Context Immune checkpoint inhibitors (ICIs) have gained a revolutionary role in management of many advanced malignancies. However, immune-related endocrine events (irEEs), have been associated with their use. irEEs have non-specific clinical presentations and variable timelines, making their early diagnosis challenging. Objective To identify risk factors, timelines, and prognosis associated with irEEs development. Design and setting Retrospective observational study within the Cleveland Clinic center. Patients Metastatic cancer adult patients who received ICIs were included. Methods 570 charts were reviewed to obtain information on demographics, ICIs used, endocrine toxicities, cancer response to treatment with ICI, and overall survival. Main Outcome Measures Incidence of irEEs, time to irEEs development, and overall survival of patients who develop irEEs. Results The final cohort included 551 patients. The median time for the diagnosis of irEEs was 11 weeks. Melanoma was associated with the highest risk for irEEs (31.3%). Ipilimumab appeared to have the highest percentage of irEEs (29.4%), including the highest risk of pituitary insufficiency (11.7%), the most severe (Grade 4 in 60%) and irreversible (100%) forms of irEEs. 45 % of patients with irEEs had adequate cancer response to ICI compared to 28.3 % of patients without irEEs (p= 0.002). Patients with irEEs had significantly better survival compared to patients without irEEs (P <0.001). Conclusions In the adult population with metastatic cancer receiving treatment with ICI, irEEs development may predict tumor response to immunotherapy and a favorable prognosis. Ipilimumab use, combination ICI therapy, and melanoma are associated with a higher incidence of irEEs.

Background Cardiac monitoring (telemetry) is a common over-utilized hospital resource in the United States. Previous studies have shown that telemetry does not improve outcomes for low-risk patients. Inappropriate utilization occurs because of lack of awareness of guideline-based indications or non-adherence to known indications. Objective A quality improvement study was conducted to reduce telemetry overutilization during the transition of care from the intensive care unit (ICU) by 15% through increasing awareness of indications for telemetry. Methods The study cohort included patients originally admitted to the ICU for sepsis who had improved and were stable for transfer to a non-ICU setting. Subjects were identified and included during pre-intervention (six weeks) and intervention (six weeks) periods. Resident physicians and nurse practitioners were targeted using multiple modalities of education: didactic lectures during week one, poster demonstrations during week three, and video presentations during week five. Results A total of 246 study subjects during the pre-intervention and 94 study subjects in the intervention period were studied; 187 of the 246 subjects in the pre-intervention arm (76%) and 58 of the 94 subjects in the intervention arm (61.7%) were transferred with telemetry. Telemetry utilization dropped by 23.1% at the end of the intervention period. Conclusion Educating the caregivers about the indications for telemetry led to a decrease in over-utilization of telemetry on the transition of care from the ICU to the regular nursing floor. Repetitive and multi-modality educational interventions were effective tools and associated with increased adherence to established guidelines for telemetry usage.