting.

Results: Of the 69 DLBCL cases, only 37 met inclusion criteria; 32 were excluded due to unavailable blocks (20, mostly sent to outside institutions), tissue exhaustion with incomplete IHC data (6), T-cell rich B cell lymphoma (5) and pending (1). 20 cases are GCB and 17 ABC. All cases are CD20 positive with high mib1. MYC is positive in 17 cases (46%) and 15 of them double positive for BCL-2 (40%).

Implications/Future Directions: DLBCL veterans at the DC VAMC have a high percentage of double expressors when compared to the literature. It will be important to examine clinical data, treatment, and outcome to develop better treatment guidelines for double-expressor DLBCL. Future studies are in plan to compare double hit lymphomas to double expressors.

Introduction: PV is associated with an increased risk of thrombosis, which contributes to morbidity and mortality of patients. Limited data exist on patients with PV among the Veterans Health Administration (VHA) population. The objective of this study is to describe the demographic and clinical characteristics of patients with PV in the VHA population.

Methods: A retrospective, observational analysis was conducted using longitudinal data from the VHA database. The analysis included adult patients who had ≥ 2 claims for PV (ICD-9 238.4) ≥ 30 days apart between 01/01/2007 and 12/31/2009 and ≥ 12 months of continuous enrollment before the first PV claim (index date). Patients were followed from the index date until the earliest date of death, disenrollment, or end of study (9/30/2012). Demographics and comorbid conditions during the pre-index period, and cytoreductive treatments, select laboratory values, thrombotic event (TE) rate, and mortality rate during the follow-up period are reported.

Results: The analysis included 7718 patients with PV; most patients were ≥ 60 years of age (70.7%), male (97.9%), and white (63.9%). The 3 most common comorbid conditions reported during the pre-index period were hypertension (71.7%), dyslipidemia (54.2%), and diabetes (24.0%). Additionally, 8.8% had arterial thrombosis, 4.5% had venous thrombosis, and 8.7% had bleeding. During the follow-up period (median 4.8 years), 23.2% of patients received cytoreductive pharmacotherapy (86.7% hydroxyurea), 32.8% had phlebotomy, and 53.0% had neither cytoreductive therapy nor phlebotomy. 86.4% and 63.3% of patients were using antihypertensive agents and anti-lipid medications, respectively. 86.7% of patients had ≥ 2 elevated HCT levels (≥ 45%) and 37.3% had ≥ 2 elevated WBC counts ( ≥ 11*109/L). 22.9% of patients had ≥ 1 TE (16.5% arterial thrombosis and 8.78% venous thrombosis). The TE rate was 60.5 per 1,000 patient years. Deaths due to any cause were reported for 23.0% of patients during follow-up.

Conclusion: The TE burden is significant among patients with PV in the VHA population. A large proportion of patients had elevated blood values, which may indicate uncontrolled PV, and may predispose patients to greater risk of clinical complications and consequences of PV.

Introduction: PV is associated with an increased risk of thrombosis, which contributes to morbidity and mortality of patients. Limited data exist on patients with PV among the Veterans Health Administration (VHA) population. The objective of this study is to describe the demographic and clinical characteristics of patients with PV in the VHA population.

Methods: A retrospective, observational analysis was conducted using longitudinal data from the VHA database. The analysis included adult patients who had ≥ 2 claims for PV (ICD-9 238.4) ≥ 30 days apart between 01/01/2007 and 12/31/2009 and ≥ 12 months of continuous enrollment before the first PV claim (index date). Patients were followed from the index date until the earliest date of death, disenrollment, or end of study (9/30/2012). Demographics and comorbid conditions during the pre-index period, and cytoreductive treatments, select laboratory values, thrombotic event (TE) rate, and mortality rate during the follow-up period are reported.

Results: The analysis included 7718 patients with PV; most patients were ≥ 60 years of age (70.7%), male (97.9%), and white (63.9%). The 3 most common comorbid conditions reported during the pre-index period were hypertension (71.7%), dyslipidemia (54.2%), and diabetes (24.0%). Additionally, 8.8% had arterial thrombosis, 4.5% had venous thrombosis, and 8.7% had bleeding. During the follow-up period (median 4.8 years), 23.2% of patients received cytoreductive pharmacotherapy (86.7% hydroxyurea), 32.8% had phlebotomy, and 53.0% had neither cytoreductive therapy nor phlebotomy. 86.4% and 63.3% of patients were using antihypertensive agents and anti-lipid medications, respectively. 86.7% of patients had ≥ 2 elevated HCT levels (≥ 45%) and 37.3% had ≥ 2 elevated WBC counts ( ≥ 11*109/L). 22.9% of patients had ≥ 1 TE (16.5% arterial thrombosis and 8.78% venous thrombosis). The TE rate was 60.5 per 1,000 patient years. Deaths due to any cause were reported for 23.0% of patients during follow-up.

Conclusion: The TE burden is significant among patients with PV in the VHA population. A large proportion of patients had elevated blood values, which may indicate uncontrolled PV, and may predispose patients to greater risk of clinical complications and consequences of PV.

Introduction: PV is associated with an increased risk of thrombosis, which contributes to morbidity and mortality of patients. Limited data exist on patients with PV among the Veterans Health Administration (VHA) population. The objective of this study is to describe the demographic and clinical characteristics of patients with PV in the VHA population.

Methods: A retrospective, observational analysis was conducted using longitudinal data from the VHA database. The analysis included adult patients who had ≥ 2 claims for PV (ICD-9 238.4) ≥ 30 days apart between 01/01/2007 and 12/31/2009 and ≥ 12 months of continuous enrollment before the first PV claim (index date). Patients were followed from the index date until the earliest date of death, disenrollment, or end of study (9/30/2012). Demographics and comorbid conditions during the pre-index period, and cytoreductive treatments, select laboratory values, thrombotic event (TE) rate, and mortality rate during the follow-up period are reported.

Results: The analysis included 7718 patients with PV; most patients were ≥ 60 years of age (70.7%), male (97.9%), and white (63.9%). The 3 most common comorbid conditions reported during the pre-index period were hypertension (71.7%), dyslipidemia (54.2%), and diabetes (24.0%). Additionally, 8.8% had arterial thrombosis, 4.5% had venous thrombosis, and 8.7% had bleeding. During the follow-up period (median 4.8 years), 23.2% of patients received cytoreductive pharmacotherapy (86.7% hydroxyurea), 32.8% had phlebotomy, and 53.0% had neither cytoreductive therapy nor phlebotomy. 86.4% and 63.3% of patients were using antihypertensive agents and anti-lipid medications, respectively. 86.7% of patients had ≥ 2 elevated HCT levels (≥ 45%) and 37.3% had ≥ 2 elevated WBC counts ( ≥ 11*109/L). 22.9% of patients had ≥ 1 TE (16.5% arterial thrombosis and 8.78% venous thrombosis). The TE rate was 60.5 per 1,000 patient years. Deaths due to any cause were reported for 23.0% of patients during follow-up.

