Normalization of a conversation tool to promote shared decision making about anticoagulation in patients with atrial fibrillation within a practical randomized trial of its effectiveness: a cross-sectional study.

BACKGROUND: Shared decision making (SDM) implementation remains challenging. The factors that promote or hinder implementation of SDM tools for use during the consultation, including contextual factors such as clinician burnout and organizational support, remain unclear. We explored these factors in the context of a practical multicenter randomized trial evaluating the effectiveness of an SDM conversation tool for patients with atrial fibrillation considering anticoagulation therapy. METHODS: In this cross-sectional study, we recruited clinicians who were regularly involved in conversations with patients regarding anticoagulation for atrial fibrillation. Clinicians reported their characteristics and burnout symptoms using the two-item Maslach Burnout Inventory. Clinicians were trained in using the SDM tool, and they recorded their perceptions of the tool's normalization potential using the Normalization MeAsure Development (NoMAD) survey instrument and verbally reflected on their answers to these survey questions. When possible, the training sessions and clinicians' verbal responses to the conversation tool were recorded. RESULTS: Our study comprised 183 clinicians recruited into the trial (168 with survey responses and 112 with recordings). Overall, clinicians gave high scores to the normalization potential of the intervention; they endorsed all domains of normalization to the same extent, regardless of site, clinician characteristics, or burnout ratings. In interviews, clinicians paid significant attention to making sense of the tool. Tool buy-in seemed to depend heavily on their ability to see the tool as accurate and "evidence-based" and their perceptions of having time in the consultation to use it. CONCLUSIONS: While time in the consultation remains a barrier, we did not find a significant association between burnout symptoms and normalization of an SDM conversation tool. Possible areas for improving the normalization of SDM conversation tools in clinical practice include enabling collaboration among clinicians to implement the tool and reporting how clinicians elsewhere use the tool. Direct measures of normalization (i.e., observing how often clinicians access the tool in practice outside of the clinical trial) may further elucidate the role that contextual factors, such as clinician burnout, play in the implementation of SDM. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02905032. Registered on 9 September 2016

