The retrospective chart review: important methodological considerations

OPTIMAL PAO 2 IS 130-160 MMHG IN THE FIRST WEEK FOR SEPSIS PATIENTS IN ICU: A RETROSPECTIVE COHORT STUDY BASED ON MIMIC-IV DATABASE

ABSTRACT

Background: The relationship between the partial pressure of oxygen in arterial blood (PaO 2 ) and the prognosis of sepsis patients, and its potential variation over time, remains unclear. The optimal PaO 2 range for sepsis patients has always been a contentious issue, with no consensus. We aimed to explore the association between different levels of PaO 2 exposure over time and the 28-day mortality of sepsis patients, and to identify the optimal PaO 2 range for sepsis patients within a specific time frame. Methods: We retrieved data on adult patients diagnosed with sepsis within 24 h before or after intensive care unit (ICU) admission from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 2.2) database. We excluded patients who were not admitted to the ICU for the first time, those with ICU stay <24 h, and those without PaO 2 results during their ICU stay. We calculated the time-weighted average (TWA) of PaO 2 and used piece-wise exponential additive mixed models (PAMMs) to estimate the time-dependent changes in the association between TWA-PaO 2 and patient prognosis. Results: A total of 16,880 sepsis patients were included in the MIMIC cohort. Results indicated that patients' TWA-PaO 2 correlates with increased 28-day mortality after ICU admission in sepsis patients, and this association was mainly manifested in the early course of the disease. With a time window of the first 1-7 days after ICU admission, the optimal TWA-PaO 2 range for sepsis patients was ≥130 mmHg and ≤160 mmHg. Increased exposure time, proportion of exposure time, and exposure dose of high-risk PaO 2 outside the range were all associated with an increased risk of 28-day mortality. Conclusion: PaO 2 in sepsis patients should be closely monitored. During the first 1-7 days of ICU admission, PaO 2 should be maintained within the range of ≥130 mmHg and ≤160 mmHg. A dose-dependent relationship exists between high-risk PaO 2 outside the range and patient outcome.

Complications and Burden of 2-Stage Tissue Expander to Implant-Based Reconstructive Surgery: A Single-Center Retrospective Study

Introduction: Two-stage reconstruction with a tissue expander/implant (TE/I) technique remains the most common breast reconstructive approach following mastectomy. This study analyzes the post-operative complications and burden associated with 2-stage TE/I reconstruction independent of acellular dermal matrix (ADM). Methods: A retrospective chart review identified patients that underwent 2-stage, reconstruction with TE/I without ADM. Demographics, implant characteristics, tissue expansion information, and complications were recorded. Patients were followed for 3 months post-implant exchange. Logistic regression analysis was used to determine which variables were predictors for complications. Results: Ninety-one TE/I reconstructions without ADM were performed in 55 patients. The incidence of complications was 45% (n = 25). Mean complications per patient was 0.84 ± 1.2, with the most common being infection with the TE (n = 15, 24.2%). Mean number of fill appointments was 3.6 ± 1.7 (range: 1-8). Univariate linear regression showed for every increase in BMI, there was a 14.8 cc increase in implant volume, on average (P < .001). Multivariable logistic regression model identified radiation history (P = .036) and increasing BMI (P = .049) as significant predictors for complications. Conclusion: Infection remains to be the leading cause of short-term complications in TE/I breast reconstruction patients. BMI and radiation are significant predictors. Larger, multicenter observational study data may elicit nuanced variation among different population demographics.

