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Immunotherapy revolutionised oncology by harnessing the native immune system to effectively treat a wide variety of malignancies even at advanced stages. Off-target immune activation leads to immune-related adverse events affecting multiple organ systems, including the cardiovascular system. In this review, we discuss the current literature describing the epidemiology, mechanisms and proposed management of cardiotoxicities related to immune checkpoint inhibitors (ICIs), chimeric antigen receptor (CAR) T-cell therapies and bispecific T-cell engagers. ICIs are monoclonal antibody antagonists that block a co-inhibitory pathway used by tumour cells to evade a T cell-mediated immune response. ICI-associated cardiotoxicities include myocarditis, pericarditis, atherosclerosis, arrhythmias and vasculitis. ICI-associated myocarditis is the most recognised and potentially fatal cardiotoxicity with mortality approaching 50%. Recently, ICI-associated dysregulation of the atherosclerotic plaque immune response with prolonged use has been linked to early progression of atherosclerosis and myocardial infarction. Treatment strategies include immunosuppression with corticosteroids and supportive care. In CAR T-cell therapy, autologous T cells are genetically engineered to express receptors targeted to cancer cells. While stimulating an effective tumour response, they also elicit a profound immune reaction called cytokine release syndrome (CRS). High-grade CRS causes significant systemic abnormalities, including cardiovascular effects such as arrhythmias, haemodynamic compromise and cardiomyopathy. Treatment with interleukin-6 inhibitors and corticosteroids is associated with improved outcomes. The evidence shows that, although uncommon, immunotherapy-related cardiovascular toxicities confer significant risk of morbidity and mortality and benefit from rapid immunosuppressive treatment. As new immunotherapies are developed and adopted, it will be imperative to closely monitor for cardiotoxicity.

BACKGROUNDSkilled physician communication is a key component of patient experience. Large-scale studies of exposure to communication skills training and its impact on patient satisfaction have not been conducted.OBJECTIVEWe aimed to examine the impact of experiential relationship-centered physician communication skills training on patient satisfaction and physician experience.DESIGNThis was an observational study.SETTINGThe study was conducted at a large, multispecialty academic medical center.PARTICIPANTSParticipants included 1537 attending physicians who participated in, and 1951 physicians who did not participate in, communication skills training between 1 August 2013 and 30 April 2014.INTERVENTIONAn 8-h block of interactive didactics, live or video skill demonstrations, and small group and large group skills practice sessions using a relationship-centered model.MAIN MEASURESHospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), Jefferson Scale of Empathy (JSE), Maslach Burnout Inventory (MBI), self-efficacy, and post course satisfaction.KEY RESULTSFollowing the course, adjusted overall CGCAHPS scores for physician communication were higher for intervention physicians than for controls (92.09 vs. 91.09, p < 0.03). No significant interactions were noted between physician specialty or baseline CGCAHPS and improvement following the course. Significant improvement in the post-course HCAHPS Respect domain adjusted mean was seen in intervention versus control groups (91.08 vs. 88.79, p = 0.02) and smaller, non-statistically significant improvements were also seen for adjusted HCAHPS communication scores (83.95 vs. 82.73, p = 0.22). Physicians reported high course satisfaction and showed significant improvement in empathy (116.4 ± 12.7 vs. 124 ± 11.9, p < 0.001) and burnout, including all measures of emotional exhaustion, depersonalization, and personal accomplishment. Less depersonalization and greater personal accomplishment were sustained for at least 3 months.CONCLUSIONSSystem-wide relationship-centered communication skills training improved patient satisfaction scores, improved physician empathy, self-efficacy, and reduced physician burnout. Further research is necessary to examine longer-term sustainability of such interventions.

BackgroundDespite its rapid expansion, little is known about use of direct to consumer (DTC) telemedicine.ObjectiveTo characterize telemedicine patients and physicians and correlates of patient satisfactionDesignCross-sectional studyParticipantsPatients and physicians of a large nationwide DTC telemedicine serviceMain MeasuresPatient characteristics included demographics and whether or not they reported insurance information. Physician characteristics included specialty, board certification, and domestic versus international medical training. Encounter characteristics included time of day, wait time, length, coupon use for free or reduced-cost care, diagnostic outcome, prescription receipt, and patient/physician geographic concordance. Patients rated satisfaction with physicians on scales of 0 to 5 stars and reported where they would have sought care had they not used telemedicine. Logistic regression was used to assess factors associated with 5-star physician ratings.Key ResultsThe analysis included 28,222 encounters between 24,040 patients and 277 physicians completed between January 2013 and August 2016. Sixty-five percent of patients were under 40 years and 32% did not report insurance information. Family medicine was the most common physician specialty (47%) and 16% trained at a non-US medical school. Coupons were used in 24% of encounters. Respiratory infections were diagnosed in 35% of encounters and 69% resulted in a prescription. Had they not used telemedicine, 43% of patients reported they would have used urgent care/retail clinic, 29% would have gone to the doctor’s office, 15% would have done nothing, and 6% would have gone to the emergency department. Eighty-five percent of patients rated their physician 5 stars. High satisfaction was positively correlated with prescription receipt (OR 2.98; 95%CI 2.74–3.23) and coupon use (OR 1.47; 95%CI 1.33–1.62).ConclusionsPatients were largely satisfied with DTC telemedicine, yet satisfaction varied by coupon use and prescription receipt. The impact of telemedicine on primary care and emergency department use is likely to be small under present usage patterns.

