Discoveries & Impact (August 2022)

Discoveries & Impact highlights select scientific discoveries per section across the Department of Internal Medicine...

Improving Healthcare Services For Patients Who Require Medical Interpreters

In the journal JACC: Heart Failure, Sarah C. Hull, MD, MBE, writes that additional time should be allotted for clinician-patient encounters requiring interpreters to allow for effective communication.

According to the U.S. Census Bureau, nearly 10 percent of people over the age of five are considered limited English proficiency (LEP). Hull urges health care systems to absorb the costs of the additional time required for heart failure (HF) patients with LEP.

“The economics of greater time allocation for clinical encounters may seem challenging, but the ethics are not: health systems have a duty to ensure sufficient clinician time to provide high-quality patient care, which hinges upon clear and thorough communication,” says Hull.

The editorial examines a recent study in JACC: Heart Failure, which found significant barriers in clinician communication for vulnerable patients with limited health literacy. Hull adds that the consequences of inadequate time allocated for office visits is also a contributor to clinician burnout in the United States. The pressure clinicians face may lead to inadequate levels of care and may be financially devastating in the long-term, with annual burnout-associated costs related to physician turnover now approaching $5 billion in the U.S.

Hull SC. Patient Communication: Take the Time to Do it Right. JACC. Heart Failure 2022, 10(6): 439-440. doi: 10.1016/j.jchf.2022.03.008. PMID: 35654528.

GI Fellows Should Pursue QI Projects

Eight years ago, the Accreditation Council for Graduate Medical Education (ACGME) added a requirement for trainees to participate in quality improvement (QI) initiatives. Despite the requisite, there hasn’t been a consistent strategy across institutions. In the new Yale paper from Digestive Diseases and Sciences, the authors demonstrated a strategy for how trainees can successfully incorporate clinically important QI projects into everyday practice.

The trio sought to improve post-procedure documentation, the timeliness of such documentation, and perceived covering provider satisfaction of GI consultant post-procedure communication. They consulted with stakeholders and created a new standardized brief-operative note template; performed a retrospective before-after study of documentation; completed a statistical analysis and have sustainably integrated this intervention into fellow workflow.

They concluded that a template was a feasible intervention that led to beneficial change in completeness of recommendations and provider satisfaction with communication. Given success of this pilot, next steps will further optimize the intervention with automation by leveraging the electronic medical record. Learn more in “Quality Improvement During Gastroenterology Fellowship: The Experience of Improving Inpatient Post-endoscopy Communication.”

Ogurick AG, Magier SJ, Hughes ML. Quality Improvement During Gastroenterology Fellowship: The Experience of Improving Inpatient Post-endoscopy Communication. Digestive Diseases And Sciences 2022, 67(6): 1932-1936. doi: 10.1007/s10620-022-07436-5. PMID: 35239095.

COVID-19-Created Cytokine Storm & Pancreatic Cell Death

The COVID-19 virus wreaked havoc on many organ systems within the human body, inducing metabolic distress.

Hyperglycemia, or high blood sugar, was reported in literature following a COVID-19 infection, but researchers from Università di Milano, Harvard Medical School, Azienda Socio-Sanitaria Territoriale (ASST) Fatebenefratelli-Sacco, University of Parma, and Yale School of Medicine sought to further understand the indirect and direct effects of the virus on pancreatic function, including reports of new-onset hyperglycemia.

Researchers looked at 10 patients hospitalized due to the virus, and consequently developed new-onset hyperglycemia, and 10 additional patients who had recovered from the infection. None of the participants had diabetes previously.

The team found that pancreatic islet function was impaired by the infection, and even increased cell death was observed. Pancreatic abnormalities were even seen in patients who died from COVID-19.

They concluded that impaired pancreatic function and survival of pancreatic islets impacted patients with new-onset hyperglycemia and those diagnosed previously with type 2 diabetes. The hyperglycemia seen in these patients may be due to the “proinflammatory” milieu initiated by a cytokine storm since there was a general increase in cell death in pancreatic β-and other cells during infection with SARS-CoV-2.” Learn more in Diabetes.

Ben Nasr M, D'Addio F, Montefusco L, Usuelli V, Loretelli C, Rossi A, Pastore I, Abdelsalam A, Maestroni A, Dell'Acqua M, Ippolito E, Assi E, Seelam AJ, Fiorina RM, Chebat E, Morpurgo P, Lunati ME, Bolla AM, Abdi R, Bonventre JV, Rusconi S, Riva A, Corradi D, Santus P, Clark P, Nebuloni M, Baldi G, Finzi G, Folli F, Zuccotti GV, Galli M, Herold KC, Fiorina P. Indirect and Direct Effects of SARS-CoV-2 on Human Pancreatic Islets. Diabetes 2022, 71(7): 1579-1590. doi: 10.2337/db21-0926. PMID: 35499468.

Designing Interventions Around Goofball Use

The use of stimulants and opioids simultaneously, referred to as “goofballs,” is increasing in people who use drugs. Researchers from the British Columbia Centre on Substance Use, University of British Columbia, Tufts University School of Medicine, and Yale School of Medicine combined data from across two qualitative and ethnographic studies undertaken with people who use drugs in Vancouver, Canada.