The Complex Journey of Women in Perinatal Psychiatric Care: Susceptibility to Illness Onset, Comorbidity and Clinical Trajectories: Le parcours complexe des femmes en psychiatrie périnatale : vulnérabilité, comorbidités et trajectoires cliniques

BackgroundMore than one in five women deal with a psychiatric disorder during the perinatal period. Whereas perinatal depression is well documented, there is still little research on the full range of perinatal psychiatric disorders and their clinical evolution across this whole period. The present study investigated the susceptibility to psychiatric illness during pregnancy and up to one year postpartum. We aimed to identify the most frequent disorders and comorbidities arising in each perinatal period. We outlined the clinical trajectories of these disorders in terms of evolution across past history, pregnancy and postpartum.MethodThrough a retrospective longitudinal design, data were collected in 2019-2020 from the medical records of the cohort of 964 women who required care in a tertiary perinatal psychiatry clinic located in Quebec City (Canada) between 2004 and 2020. Incidence rates of the full range of psychiatric disorders were estimated per period and their evolution across time identified clinical trajectories.ResultsDuring pregnancy, 34 different disorders were newly diagnosed with incidence rates ranging from 0.1% to 15.5% (45.6% of women having had at least one disorder diagnosed during pregnancy) whereas, during postpartum, 36 disorders were newly diagnosed with incidence rates ranging from 0.1% to 31.0% (67.5% of women having had at least one disorder diagnosed during postpartum). For most disorders, rates were significantly higher in postpartum than in pregnancy. A woman could develop multiple disorders during a given perinatal period: this comorbidity involved various combinations of diagnoses in 28% of women during pregnancy and 38% during postpartum. We outlined 52 different clinical trajectories from past history to postpartum, underlining the heterogeneity of the perinatal course.ConclusionsPregnancy is a susceptible period for women with past psychiatric histories whereas postpartum could trigger a new illness in women without a past history or pregnancy-onset psychiatric disorder.

Referral Patterns, Pathways to Care, Symptom Profile, and Diagnoses of Children Attending a Child Psychiatry Unit in South India: A Retrospective Chart Review

Background

Childhood mental disorders are a major global concern, particularly in India. Despite efforts to establish child psychiatry services, the treatment gap persists. This study investigates referral patterns, pathways to care, and diagnostic trends among children attending a child psychiatry unit (CPU).

Methods

A retrospective chart review (2017-2022) was conducted at the CPU of Kasturba Medical College, Manipal. Two investigators analyzed 1,046 files, extracting data on demographics, pathways to care, reasons for referral, and diagnoses. Inter-rater reliability was confirmed, and associations between pathways to care, diagnosis, and demographics were examined.

Results

This study included children with a mean age of 11.2 years, predominantly male (63.2%). Most children (97.5%) first sought care from a healthcare provider, with 29.3% consulting mental health professionals (MHPs) and 59.6% visiting medical specialists. Primary reasons for referral included behavioral disturbances, emotional disturbances, and academic decline. Common primary diagnoses were attention deficit hyperactivity disorder (16.5%), mental retardation (14.7%), and pervasive developmental disorder (12.6%). Significant associations were found between pathways to care and diagnosis (P = .001), as well as between gender and both referral reasons (P < .001) and diagnoses (P < .001).

Conclusions

The study provides insights into the demographic and clinical characteristics of children with mental health problems in India. The medical model of care pathways is a positive shift, and these findings can guide gender- and culture-sensitive service planning, optimize resource allocation, and inform future research in child psychiatry.

Identifying Patient-Reported Outcome Measure Documentation in Veterans Health Administration Chiropractic Clinic Notes: Natural Language Processing Analysis

Background

The use of patient-reported outcome measures (PROMs) is an expected component of high-quality, measurement-based chiropractic care. The largest health care system offering integrated chiropractic care is the Veterans Health Administration (VHA). Challenges limit monitoring PROM use as a care quality metric at a national scale in the VHA. Structured data are unavailable, with PROMs often embedded within clinic text notes as unstructured data requiring time-intensive, peer-conducted chart review for evaluation. Natural language processing (NLP) of clinic text notes is one promising solution to extracting care quality data from unstructured text.

Objective

This study aims to test NLP approaches to identify PROMs documented in VHA chiropractic text notes.