Clinical and Molecular Heterogeneity of Moderate Aplastic Anemia

Abstract Based on clinical Camitta criteria, acquired aplastic anemia is categorized according to the degree of blood count depression as severe (sAA) or moderate (mAA). In some cases mAA is a precursor of sAA; in others it is a pathophysiologically distinct chronic non-progressive entity (chronic mAA (cmAA)). It is also possible that some seemingly mAA cases represent entities ranging from congenital bone marrow failure syndromes or hypocellular MDS to misdiagnosed systemic conditions with secondary aplasias. Discriminating true cmAA from these may be important for clinical management and requires prolonged observation. We have been able to accurately dx and treat patients (pts) with acute sAA. In contrast, pts with cmAA can have mildly depressed counts, which remain relatively stable for yrs without the need for treatment (tx).Tx delay, though, may lead to unopposed destruction of stem cells. At our institution we have evaluated and managed 308 AA pts from 1998-2018. Of these pts, we identified 88 who met the Camitta criteria for mAA and of these, 2 progressed to sAA within 3 mos, 1 had clinically significant PNH at dx, and 85 were truly cmAA. Focusing on this true cmAA cohort our goals were to identify its distinct clinical features and response to therapies. The median f/u for the cohort was 45 mos, with median Hgb 10.1 g/dl, ANC 1.36 k/uL, Plts 47 k/uL, and absolute retic count of 0.053 M/uL at dx. The median age for cmAA was 43 yrs (range 6-88), with 55% (47/85) females (vs 48% (108/223) for sAA p=.31). By ultra-sensitive flow cytometry, PNH clones were found in 26% (22/85) of pts at presentation of cmAA vs 22% (50/223) for sAA. From initial dx to last f/u 72% (61/85) remained mAA, of whom 57% (35/61) of pts did not require any tx. Those pts who required tx received at least one line of therapy, in most instances immunosuppression with cyclosporine (ORR~67%) and supportive care. Of those who required tx, 46% achieved a CR, 35% PR and 19% NR to 1st line tx. As no obvious distinction for cmAA was identified based on clinical presentation, we next classified pts based on the number of cell lineages involved, transfusion requirements, and severity of the counts (characterized into mild, moderate and severe based on severity of deviation from normal). At the time of dx 29 pts were transfusion dependent, of which one pt had a single cytopenia, 8 pts had bicytopenia, and 20 had pancytopenia. Based on our findings 34% (10/29) of pts who were transfusion dependent with borderline severe pancytopenia received ≥ 1 therapy and eventually progressed to sAA, in contrast to those mAA that were transfusion independent with similar counts. The overall median time to transformation was 14 yrs (CI=95%, 5.9-21.7). Average time to progression to sAA was 31 mos, with a progression rate of 21% (CI=95%; 10-30). Across the entire cohort, 16% (14/85) progressed to sAA, 11% (9/85) to full-blown PNH, and 1% (1/85) to AML. At progression 3 pts acquired -7 and another acquired additional chromosome six. One pt did receive allo-HSCT for mAA. In contrast, in sAA 8.5% (19/223) pts progressed to MDS/AML and 8.5% (19/223) to PNH, where the median time to transformation was 24 yrs. We also performed a sub-cohort analysis of somatic events present in these pts: at dx 79% (67/85) had normal karyotype. NGS for somatic mutations revealed the presence of at least 1 mutation in cmAA and sAA (p:0.47). Serial NGS was available for 11/85 for assessment of clonal dynamics. At the time of dx 8 out of 11 pts had no mutations at presentations and the three other pts had a single mutation in RUNX1, ASXL1, and PIGA, of which the RUNX1 was found to be a transient clone (VAF: 30%) at the time of last f/u. The pt with ASXL1 eventually progressed to MDS with -7 with expansion of the clone from 3 to 19% and the pt with a PIGA clone was never treated for mAA progressed to full-blown PNH requiring tx with eculizumab. NGS from the last follow up revealed 6/11 pts acquired single mutation ETV6 (VUS), ASXL1, and PIGA, of which 4 pts went on to receiving tx for PNH. In sum, our results suggest that cmAA does not have, unlike sAA, a relentless clinical course. The rate of evolution from mAA to sAA was 30% in 10 yrs with median time to progression 2.6 yrs, with a similar rate of evolution to PNH with median time to progression of 4yrs and only one pt progressed to AML. In relation to sAA, there was not a significant difference in progression to MDS or PNH and the survival and response to therapy of these pts was excellent as expected from Camitta's criteria. Disclosures Thota: Incyte: Speakers Bureau. Sekeres:Celgene: Membership on an entity's Board of Directors or advisory committees; Opsona: Membership on an entity's Board of Directors or advisory committees; Opsona: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees. Carraway:Balaxa: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; FibroGen: Consultancy; Jazz: Speakers Bureau; Amgen: Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Speakers Bureau; Novartis: Speakers Bureau. Maciejewski:Ra Pharmaceuticals, Inc: Consultancy; Ra Pharmaceuticals, Inc: Consultancy; Alexion Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Apellis Pharmaceuticals: Consultancy; Alexion Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Apellis Pharmaceuticals: Consultancy