Conclusion: The TE burden is significant among patients with PV in the VHA population. A large proportion of patients had elevated blood values, which may indicate uncontrolled PV, and may predispose patients to greater risk of clinical complications and consequences of PV.

The purpose of the initiative is to increase the percentage of eligible female veterans who receive biennial mammography to over 80% consistently at the Minneapolis VA (MVA) medical center.

The External Peer Review Program (EPRP) evaluates a number of charts each month to report quality of care on a variety of performance measures. Breast Cancer Screening is among those evaluated with the goal of a 77% completion rate. In 2012 the average EPRP showed MVA’s completion rate at 77%. It also highlighted that it was below target for 4 months. Clinical Reminders are relied upon for provider notification, however, the current process depends on clinicians going into individual charts to see and act on them. Oftentimes this is not done in an acceptable amount of time.

The Corporate Data Warehouse (CDW) stores clinical information from VistA. A pro-active process to address biennial mammography completion was reproduced using methods that query the CDW. Reports that evaluated all veterans, overdue or nearly due, for breast cancer screening were created. Lists of these patients were generated and sent to providers/PACT teams for evaluation and resolution. These “push” reports were distributed quarterly, starting in January 2014, and increased to monthly in 2015.

EPRP results are highly variable and depend on the sample selection for any given month. Therefore a rolling 12 month average, median, and standard deviation of the samples are reported along with actual monthly values.

The MVA breast cancer screening rate, as reported by EPRP, improved from a 12 month average of 80% to a 12 month average of 95% over 2 years. The variability/standard deviation was reduced by 50% as quality improved.

“Push” reports can help improve rates of early breast cancer detection by screening within the recommended period of time. This panel management tool can be created at any VA facility and can be extrapolated to other quality measures.

The purpose of the initiative is to increase the percentage of eligible female veterans who receive biennial mammography to over 80% consistently at the Minneapolis VA (MVA) medical center.

The External Peer Review Program (EPRP) evaluates a number of charts each month to report quality of care on a variety of performance measures. Breast Cancer Screening is among those evaluated with the goal of a 77% completion rate. In 2012 the average EPRP showed MVA’s completion rate at 77%. It also highlighted that it was below target for 4 months. Clinical Reminders are relied upon for provider notification, however, the current process depends on clinicians going into individual charts to see and act on them. Oftentimes this is not done in an acceptable amount of time.

The Corporate Data Warehouse (CDW) stores clinical information from VistA. A pro-active process to address biennial mammography completion was reproduced using methods that query the CDW. Reports that evaluated all veterans, overdue or nearly due, for breast cancer screening were created. Lists of these patients were generated and sent to providers/PACT teams for evaluation and resolution. These “push” reports were distributed quarterly, starting in January 2014, and increased to monthly in 2015.

EPRP results are highly variable and depend on the sample selection for any given month. Therefore a rolling 12 month average, median, and standard deviation of the samples are reported along with actual monthly values.

The MVA breast cancer screening rate, as reported by EPRP, improved from a 12 month average of 80% to a 12 month average of 95% over 2 years. The variability/standard deviation was reduced by 50% as quality improved.

“Push” reports can help improve rates of early breast cancer detection by screening within the recommended period of time. This panel management tool can be created at any VA facility and can be extrapolated to other quality measures.

The purpose of the initiative is to increase the percentage of eligible female veterans who receive biennial mammography to over 80% consistently at the Minneapolis VA (MVA) medical center.

The External Peer Review Program (EPRP) evaluates a number of charts each month to report quality of care on a variety of performance measures. Breast Cancer Screening is among those evaluated with the goal of a 77% completion rate. In 2012 the average EPRP showed MVA’s completion rate at 77%. It also highlighted that it was below target for 4 months. Clinical Reminders are relied upon for provider notification, however, the current process depends on clinicians going into individual charts to see and act on them. Oftentimes this is not done in an acceptable amount of time.

The Corporate Data Warehouse (CDW) stores clinical information from VistA. A pro-active process to address biennial mammography completion was reproduced using methods that query the CDW. Reports that evaluated all veterans, overdue or nearly due, for breast cancer screening were created. Lists of these patients were generated and sent to providers/PACT teams for evaluation and resolution. These “push” reports were distributed quarterly, starting in January 2014, and increased to monthly in 2015.

EPRP results are highly variable and depend on the sample selection for any given month. Therefore a rolling 12 month average, median, and standard deviation of the samples are reported along with actual monthly values.

The MVA breast cancer screening rate, as reported by EPRP, improved from a 12 month average of 80% to a 12 month average of 95% over 2 years. The variability/standard deviation was reduced by 50% as quality improved.

“Push” reports can help improve rates of early breast cancer detection by screening within the recommended period of time. This panel management tool can be created at any VA facility and can be extrapolated to other quality measures.

Purpose: Traditional radiation therapy for prostate cancer is given over 39 – 42 daily fractions. There have been increasing efforts to decrease the treatment time by using hypofractionated radiotherapy. The purpose of this retrospective study is to evaluate the acute toxicities (RTOG definition) in prostate cancer patients when using hypofractionated radiotherapy.

Methods: 42 patients were treated with 25 daily fractions from 2014 – 2015. Patient, tumor, and dosimetric factors (rectal and bladder min dose, max dose, mean dose, median dose, volume, V31, V50, as well as PTV max, min, mean, and median doses) were analyzed to find associations between acute (< 90 days) GU and GI toxicities.

Results: The median age was 68 with a median follow-up of 18 months. There were 2 low, 12 intermediate, and 18 high risk patients (NCCN criteria). Dose fractionations schemas used were 267 cGy (n = 6), 270 cGy (n = 14); 275 cGy (n = 17), and some high risk patients received a simultaneous integrated boost (SIB) of 300 cGy (n = 5) to a smaller volume of the prostate. 13 patients received pelvic irradiation via SIB at 200 cGy per fraction. 10 patients received no androgen deprivation therapy (ADT), 15 received short term ADT (≤ 6 months), and 17 received long term ADT (> 6 months). Grade 0 acute GU toxicity occurred in 12 patients (29%), grade 1 in 7 (17%), grade 2 in 22 (52%), and grade 3 in 1 (2%). Grade 0 acute GI toxicity occurred in 30 patients (71%), grade 1 in 5 (12%), grade 2 in 7 (17), and no grade 3 toxicity. There were no grade 4 or 5 toxicities. On univariate analysis, factors positively associated with acute GU toxicity were AUA score (P = .02) and PTV max dose (P = .04); acute GI were pelvic radiation (P = .04) and rectal min dose (P = .02). These factors were not significant on multivariate analysis.

Conclusion: Volumetric Arc Therapy based hypofractionated radiotherapy was well tolerated and is an acceptable treatment for prostate cancer patients. Larger and adequately powered studies are needed to validate these findings.

