Search

Context.--In 2018 the College of American Pathologists Diagnostic Immunology and Flow Cytometry Committee designed and implemented a new plasma cell neoplasia flow cytometry proficiency testing program--PCNEO--to allow clinical flow cytometry laboratories to monitor and assess their performance compared with a peer group. Objective.--To report the results from the first 4 years of the PCNEO program. Design.--Program participants were sent 2 sets of challenges per year, each including 1 wet challenge and 2 dry challenges, with associated clinical and laboratory findings. The wet challenges were composed of myeloma cell line specimens (with or without dilution in preserved whole blood) for flow cytometric analysis. The dry (paper) challenges were composed of clinical case summaries and images of flow cytometric test results from various flow cytometry laboratories of committee members. Results.--A total of 116 to 145 laboratories from 17 countries enrolled in the proficiency testing program. For the wet challenges, almost all participants (97%--100%; cumulative, 98.2%) correctly identified the presence of neoplastic plasma cell populations based on flow cytometric analysis of undiluted myeloma cell lines. Slightly fewer participants (89.0%--97.4%; cumulative, 95.2%) correctly identified the presence of neoplastic plasma cell populations based on flow cytometric analysis of diluted myeloma cell lines (10% or 50% dilutions into peripheral blood) intended to better represent a typical clinical sample. There was generally agreement among 80% or more of participants for positive or negative staining for CD38, CD138, CD19, CD20, and surface and cytoplasmic K and λ light chains. Similarly, 84% to 100% of participants were able to correctly identify the presence of neoplastic plasma cell populations in paper challenges, including the presence of small, neoplastic plasma cell populations (0.01%--5.0% clonal plasma cells) and the presence of nonneoplastic plasma cell populations (correctly identified by 91%--96% of participants). Conclusions.--Participant performance in the new proficiency testing program was excellent overall, with the vast majority of participants able to perform flow cytometric analysis and identify neoplastic plasma cell populations and to identify small plasma cell clones or expanded populations of reactive plasma cells in dry challenge flow cytometry results. This program will allow laboratories to verify the accuracy of their testing program and test interpretations for the assessment of patients suspected of having a plasma cell neoplasm. [ABSTRACT FROM AUTHOR]

Aims: To elicit experiences of patients, family caregivers, and healthcare professionals in intermediate care units (IMCUs) in an academic medical centre in Baltimore, MD related to the challenges and intricacies of multimorbidity management to inform development of a multimorbidity symptom management toolkit. Design: Experience‐based co‐design. Methods: Between July and October 2021, patients aged 55 years and older with multimorbidity admitted to IMCUs at an academic medical centre in Baltimore, Maryland, USA were recruited and interviewed in person. Interdisciplinary healthcare professionals working in the IMCU were interviewed virtually. Participants were asked questions about their role in recognizing and treating symptoms, factors affecting the quality of life, symptom burden and trajectory over time, and strategies that have and have not worked for managing symptoms. An inductive thematic analysis approach was used for analysis. Results: Twenty‐three interviews were conducted: 9 patients, 2 family caregivers, and 12 healthcare professionals. Patients' mean age was 67.5 (±6.5) years, over half (n = 5) were Black or Hispanic, and the average number of comorbidities was 3.67. Five major themes that affect symptom management emerged: (1) the patient–provider relationship; (2) open and honest communication; (3) accessibility of resources during hospitalization and at discharge; (4) caregiver support, training, and education; and (5) care coordination and follow‐up care. Conclusion: Patients, caregivers, and healthcare professionals often have similar goals but different priorities for multimorbidity management. It is imperative to identify shared priorities and target holistic interventions that consider patient and caregiver experiences to improve outcomes. Implications for the Profession and/or Patient Care and Impact: This paper addresses the paucity of research related to the shared experience of disease trajectory and symptom management for people living with multimorbidity. We found that patients, caregivers, and healthcare professionals often have similar goals but different care and communication priorities. Understanding differing priorities will help better design interventions to support symptom management so people with multimorbidity can have the best possible quality of life. Reporting Method: We have adhered to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines in our reporting. Patient or Public Contribution: This study has been designed and implemented with patient and public involvement throughout the process, including community advisory board engagement in the project proposal phase and interview guide development, and member checking in the data collection and analysis phases. The method we chose, experience‐based co‐design, emphasizes the importance of engaging members of a community to act as experts in their own life challenges. In the coming phases of the study, the public will be involved in developing and testing a new intervention, informed by these qualitative interviews and co‐design events, to support symptom management for people with multimorbidity. [ABSTRACT FROM AUTHOR]

