Benefits of a novel in-line decision support and ordering platform to support genomic test ordering

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Background: For many cancer patients, identifying the best treatment options requires timely genomic and molecular testing. However, only a small fraction of eligible patients receive timely access to evidence-based testing. Testing barriers include the clinician efforts to stay abreast of the vast number of genomic tests, rapidly evolving recommendations, and the variety of vendors offering these costly tests. We piloted a genomic test ordering solution that is integrated directly with the EMR and evaluated its benefits. Methods: We worked with experts from multiple specialties to finalize simple, context-based decision support and used standard EMR functionality to enable providers to order appropriate tests directly from the decision support webpage, seamlessly queuing orders in the EMR. We evaluated a set of metrics based on expected benefits of this new solution. We focused our analysis on lung cancer patients, and on five genomic tests: blood-based NGS, tissue-based NGS, EGFR PCR, PDL1 28-8, PDL1 22C3. Regional oncologists and nurse navigators were surveyed before and after the pilot period to ascertain ordering length of time and experience. Aggregate claims data were reviewed to assess adherence rates to recommended testing guidance and the ordering tool. The pilot launched July 2021, and six-month pre- and post-pilot data were used to evaluate its impact. Results: We received 46 and 53 pre- and post-pilot survey responses, respectively. There was an increase in the proportion of respondents who reported that ordering took ‘Less than 5 minutes’ (39% (pre) to 72% (post)), and that the ordering process was ‘Easy’ (28% (pre) to 74% (post)). In pre-pilot survey comments, ‘knowing the right test’ and ‘how to order’ comprised 30% of 40 comments. These issues were not raised in the 37 post-pilot survey comments we received. Approximately 35% of post-pilot comments revealed no issues with the new process, though 24% of comments expressed issues finding test guidance and the order button. Adherence to recommended guidance and the ordering tool grew from 0% to 44% from July to November 2021 but maintained a steady pace since then to April 2022. Conclusions: Connecting genomic test decision support to ordering capability can lead to significant benefits for providers and patients. The pilot was successful in saving ordering time, improving the ordering experience, and improving adherence to guideline concordant treatments. Success factors include elimination of a cumbersome ordering interface, development of individually orderable tests, implementation of a central ordering location, and guidance to preferred vendors. There are opportunities to improve clinician onboarding, boost adherence rates, and assess other impacts to outcomes such as cost savings and time to treatment. Additional analyses are required to understand the broader impact to these measures.

Successful treatment of active haemorrhage from a duodenal diverticulum using surgicel (absorbable haemostat): a case report

Haemorrhage is one of the rare but serious complications of duodenal diverticula. Current methods of treatment include: endoscopy with injection therapy or hemoclip application and diverticulectomy. In this paper we present the case of a 61 year old man with life threatening haemorrhage who was managed successfully with gentle packing of a bleeding duodenal diverticulum using SURGICEL (Absorbable Haemostat). This appears to be a simple and effective way of dealing with the problem especially in situations where other methods are ineffective or inapplicable. Early surgical intervention before the development of any coagulopathy increases the chances of a successful outcome. It has not been possible to find a similar report from a thorough literature search.

Cognitive underpinnings of narrative attachment assessment

Traditional story completion methods used to examine attachment representations in childhood draw heavily on socially significant content and clinical judgment. Using these methods with 37-month-olds, Bretherton, Ridgeway, and Cassidy (1990) found that attachment security scored from story completions were related to a wide range of secure base, personality, intellectual, and family variables. We examined story completions from 24 of Bretherton et al. 's (1990) subjects who had also produced story completions at 54 months, but scored passage length (idea units) and scriptedness. Results captured much of the attachment-related variance associated with the traditional scoring, but had better discriminant validity vis-à-vis general developmental level. These results indicate that analysis of cognitive variables underlying conventional scoring can advance understanding of attachment representations and their relations to the organization and content of attachment-related narratives.

Induced mood and preschoolers' behavior: Isolating the effects of hedonic tone and degree of arousal

A circumplex model of emotion was used to examine the role of hedonic tone and degree of arousal in the effects of induced mood on children's persistence behavior. A total of 45 preschool children were asked to describe and think about either exciting, calm, or sad experiences and then perform a persistence task. Heart rate was continuously recorded throughout the session. Observers' ratings of facial expressions and parents' ratings of the experiences provided convergent validation of the induction procedure. Children in the excited induction were rated as displaying facial expressions and generating situations that were high on both pleasure and arousal. The facial expressions and situations of those in the calm induction were also rated as positive, but less arousing, whereas those in the sad induction were rated as low on both. Concurrent heart rate recordings showed differential effects of the mood condition on autonomic arousal during the period when the children were generating the affect-inducing situations. These effects dissipated shortly after the beginning of the concentration phase of the induction procedure. Subsequent performance on a persistence task indicated that higher levels of arousal increased the amount of work completed, whereas higher levels of pleasure did not. Differential levels of autonomic arousal were displayed during the persistence task. These findings validate two important elements of the experimental design: excited versus calm states induce similar levels of pleasure but different levels of arousal, and calm versus sad states induce similar levels of arousal but different levels of pleasure. In previous research, hedonic tone and degree of arousal have often been confounded.(ABSTRACT TRUNCATED AT 250 WORDS)