Purpose: Traditional radiation therapy for prostate cancer is given over 39 – 42 daily fractions. There have been increasing efforts to decrease the treatment time by using hypofractionated radiotherapy. The purpose of this retrospective study is to evaluate the acute toxicities (RTOG definition) in prostate cancer patients when using hypofractionated radiotherapy.

Methods: 42 patients were treated with 25 daily fractions from 2014 – 2015. Patient, tumor, and dosimetric factors (rectal and bladder min dose, max dose, mean dose, median dose, volume, V31, V50, as well as PTV max, min, mean, and median doses) were analyzed to find associations between acute (< 90 days) GU and GI toxicities.

Results: The median age was 68 with a median follow-up of 18 months. There were 2 low, 12 intermediate, and 18 high risk patients (NCCN criteria). Dose fractionations schemas used were 267 cGy (n = 6), 270 cGy (n = 14); 275 cGy (n = 17), and some high risk patients received a simultaneous integrated boost (SIB) of 300 cGy (n = 5) to a smaller volume of the prostate. 13 patients received pelvic irradiation via SIB at 200 cGy per fraction. 10 patients received no androgen deprivation therapy (ADT), 15 received short term ADT (≤ 6 months), and 17 received long term ADT (> 6 months). Grade 0 acute GU toxicity occurred in 12 patients (29%), grade 1 in 7 (17%), grade 2 in 22 (52%), and grade 3 in 1 (2%). Grade 0 acute GI toxicity occurred in 30 patients (71%), grade 1 in 5 (12%), grade 2 in 7 (17), and no grade 3 toxicity. There were no grade 4 or 5 toxicities. On univariate analysis, factors positively associated with acute GU toxicity were AUA score (P = .02) and PTV max dose (P = .04); acute GI were pelvic radiation (P = .04) and rectal min dose (P = .02). These factors were not significant on multivariate analysis.

Conclusion: Volumetric Arc Therapy based hypofractionated radiotherapy was well tolerated and is an acceptable treatment for prostate cancer patients. Larger and adequately powered studies are needed to validate these findings.

Purpose: Traditional radiation therapy for prostate cancer is given over 39 – 42 daily fractions. There have been increasing efforts to decrease the treatment time by using hypofractionated radiotherapy. The purpose of this retrospective study is to evaluate the acute toxicities (RTOG definition) in prostate cancer patients when using hypofractionated radiotherapy.

Methods: 42 patients were treated with 25 daily fractions from 2014 – 2015. Patient, tumor, and dosimetric factors (rectal and bladder min dose, max dose, mean dose, median dose, volume, V31, V50, as well as PTV max, min, mean, and median doses) were analyzed to find associations between acute (< 90 days) GU and GI toxicities.

Results: The median age was 68 with a median follow-up of 18 months. There were 2 low, 12 intermediate, and 18 high risk patients (NCCN criteria). Dose fractionations schemas used were 267 cGy (n = 6), 270 cGy (n = 14); 275 cGy (n = 17), and some high risk patients received a simultaneous integrated boost (SIB) of 300 cGy (n = 5) to a smaller volume of the prostate. 13 patients received pelvic irradiation via SIB at 200 cGy per fraction. 10 patients received no androgen deprivation therapy (ADT), 15 received short term ADT (≤ 6 months), and 17 received long term ADT (> 6 months). Grade 0 acute GU toxicity occurred in 12 patients (29%), grade 1 in 7 (17%), grade 2 in 22 (52%), and grade 3 in 1 (2%). Grade 0 acute GI toxicity occurred in 30 patients (71%), grade 1 in 5 (12%), grade 2 in 7 (17), and no grade 3 toxicity. There were no grade 4 or 5 toxicities. On univariate analysis, factors positively associated with acute GU toxicity were AUA score (P = .02) and PTV max dose (P = .04); acute GI were pelvic radiation (P = .04) and rectal min dose (P = .02). These factors were not significant on multivariate analysis.

Conclusion: Volumetric Arc Therapy based hypofractionated radiotherapy was well tolerated and is an acceptable treatment for prostate cancer patients. Larger and adequately powered studies are needed to validate these findings.

Purpose: Distress screening (DS) of cancer patients is likely to improve access to supportive care services and adherence to cancer treatment.

Background: We assessed DS at the CAVHS and the University of Arkansas for Medical Sciences by completing Quality Oncology and Practice Initiatives (QOPI) survey. At baseline, we identified assessment of distress screening in only 15% of patients compared to the national average of 50%.

Methods: Based on QOPI data, we performed 3 Plan-Do-Study-Act (PDSA) cycles. We implemented a DS template on computer patient record system (CPRS) at the CAVHS hematology-oncology clinic, validated the template after initial use, and modified it in each PDSA cycle.

Results: At baseline DS was identified in 18 out of 121 charts (15%) per QOPI survey results in 2013 Spring Round. During our first PDSA cycle, we decided to add DS templates to all electronic medical notes in CPRS. We validated the template in 20 patient charts. Thereafter, in the second PDSA cycle, we modified the template and included distress thermometer (DT). After this intervention, we noted distress screening in 27 of 100 charts from 14 providers. Out of these 27 patients, 4 had a distress score of 4 or greater; these patients were all referred to subspecialty services. We did a third PDSA cycle and DS improved to 46% (51 out of 111 charts) on QOPI 2015 Spring Round. Subsequently, we added daily reminders at staff meetings, weekly e-mail reminders, and visual DT in each clinic room to perform DS and improved DS to 55 screenings out of 100 charts audited (27% to 55%). In these patients, only 1 had score of 4 and 7 had scores of 3. Intervention was offered in 15 out of 55 (27.2%) patients including counseling and referral to subspecialty services.

Conclusion: Distress screening is important for identifying patients who need intervention. QOPI is an excellent method of evaluating compliance to distress screening and PDSA cycles are effective in improving compliance. We improved DS by more than 200% using QOPI, PDSA and other quality improvement methods.

Purpose: Distress screening (DS) of cancer patients is likely to improve access to supportive care services and adherence to cancer treatment.

Background: We assessed DS at the CAVHS and the University of Arkansas for Medical Sciences by completing Quality Oncology and Practice Initiatives (QOPI) survey. At baseline, we identified assessment of distress screening in only 15% of patients compared to the national average of 50%.

Methods: Based on QOPI data, we performed 3 Plan-Do-Study-Act (PDSA) cycles. We implemented a DS template on computer patient record system (CPRS) at the CAVHS hematology-oncology clinic, validated the template after initial use, and modified it in each PDSA cycle.

