Advancing the care of individuals with cancer through innovation & technology: Proceedings from the cardiology oncology innovation summit 2020 and 2021

As cancer therapies increase in effectiveness and patients' life expectancies improve, balancing oncologic efficacy while reducing acute and long-term cardiovascular toxicities has become of paramount importance. To address this pressing need, the Cardiology Oncology Innovation Network (COIN) was formed to bring together domain experts with the overarching goal of collaboratively investigating, applying, and educating widely on various forms of innovation to improve the quality of life and cardiovascular healthcare of patients undergoing and surviving cancer therapies. The COIN mission pillars of innovation, collaboration, and education have been implemented with cross-collaboration among academic institutions, private and public establishments, and industry and technology companies. In this report, we summarize proceedings from the first two annual COIN summits (inaugural in 2020 and subsequent in 2021) including educational sessions on technological innovations for establishing best practices and aligning resources. Herein, we highlight emerging areas for innovation and defining unmet needs to further improve the outcome for cancer patients and survivors of all ages. Additionally, we provide actionable suggestions for advancing innovation, collaboration, and education in cardio-oncology in the digital era.

Improving Code Status Documentation Rates Using Communication Skills Training in Vascular Surgery: A Quality Improvement Initiative

Introduction: Code status discussions are poorly understood by patients and variably performed by admitting providers, yet they are used as a quality metric. Surgical specialties, such as Vascular Surgery, admit patients with urgent and life-threatening illness. Surgical trainees are less likely to receive communication skills interventions when compared with nonsurgical specialties. Without a documented code status, nurses and physicians lack guidance on patient preference in the case of cardiopulmonary arrest and may deliver unwanted measures, which may also result in poor outcomes. Methods: We conducted a before-after Plan-Do-Study-Act quality improvement project between May 2018 and May 2019. A needs assessment included baseline code status documentation rates for the Vascular Surgery department admissions. A communication skills training (CST) and documentation intervention was provided to all Vascular Surgery trainees and advance practice providers (APPs). Departmental e-mails were sent over the 12-month intervention period, which demonstrated the code status documentation rates and served as reminders to document code status. Results: A total of 29 vascular surgery trainees and APPs received the intervention. At completion of the intervention, learners reported increased comfort initiating a code status discussion, making a recommendation for cardiopulmonary resuscitation (CPR) status, and having a strategy to discuss code status. A total of 2762 patient admissions were reviewed, with 1562 patient admissions occurring during the 12-month intervention period. The average code status documentation rate for the three months before the intervention was 7.8%. At the end of the 12-month intervention, documentation rates were 44.9% and 6 months after completion of the study period, average rates remained 45.2%. There was no change in admission rates during the study period. Discussion: CST and regular reminders increased vascular surgery residents' and APPs' comfort in engaging in code status discussions. After intervention, documentation of code status discussions increased with persistence up to six months after the intervention.

Case Report: Single Dose Anti-PD1 in a Patient With Metastatic Melanoma and Cardiac Allograft

Background

Immune-checkpoint inhibition has improved outcomes in metastatic melanoma. However, limited data describes the safety and efficacy of this treatment in the setting of cardiac allograft. Emerging translational and clinical evidence suggests that the majority of the benefit from these therapies is driven by the initial dose(s), and that attenuated dosing schedules may be as effective as continuous treatment.

Case presentation

We present a case vignette of a cardiac transplant recipient with metastatic melanoma who experienced six months of clinical benefit after one dose of pembrolizumab and did not suffer allograft rejection.

Conclusion

This case adds to the current available literature on the administration of checkpoint inhibitors in patients with cardiac allografts. Further, it explores potential markers of immunotherapy response and supports the potential of shorter or individualized immune-checkpoint blockade dosing strategies.

Atypical Case of Epicardial Amyloid Mass without Classical Features of Myocardial Infiltration

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Epicardial amyloid deposition without typical features of cardiac amyloid can occur.

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Multimodality imaging enables diagnosis and management of systemic amyloid.

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Novel antibody therapies for AL amyloidosis can alleviate symptoms.

Standardization of Inpatient CPR Status Discussions and Documentation Within the Division of Hematology-Oncology at UPMC Shadyside: Results From PDSA Cycles 1 and 2

PURPOSE

In December 2016, 49% of patients admitted to inpatient oncology services at University of Pittsburgh Medical Center Shadyside Hospital had cardiopulmonary resuscitation (CPR) status discussion documentation before discharge. The aim of this project was to improve the rate of CPR status conversations.

METHODS

During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses, advance practice providers (APPs), medicine housestaff, and palliative care faculty. All oncology clinicians and inpatient team members were reminded weekly to discuss and document CPR status preferences. APPs received training on efficient and effective CPR status assessment from palliative care faculty. Oncology leadership received monthly e-mail updates of CPR status documentation rates and endorsed CPR status best practice guidelines. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed, and themes were shared with oncology leadership and reviewed with APPs.