Decisional Regret Surrounding Dialysis Initiation: A Comparative Analysis

Rationale & Objective: Dialysis comes with a substantial treatment burden, so patients must select care plans that align with their preferences. We aimed to deepen the understanding of decisional regret with dialysis choices. Study Design: This study had a mixed-methods explanatory sequential design. Setting & Participants: All patients from a single academic medical center prescribed maintenance in-center hemodialysis or presenting for home hemodialysis or peritoneal dialysis check-up during 3 weeks were approached for survey. A total of 78 patients agreed to participate. Patients with the highest (15 patients) and lowest decisional regret (20 patients) were invited to semistructured interviews. Predictors: Decisional regret scale and illness intrusiveness scale were used in this study. Analytical Approach: Quantitatively, we examined correlations between the decision regret scale and illness intrusiveness scale and sorted patients into the highest and lowest decision regret scale quartiles for further interviews; then, we compared patient characteristics between those that consented to interview in high and low decisional regret. Qualitatively, we used an adapted grounded theory approach to examine differences between interviewed patients with high and low decisional regret. Results: Of patients invited to participate in the interviews, 21 patients (8 high regret, 13 low regret) agreed. We observed that patients with high decisional regret displayed resignation toward dialysis, disruption of their sense of self and social roles, and self-blame, whereas patients with low decisional regret demonstrated positivity, integration of dialysis into their identity, and self-compassion. Limitations: Patients with the highest levels of decisional regret may have already withdrawn from dialysis. Patients could complete interviews in any location (eg, home, dialysis unit, and clinical office), which may have influenced patient disclosure. Conclusions: Although all patients experienced disruption after dialysis initiation, patients’ approach to adversity differs between patients experiencing high versus low regret. This study identifies emotional responses to dialysis that may be modifiable through patient-support interventions. Plain-Language Summary: As part of a quality improvement initiative in our dialysis practice, a patient stated, “I wish I never started dialysis.” This quote served as the catalyst for embarking on a research project with the aim to understand why patients living with end-stage kidney disease have regret about starting and continuing dialysis, a lifesaving but time-intensive measure. We surveyed and interviewed patients on the topic and learned that patients experiencing regret had a disrupted sense of self and blamed themselves for their need of dialysis. Patients with little to no regret demonstrated positivity and self-compassion. These findings will help health care professionals as they work with patients considering dialysis or having newly started dialysis

Distinctive and common features of moderate aplastic anaemia

The therapy algorithm for severe aplastic anaemia (sAA) is established but moderate AA (mAA), which likely reflects a more diverse pathogenic mechanism, often represents a treatment/management conundrum. A cohort of AA patients (n = 325) was queried for those with non-severe disease using stringent criteria including bone marrow hypocellularity and chronic persistence of moderately depressed blood counts. As a result, we have identified and analyzed pathological and clinical features in 85 mAA patients. Progression to sAA and direct clonal evolution (paroxysmal nocturnal haemoglobinuria/acute myeloid leukaemia; PNH/AML) occurred in 16%, 11% and 1% of mAA cases respectively. Of the mAA patients who received immunosuppressive therapy, 67% responded irrespective of time of initiation of therapy while conservatively managed patients showed no spontaneous remissions. Genomic analysis of mAA identified evidence of clonal haematopoiesis with both persisting and remitting patterns at low allelic frequencies; with more pronounced mutational burden in sAA. Most of the mAA patients have autoimmune pathogenesis similar to those with sAA, but mAA contains a mix of patients with diverse aetiologies. Although progression rates differed between mAA and sAA (P = 0·003), cumulative incidences of mortalities were only marginally different (P = 0·095). Our results provide guidance for diagnosis/management of mAA, a condition for which no current standard of care is established