BackgroundUrinary tract infections (UTI) are a common reason for seeking care via direct to consumer (DTC) telemedicine, yet patterns of care, including antibiotic prescribing, have not been reported.ObjectiveTo describe management of UTI in a large nationwide DTC telemedicine platform.DesignCross-sectional observational study.ParticipantsPatients seeking care for or diagnosed with UTI via DTC telemedicine between July 2016 and July 2018.Main MeasuresPatient measures included age, sex, geographic region, satisfaction with care, and patient-reported call reason. High-risk patients were defined as males, patients over 65 years, or those diagnosed with pyelonephritis. Physician measures included specialty and geographic region. Antibiotic prescription was assessed overall and by antibiotic type. Variation in antibiotic prescriptions was assessed by patient and physician factors, including geographic region of both parties.Key ResultsOf the 20,600 patients diagnosed with a UTI during the study period, 96% were female. Most (84%) stated their call reason was a UTI. Overall, 94% of UTI patients received an antibiotic; 56% got nitrofurantoin, 29% got trimethoprim-sulfamethoxazole, and 10% got a quinolone. Receipt of an antibiotic was associated with higher satisfaction with care (p < 0.001). While nitrofurantoin was the most common antibiotic for all physician regions, antibiotic type varied by physician region. Of the 6% of the study population defined as high risk, 69% received an antibiotic: 72% of males, 91% of women over 65, and 21% of patients diagnosed with pyelonephritis.ConclusionsManagement of UTI via DTC telemedicine appears to be appropriate for average-risk patients, and most are able to self-diagnose. Most patients received guideline-concordant care, but over half of high-risk patients received antibiotics. DTC telemedicine offers convenient, low-cost care that is generally appropriate. Efforts should be made to ensure high-risk patients get proper follow-up.

BackgroundAlcohol use disorder (AUD) imposes a high mortality and economic burden. Effective treatment is available, though underutilized.ObjectiveDescribe trends in AUD pharmacotherapy, variation in prescribing, and associated patient factors.DesignRetrospective cohort using electronic health records from 2010 to 2019.ParticipantsPrimary care patients from 39 clinics in Ohio and Florida with diagnostic codes for alcohol dependence or abuse plus social history indicating alcohol use. PCPs in family or internal medicine with at least 20 AUD patients.Main MeasuresPharmacotherapy for AUD (naltrexone, acamprosate, and disulfiram), abstinence from alcohol, patient demographics, and comorbidities. Generalized linear mixed models were used to identify patient factors associated with prescriptions and the association of pharmacotherapy with abstinence.Key ResultsWe identified 13,250 patients; average age was 54 years, 66.9% were male, 75.0% were White, and median household income was $51,776 per year. Over 10 years, the prescription rate rose from 4.4 to 5.6%. Patients who were Black (aOR 0.74; 95% CI 0.58, 0.94) and insured by Medicare versus commercial insurance (aOR 0.61; 95% CI 0.48, 0.78) were less likely to be treated. Higher median household income ($10,000 increment, aOR 1.06; 95% CI 1.03, 1.10) and Medicaid versus commercial insurance (aOR 1.52; 95% CI 1.24, 1.87) were associated with treatment. Receiving pharmacotherapy was associated with subsequent documented abstinence from alcohol (aOR 1.60; 95% CI 1.33, 1.92). We identified 236 PCPs. The average prescription rate was 3.6% (range 0 to 24%). The top decile prescribed to 14.6% of their patients. The bottom 4 deciles had no prescriptions. Family physicians had higher rates of pharmacotherapy than internists (OR 1.50; 95% CI 1.21, 1.85).ConclusionsMedications for AUD are infrequently prescribed, but there is considerable variation among PCPs. Increasing the use of pharmacotherapy by non-prescribers may increase abstinence from alcohol.