RESULTS

After PDSA cycle 1, CPR status assessment rates increased from 49% to greater than 80%. In 2017, more than 1,500 more CPR status discussions were documented than in 2016. The percentage of patients discharged with "comfort measures only" or "do not resuscitate" orders increased from 14.2% (95% CI, 9.5% to 19.0%) to 19.8% (95% CI, 15.6% to 24.0%). For PDSA cycle 2, charts of 60 patients without CPR assessment were reviewed. Of these, 52% were admitted overnight by nocturnists and 48% by daytime APPs. Fifty-five percent of patients (n = 33 of 60) had metastatic disease. CPR status was documented on previous admissions for 53% of patients (n = 31 of 60) in the past 12 months. Fifteen percent (n = 11 of 60) were admitted for scheduled inpatient chemotherapy.

CONCLUSION

A multipronged approach significantly increased CPR status assessments. More patients transitioned to comfort measures only or do not resuscitate when their preferences were clearly assessed and documented.

Myocardial extravascular extracellular volume fraction measurement by gadolinium cardiovascular magnetic resonance in humans: slow infusion versus bolus

BACKGROUND

Myocardial extravascular extracellular volume fraction (Ve) measures quantify diffuse fibrosis not readily detectable by conventional late gadolinium (Gd) enhancement (LGE). Ve measurement requires steady state equilibrium between plasma and interstitial Gd contrast. While a constant infusion produces steady state, it is unclear whether a simple bolus can do the same. Given the relatively slow clearance of Gd, we hypothesized that a bolus technique accurately measures Ve, thus facilitating integration of myocardial fibrosis quantification into cardiovascular magnetic resonance (CMR) workflow routines. Assuming equivalence between techniques, we further hypothesized that Ve measures would be reproducible across scans.

METHODS

In 10 volunteers (ages 20-81, median 33 yr, 3 females), we compared serial Ve measures from a single short axis slice from two scans: first, during a constant infusion, and second, 12-50 min after a bolus (0.2 mmol/kg gadoteridol) on another day. Steady state during infusion was defined when serial blood and myocardial T1 data varied <5%. We measured T1 on a 1.5 T Siemens scanner using a single-shot modified Look Locker inversion recovery sequence (MOLLI) with balanced SSFP. To shorten breath hold times, T1 values were measured with a shorter sampling scheme that was validated with spin echo relaxometry (TR = 15 sec) in CuSO4-Agar phantoms. Serial infusion vs. bolus Ve measures (n = 205) from the 10 subjects were compared with generalized estimating equations (GEE) with exchangeable correlation matrices. LGE images were also acquired 12-30 minutes after the bolus.

RESULTS

No subject exhibited LGE near the short axis slices where Ve was measured. The Ve range was 19.3-29.2% and 18.4-29.1% by constant infusion and bolus, respectively. In GEE models, serial Ve measures by constant infusion and bolus did not differ significantly (difference = 0.1%, p = 0.38). For both techniques, Ve was strongly related to age (p < 0.01 for both) in GEE models, even after adjusting for heart rate. Both techniques identically sorted older individuals with higher mean Ve values.

CONCLUSION

Myocardial Ve can be measured reliably and accurately 12-50 minutes after a simple bolus. Ve measures are also reproducible across CMR scans. Ve estimation can be integrated into CMR workflow easily, which may simplify research applications involving the quantification of myocardial fibrosis.

Molecular and imaging techniques for bacterial biofilms in joint arthroplasty infections

Biofilm formation on surfaces is an ancient and integral strategy for bacterial survival. Billions of years of adaptation provide microbes with the ability to colonize any surface, including those used in orthopaedic surgery. Although remarkable progress has been made in the treatment of orthopaedic diseases with implanted prostheses, infection rates remain between 1% and 2%, and are higher for revision surgeries. The chronic nature of implant infections, their nonresponsiveness to antibiotics, and their frequent culture negativity can be explained by the biofilm paradigm of infectious disease. However, the role of biofilms in orthopaedic implant infections and aseptic loosening is controversial. To address these issues, we developed molecular diagnostic and confocal imaging techniques to identify and characterize biofilms associated with infected implants. We designed PCR and reverse transcription (RT)-PCR-based assays that can be used to detect bacterial infections associated with culture-negative joint effusions that distinguish between physiologically active Staphylococcus aureus and Staphylococcus epidermidis. Using clinical isolates of Pseudomonas aeruginosa, we constructed a series of reporter strains expressing colored fluorescent proteins to observe biofilms growing on 316L stainless steel and titanium orthopaedic screws. Three-dimensional structures of Pseudomonas aeruginosa and staphylococci biofilms growing on the screws were documented using confocal microscopy. The application of these tools for clinical diagnosis and biofilm research in animal and in vitro models is discussed.

