Taking Control of Castleman Disease: Leveraging Precision Medicine Technologies to Accelerate Rare Disease Research

Castleman disease (CD) is a rare and heterogeneous disorder characterized by lymphadenopathy that may occur in a single lymph node (unicentric) or multiple lymph nodes (multicentric), the latter typically occurring secondary to excessive proinflammatory hypercytokinemia. While a cohort of multicentric Castleman disease (MCD) cases are caused by Human Herpes Virus-8 (HHV-8), the etiology of HHV-8 negative, idiopathic MCD (iMCD), remains unknown. Breakthroughs in “omics” technologies that have facilitated the development of precision medicine hold promise for elucidating disease pathogenesis and identifying novel therapies for iMCD. However, in order to leverage precision medicine approaches in rare diseases like CD, stakeholders need to overcome several challenges. To address these challenges, the Castleman Disease Collaborative Network (CDCN) was founded in 2012. In the past 3 years, the CDCN has worked to transform the understanding of the pathogenesis of CD, funded and initiated genomics and proteomics research, and united international experts in a collaborative effort to accelerate progress for CD patients. The CDCN’s collaborative structure leverages the tools of precision medicine and serves as a model for both scientific discovery and advancing patient care

The Incorporation of a Case-Based Health Equity Curriculum Into M&M Conference

Learning Objectives: To deliver evidence-based health equity education in resident and faculty conference using case-based content to highlight examples of inequity in emergency medicine practice.Background: While GME requires formal education on health disparities, there is a lack of standardized education in emergency medicine (EM) residency curricula on these topics. Educational Objectives: 1. To evaluate health disparities in an evidence-based manner using anonymized ED-specific case examples 2. To increase structural competency regarding the systems that perpetuate these disparities 3. To equip EM providers with actionable steps to mitigate these disparities 4. To develop a curriculum that can be replicated by other programs. Curricular Design: The Health Equity Curriculum (HEC) was developed using Kern’s curricular design framework. A consensus group of residents and faculty members met over 4 months to identify curriculum gaps. Patient and provider-centered topics were identified through informal needs assessment of the trainees with the plan to deliver them over two years. To maximize reach, the 30-minute HEC lectures were integrated into the monthly morbidity and mortality (M&M) conference stressing how healthcare disparities lead to measurable adverse outcomes. This approach was modeled after a surgical M&M series at the University of Michigan with proven success. Interested residents prepared lectures for each topic using a standard format. Faculty experts were recruited to mentor each resident. The concept was introduced at faculty meetings and residency conference with the support of departmental and residency leadership. Monthly lectures were launched in February 2021, with topics presented in a stepwise fashion to allow each lecture to build upon previous ones. Feedback was collected after 6 months via anonymous surveys sent by email. Impact/Effectiveness: Our HEC contributes to GME by providing an evidence-based series of lectures generalizable to all EDs. Our 6-month survey respondents expressed an overall satisfaction with the curriculum in increasing their understanding of health disparities

Racial Differences in Triage for Emergency Department Patients with Subjective Chief Complaints

Introduction: Black and Hispanic patients are frequently assigned lower acuity triage scores than White patients. This can lead to longer wait times, less aggressive care, and worse outcomes. In this study we aimed to determine whether these effects are more pronounced for patients with subjective complaints.Methods: We performed a retrospective analysis for all adult visits between 2016-2019 at an urban academic emergency department (ED) with acuity-based pods. We determined rates of initial high-acuity triage both across all patients and among the subset located in the high-acuity pod at time of disposition (either through initial assignment or subsequent up-triage). Analysis was performed for common chief complaints categorized as subjective (chest pain, dyspnea, any pain); observed (altered mental status); numeric (fever, hypotension); or protocolized (stroke, ST-elevation myocardial infarction). We constructed logistic regression models to control for age, race, gender, method of arrival, and final disposition.Results: We analyzed 297,355 adult ED visits. Black and Hispanic patients were less likely to be triaged to high-acuity beds (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.73-0.79 for Black, and aOR 0.87, 95% CI 0.84-0.90 for Hispanic patients). This effect was more pronounced for those with subjective chief complaints, including chest pain (aOR 0.76, 95% CI 0.73-0.79 for Black and 0.88, 95% CI 0.78-0.99 for Hispanic patients), dyspnea (aOR 0.79, 95% CI 0.68-0.92 and 0.8, 95% CI 0.72-0.99), and any pain (aOR 0.83, 95% CI 0.75-0.92 and 0.89, 95% CI 0.82-0.97, respectively). Among patients in the high-acuity pod at time of disposition, Black and Hispanic patients were disproportionately triaged to lower acuity pods on arrival (aOR 1.47, 95% CI 1.33-1.63 for Black and aOR 1.27, 95% CI 1.15-1.40 for Hispanic adults), with significant differences observed only for subjective chief complaints. No differences were observed for observed, objective, or protocolized complaints in either analysis.Conclusion: Black and Hispanic adults, including those who ultimately required high-acuity resources, were disproportionately triaged to lower acuity pods. This effect was more pronounced for patients with subjective chief complaints. Additional work is needed to identify and overcome potential bias in the assessment of patients with subjective chief complaints in ED triage

Applying crisis standards of care to critically ill patients during the COVID-19 pandemic: Does race/ethnicity affect triage scoring?

ObjectiveGiven the variability in crisis standards of care (CSC) guidelines during the COVID-19 pandemic, we investigated the racial and ethnic differences in prioritization between 3 different CSC triage policies (New York, Massachusetts, USA), as well as a first come, first served (FCFS) approach, using a single patient population.MethodsWe performed a retrospective cohort study of patients with intensive care unit (ICU) needs at a tertiary hospital on its peak COVID-19 ICU census day. We used medical record data to calculate a CSC score under 3 criteria: New York, Massachusetts with full comorbidity list (Massachusetts1), and MA with a modified comorbidity list (Massachusetts2). The CSC scores, as well as FCFS, determined which patients were eligible to receive critical care under 2 scarcity scenarios: 50 versus 100 ICU bed capacity. We assessed the association between race/ethnicity and eligibility for critical care with logistic regression.ResultsOf 211 patients, 139 (66%) were male, 95 (45%) were Hispanic, 23 (11%) were non-Hispanic Black, and 69 (33%) were non-Hispanic White. Hispanic patients had the fewest comorbidities. Assuming a 50 ICU bed capacity, Hispanic patients had significantly higher odds of receiving critical care services across all CSC guidelines, except FCFS. However, assuming a 100 ICU bed capacity, Hispanic patients had greater odds of receiving critical care services under only the Massachusetts2 guidelines (odds ratio, 2.05; 95% CI, 1.09 to 3.85).ConclusionVarying CSC guidelines differentially affect racial and ethnic minority groups with regard to risk stratification. The equity implications of CSC guidelines require thorough investigation before CSC guidelines are implemented