Researchers noticed three themes with study participants for the use of goofballs: altering or enhancing opioid effects; altering or enhancing methamphetamine effects, and a balancing effect.

The authors note that understanding that people who use goofballs, do so for a rational, pleasurable purpose and can help inform future harm reduction strategies. This paper is an important contribution to polysubstance literature. Learn more in the International Journal of Drug Policy.

Ivsins A, Fleming T, Barker A, Mansoor M, Thakarar K, Sue K, McNeil R. The practice and embodiment of "goofballs": A qualitative study exploring the co-injection of methamphetamines and opioids. The International Journal On Drug Policy 2022, 107: 103791. doi: 10.1016/j.drugpo.2022.103791. PMID: 35830749.

Palliative Care Physicians: Get Waiver/Training to Prescribe Buprenorphine

In a new editorial published in the Journal of Palliative Medicine, authors from Boston College’s William F. Connell School of Nursing; University of California, San Francisco; University of Pittsburgh, Harvard Medical School, and Yale School of Medicine, discuss the need for obtaining a DEA X waiver for palliative care clinicians so they can prescribe buprenorphine.

They outline the importance of providing buprenorphine and/or naxolone to those patients with substance use disorders seeking palliative care, and walk providers through the necessary steps to obtain the waiver.

The authors argue that “what is critical to good palliative care is connection to patients and responsiveness to their individual needs.” Read more: The X Waiver to Prescribe Buprenorphine: The Why and How.

Fitzgerald Jones K, Ho JJ, Merlin JS, Weimer M, Sager Z, Kapo J, Childers J. The X Waiver to Prescribe Buprenorphine: The Why and How. Journal Of Palliative Medicine 2022, 25(7): 1021-1023. doi: 10.1089/jpm.2022.0170. PMID: 35775892.

Non-Medication Allergies & Types B or O Blood = Increased Risk of Iron Infusion Reaction

Anemia can have many causes, but iron deficiency anemia (IDA) is the most common variation around the world. Oral iron supplements are the first line treatment, but some patients may experience gastrointestinal distress. Iron delivered by an intravenous infusion can aid these patients, but infusion related reactions are possible. These reactions can range from mild to life-threatening.

In this new study in the European Journal of Haematology, scientists across Yale School of Medicine, Yale School of Public Health, and Harvard T.H. Chan School of Public Health sought to understand risk factors for these IV iron infusion-related reactions and the best next step for patients who experience these reactions.

They performed a chart review of 330 patients who received IV iron during a five-year period at Yale Cancer Center/Smilow Cancer Hospital. Of the 330 patients receiving IV iron infusion, 58 patients had an iron infusion reaction. Eleven of those patients had a severe reaction initially. Seven of the patients received a different formulation with a future injection and tolerated the change, three patients were transitioned to oral iron, while one patient had another reaction to an iron infusion.

Researchers found that a history of non-medication allergies and type B or O blood types were associated with an increased risk of an iron infusion-related reaction. Learn more in “Association of iron infusion reactions with ABO blood type.”

Butt A, Muradashvili T, Soliman S, Li F, Burns AJ, Brooks A, Browning S, Bar N, Borgman G, Goshua G, Hwa J, Martin K, Rinder H, Tormey C, Pine AB, Bona RD, Lee AI, Neparidze N. Association of iron infusion reactions with ABO blood type. European Journal Of Haematology 2022 doi: 10.1111/ejh.13838. PMID: 35871468.

Differences in Triple-Negative Breast Cancer Tumor Microenvironment in African American & non-African American Patients

Differences in the tumor immune microenvironment may result in discrepancies in how cancer patients respond to treatment. The authors of an article in NPJ Breast Cancer hypothesized that differences in the tumor immune microenvironment may exist between African American and non-African American patients due to ancestry-related or socioeconomic factors.

Their findings are from the analysis of clinically matched triple-negative breast cancer (TNBC) tissues from self-identified African American and non-African American patients. Overall, they found that there is greater immune infiltration and inflammation in African American TNBC and greater alterations and expression of genes that directly impact cancer cells and cellular metabolism in non-African American TNBC.

These differences may impact response to immune checkpoint inhibitors and other therapeutic agents that modulate the immune microenvironment, the authors said. Read the article here.

Marczyk M, Qing T, O'Meara T, Yagahoobi V, Pelekanou V, Bai Y, Reisenbichler E, Cole KS, Li X, Gunasekharan V, Ibrahim E, Fanucci K, Wei W, Rimm DL, Pusztai L, Blenman KRM. Tumor immune microenvironment of self-identified African American and non-African American triple negative breast cancer. NPJ Breast Cancer 2022, 8(1): 88. doi: 10.1038/s41523-022-00449-3. PMID: 35869114. PMCID: PMC9307813.

Management of Hereditary Angioedema in Women of Childbearing Age

In a review article published in Allergy, Asthma & Clinical Immunology, Florence Ida Hsu, MD, and colleagues, offer considerations in the management of hereditary angioedema (HAE), a rare autosomal condition, in women of childbearing age.