Methods

VHA chiropractic notes from October 1, 2017, to September 30, 2020, were obtained from the VHA Musculoskeletal Diagnosis/Complementary and Integrative Health Cohort. A rule-based NLP model built using medspaCy and spaCy was evaluated on text matching and note categorization tasks. SpaCy was used to build bag-of-words, convoluted neural networks, and ensemble models for note categorization. Performance metrics for each model and task included precision, recall, and F-measure. Cross-validation was used to validate performance metric estimates for the statistical and machine-learning models.

Results

Our sample included 377,213 visit notes from 56,628 patients. The rule-based model performance was good for soft-boundary text-matching (precision=81.1%, recall=96.7%, and F-measure=88.2%) and excellent for note categorization (precision=90.3%, recall=99.5%, and F-measure=94.7%). Cross-validation performance of the statistical and machine learning models for the note categorization task was very good overall, but lower than rule-based model performance. The overall prevalence of PROM documentation was low (17.0%).

Conclusions

We evaluated multiple NLP methods across a series of tasks, with optimal performance achieved using a rule-based method. By leveraging NLP approaches, we can overcome the challenges posed by unstructured clinical text notes to track documented PROM use. Overall documented use of PROMs in chiropractic notes was low and highlights a potential for quality improvement. This work represents a methodological advancement in the identification and monitoring of documented use of PROMs to ensure consistent, high-quality chiropractic care for veterans.

Long-term retention rate, adverse event temporal patterns and rescue treatment strategies of mycophenolate mofetil in systemic sclerosis: insights from real-life

OBJECTIVES

MMF is a mainstay for the treatment of SSc. The occurrence and implications of MMF-related adverse events (AEs) on drug retention rates in real life remain poorly defined. We aimed to determine the MMF retention rate and to investigate the causes and patterns of discontinuation, AEs and treatment options used after discontinuation.

METHODS

SSc patients who started MMF treatment underwent a retrospective longitudinal assessment for up to 5 years. We documented the incidence, predictors and impacts of MMF treatment on gastrointestinal intolerance, infections, laboratory abnormalities and cancer. Rescue strategies implemented after MMF discontinuation were recorded.

RESULTS

The 5-year MMF retention rate of 554 patients stood at 70.7%, and 19.6% of them stopped MMF due to AEs. One out of every four patients experienced a dose reduction or discontinuation of MMF due to AEs, with gastrointestinal intolerance being the predominant cause. The 5-year cumulative incidence rates for gastrointestinal intolerance, cancer, severe infections and laboratory toxicity leading to MMF discontinuation were 6.4%, 4.1%, 3.1% and 2.1%, respectively. Lower respiratory tract was the most affected, with bacteria being the predominant causative agent. Intestinal and pulmonary circulation involvement were tied to elevated AE rates and MMF discontinuation. The most common approaches post-MMF cessation were 'watch and wait' and switch to rituximab.

CONCLUSIONS

: MMF use in SSc appears to be limited by the occurrence of AEs, both in terms of persistence and dosing of the drug. Rescue options after MMF discontinuation are limited and many patients remain without immunosuppressant.

Trends in adverse pregnancy outcomes in Louisiana, 2017 to 2022

Natural disasters can lead to more adverse pregnancy outcomes (APO). It is unclear if the extended COVID-19 pandemic has impacted APOs and pre-existing conditions among perinatal populations with increased risk of severe maternal morbidity and mortality.A retrospective chart review was conducted of hospital records and birth certificates in the largest birth hospital in Louisiana from 2017 to 2022. Amongst 27,877 births (50.9% White, 38.3% Black, 28.9 ± 5.6 years), gestational diabetes (GDM) was lowest in pre-pandemic conceptions (11.0%, June 2017-May 2019) and rose to 16.4% early pandemic (October 2019-February 2020) but leveled off at 12.2% in peak (March 2020-February 2021) and late pandemic (March 2021-September 2021). Individuals who conceived in early and peak pandemic were 47% (95% CI 33, 63) and 11% (95% CI 2, 20) more likely to develop GDM respectively, compared to pre-pandemic conceptions. Individuals who delivered during early (aRR: 1.54, 95% CI 1.33-1.78), peak (aRR: 1.48, 95% CI 1.32-1.65), and late (aRR: 1.62, 95% CI 1.41, 1.85) pandemic were more likely to develop preeclampsia and HELLP syndrome compared to pre-pandemic conceptions. Individuals were also 17% (95% CI 5, 32) more likely to enter pregnancy with chronic hypertension in peak pandemic compared to pre-pandemic. In paired analysis (n = 3390), individuals with a pandemic conception that occurred early pandemic had a higher risk of developing GDM compared to their pre-pandemic pregnancy (aOR 3.26, 95% CI 1.52, 6.97). Supporting birthing individuals amongst significant stressful events, especially in early gestation, is critical for preventing APOs and severe maternal morbidity and mortality.

Association of inflammatory biomarkers with new functional morbidity at hospital discharge in children who survive severe sepsis

Objective

New functional morbidity is common in critically ill children who survive sepsis; yet, the underlying biological mechanisms, particularly the impact of inflammation, remain unknown. We sought to test the hypothesis that increased levels of inflammatory biomarkers during the acute phase of pediatric sepsis are associated with new functional morbidity at hospital discharge.

Methods

We conducted a post hoc secondary analysis of the MitoPSe clinical study, including N = 119 critically ill children who survived sepsis. Data collected included demographic and clinical variables and 31 inflammatory biomarkers collected at three distinct timepoints (within days 1-2 of PICU admission, days 3-5, and days 8-14). The primary outcome was new functional morbidity, defined as at least a one-point increase in the pediatric overall performance category from baseline to hospital discharge.

Results

New functional morbidity occurred in 38 children (32%) and was associated with increased plasma levels of interleukin (IL)-6, IL-18, sIL-2Ra, MCP1, IL-8 (CXCL8), sIL-1RII, IL-10, MIP1a, and IL-2r and decreased RANTES (CCL5) (p < .001) at all three timepoints. However, after adjusting for differences in chronic comorbid conditions, hospital length of stay, number of organ dysfunctions, and severity of illness, absolute biomarker levels, and trajectories were not significantly different between patients with or without new functional morbidity at hospital discharge.

Conclusions

In this sample of critically ill children treated for sepsis, increased inflammatory biomarker levels and the trajectory of change during the acute phase of pediatric sepsis were not independently associated with new functional morbidity at hospital discharge. Inflammatory biomarker levels likely reflect illness severity and other clinical variables associated with illness. However, these biomarkers may still be useful in identifying patients at risk of developing functional morbidity, despite the lack of causation within this study.

Dementia prevalence and risk factors in people with and without HIV in Malawi: A medical record review

BACKGROUND

Sub-Saharan Africa (SSA) is experiencing a rapid increase in its aging population, including people living with human immunodeficiency virus (HIV) (PLHIV). The purpose of this study was to determine the prevalence of dementia among PLHIV and people without HIV (POHIV) in Malawi.

METHODS

We conducted a retrospective medical record review of 400 consecutive patients from a single tertiary health center (200 PLHIV from an HIV clinic and 200 POHIV from an outpatient clinic) in Lilongwe, Malawi.

RESULTS

The overall rate of dementia was higher in PLHIV than that in POHIV (22% vs 10%; p = 1.4e). Older age, unknown employment or unemployed, and depression were significant risk factors for dementia for PLHIV, while older age and depression were significant among POHIV.

DISCUSSION

Our study confirmed the increased risk of dementia in PLHIV and provides valuable groundwork for future dementia studies to accurately examine the prevalence and risk factors of dementia in SSA, including Malawi.

HIGHLIGHTS

Malawians, in SSA, face the double burden of HIV AD and related dementias. We conducted a retrospective medical record review to assess dementia prevalence and risk factors. Dementia prevalence was higher in PLHIV than in POHIV. Older age, unknown employment or unemployed, and depression were risk factors for dementia in PLHIV. Our findings, reflecting the current diagnosing and medical documenting practice in Malawi, provide valuable groundwork for future dementia research in Malawi.