Results: At baseline DS was identified in 18 out of 121 charts (15%) per QOPI survey results in 2013 Spring Round. During our first PDSA cycle, we decided to add DS templates to all electronic medical notes in CPRS. We validated the template in 20 patient charts. Thereafter, in the second PDSA cycle, we modified the template and included distress thermometer (DT). After this intervention, we noted distress screening in 27 of 100 charts from 14 providers. Out of these 27 patients, 4 had a distress score of 4 or greater; these patients were all referred to subspecialty services. We did a third PDSA cycle and DS improved to 46% (51 out of 111 charts) on QOPI 2015 Spring Round. Subsequently, we added daily reminders at staff meetings, weekly e-mail reminders, and visual DT in each clinic room to perform DS and improved DS to 55 screenings out of 100 charts audited (27% to 55%). In these patients, only 1 had score of 4 and 7 had scores of 3. Intervention was offered in 15 out of 55 (27.2%) patients including counseling and referral to subspecialty services.

Conclusion: Distress screening is important for identifying patients who need intervention. QOPI is an excellent method of evaluating compliance to distress screening and PDSA cycles are effective in improving compliance. We improved DS by more than 200% using QOPI, PDSA and other quality improvement methods.

Purpose: Distress screening (DS) of cancer patients is likely to improve access to supportive care services and adherence to cancer treatment.

Background: We assessed DS at the CAVHS and the University of Arkansas for Medical Sciences by completing Quality Oncology and Practice Initiatives (QOPI) survey. At baseline, we identified assessment of distress screening in only 15% of patients compared to the national average of 50%.

Methods: Based on QOPI data, we performed 3 Plan-Do-Study-Act (PDSA) cycles. We implemented a DS template on computer patient record system (CPRS) at the CAVHS hematology-oncology clinic, validated the template after initial use, and modified it in each PDSA cycle.

Results: At baseline DS was identified in 18 out of 121 charts (15%) per QOPI survey results in 2013 Spring Round. During our first PDSA cycle, we decided to add DS templates to all electronic medical notes in CPRS. We validated the template in 20 patient charts. Thereafter, in the second PDSA cycle, we modified the template and included distress thermometer (DT). After this intervention, we noted distress screening in 27 of 100 charts from 14 providers. Out of these 27 patients, 4 had a distress score of 4 or greater; these patients were all referred to subspecialty services. We did a third PDSA cycle and DS improved to 46% (51 out of 111 charts) on QOPI 2015 Spring Round. Subsequently, we added daily reminders at staff meetings, weekly e-mail reminders, and visual DT in each clinic room to perform DS and improved DS to 55 screenings out of 100 charts audited (27% to 55%). In these patients, only 1 had score of 4 and 7 had scores of 3. Intervention was offered in 15 out of 55 (27.2%) patients including counseling and referral to subspecialty services.

Conclusion: Distress screening is important for identifying patients who need intervention. QOPI is an excellent method of evaluating compliance to distress screening and PDSA cycles are effective in improving compliance. We improved DS by more than 200% using QOPI, PDSA and other quality improvement methods.

Pediatric Hospital Medicine 2016, cosponsored by the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA), and the Society of Hospital Medicine (SHM), took place July 28–31 in Chicago. Didn’t make it? Here are all the news, research, and talking points you need to know.

Shape Your Brain to Avoid Burnout

Presenter: Lisa Zaoutis, MD, FHM

Amid the skyscrapers of the Windy City, Pediatric Hospital Medicine (PHM) 2016 swept into town, bringing with it the denizens of pediatric hospitalist programs across the country. Some 1,150 attendees, composed of hospitalists, PHM program leaders, and advanced-care practitioners, gathered to educate and inspire one another in the care of hospitalized children.

Lisa Zaoutis, MD, FHM, director of the pediatric residency program at The Children’s Hospital of Philadelphia, kicked off the conference with the opening plenary. Initially titled “North Star and Space,” she quickly changed the title to “Changing Our Minds.” Touching on the disconnect between positive experiences that bring physicians into pediatric hospital medicine and negative experiences that often drive behavior, she started with the beginning: the evolution of our brains.

“We are wired toward the negative,” Dr. Zaoutis said. “We are Teflon for positive experiences and Velcro for negative experiences.”

Delving deeper into neuroanatomy, Dr. Zaoutis spoke of “amygdala hijack,” where chronic stress inherent to the professional lives of pediatric hospitalists leads to anxiety responses that are faster, more robust, and more easily triggered.

But all is not lost, Dr. Zaoutis noted, as our brains are more plastic than previously known. The “neural Darwinism” of our brains, she said, leads to epigenetic intracellular changes, more sensitive synapses, improved blood flow, and even new cells as a result of experience-dependent neuroplasticity. For example, London taxi drivers have thicker white matter in their hippocampus as a result of learning London city streets, and mindfulness meditators have thicker gray matter in regions that control attention and self-insight.

Key Takeaways

The lesson for pediatric hospitalists, according Dr. Zaoutis, is that you can shape your brain for greater joy.

“Consciously choose activities” that counter our evolutionary negativity bias, Dr. Zaoutis said.

Here’s how to do it:

1. Have a positive experience. (You can create one or retrieve a prior one.)
2. Enrich it and install it by dwelling on it for at least 15–30 seconds.
3. Absorb it into your body, which may require somatizing it. (Dr. Zaoutis presses her hand into her chest to aid in this.)

Further, spread this to your group by the old medical training technique of “see one, do one, teach one.” See if you can start your sign-out with the best thing that happened to you in the week. Most important, start with observing yourself.

Weijen Chang, MD, SFHM, is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California, San Diego (UCSD) School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to wwch@ucsd.edu.

New AAP Guideline on Evaluating, Managing Febrile Infants

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was an update on the anticipated AAP guidelines for febrile infants ages 7–90 days. The updated guidelines stress the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C.

Exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The updated guideline will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment.

It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk.

Key Takeaway

An updated AAP guideline algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days, and 60–90 days will be coming in the near future. It will help standardize care in this population but should not be used as a substitute for clinical judgment.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Promoting, Teaching Pediatric High-Value Care

Presenters: Lauren L. Walker, MD, FAAP; Alan Schroeder, MD, FAAP; Michael

Tchou, MD, FAAP; Jimmy Beck, MD, MEd; Lisa Herrmann, MD; Ricardo Quinonez, MD, FAAP

Pediatric hospitalists gathered to attend a fruitful discussion on not only how to change our way of thinking but also how to feed it forward to our trainees. The barriers to promoting and teaching high-value care are plenty and essentially universal to academic and community sites: We have had no formal teaching, there is cultural resistance, and there is lack of transparency on costs and charges.

The questions we perhaps should be asking ourselves, our trainees, and our families are:

• “What matters?” instead of “What’s the matter?”
• “Does that test benefit the patient? What are the harms of the test?” instead of “Will that test change our management?”

There is still a long way to go to move the pendulum to the side of value-based practice and teaching. There is still controversy on how and whether cost should be discussed with the family. Cost is more than just monetary value; family anxiety and patient harm may resonate more with families as we perfect our skills in shared decision making.