“Fluctuations in female sex hormones—such as the changes that occur during puberty, menses, contraceptive use, pregnancy, and menopause—can all affect the frequency and severity of HAE attacks. Disease management decisions for women of childbearing age may be more complex and require additional considerations since they could develop complications related to contraception, pregnancy, labor, delivery, and lactation,” the authors write.

The review also includes a discussion of the risks and benefits of medication use before, during and after pregnancy. Read the review here.

Hsu FI, Lumry W, Riedl M, Tachdjian R. Considerations in the management of hereditary angioedema due to C1-INH deficiency in women of childbearing age. Allergy, Asthma, And Clinical Immunology : Official Journal Of The Canadian Society Of Allergy And Clinical Immunology 2022, 18(1): 64. doi: 10.1186/s13223-022-00689-9. PMID: 35831891.

Consensus Conference Reviews Advanced Infectious Disease Diagnostics in Solid Organ Transplant Recipients

In the last decade, there has been an explosion of advanced assays for the diagnosis of infectious diseases, yet evidence‐based recommendations to inform their best use in the care of transplant recipients are lacking.

A consensus conference led Marwan Mikheal Azar, MD, and sponsored by the American Society of Transplantation (AST) was convened in December 2021 that represented a collaborative effort by experts in transplant infectious diseases, diagnostic stewardship, and clinical microbiology from centers across North America. Together they evaluated current uses, unmet needs and future directions for evaluations.

They also reviewed literature, determined assay advantages and limitations, developed best practice guidance, and identified areas of future investigation. Read the findings and consensus statements in a meeting report in the American Journal of Transplantation.

Azar MM, Turbett S, Gaston D, Gitman M, Razonable R, Koo S, Hanson K, Kotton C, Silveira F, Banach DB, Basu SS, Bhaskaran A, Danziger-Isakov L, Bard JD, Gandhi R, Hanisch B, John TM, Odom John AR, Letourneau AR, Luong ML, Maron G, Miller S, Prinzi A, Schwartz I, Simner P, Kumar D. A Consensus Conference to Define the Utility of Advanced Infectious Disease Diagnostics in Solid Organ Transplant Recipients. American Journal Of Transplantation : Official Journal Of The American Society Of Transplantation And The American Society Of Transplant Surgeons 2022 doi: 10.1111/ajt.17147. PMID: 35822346.

Yale’s Lung Cancer Screening Program Develops Standardized Reporting of Incidental, Non-Lung Cancer (Category S) Findings

Lung cancer screening (LCS) with low-dose CT (LDCT) is approved by the United States Preventive Services Task Force and should be incorporated into preventive health maintenance for at-risk individuals. The American College of Radiology developed a standardized reporting system (Lung-RADS) for positive LCS findings, specifically lung nodules, to guide management that will maximize benefit and minimize unnecessary evaluation.

Chest LDCT also identifies many non-nodule findings unrelated to lung cancer, classified in Lung-RADS as Category S incidental findings (IFs). IFs are very common in the population of patients undergoing LCS but reporting of IFS is not standardized within Lung-RADS. While identification of a clinically significant IF may be of benefit to an individual patient, variability of reporting for non-clinically significant IFs may trigger unwarranted evaluation with potential for harm, excess cost, and patient distress.

In response to these concerns, Yale’s multidisciplinary lung cancer screening program developed a structured system for standardized reporting of category S findings based on recommendations of the American College of Radiology and relevant specialty societies.

Tanoue LT, Sather P, Cortopassi I, Dicks D, Curtis A, Michaud G, Bader A, Gange C, Detterbeck F, Killam J. Standardizing the Reporting of Incidental, Non-Lung Cancer (Category S) Findings Identified on Lung Cancer Screening Low-Dose CT Imaging. Chest 2022, 161(6): 1697-1706. doi: 10.1016/j.chest.2021.12.662. PMID: 35032477.

Understanding How Community Care Affects Veterans w/ Advanced Kidney Disease

Veterans increasingly receive community care that is financed by the U.S. Department of Veterans Affairs. To better understand the implications of VA purchased community care on the VA system as well as veterans and their families, researchers analyzed documentation in the electronic health records of a random sample of veterans with advanced kidney disease.

Three interrelated themes emerged: VA staff members and clinicians provide extensive services to coordinate purchased private sector care and are relied upon by veterans to fill gaps in their care. Meanwhile, veterans and their families perform the “hidden work” of navigating a challenging referral process, a process that also strains the VA system, the authors found.

The challenges of cross system care merit consideration when assessing the value of purchased care. To read the article in JAMA Internal Medicine, go here.

O'Hare AM, Butler CR, Laundry RJ, Showalter W, Todd-Stenberg J, Green P, Hebert PL, Wang V, Taylor JS, Van Eijk M, Matthews KL, Crowley ST, Carey E. Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records. JAMA Internal Medicine 2022, 182(7): 710-719. doi: 10.1001/jamainternmed.2022.1379. PMID: 35576068. PMCID: PMC9112136.

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