Real-World Treatment of Schizophrenia in Adults With a 22q11.2 Microdeletion: Traitement dans le monde réel de la schizophrénie chez des adultes atteints du syndrome de microdélétion 22q11.2

OBJECTIVE

One in every 4 individuals born with a 22q11.2 microdeletion will develop schizophrenia. Thirty years of clinical genetic testing capability have enabled detection of this major molecular susceptibility for psychotic illness. However, there is limited literature on the treatment of schizophrenia in individuals with a 22q11.2 microdeletion, particularly regarding the issue of treatment resistance.

METHODS

From a large, well-characterized adult cohort with a typical 22q11.2 microdeletion followed for up to 25 years at a specialty clinic, we studied all 107 adults (49 females, 45.8%) meeting the criteria for schizophrenia or schizoaffective disorder. We performed a comprehensive review of lifetime (1,801 patient-years) psychiatric records to determine treatments used and the prevalence of treatment-resistant schizophrenia (TRS). We used Clinical Global Impression-Improvement (CGI-I) scores to compare within-individual responses to clozapine and nonclozapine antipsychotics. For a subgroup with contemporary data (n = 88, 82.2%), we examined antipsychotics and dosage at the last follow-up.

RESULTS

Lifetime treatments involved on average 4 different antipsychotic medications per individual. Sixty-three (58.9%) individuals met the study criteria for TRS, a significantly greater proportion than for a community-based comparison (42.9%; χ2 = 10.38, df = 1, p < 0.01). The non-TRS group was enriched for individuals with genetic diagnosis before schizophrenia diagnosis. Within-person treatment response in TRS was significantly better for clozapine than for nonclozapine antipsychotics (p < 0.0001). At the last follow-up, clozapine was the most common antipsychotic prescribed, followed by olanzapine, risperidone, and paliperidone. Total antipsychotic chlorpromazine equivalent dosages were in typical clinical ranges (median: 450 mg; interquartile range: 300, 750 mg).

CONCLUSION

The results for this large sample indicate that patients with 22q11.2 microdeletion have an increased propensity to treatment resistance. The findings provide evidence about how genetic diagnosis can inform clinical psychiatric management and could help reduce treatment delays. Further research is needed to shed light on the pathophysiology of antipsychotic response and on strategies to optimize outcomes.

PLAIN LANGUAGE SUMMARY TITLE

Real-world treatment of schizophrenia in adults with a 22q11.2 microdeletion.

Charting Diagnostic Safety: Exploring Patient-Provider Discordance in Medical Record Documentation

BACKGROUND

The 21st Century Cures Act enables patients to access their medical records, thus providing a unique opportunity to engage patients in their diagnostic journey.

OBJECTIVE

To explore the concordance between patients' self-reported diagnostic concerns and clinician-interpreted information in their electronic health records.

DESIGN

We conducted a mixed-methods analysis of a cohort of 467 patients who completed a structured data collection instrument (the Safer Dx Patient) to identify diagnostic concerns while reviewing their clinician's notes. We conducted a qualitative content analysis of open-ended responses on both the tools and the case summaries. Two clinical chart reviewers, blinded to patient-reported diagnostic concerns, independently conducted chart reviews using a different structured instrument (the Revised Safer Dx Instrument) to identify diagnostic concerns and generate case summaries. The primary outcome variable was chart review-identified diagnostic concerns. Multivariate logistic regression tested whether the primary outcome was concordant with patient-reported diagnostic concerns.

SETTING

Geisinger, a large integrated healthcare organization in rural and semi-urban Pennsylvania.

PARTICIPANTS

Cohort of adult patients actively using patient portals and identified as "at-risk" for diagnostic concerns using an electronic trigger algorithm based on unexpected visit patterns in a primary care setting.