Forty-five years ago, the first author of this paper surveyed the US medical schools to determine their offerings on EOL (End-of-Life) issues. The results showed limited exposure for medical school students to learn about dying and death, thus their "learning" was apparently on-the-job training. The EOL offerings were so limited that the American Association of Medical Colleges (AAMC), following the 1975 publication from the survey, contacted the first author to inquire about death and dying in the curricula of their medical schools. Apparently, it was so insignificant that the AAMC did not have such information. Palliative medicine, geriatric medicine, and hospice were then in the "birthing" process, a mere blur on the horizon. Today, as in 1975, it is likely that most medical students have personally had minimal experience with death and that for many entering students, other than on television, the cadaver is their first sight of a dead person. The objective of this research is a longitudinal study at five-year intervals since 1975 reporting on EOL education in US medical schools. The total number of medical schools has increased from 113 in 1975 to 150 in 2020. The current study surveyed medical schools electronically and via postal services with a response rate of 37%. Findings from the survey over time revealed significant inclusion of death and dying and palliative medicine as well as geriatrics and hospice. Gross anatomy has evolved from strictly hands-on to integrating 3D/virtual models, a change not without controversy. A noticeable difference in emphasis is obvious as care now plays a more significant role in medical training than previously, thus making modern medicine not only about cure, but more about care than was previously emphasized. Communication with dying patients and families, analgesics for chronic pain, and advance directives all are covered in over 90% of schools today. The current emphasis on EOL care, not just disease management, is increasing and puts more of a human face on modern medicine. [ABSTRACT FROM AUTHOR]

In this paper, six social work scholars at varying career stages and institutions used collaborative autoethnography to identify (1) structural constraints and tensions to engage in participatory action research (PAR) in the academy, (2) the strategies we have used to navigate this work, and (3) suggestions for structural changes necessary to meaningfully value this work in the academy. Key structural constraints and tensions center around questioning the legitimacy of this work, time necessary to do this work, challenges funding this work, and inherent ableism in the academy. We share case examples of strategies PAR scholars have used to navigate or subvert academic expectations, including operationalizing values, rooting in movements, uplifting accessibility and knowledge; holding accountability to community, and articulating commitments. We end with recommendations for social work institutions and funders to meaningfully elevate, support, and fund PAR work in the academy. Specifically, we see the need for social work institutions to elevate PAR training and reward systems as legitimate knowledge, build support systems for conducting PAR in the academy, revise evaluation of scholars at milestones to value PAR; funders should also work to align funding opportunities and practices with participatory praxis. [ABSTRACT FROM AUTHOR]

Medical mistrust among the public was amplified during the COVID-19 pandemic due to racial and social inequities in infection rates and misinformation in the media. In Boston, two initiatives were launched by the Boston University Clinical Translational Science Institute (BU CTSI), Boston Medical Center (BMC), community health centers (CHCs), and community organizations to establish longitudinal and authentic partnerships with community-research boundary spanners who remained trusted sources of information. Each initiative addressed the immediate need for community-informed and partnered COVID research and provided a structure for longitudinal partnerships. In this paper, we describe the process of envisioning how these two initiatives could move from isolation toward collective impact. We also identify opportunities to improve community-engaged research practices within an academic health system. Our approach provides a structure that other organizations can use to align initiatives and move toward boundary-crossing partnerships which foster health equity. [ABSTRACT FROM AUTHOR]