Impact of Eltrombopag on Clonal Evolution in Refractory Aplastic Anemia

Abstract Despite documented success of IST in tx of aplastic anemia (AA), a significant minority of pts remain refractory to tx and most clinical responses are incomplete. Due to comorbidities, HSCT may not be available for all refractory pts and until recently anabolic steroids were the mainstay of salvage tx. With the approval of the novel cMpl agonist eltrombopag (E), first in refractory and now in the upfront setting for SAA, the tx paradigm has changed. Clonal evolution from AA to MDS remains a serious complication. With the advent of E, a valid question proposed is whether the growing use of E would improve recovery rates thereby decreasing the rate of clonal evolution or if stimulation of growth factor receptors by E would potentially increase progression to sMDS. At our institution, 308 AA pts were managed from 1998-2018. Of these, 35 (median age 67 yrs, f/u 42 mo, F: M 17:18) were tx with E for IST-refractory AA (50-150 mg PO QD), with median tx duration of 19 mos; in contrast 202 pts tx in the non-E era received ~2 tx lines (median age 40 yrs, f/u 60 mo, F: M 99:103). Response was evaluated by sustained improvement in blood counts and transfusion independence after 12 wks of tx. This was attained in 66% (23/35). 14% (5/35) had stable disease w/intermittent transfusions (1 underwent HSCT). Among non-responders 1 developed PNH prompting tx w/eculizumab, 1 received HSCT and 2 progressed to MDS/AML. In non-E SAA pts, ORR to 1st tx was 61%. 18 progressed to hemolytic PNH, 20 to MDS/AML and 49 to HSCT. The MDS/AML evolution rate from SAA in pre-E era has been~15% in 10yrs(Socié, G et al. 2000). Our analysis was confirmatory, with median time to progression of 4 yrs. This implies that no firm estimates can be made on the impact of E on MDS progression on clinical grounds alone. Somatic mutations (SM) typical of MDS have been detected in AA/PNH. Studies show that SM present at evolution to MDS can be detected at AA dx in 30% pts. Clearly, some of the SM seen in AA constitute a progression risk, while others likely reflect clonal hematopoiesis. We studied clonal kinetics using deep NGS to identify early signs of clonal evolution/eradication and subsequently predict MDS risk. Reported is our retrospective analysis using a case control approach. 35 E-tx pts were matched with 32 non-E tx pts using response rates and clinical parameters. Serial samples were obtained at start and end of tx for both groups. 4/35 E pts had a chromosomal abnormality at dx(t[10;18],+Y,+12 and del11q, i(7)(q10); latter 3 resolved on f/u). In non-E pts, 3 had cytogenetic abnormality at dx (del16q,+15,+Y; latter two acquired + 6 and -7). Due to close PNH association we evaluated E related size of PNH clone. PNH granulocyte expansion was seen in 11/35 after E and in 5/32 non-E pts. In the E group, 2/35 progressed to MDS/AML compared to 7/32 in the non-E group (p=.08). Similarly there was no difference in PNH progression (p=.36). Serial NGS analysis for both groups revealed a ≥1 SM per pt (BCOR, PIGA, ASXL1, DNMT3A, etc.) in 14 E- pts vs 4 in control group (U2AF1, NF1,PHF6,SAMD9L). Average VAF of BCOR was 19% and PIGA was 24% in E and it was 34% in non E. At the end of observation period, 22/35 (E) had ≥1 SM vs 12/32 in control. NGS post tx noted that 5/35 w/single SM (CEBPA, EZH2, SAMD9L, U2AF1, TP53) had minimal expansion of their clone. Only the pt w/EZH2 acquired 2 additional clones of RUNX1 and U2AF1. The pt w/TP53 developed MDS. 6 pts expanded their original clone (BCOR, ASXL1/U2AF2, PIGA, VHL, NRAS, PIGA) of which the latter 4 acquired 1 additional SM (ZRSR2, PIGA, ASXL1, BCORL1). 1 pt had regression of the RIT1 clone, but acquired a BCOR. 2 others had transient clones of BCOR and DNMT3A at dx w/acquisition of ASXL1. Of those w/baseline SM, 8/21 acquired new SM, of which 1 developed AML w/ gain of DNMT3A, ASXL1 and U2AF1. In the controls, 2 pts w/NF1 and SAMD9L expanded their original clone and acquired ASXL1/SETBP1 and TP53 respectively, w/both having MDS/AML progression. 1 pt had a decrease in U2AF1 and another had a transient PHF6 clone. Pts without baseline SM acquired ~2 SM during the disease course. Many of these are the same SM classically found in MDS/AML. To date, there are no data to support an increased clonal evolution risk with use of E in AA pts either on clinical grounds or by molecular testing. However, presence of certain somatic mutations (CBL, SETBP1, DTA andRUNX1) strongly associated w/MDS/AML progression may warrant caution in the application of E or at least close molecular monitoring. Disclosures Thota: Incyte: Speakers Bureau. Nazha:MEI: Consultancy. Carraway:Balaxa: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; FibroGen: Consultancy; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Jazz: Speakers Bureau; Amgen: Membership on an entity's Board of Directors or advisory committees; Novartis: Speakers Bureau; Agios: Consultancy, Speakers Bureau. Sekeres:Opsona: Membership on an entity's Board of Directors or advisory committees; Opsona: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees. Maciejewski:Apellis Pharmaceuticals: Consultancy; Ra Pharmaceuticals, Inc: Consultancy; Ra Pharmaceuticals, Inc: Consultancy; Apellis Pharmaceuticals: Consultancy; Alexion Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Alexion Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau