The University of Pennsylvania Health System (UPHS) is a major multi-hospital health system headquartered in Philadelphia, Pennsylvania. UPHS and the Perelman School of Medicine at the University of Pennsylvania together comprise Penn Medicine, a clinical and research entity of the University of Pennsylvania. UPHS hospitals include the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Pennsylvania Hospital, Chester County Hospital, Lancaster General Hospital, and Princeton Medical Center. The UPHS is home to the first hospital in the United States, the Pennsylvania Hospital.
BACKGROUND:Despite the paucity of outcome data, axillary lymph node dissection (ALND) is increasingly being omitted in patients with positive sentinel lymph nodes after neoadjuvant chemotherapy, particularly in those with low-volume residual disease. We investigated oncological outcomes in patients with breast cancer and residual micrometastases in the sentinel lymph nodes treated with or without ALND. METHODS:OPBC-07/microNAC was a retrospective cohort study, using data obtained from the institutional databases of 84 cancer centres in 30 countries. Patients aged 18 years or older with clinical T1-4, N0-3 breast cancer at diagnosis treated with neoadjuvant chemotherapy followed by surgery between Jan 1, 2013, and May 31, 2023, who were found to have residual micrometastases (metastasis measuring >0·2 mm or >200 cells, not exceeding 2·0 mm in size) on frozen section or on final paraffin sections as determined by sentinel lymph node biopsy, targeted axillary dissection (sentinel lymph node biopsy with single or dual-tracer mapping plus image-guided localisation of the initially biopsy-proven and clipped node), or the marking axillary lymph nodes with radioactive iodine seeds (MARI) procedure were eligible for inclusion. The primary endpoint was the 5-year rate of any axillary recurrence (isolated or combined with local or distant recurrence) stratified by type of axillary surgery. Given the median follow-up, here we report 3-year rates and exploratory 5-year estimates. This study was registered with ClinicalTrials.gov, NCT06529302. FINDINGS:1585 female patients with ypN1mi disease were analysed, of whom 804 (50·7%) underwent ALND and 781 (49·3%) did not. Of 1585 women, 238 (15·0%) self-identified as Asian, 65 (4·1%) as Black, 200 (12·6%) as Hispanic, 968 (61·1%) as White, and 114 (7·2%) as unknown race and ethnicity. 925 (58·4%) of 1585 women had cT2 tumours, 1054 (66·5%) were node positive, and 1267 (79·9%) received nodal radiotherapy. The median follow-up was 3·1 years (IQR 1·8-5·2). The 3-year rate of any axillary recurrence (isolated or combined with local or distant recurrence) for the entire cohort was 2·0% (95% CI 1·3-2·9), with no statistical difference identified by extent of axillary surgery. However, patients with triple-negative disease who did not receive ALND had significantly higher rates of any axillary recurrence than women treated with ALND (8·7% [95% CI 4·4-15·0] vs 2·4% [95% CI 0·7-6·5], p=0·018). On multivariable analysis, triple-negative breast cancer (hazard ratio 3·83 [95% CI 1·72-8·52]) and omission of nodal radiotherapy (2·62 [1·19-5·73]) but not omission of ALND (0·86 [0·37-2·00]) were independently associated with an increased risk of any axillary recurrence. INTERPRETATION:Overall, these results do not support ALND for all patients with ypN1mi on sentinel lymph node biopsy treated with nodal radiotherapy; however, tumour biology should be taken into account when considering ALND omission. FUNDING:US National Institutes of Health, National Cancer Institute.
Telemedicine usage surged during the COVID-19 pandemic, shaping how patients access healthcare services. Its sustained role in post-pandemic healthcare may uncover long-term trends and variations in utilization. To characterize telemedicine utilization from 2019 to 2024 and identify patient characteristics associated with telemedicine use. This retrospective cohort study analyzed outpatient visits across five hospitals within the University of Pennsylvania Health System (Penn Medicine) from January 1, 2019, to September 30, 2024. The primary outcome was whether each outpatient encounter was conducted via telemedicine (vs in-person). We used multivariable logistic regression clustering on patients to assess associations between telemedicine use and patient- and encounter-level characteristics, including demographics, insurance, patient portal use, income, clinical comorbidity, distance from care, provider specialty, encounter type, hospital index, and visit year. The study included 46,149,734 visits among 2,248,341 patients. Telemedicine surged from 1
Background Emergency departments are often chaotic environments where delays can significantly impact patient care. Key items are stored in supply carts in or near patient rooms to promote efficiency and enable nurses to spend more time assisting patients. However, disorganization, lack of standardization, and lack of stocking can cause significant delays and negatively impact the quality of care. Objective This study utilized human-centered and participatory design to improve the workflow for supply acquisition in an emergency department. Methods Using a mixed methods, participatory design approach following the double diamond framework, the team worked with nursing staff and physicians in an urban emergency department to understand the root causes of frustrations with the current supply carts. Qualitative findings about bedside nursing workflows were integrated with quantitative observations of inventory and supply usage to drive a rapid-cycle prototyping process to optimize supply management in the bedside cart. Results A lack of clinical staffing exacerbates preexisting challenges with restocking the medical supplies in the bedside carts. This problem is compounded by the misallocation of supplies, with high-frequency items underrepresented and low-frequency items overrepresented in the bedside carts. This leads to wastage of the seldom-used supplies and a lack of access to the most used supplies. The reorganization of the cart through co-design with nursing staff sped up supply acquisition by approximately 20% overall, tripled the availability of the most important supplies, and reduced the need for restocking from once per shift to once per 3 shifts, thus producing tangible improvements even within institutional limitations. Conclusions A participatory design process, using human factors principles in tandem with extensive input from end users, enables improvements to stocking. Implications for practice include (1) lack of easy access to appropriate supplies negatively impacts patient care and contributes to nurse burnout and frustration, (2) human factors engineering can improve access to patient care supplies through redesigning the layout of hospital supply carts to better align with workflows, and (3) co-design with frequent collaboration from stakeholders and end users ensures that solutions address the issues that matter most in a sustainable way.
RATIONALE:Efficient distribution of scarce critical care resources is essential to save the most lives in times of crisis. Evidence-based practices and processes enhance clinical decision-making. OBJECTIVES:The objective of these guidelines was to develop evidence-based, rather than expert-based, recommendations for triaging critically ill patients eligible for ICU admission during times of crisis-level shortages in ICU capacity. DESIGN:The American College of Critical Care Medicine Board convened a 21-member multidisciplinary panel, comprising doctors in medicine, nursing, and law; advanced practice providers; respiratory therapists; ethicists; and patient/family representatives. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including task force selection and voting. METHODS:The panel members identified and formulated five fundamental Patient, Intervention, Comparator, and Outcomes questions. The panel conducted a systematic review for each question to identify the best available evidence, analyzed the evidence, and assessed the certainty of the evidence using the GRADE methodology. The GRADE evidence-to-decision framework was used to formulate the recommendations. Good practice statements were included to provide additional guidance. RESULTS:The panel generated one conditional recommendation and five no recommendation statements. CONCLUSIONS:Crisis-level shortages significantly disrupt patient care. Despite the role of triage in minimizing adverse outcomes, there is a lack of evidence, as opposed to expert opinion, to guide practice recommendations in the critical clinical scenarios considered by the panel.
Severe and extreme hypertriglyceridemia (sHTG [TG 500–879 mg/dL; 5.65–9.93 mmol/L]; eHTG [TG ≥ 880 mg/dL; ≥ 9.94 mmol/L]) are important risk factors for acute pancreatitis (AP) and cardiovascular (CV) events. The objective of this study was to estimate rates of AP and CV events for adults with (and without) sHTG/eHTG in US clinical practice. A retrospective design and data from the MarketScan Research Databases were employed. Study population comprised adults with ≥ 1 TG value and was stratified by index TG (< 150, 150–499, 500–879, ≥ 880 mg/dL; < 1.69, 1.69–5.64, 5.65–9.93, ≥ 9.94 mmol/L). AP/CV events (per 1,000 person-years [PY]) were ascertained from index TG through end of study period, and were estimated for TG-specific subgroups and selected subsets defined therein. Study population totaled 1.8 M adults (TG < 150 mg/dL [< 1.69 mmol/L]: N = 1.3 M; TG 150–499 mg/dL [1.69–5.64 mmol/L]: N = 449 K; TG 500–879 mg/dL [5.65–9.93 mmol/L]: N = 12,050; TG ≥ 880 mg/dL [≥ 9.94 mmol/L]: N = 3,944). AP rates (per 1,000 PY) increased from lowest to highest TG value (0.6 [< 150 mg/dL; < 1.69 mmol/L]) to 9.9 [≥ 880 mg/dL; ≥ 9.94 mmol/L]); rates were highest for adults with TG ≥ 880 mg/dL (≥ 9.94 mmol/L) and history of AP (193.0), pre-existing diabetes (13.9), or history of LLT (13.9). CV event rates (per 1,000 PY) also increased from lowest to highest TG value (3.3 [< 150 mg/dL; < 1.69 mmol/L]) to 10.3 [≥ 880 mg/dL; ≥ 9.94 mmol/L]); rates were highest for adults with TG ≥ 880 mg/dL (≥ 9.94 mmol/L) and history of CV events (116.5), pre-existing diabetes (18.1), or history of LLT (14.5). Rates of AP/CV events are substantially higher among adults with elevated TG values, and are especially high among adults with sHTG or eHTG, in particular those with these conditions and other risk factors. Understanding the magnitude of disease risk among sHTG/eHTG patients, with increasing TG levels as well as within important subgroups, is critical to improving patient care and outcomes.