The study aimed to analyze the Journal of Hospital Librarianship (JHL) publications between 2001 and 2020 as indexed in Elsevier's Scopus database. The dataset was extracted on February 25, 2021 and 807 records were identified for data analysis. Various bibliometric indicators of the papers were assessed. There was an average of 1.32 citations per document. Sixty percent of the papers were single-authored, but the multi-author papers had a higher number of citations. The USA was identified as the country with the most contributions; Louisiana State University was the highest contributing institution, while Helen-Ann Brown Epstein was the most prolific author. [ABSTRACT FROM AUTHOR]

Background: Nazi Germany surrendered to the Allies on May 8, 1945. Six months later, the Allies tried the surviving leaders of Nazi Germany at the first Nuremberg trial. Later, the United States conducted 12 additional trials. The first one, The Unites States of America versus Karl Brandt et al., has been dubbed the Doctors' Trial. During the trial, the prosecution relied on the testimony of Dr. Andrew Ivy and Dr. Leo Alexander. At the end of the trial, Judge Sebring enunciated 10 principles needed to conduct human subject research-the Nuremberg Code. Authorship of the Code has been the subject of dispute, with both Ivy and Alexander claiming sole authorship.Methods: In the summer of 2017, I visited Duke University Medical Center's Archives and surveyed the contents of boxes labeled "Alexander's papers." I also explored online databases with information on the Doctors' Trial. Pertinent documents were compared across collections, and against scholarly works on the topic.Results: Box 3 of Alexander's papers at Duke University Medical Center's Archives contains a three-page document with six principles that, nearly word for word, were included in what is known as the Nuremberg Code. Alexander's name and appointment are typed at the end of the document.Conclusions: Although the Nuremberg Code is likely to have been an unplanned collaboration among members of the prosecuting team and the judges, I present evidence suggesting that Alexander drafted the blueprint and was the main contributor to the final version of the Code. [ABSTRACT FROM AUTHOR]

This paper reports findings from a qualitative study on the triggers of hospital social workers' moral distress at a large southern U.S. health system. Moral distress occurs when ethical conflict cannot be resolved in a way that aligns with an individual's personal and professional values and ethics. Participants indicated that moral distress derives from both individual interactions and the culture and climate of health systems. For example, participants expressed how sources of moral distress derived from client-centered decisions, such as end-of-life care and patient autonomy; interpersonal dynamics, including team or supervisory conflict; structural issues, such as insurance barriers or internal hospital policies; and organizational values, such as perceptions of institutional support and validation. Implications of this research suggest that health systems need to foster positive ethical environments that nurture clinicians' health and mental health through programs that aim to increase moral resilience, promote empowerment, and foster wellness. [ABSTRACT FROM AUTHOR]

Faith-based organizations (FBOs) can play an important role in improving health outcomes. Lay community health advisors (CHAs) are integral to these efforts. This paper assesses the sustainability of a CHA training program for congregants in African-American and Latino FBOs and subsequent implementation of educational workshops. The program is unique in that a health care chaplain in an academic medical center was central to the program's development and implementation. Forty-eight CHAs in 11 FBOs were trained to teach workshops on cardiovascular health, mental health, diabetes, and smoking cessation. Two thousand four hundred and forty-four participants attended 70 workshops. This program has the potential to be a model to educate individuals and to address health inequities in underserved communities. Health care chaplains in other medical centers may use this as a model for enhancing community engagement and education. [ABSTRACT FROM AUTHOR]