RESULTS

In 467 cohort patients, chart review identified 31 (6.4%) diagnostic concerns, of which only 11 (21.5%) overlapped with 51 patient-reported diagnostic concerns. Content analysis revealed several areas of discordant understanding of the diagnostic process between clinicians and patients. Multivariate logistic regression analysis showed that clinician-identified diagnostic concerns were associated with patients who self-reported "I feel I was incorrectly diagnosed during my visit" (odds ratio 1.65, 95% CI 1.17-2.3, p < 0.05).

CONCLUSION

Patients and clinicians appear to have certain differences in their mental models of what is considered a diagnostic concern. Efforts to integrate patient perspectives and experiences with the diagnostic process can lead to better measurement of diagnostic safety.

Patient Safety Events Among People from Ethnic Minority Backgrounds: A Retrospective Medical Record Review of Australian Cancer Services

OBJECTIVES

People from ethnic minority backgrounds are exposed to greater risk of patient safety events (such as healthcare-acquired infections and medication errors) occurring in their healthcare. However, evidence of the type and frequency of patient safety events occurring in cancer care among patients from ethnic minority background is lacking. This study sought to address this evidence gap.

DESIGN

A two-stage retrospective medical record review was conducted at four cancer services in two Australian states. Eligible medical records at each service that were identified as belonging to ethnic minority patients were reviewed by two clinician researchers in stage one, followed by authentication of extracted data by a site-specific cancer clinician in stage two. Descriptive statistics were used to report the frequency and type of safety events. Chi-square and independent sample T-tests were used to examine the association between safety events and patient socio-cultural indicators.

RESULTS

A total of 628 patient records were included. Of the 628 patient records, 212 (33.75%) documented at least one safety event. A total of 410 safety events were documented in the 212 patient records. Medication-related safety events were most commonly documented (121/410, 29.5%), followed by clinical process/procedure-related safety events (76/410, 18.5%) and patient accidents (60/410, 14.6%). The occurrence of a safety event was associated with patient records that documented 'no interpreter was required'.

CONCLUSION

Patient safety events in cancer care occur frequently among patients from ethnic minority backgrounds. Unsafe cancer care for this population is associated with inadequate use of interpreters, lack of shared understanding and expectations of care processes linked to cultural and linguistic barriers. Approaches to enhance engagement are required.

An Observational Review of Tonsillectomy and Appendectomy Procedures Conducted at a Tertiary Care Hospital

BACKGROUND

Tonsillectomy and appendectomy are the most frequently performed surgical procedures in pediatric and adult populations. However, comprehensive data examining their occurrence within the same hospital setting remain sparse. This study aimed to characterize the demographic and clinical profiles of patients undergoing tonsillectomy and assess the frequency and outcomes of those who additionally underwent appendectomy.

METHODS

A retrospective review was performed on 337 patients who underwent tonsillectomy at a tertiary care hospital from 2015 to 2017. Data collected included age, nationality, sex, year of tonsillectomy, and details of any concurrent or subsequent appendectomy, such as complicating factors (e.g., perforation and abscess), imaging findings (appendicolith), and pathology results. Statistical analyses were performed using Minitab 18 (Minitab, Inc., State College, PA).

RESULTS

Among 337 patients, five (1.5%) underwent appendectomy in addition to tonsillectomy. Overall, 78.3% (264/337) of the tonsillectomy group were pediatric vs. 21.7% (73/337) adult, while 60% (3/5) of the appendectomy group were pediatric and 40% (2/5) adult (p = 0.33). The mean (standard deviation) age across the entire cohort was 16.17 (10.48) years, and 55.2% (186/337) were men. No cases of complicated appendicitis were identified among the appendectomy patients, although three (representing 0.9% of the total cohort and 60% of the appendectomy subgroup) exhibited an appendicolith on imaging. Pathology findings confirmed acute appendicitis in four (1.2%) of these cases and a normal appendix in one (0.3%). Statistical comparisons revealed no significant difference in median age between patients undergoing tonsillectomy alone and those who also had an appendectomy (p = 0.86), nor in distribution by gender across procedures (p = 0.78).