When it comes to historical violence and contemporary inequality, none of us are completely innocent. We may not be direct agents of harm, but we may still contribute to, inhabit, or benefit from regimes of domination that we neither set up nor control. Arguing that the familiar categories of victim, perpetrator, and bystander do not adequately account for our connection to injustices past and present, Michael Rothberg offers a new theory of political responsibility through the figure of the implicated subject. The Implicated Subject builds on the comparative, transnational framework of Rothberg's influential work on memory to engage in reflection and analysis of cultural texts, archives, and activist movements from such contested zones as transitional South Africa, contemporary Israel/Palestine, post-Holocaust Europe, and a transatlantic realm marked by the afterlives of slavery. As these diverse sites of inquiry indicate, the processes and histories illuminated by implicated subjectivity are legion in our interconnected world. An array of globally prominent artists, writers, and thinkers—from William Kentridge, Hito Steyerl, and Jamaica Kincaid, to Hannah Arendt, Primo Levi, Judith Butler, and the Combahee River Collective—speak to this interconnection and show how confronting our own implication in difficult histories can lead to new forms of internationalism and long-distance solidarity.

As patient-initiated messaging rises, identifying variation in message volume and its relationship to clinician workload is essential. To describe the association between variation in message volume over time and time spent on the electronic health record (EHR) outside of scheduled hours. Retrospective cohort study. Primary care clinicians at Cleveland Clinic Health System. We categorized clinicians according to their number of quarterly incoming medical advice messages (i.e., message volume) between January 2019 and December 2021 using group-based trajectory modeling. We assessed change in quarterly messages and outpatient visits between October-December 2019 (Q4) and October-December 2021 (Q12). The primary outcome was time outside of scheduled hours spent on the EHR. We used mixed effects logistic regression to describe the association between incoming portal messages and time spent on the EHR by clinician messaging group and at the clinician level. Among the 150 clinicians, 31% were in the low-volume group (206 messages per quarter per clinician), 47% were in the moderate-volume group (505 messages), and 22% were in the high-volume group (840 messages). Mean quarterly messages increased from 340 to 695 (p < 0.001) between Q4 and Q12; mean quarterly outpatient visits fell from 711 to 575 (p = 0.005). While time spent on the EHR outside of scheduled hours increased modestly for all clinicians, this did not significantly differ by message group. Across all clinicians, each additional 10 messages was associated with an average of 12 min per quarter of additional time spent on the EHR (p < 0.001). Message volume increased substantially over the study period and varied by group. While messages were associated with additional time spent on the EHR outside of scheduled hours, there was no significant difference in time spent on the EHR between the high and low message volume groups.

Patients with bacteremia often have elevated white blood cell (WBC) and neutrophil counts, yet these alone are poor predictors of bacteremia. Data on the continuous relationship between WBC response and bacteremia are lacking. This study aims to characterize the relationship of WBC count, neutrophil percentage, and absolute neutrophil count (ANC) to bacteremia using interval likelihood ratios (ILRs) derived from a large sample of hospitalized patients. Retrospective cohort study in a large healthcare system from 2017 to 2018. This study included non-surgical inpatients who had at least one complete blood count (CBC) with differential up to 24 hours after admission and a blood culture. Patients with immunosuppression and malignancy or who received antibiotics before negative blood cultures were excluded. Predictors were WBC count, ANC, and neutrophil percentage. The outcome was bacteremia. We compared test discrimination using the area under the receiver operating characteristics curve (AUROC). We calculated ILRs for bacteremia across test value intervals. As a practical example, we assumed a 5% pre-test probability of bacteremia and calculated the post-test probability for each interval. We compared this approach to a threshold approach using a threshold of 70% neutrophils. Of 25,776 patients with a CBC with differential and blood culture, 1160 had bacteremia. AUROC was highest for neutrophil percentage (0.74), followed by ANC (0.63) and WBC count (0.58). Probability of bacteremia increased exponentially from neutrophil percentage 80 to 100%. Odds of bacteremia varied 35-fold based on neutrophil percentage. A threshold approach with a cut-off of 70% significantly underestimated bacteremia risk at higher levels. ILRs offered a more discriminating approach to estimating the probability of bacteremia than a single threshold. Physicians assessing risk of bacteremia should pay attention to the magnitude of abnormality because very high and very low values have much stronger predictive power than dichotomized results.

BACKGROUND Internet-based social networking tools that allow users to share content have enabled a new form of public reporting of physician performance: the physician-rating website. OBJECTIVE To describe the structure and content of physician-rating websites and to assess the extent to which a patient might find them valuable. METHODS We searched Google for websites that allowed patients to review physicians in the US. We included websites that met predetermined criteria, identified common elements of these websites, and recorded website characteristics. We then searched the websites for reviews of a random sample of 300 Boston physicians. Finally, we separately analyzed quantitative and narrative reviews. RESULTS We identified 33 physician-rating websites, which contained 190 reviews for 81 physicians. Most reviews were positive (88%). Six percent were negative, and six percent were neutral. Generalists and subspecialists did not significantly differ in number or nature of reviews. We identified several narrative reviews that appeared to be written by the physicians themselves. CONCLUSION Physician-rating websites offer patients a novel way to provide feedback and obtain information about physician performance. Despite controversy surrounding these sites, their use by patients has been limited to date, and a majority of reviews appear to be positive.