Objective: Neuropsychological assessment is the cornerstone of concussion management, and the nature of its delivery can vary widely. While literature concerning post-concussion care typically revolves around in-person evaluation, the proliferation of computerized neuropsychological tests (CNTs) has allowed for some distance between concussion patients and the neuropsychologist. In the wake of a global pandemic, several papers describing the use of telehealth for concussion care have emerged; however, the small samples found in these studies may suggest that access to care remains an issue. Additionally, telehealth may not be a sustainable fee-for-service approach as CMS aims to curtail telehealth reimbursement for behavioral health clinicians. The objective of the present study is to describe a remote neuropsychological consultation model of concussion management and evaluate its productivity and impact in a rural setting. Participants and Methods: In this model, a neuropsychologist based at an academic medical center in the northeastern United States consulted to middle school, high school, and collegiate concussion management programs. Students typically were administered baseline ImPACT tests prior to participation in sports, and all students in the current sample completed post-injury ImPACT tests as part of return to play protocols. The neuropsychologist read test results through the test's online portal, then communicated interpretation and recommendations via email or phone to the school's representative (e.g., athletic trainer, athletic director, or school nurse). 837 unique concussions were recorded between 2019 and 2022. After removing abnormal cases (e.g., COVID-19 school closures, extended college breaks, non-concussions, and non-return to play decisions), 790 unique concussions (51.4% male) were included for analysis, with a mean age of 16.84 years (SD=2.17). Descriptive statistics were used to characterize the sample. Results: Across 790 unique concussions, 7 were middle school, 571 were high school, and 212 were college students. 1,750 total postinjury ImPACT tests were administered over the three-year period. Per concussion, an average of 2.22 (SD=0.90) tests were used. Average time to the last ImPACT given was 18.47 days (SD=16.59), with a median of 15 days. Ten concussions (1.27% of total concussions) occurred within 3 months of a previous injury. The distance between schools and the medical center ranged from 2.4 to 102 miles (M=60.29; SD=34.34). Conclusions: The current study suggests that there is value in a remote model of neuropsychological consultation for concussion management. While telehealth offers a promising method of evaluation for concussion, it may be inaccessible and present reimbursement challenges. The remote consultation model described here increases access to care by eliminating in-person visits, which decreases demand for physical space at medical centers and increases access to rural populations with seemingly no negative effect on care. This consultation model also allows neuropsychologists working in concussion management more flexibility, potentially increasing the volume of cases they can assess. This program evaluation suggests remote models have merit, but replication studies in different regions of the country are needed. [ABSTRACT FROM AUTHOR]

The integration of medical schools and clinical partners is effectively established through the formation of academic medical centers (AMCs). The tripartite mission of AMCs emphasizes the importance of providing critical clinical services, medical innovation through research, and the education of future health care leaders. Although AMCs represent only 5% of all hospitals, they contribute substantially to serving disadvantaged populations of patients, including an estimated 37% of all charity care and 26% of all Medicaid hospitalizations. Currently, most AMCs use a business model centered upon revenue generated from hospital services and/or practice plans. In the last decade, mounting financial demands have placed significant pressure on AMC finances because of the rising costs associated with complex clinical care and operating diverse graduate medical education programs. A shift toward population health-centric health care management strategies will profoundly influence the predominant forms of health care delivery in the United States in the foreseeable future. Health systems are increasingly pursuing new strategies to manage financial risk, such as forming Accountable Care Organizations and provider-sponsored plans to provide value-based care. Refocusing research and operational capacity toward population health management fosters collaboration and enables reintegration with hospital and clinical partners across care networks, and can potentially create new revenue streams for AMCs. Despite the benefits of population health integration, current literature lacks a blueprint to guide AMCs in the transformation toward sustainable population health management models. The purpose of this paper is to propose a modern conceptual framework that can be operationalized by AMCs in order to achieve a sustainable future. [ABSTRACT FROM AUTHOR]