Key Takeaway

This serves as an exciting time to unite and better our understanding about why we do what we do and deliberately think about downstream effects. High-value care curriculum for medical students, residents, fellows, and even faculty is an area ripe for further research.

Akshata Hopkins, MD, FAAP, is an academic hospitalist at Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.

How to Design, Improve Educational Programs at Community Hospitals

Presenters: Christopher Russo, MD, FAAP; Laura Hodo, MD, and Lauren Wilson, MD

One session at PHM16 focused on ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.

During the didactic session, a general background of the importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy,” “exposure to different career paths,” and “transfer decision making.”

Some of the challenges discussed in regard to developing an educational structure in community settings included:

1. Logistics

• Making the case for education
• Legal framework (e.g., affiliation agreements, liability)
• Finances (e.g., GME funding)
• Paperwork burden (e.g., licensing, credentialing)

2. Learning environment

• Complementing clinical work with materials
• Autonomy/supervision balancing
• Developing clinical teachers

The didactic session also reviewed the six steps for curriculum development: general needs assessment, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation/feedback. Each of these was described in further detail with relevant examples.

Groups were broken into small groups based on four learner types: medical students, family medicine residents, pediatric residents, and PHM fellows. Within each group, a “program development matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.

A separate “curriculum development matrix” was used during breakout groups that focused on curriculum development. This matrix was broken into three areas: educational strategies, implementation, and evaluation/feedback. These were further broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short- and long-term goals with action steps for both of these matrix subgroups.

Key Takeaway

Overall, the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools for sites that wish to develop or improve their current educational framework.

Francisco Alvarez, MD, FAAP, is a pediatric hospitalist and director of the Children’s National Health System Community Hospital Services in Washington, D.C.

Tips on Meeting Needs of Children with a Medical Complexity

Presenters: Mary L. Ehlenbach, MD, FAAP; Megan Z. Cardoso, MD, FAAP, and Christina Kleier, ARNP, PNP

This session at PHM16 was focused on logistical tips on how to build a pediatric complex-care program. Presenters opened with a discussion on how to define children with medical complexity. This involved reviewing different methods, including using research-based aggregation of ICD-10 codes, relying on referral from both families and other providers, and identifying patients by consumption of hospital resources. The presentation continued by highlighting that although medically complex children make up only a small percentage of the overall population of children, they account for about one-third of healthcare spending. Because of advances in technology and medicine, this group of children is growing in numbers. It currently makes up about 10% of all pediatric admissions.

Key Takeaways

1. Children with medical complexity are a growing population on which a large proportion of healthcare resources are utilized. A program dedicated to serving the needs of this population may be helpful in reducing costs and improving the patient and family experience during hospitalizations.

2. When working to initiate a complex-care program:

• Set clear guidelines about which children the program is intended to serve and in what capacity it will function.
• Ensure the team composition is sustainable and meets the needs of the patients.
• Aggregate data about if the program is helping. This may be difficult to quantify since these are mostly qualitative measures.
• Include team members who are nonclinical to aid in improving hospital revenue and highlighting program benefits to the institution.

Margaret Rush, MD, is a hospitalist fellow at Children’s National Medical Center in Washington, D.C.

A Picture Is Worth a Thousand Words

Presenter: Kenneth Roberts, MD

PHM16’s “Visual Diagnosis: Signs and Why They Matter” session was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses or overdiagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.

Many of the presented cases highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.

In other instances, such as with Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis was necessary to help guide management and future treatment, including subspecialty evaluation.

Key Takeaway

Many diseases with visual presentations will have a benign course and require no treatment. Acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.

This session underscores the need for experience and exposure to various signs not only with rare medical conditions but also in common illnesses such as Kawasaki disease and scarlet fever that may present similarly.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Pediatric Hospital Medicine 2016, cosponsored by the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA), and the Society of Hospital Medicine (SHM), took place July 28–31 in Chicago. Didn’t make it? Here are all the news, research, and talking points you need to know.

Shape Your Brain to Avoid Burnout

Presenter: Lisa Zaoutis, MD, FHM

Amid the skyscrapers of the Windy City, Pediatric Hospital Medicine (PHM) 2016 swept into town, bringing with it the denizens of pediatric hospitalist programs across the country. Some 1,150 attendees, composed of hospitalists, PHM program leaders, and advanced-care practitioners, gathered to educate and inspire one another in the care of hospitalized children.

Lisa Zaoutis, MD, FHM, director of the pediatric residency program at The Children’s Hospital of Philadelphia, kicked off the conference with the opening plenary. Initially titled “North Star and Space,” she quickly changed the title to “Changing Our Minds.” Touching on the disconnect between positive experiences that bring physicians into pediatric hospital medicine and negative experiences that often drive behavior, she started with the beginning: the evolution of our brains.

“We are wired toward the negative,” Dr. Zaoutis said. “We are Teflon for positive experiences and Velcro for negative experiences.”

Delving deeper into neuroanatomy, Dr. Zaoutis spoke of “amygdala hijack,” where chronic stress inherent to the professional lives of pediatric hospitalists leads to anxiety responses that are faster, more robust, and more easily triggered.

But all is not lost, Dr. Zaoutis noted, as our brains are more plastic than previously known. The “neural Darwinism” of our brains, she said, leads to epigenetic intracellular changes, more sensitive synapses, improved blood flow, and even new cells as a result of experience-dependent neuroplasticity. For example, London taxi drivers have thicker white matter in their hippocampus as a result of learning London city streets, and mindfulness meditators have thicker gray matter in regions that control attention and self-insight.

Key Takeaways

The lesson for pediatric hospitalists, according Dr. Zaoutis, is that you can shape your brain for greater joy.

“Consciously choose activities” that counter our evolutionary negativity bias, Dr. Zaoutis said.

Here’s how to do it:

1. Have a positive experience. (You can create one or retrieve a prior one.)
2. Enrich it and install it by dwelling on it for at least 15–30 seconds.
3. Absorb it into your body, which may require somatizing it. (Dr. Zaoutis presses her hand into her chest to aid in this.)

Further, spread this to your group by the old medical training technique of “see one, do one, teach one.” See if you can start your sign-out with the best thing that happened to you in the week. Most important, start with observing yourself.

Weijen Chang, MD, SFHM, is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California, San Diego (UCSD) School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to wwch@ucsd.edu.

New AAP Guideline on Evaluating, Managing Febrile Infants

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was an update on the anticipated AAP guidelines for febrile infants ages 7–90 days. The updated guidelines stress the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C.

Exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The updated guideline will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment.

It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk.