Successful medical management of Acanthamoeba keratitis

Seven patients with documented Acanthamoeba keratitis were treated with prolonged and intensive triple antiamoebic therapy consisting of topical neomycin-polymyxin B-gramicidin, propamidine isethionate 0.1%, and miconazole nitrate 1%. Additionally, five patients were treated with topical corticosteroids. Six of seven patients were cured of Acanthamoeba keratitis with medical therapy alone, one patient required therapeutic penetrating keratoplasty to eradicate the infection. Two patients underwent penetrating keratoplasty to improve their vision after medical therapy. Our series differs from previous reports in that triple antiamoebic therapy was used in all seven patients and was successful in both early and advanced cases of Acanthamoeba keratitis. Prolonged and intensive topical therapy with these three antiamoebic drugs may be an effective mode of therapy for Acanthamoeba keratitis.

Four cases of keratoconus and posterior polymorphous corneal dystrophy

We examined four young men with keratoconus and posterior polymorphous corneal dystrophy. All four patients showed central corneal steepening and irregularity, and large areas of irregular polymorphous opacification at the level of Descemet's membrane (in at least one cornea of each patient), which are consistent with posterior polymorphous dystrophy.

Induction of acute corneal allograft rejection by alpha-2 interferon

A 38-year-old man who underwent corneal transplantation in 1973 for treatment of a keratoconus is described. In 1982, hairy cell leukemia was diagnosed and he was treated with splenectomy followed by chlorambucil and androgen therapy. In April 1984, treatment with alpha-2 interferon was begun, and two weeks later, evidence of acute corneal allograft rejection developed. The allograft rejection responded to temporary discontinuation of alpha-interferon and the administration of topical corticosteroid. Treatment with interferon was resumed, and he has subsequently had no clinical evidence of rejection. Although the mechanism of antineoplastic activity of alpha-interferon in hairy cell leukemia is unknown, the observations described in this report suggest that clinically important immune phenomena may occur in patients undergoing interferon therapy.

Dematiaceous fungal keratitis following penetrating keratoplasty

A keratitis with an unusual, sessile, filamentary mass extending into the anterior chamber developed in a patient three weeks after penetrating keratoplasty. The causative organism was identified as Exophilia (Wangiella) dermatitidis, a dematiaceous fungus. The infection was cured with a combination of medical and surgical therapy. Inoculation of the isolate into rabbit corneas produced a similar keratitis from which the same organism was cultured. Miconazole levels measured in corneal tissue removed at surgery were approximately 25 times greater than the minimum inhibitory concentration for the fungal isolate.

UCLA clinical trial of radial keratotomy. Preliminary report

A clinical trail of radial keratotomy ws begun under a strict research protocol at the Jules Stein Eye Institute in November 1979. The results for the first 52 eyes undergoing radial keratotomy are reported three months after surgery. Preoperatively uncorrected visual acuity was less than 20/200 in all 52 eyes. and postoperative visual acuity was less than 20/200 in 11 eyes (21%). Three months postoperatively, uncorrected visual acuity was 20/40 or better in 27 eyes (52%) and 20/20 or better in 13 eyes (25%). Postoperatively the best-corrected visual acuity decreased in 10 eyes (20%), but maximum decrease in any eye was one line of snellen letters. Preoperatively mean refractive error was -4.9 (/+-2.2) diopters, and postoperatively the mean decrease in myopia was 3.4 (/+-2.2) diopters. Postoperatively 13 eyes (25%) had a hyperopic refractive error of +0.25 to +3.25 diopters, but all of these eyes were able to accommodate and obtain 20/20 visual acuity without glasses. Postoperatively there was no statistically significant change in axial length, anterior chamber depth, or scleral rigidity, but there was a mean corneal endothelial cell loss of 10% (P = 0.0002). Decrease in myopia achieved by radial keratotomy did not correlate with the steepness of corneal curvature, corneal diameter, or scleral rigidity. Three months after surgery, significant symptoms of glare were present in 10 eyes (20%0, and annoying variable visual acuity was noted in five eyes (10%).

Corneal endothelial damage from previously implanted intraocular lenses

Intraocular lenses which had been surgically removed from human eyes were compared to new uncoated IOLs with regard to damage caused by dynamic and static contact with fresh rabbit corneal endothelium. Previously implanted IOLs caused consistently less endothelial damage. Possible mechanisms and the implications of these findings for the corneal surgeon doing pseudophakic keratoplasty are discussed.

Corneal edema: cause and treatment

Corneal edema, adequately understood and appropriately treated, has a good prognosis. The pathophysiological bases and the various causes are considered. Goals and techniques of medical and surgical therapies are reviewed.