This paper describes the design and protocol of a pragmatic, randomized trial to evaluate the comparative effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for chronic pain for the voluntary tapering of opioid dose in adults with chronic noncancer pain. Integrated Services for Pain: Interventions to Reduce Pain Effectively (INSPIRE) is a multicenter, randomized trial conducted at three academic health centers in the southeastern United States. Participants are adults receiving long-term opioid therapy of at least 20 morphine milligram equivalents daily for chronic noncancer pain. Participants were randomized to either the shared decision-making intervention or the motivational interviewing session and cognitive behavioral therapy for chronic pain intervention. All participants also received guideline-concordant care supporting opioid pharmacotherapy. The primary outcome was change from baseline in average daily prescribed opioid dose at 12 months, using prescribing data from electronic health records. Secondary outcomes were Patient-Reported Outcomes Measurement Information System Pain Interference and Physical Function at 12 months. This trial evaluates the comparative effectiveness of shared decision making versus motivational interviewing plus cognitive behavioral therapy for chronic pain for the voluntary tapering of opioid dose in adults with chronic noncancer pain. Results from this study can guide clinicians, researchers, and policymakers as they seek to reduce opioid prescribing and improve management of chronic pain. ClinicalTrials.gov Identifier: NCT03454555 (https://clinicaltrials.gov/ct2/show/record/NCT03454555). Participant enrollment began on June 26, 2019. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance (AMR) continues to present a challenge to international healthcare systems and structures of public health. The focus on optimizing antibiotic prescribing in human populations has challenged healthcare systems charged with making responsible their physician-prescribers. In the United States, physicians in almost every specialty and role use antibiotics as part of their therapeutic armamentariums. In United States hospitals, most patients are administered antibiotics during their stay. Therefore, antibiotic prescribing and utilization is a commonly accepted part of medical practice. In this paper, we utilize social science work on antibiotic prescribing to examine a critical space of care in United States hospital settings. From March to August 2018, we used ethnographic methods to study hospital-based medical intensive care unit physicians at the offices and hospital floors they frequent in two urban United States teaching hospitals. We focused on eliciting the interactions and discussions surrounding antibiotic decision-making that are uniquely influenced by the context of medical intensive care units. We argue that antibiotic use in the medical intensive care units under study was shaped by urgency, hierarchy, and uncertainty representative of the medical intensive care unit's role within the larger hospital system. We conclude that by studying the culture of antibiotic prescribing in medical intensive care units, we can see more clearly both the vulnerability of the looming antimicrobial resistance crisis and by contrast the perceived insignificance of stewarding antibiotic use when considered alongside the fragility of life amidst acute medical concerns regularly experienced in the unit. • Antibiotic prescribing in the intensive care unit was shaped by existing workflows. • The pressure to treat patients in an urgent manner led to increased antibiotic use. • Felt urgency combined with complicated patient cases fostered uncertainty. • Participants recognized an interconnectedness with other teams working in the unit. • Participants used timeliness as a rationale for antibiotic prescribing. [ABSTRACT FROM AUTHOR]

A number of conceptual frameworks have emerged with the goal of helping clinicians understand and navigate the intersections of the health system and broader political, economic, and cultural processes when they care for patients. In this study, we analyze the impact that one emerging framework, "structural competency," had on medical students' and physicians' understanding of societal problems affecting patient health and the practices of health systems. In this sub-analysis of a longitudinal qualitative study conducted between August and December 2020, we analyzed 19 semi-structured interviews with 7 first-year medical students, 7 upper-level medical students, and 5 physician course facilitators who participated in a course called Introduction to Medicine and Society at an medical school in the United States affiliated with a large urban academic medical center. This paper focuses on three main findings: how medical students and faculty describe "structures" and their effects on patients and patient care; how they use or imagine using structural competency to improve patient-physician communication and work interprofessionally to address social needs; and the emotional and personal reactions that confronting societal challenges provokes. We conclude that structural competency enhances existing efforts to improve patient-physician communication and to address patients' social needs. However, we highlight how structural competency efforts might fall short of their goal to shift physicians' perspectives "upstream" to the determinants of health due to both critical ambiguities in the concept and inattention to the emotional and personal impacts of addressing societal problems in the clinic. These findings have practical implications for how clinicians are trained to act on societal issues from within the health system and conceptual implications for refining how existing frameworks and curricula conceive of the intersection between healthcare and broader processes. • Ambiguity of 'structure' and 'structural competency' hinders applicability. • Emphasis on 'structure' may unintentionally essentialize marginalized patients. • Trainees' affective responses are key to addressing societal factors in the clinic. • Humility and self-reflection helped trainees better address 'structure'. [ABSTRACT FROM AUTHOR]