Key Takeaway

An updated AAP guideline algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days, and 60–90 days will be coming in the near future. It will help standardize care in this population but should not be used as a substitute for clinical judgment.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Promoting, Teaching Pediatric High-Value Care

Presenters: Lauren L. Walker, MD, FAAP; Alan Schroeder, MD, FAAP; Michael

Tchou, MD, FAAP; Jimmy Beck, MD, MEd; Lisa Herrmann, MD; Ricardo Quinonez, MD, FAAP

Pediatric hospitalists gathered to attend a fruitful discussion on not only how to change our way of thinking but also how to feed it forward to our trainees. The barriers to promoting and teaching high-value care are plenty and essentially universal to academic and community sites: We have had no formal teaching, there is cultural resistance, and there is lack of transparency on costs and charges.

The questions we perhaps should be asking ourselves, our trainees, and our families are:

• “What matters?” instead of “What’s the matter?”
• “Does that test benefit the patient? What are the harms of the test?” instead of “Will that test change our management?”

There is still a long way to go to move the pendulum to the side of value-based practice and teaching. There is still controversy on how and whether cost should be discussed with the family. Cost is more than just monetary value; family anxiety and patient harm may resonate more with families as we perfect our skills in shared decision making.

Key Takeaway

This serves as an exciting time to unite and better our understanding about why we do what we do and deliberately think about downstream effects. High-value care curriculum for medical students, residents, fellows, and even faculty is an area ripe for further research.

Akshata Hopkins, MD, FAAP, is an academic hospitalist at Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.

How to Design, Improve Educational Programs at Community Hospitals

Presenters: Christopher Russo, MD, FAAP; Laura Hodo, MD, and Lauren Wilson, MD

One session at PHM16 focused on ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.

During the didactic session, a general background of the importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy,” “exposure to different career paths,” and “transfer decision making.”

Some of the challenges discussed in regard to developing an educational structure in community settings included:

1. Logistics

• Making the case for education
• Legal framework (e.g., affiliation agreements, liability)
• Finances (e.g., GME funding)
• Paperwork burden (e.g., licensing, credentialing)

2. Learning environment

• Complementing clinical work with materials
• Autonomy/supervision balancing
• Developing clinical teachers

The didactic session also reviewed the six steps for curriculum development: general needs assessment, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation/feedback. Each of these was described in further detail with relevant examples.

Groups were broken into small groups based on four learner types: medical students, family medicine residents, pediatric residents, and PHM fellows. Within each group, a “program development matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.

A separate “curriculum development matrix” was used during breakout groups that focused on curriculum development. This matrix was broken into three areas: educational strategies, implementation, and evaluation/feedback. These were further broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short- and long-term goals with action steps for both of these matrix subgroups.

Key Takeaway

Overall, the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools for sites that wish to develop or improve their current educational framework.

Francisco Alvarez, MD, FAAP, is a pediatric hospitalist and director of the Children’s National Health System Community Hospital Services in Washington, D.C.

Tips on Meeting Needs of Children with a Medical Complexity

Presenters: Mary L. Ehlenbach, MD, FAAP; Megan Z. Cardoso, MD, FAAP, and Christina Kleier, ARNP, PNP

This session at PHM16 was focused on logistical tips on how to build a pediatric complex-care program. Presenters opened with a discussion on how to define children with medical complexity. This involved reviewing different methods, including using research-based aggregation of ICD-10 codes, relying on referral from both families and other providers, and identifying patients by consumption of hospital resources. The presentation continued by highlighting that although medically complex children make up only a small percentage of the overall population of children, they account for about one-third of healthcare spending. Because of advances in technology and medicine, this group of children is growing in numbers. It currently makes up about 10% of all pediatric admissions.

Key Takeaways

1. Children with medical complexity are a growing population on which a large proportion of healthcare resources are utilized. A program dedicated to serving the needs of this population may be helpful in reducing costs and improving the patient and family experience during hospitalizations.

2. When working to initiate a complex-care program:

• Set clear guidelines about which children the program is intended to serve and in what capacity it will function.
• Ensure the team composition is sustainable and meets the needs of the patients.
• Aggregate data about if the program is helping. This may be difficult to quantify since these are mostly qualitative measures.
• Include team members who are nonclinical to aid in improving hospital revenue and highlighting program benefits to the institution.

Margaret Rush, MD, is a hospitalist fellow at Children’s National Medical Center in Washington, D.C.

A Picture Is Worth a Thousand Words

Presenter: Kenneth Roberts, MD

PHM16’s “Visual Diagnosis: Signs and Why They Matter” session was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses or overdiagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.

Many of the presented cases highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.

In other instances, such as with Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis was necessary to help guide management and future treatment, including subspecialty evaluation.

Key Takeaway

Many diseases with visual presentations will have a benign course and require no treatment. Acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.

This session underscores the need for experience and exposure to various signs not only with rare medical conditions but also in common illnesses such as Kawasaki disease and scarlet fever that may present similarly.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Pediatric Hospital Medicine 2016, cosponsored by the American Academy of Pediatrics (AAP), the Academic Pediatric Association (APA), and the Society of Hospital Medicine (SHM), took place July 28–31 in Chicago. Didn’t make it? Here are all the news, research, and talking points you need to know.

Shape Your Brain to Avoid Burnout

Presenter: Lisa Zaoutis, MD, FHM

Amid the skyscrapers of the Windy City, Pediatric Hospital Medicine (PHM) 2016 swept into town, bringing with it the denizens of pediatric hospitalist programs across the country. Some 1,150 attendees, composed of hospitalists, PHM program leaders, and advanced-care practitioners, gathered to educate and inspire one another in the care of hospitalized children.

Lisa Zaoutis, MD, FHM, director of the pediatric residency program at The Children’s Hospital of Philadelphia, kicked off the conference with the opening plenary. Initially titled “North Star and Space,” she quickly changed the title to “Changing Our Minds.” Touching on the disconnect between positive experiences that bring physicians into pediatric hospital medicine and negative experiences that often drive behavior, she started with the beginning: the evolution of our brains.

“We are wired toward the negative,” Dr. Zaoutis said. “We are Teflon for positive experiences and Velcro for negative experiences.”

Delving deeper into neuroanatomy, Dr. Zaoutis spoke of “amygdala hijack,” where chronic stress inherent to the professional lives of pediatric hospitalists leads to anxiety responses that are faster, more robust, and more easily triggered.

But all is not lost, Dr. Zaoutis noted, as our brains are more plastic than previously known. The “neural Darwinism” of our brains, she said, leads to epigenetic intracellular changes, more sensitive synapses, improved blood flow, and even new cells as a result of experience-dependent neuroplasticity. For example, London taxi drivers have thicker white matter in their hippocampus as a result of learning London city streets, and mindfulness meditators have thicker gray matter in regions that control attention and self-insight.

Key Takeaways

The lesson for pediatric hospitalists, according Dr. Zaoutis, is that you can shape your brain for greater joy.

“Consciously choose activities” that counter our evolutionary negativity bias, Dr. Zaoutis said.

Here’s how to do it:

1. Have a positive experience. (You can create one or retrieve a prior one.)
2. Enrich it and install it by dwelling on it for at least 15–30 seconds.
3. Absorb it into your body, which may require somatizing it. (Dr. Zaoutis presses her hand into her chest to aid in this.)

Further, spread this to your group by the old medical training technique of “see one, do one, teach one.” See if you can start your sign-out with the best thing that happened to you in the week. Most important, start with observing yourself.

Weijen Chang, MD, SFHM, is pediatric editor of The Hospitalist. He is associate clinical professor of medicine and pediatrics at the University of California, San Diego (UCSD) School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. Send comments and questions to wwch@ucsd.edu.

New AAP Guideline on Evaluating, Managing Febrile Infants

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was an update on the anticipated AAP guidelines for febrile infants ages 7–90 days. The updated guidelines stress the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The inclusion criteria for infants for this upcoming algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C.

Exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The updated guideline will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment.

It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well. These guidelines should be tailored for individual patients to provide the best care possible while minimizing risk.

Key Takeaway

An updated AAP guideline algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days, and 60–90 days will be coming in the near future. It will help standardize care in this population but should not be used as a substitute for clinical judgment.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Promoting, Teaching Pediatric High-Value Care

Presenters: Lauren L. Walker, MD, FAAP; Alan Schroeder, MD, FAAP; Michael

Tchou, MD, FAAP; Jimmy Beck, MD, MEd; Lisa Herrmann, MD; Ricardo Quinonez, MD, FAAP

Pediatric hospitalists gathered to attend a fruitful discussion on not only how to change our way of thinking but also how to feed it forward to our trainees. The barriers to promoting and teaching high-value care are plenty and essentially universal to academic and community sites: We have had no formal teaching, there is cultural resistance, and there is lack of transparency on costs and charges.

The questions we perhaps should be asking ourselves, our trainees, and our families are:

• “What matters?” instead of “What’s the matter?”
• “Does that test benefit the patient? What are the harms of the test?” instead of “Will that test change our management?”

There is still a long way to go to move the pendulum to the side of value-based practice and teaching. There is still controversy on how and whether cost should be discussed with the family. Cost is more than just monetary value; family anxiety and patient harm may resonate more with families as we perfect our skills in shared decision making.

Key Takeaway

This serves as an exciting time to unite and better our understanding about why we do what we do and deliberately think about downstream effects. High-value care curriculum for medical students, residents, fellows, and even faculty is an area ripe for further research.

Akshata Hopkins, MD, FAAP, is an academic hospitalist at Johns Hopkins All Children’s Hospital in St. Petersburg, Fla.

How to Design, Improve Educational Programs at Community Hospitals

Presenters: Christopher Russo, MD, FAAP; Laura Hodo, MD, and Lauren Wilson, MD

One session at PHM16 focused on ways to design and improve education within community hospital settings. It was done via a didactic session, breakout groups, and an electronic assessment tool. Facilitators included the workshop leaders and co-leaders along with current PHM fellows and educators from community and academic settings.

During the didactic session, a general background of the importance of education during times of increasing academic and community site affiliations was discussed. This included the strengths of community hospitals for learners such as “appropriate learner autonomy,” “exposure to different career paths,” and “transfer decision making.”

Some of the challenges discussed in regard to developing an educational structure in community settings included:

1. Logistics

• Making the case for education
• Legal framework (e.g., affiliation agreements, liability)
• Finances (e.g., GME funding)
• Paperwork burden (e.g., licensing, credentialing)

2. Learning environment

• Complementing clinical work with materials
• Autonomy/supervision balancing
• Developing clinical teachers

The didactic session also reviewed the six steps for curriculum development: general needs assessment, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation/feedback. Each of these was described in further detail with relevant examples.

Groups were broken into small groups based on four learner types: medical students, family medicine residents, pediatric residents, and PHM fellows. Within each group, a “program development matrix” was distributed to assess the support from leadership and logistics within each setting. Each one of these was separated into subgroups such as credentialing, financial support, housing/travel, and preceptor recruitment.

A separate “curriculum development matrix” was used during breakout groups that focused on curriculum development. This matrix was broken into three areas: educational strategies, implementation, and evaluation/feedback. These were further broken down into subgroups such as content, identifying resources, and remediation planning. The group was asked to determine short- and long-term goals with action steps for both of these matrix subgroups.

Key Takeaway

Overall, the session presented a structured way of assessing the educational environment for learners in community settings. It gave tangible tools for sites that wish to develop or improve their current educational framework.

Francisco Alvarez, MD, FAAP, is a pediatric hospitalist and director of the Children’s National Health System Community Hospital Services in Washington, D.C.

Tips on Meeting Needs of Children with a Medical Complexity

Presenters: Mary L. Ehlenbach, MD, FAAP; Megan Z. Cardoso, MD, FAAP, and Christina Kleier, ARNP, PNP

This session at PHM16 was focused on logistical tips on how to build a pediatric complex-care program. Presenters opened with a discussion on how to define children with medical complexity. This involved reviewing different methods, including using research-based aggregation of ICD-10 codes, relying on referral from both families and other providers, and identifying patients by consumption of hospital resources. The presentation continued by highlighting that although medically complex children make up only a small percentage of the overall population of children, they account for about one-third of healthcare spending. Because of advances in technology and medicine, this group of children is growing in numbers. It currently makes up about 10% of all pediatric admissions.

Key Takeaways

1. Children with medical complexity are a growing population on which a large proportion of healthcare resources are utilized. A program dedicated to serving the needs of this population may be helpful in reducing costs and improving the patient and family experience during hospitalizations.

2. When working to initiate a complex-care program:

• Set clear guidelines about which children the program is intended to serve and in what capacity it will function.
• Ensure the team composition is sustainable and meets the needs of the patients.
• Aggregate data about if the program is helping. This may be difficult to quantify since these are mostly qualitative measures.
• Include team members who are nonclinical to aid in improving hospital revenue and highlighting program benefits to the institution.

Margaret Rush, MD, is a hospitalist fellow at Children’s National Medical Center in Washington, D.C.

A Picture Is Worth a Thousand Words

Presenter: Kenneth Roberts, MD

PHM16’s “Visual Diagnosis: Signs and Why They Matter” session was a review of case presentations in which visual clues were vital to establishing a diagnosis. Though much of the content was presented with pictures, the emphasis was placed on the importance of correct diagnosis to avoid both misdiagnoses or overdiagnoses and the potential harm that may result from inappropriate treatment. This may also translate into poor utilization of resources and significant financial burden that can result from the unnecessary hospitalization of a patient.

Many of the presented cases highlighted examples in which there was extensive workup, hospitalization, subspecialty evaluation, and even incorrect treatment of patients.

In other instances, such as with Henoch-Schonlein purpura, Waardenburg syndrome, or McCune-Albright syndrome, the correct diagnosis was necessary to help guide management and future treatment, including subspecialty evaluation.

Key Takeaway

Many diseases with visual presentations will have a benign course and require no treatment. Acknowledging this is important in providing reassurance to a family that may be very anxious over the physical appearance of their child.

This session underscores the need for experience and exposure to various signs not only with rare medical conditions but also in common illnesses such as Kawasaki disease and scarlet fever that may present similarly.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Abstract: Docetaxel is a commonly used chemotherapeutic agent used in a variety of cancer treatment plans. We present a case of apparent docetaxel-induced Stevens-Johnson syndrome (SJS) in a patient recently treated with docetaxel for metastatic prostate cancer. This medication is not classically associated with the development of SJS.

A 63-year-old gentleman with a past medical history of hypertension, hyperlipidemia, and metastatic prostate adenocarcinoma to retroperitoneal lymph nodes, lung, and bone presented to the emergency room with a one-week history of a rash affecting his hands, feet, back, and chest. It developed into blisters that later ruptured. it was especially painful in the hands and feet. He also reported red eyes and difficulty eating for a week.

Vital Signs: Temp 36.4°C, 83/min, R.R 12/min, BP 121/60 mm Hg. Physical examination of the patient revealed a severe rash covering less than 30% of the body, oral ulcers, and conjunctival redness.

The patient’s cancer treatment regimen included active hormonal therapy with leuprolide and active chemotherapy with docetaxel. He had received 2 cycles of docetaxel therapy (75 mg/m2), with the last dose of docetaxel received 2 weeks prior to presentation.

Treatment of the patient included intravenous fluid replacement, prednisone, piperacillin/tazobactam, ondansetron, and morphine. The skin lesions were kept clean with regular dressing changes.

Because our searches for an established association between SJS and docetaxel were in vain, we elected to obtain a punch biopsy of the lesions to establish pathological evidence of our diagnosis. The punch biopsies were obtained from the edges of lesions on the left forearm and left medial foot. Light microscopy confirmed the diagnosis of SJS (clinical pics, pathology slides are available).

Discussion: Docetaxel is a widely used chemotherapeutic agent in the treatment of breast, lung, prostate and other cancers. The classically known side effects of docetaxel therapy include alopecia, pancytopenia, hepatotoxicity, nausea, vomiting, and diarrhea. A number of popular clinical pharmacology resources do not include Stevens-Johnson syndrome (SJS) as a known complication of docetaxel chemotherapy. However, the current case and the cases written by a handful of other clinicians may provide clinical evidence that docetaxel therapy is associated with the development of this potentially life-threatening dermatologic condition.

Abstract: Docetaxel is a commonly used chemotherapeutic agent used in a variety of cancer treatment plans. We present a case of apparent docetaxel-induced Stevens-Johnson syndrome (SJS) in a patient recently treated with docetaxel for metastatic prostate cancer. This medication is not classically associated with the development of SJS.

A 63-year-old gentleman with a past medical history of hypertension, hyperlipidemia, and metastatic prostate adenocarcinoma to retroperitoneal lymph nodes, lung, and bone presented to the emergency room with a one-week history of a rash affecting his hands, feet, back, and chest. It developed into blisters that later ruptured. it was especially painful in the hands and feet. He also reported red eyes and difficulty eating for a week.

Vital Signs: Temp 36.4°C, 83/min, R.R 12/min, BP 121/60 mm Hg. Physical examination of the patient revealed a severe rash covering less than 30% of the body, oral ulcers, and conjunctival redness.

The patient’s cancer treatment regimen included active hormonal therapy with leuprolide and active chemotherapy with docetaxel. He had received 2 cycles of docetaxel therapy (75 mg/m2), with the last dose of docetaxel received 2 weeks prior to presentation.

Treatment of the patient included intravenous fluid replacement, prednisone, piperacillin/tazobactam, ondansetron, and morphine. The skin lesions were kept clean with regular dressing changes.

Because our searches for an established association between SJS and docetaxel were in vain, we elected to obtain a punch biopsy of the lesions to establish pathological evidence of our diagnosis. The punch biopsies were obtained from the edges of lesions on the left forearm and left medial foot. Light microscopy confirmed the diagnosis of SJS (clinical pics, pathology slides are available).

Discussion: Docetaxel is a widely used chemotherapeutic agent in the treatment of breast, lung, prostate and other cancers. The classically known side effects of docetaxel therapy include alopecia, pancytopenia, hepatotoxicity, nausea, vomiting, and diarrhea. A number of popular clinical pharmacology resources do not include Stevens-Johnson syndrome (SJS) as a known complication of docetaxel chemotherapy. However, the current case and the cases written by a handful of other clinicians may provide clinical evidence that docetaxel therapy is associated with the development of this potentially life-threatening dermatologic condition.

Abstract: Docetaxel is a commonly used chemotherapeutic agent used in a variety of cancer treatment plans. We present a case of apparent docetaxel-induced Stevens-Johnson syndrome (SJS) in a patient recently treated with docetaxel for metastatic prostate cancer. This medication is not classically associated with the development of SJS.

A 63-year-old gentleman with a past medical history of hypertension, hyperlipidemia, and metastatic prostate adenocarcinoma to retroperitoneal lymph nodes, lung, and bone presented to the emergency room with a one-week history of a rash affecting his hands, feet, back, and chest. It developed into blisters that later ruptured. it was especially painful in the hands and feet. He also reported red eyes and difficulty eating for a week.

Vital Signs: Temp 36.4°C, 83/min, R.R 12/min, BP 121/60 mm Hg. Physical examination of the patient revealed a severe rash covering less than 30% of the body, oral ulcers, and conjunctival redness.

The patient’s cancer treatment regimen included active hormonal therapy with leuprolide and active chemotherapy with docetaxel. He had received 2 cycles of docetaxel therapy (75 mg/m2), with the last dose of docetaxel received 2 weeks prior to presentation.

Treatment of the patient included intravenous fluid replacement, prednisone, piperacillin/tazobactam, ondansetron, and morphine. The skin lesions were kept clean with regular dressing changes.

Because our searches for an established association between SJS and docetaxel were in vain, we elected to obtain a punch biopsy of the lesions to establish pathological evidence of our diagnosis. The punch biopsies were obtained from the edges of lesions on the left forearm and left medial foot. Light microscopy confirmed the diagnosis of SJS (clinical pics, pathology slides are available).

Discussion: Docetaxel is a widely used chemotherapeutic agent in the treatment of breast, lung, prostate and other cancers. The classically known side effects of docetaxel therapy include alopecia, pancytopenia, hepatotoxicity, nausea, vomiting, and diarrhea. A number of popular clinical pharmacology resources do not include Stevens-Johnson syndrome (SJS) as a known complication of docetaxel chemotherapy. However, the current case and the cases written by a handful of other clinicians may provide clinical evidence that docetaxel therapy is associated with the development of this potentially life-threatening dermatologic condition.