CONCLUSION

This review highlights the young demographic profile of patients undergoing tonsillectomy in a tertiary care hospital and underscores the relatively low incidence of appendectomy in this cohort. Despite the small subset of appendectomy cases, timely intervention may have contributed to the absence of complicated appendicitis. Notably, institutionwide data suggest that negative appendectomies remain rare overall, indicating a need for further research into this phenomenon. These findings underscore the need for continued surveillance and future multicenter studies to better elucidate potential shared risk factors and outcomes associated with these commonly performed surgical procedures.

Role of neck dissections in the management of carotid body tumors

Objective

Carotid body tumors (CBTs) are rare neoplasms of the paraganglia at the carotid bifurcation. While typically benign, CBTs occasionally exhibit malignancy, metastasizing to nearby lymph nodes. Histopathologic analysis alone is insufficient to confirm malignancy, requiring metastases to non-neuroendocrine tissue for a definitive diagnosis. The role of selective neck dissections (SNDs) in detecting malignancy and guiding subsequent management remains uncertain.

Method

A retrospective case series through electronic chart review was performed on 21 patients undergoing CBT surgeries between 2002 and 2022 at a Canadian institution. SNDs were performed on all 21 patients. Data collection included patient demographics, genetic and laboratory testing results, preoperative imaging, intraoperative and postoperative complications, histologic analysis of neck SND and tumor specimen, and follow-up results.

Results

Of the 21 surgical resections, there were three cases (14.3%) of carotid artery injuries and six cases (28.6%) of nerve injuries. One patient (4.8%) experienced three intraoperative strokes. Three patients (14.3%) were found to have lymph node involvement, confirming malignancy, and underwent further treatment with radiotherapy. Interestingly, two patients with carotid injuries had malignant tumors, demonstrating a statistical significance between carotid injury and malignancy (OR 34.00, 95% CI: 1.48, 781.83, p = .041).

Conclusion

SNDs are a useful adjunct in detecting malignancy during CBT surgeries. The incidence of malignancy in CBT is low but not negligible, and SND should be considered in patients to prevent inadvertent underdetection of metastatic disease. This study's 14.3% incidence of malignancy suggests that there may be a rationale for considering the universal implementation of SND during CBT resections.

Level of Evidence

4.

Frontotemporal Dementia Differential Diagnosis in Clinical Practice: A Single-Center Retrospective Review of Frontal Behavioral Referrals

Background and Objectives

Many neurodegenerative syndromes present with impairment of frontal networks, especially frontoinsular networks affecting social and emotional cognition. People presenting with frontal network impairments may be considered for a frontotemporal dementia (FTD) diagnosis. We sought to examine the diagnostic mix of patients referred with frontal network impairments to a single cognitive neurology service.

Methods

A retrospective review was conducted of all patients seen between January 2010 and December 2019 at the Eastern Cognitive Disorders Clinic, a quaternary cognitive neurology clinic in Melbourne, Australia. Patients were included if they met the following criteria: (1) were referred for suspected FTD or with a preexisting diagnosis of a FTD syndrome, (2) were referred for 'frontal behaviors' (i.e., disinhibition, disorganization, poor judgment, loss of empathy, apathy) and/or had an informant report of behavior change, and (3) had available referral documents and clinical consensus diagnosis. Referral diagnosis was compared against final diagnosis adjudicated by a consensus multidisciplinary team. Case details including age of symptom onset, Cambridge Behavioural Inventory-Revised scores, psychiatric history, and Charlson Comorbidity Index were compared against the final diagnosis.

Results

In total, 161 patients aged 42-82 years (mean = 64.5, SD = 9.0; 74.5% men) met inclusion criteria. The commonest final diagnosis was a FTD syndrome (44.6%: 26.7% behavioral variant FTD (bvFTD), 9.3% progressive supranuclear palsy, 6.2% semantic dementia, 1.2% corticobasal syndrome, and 1.2% FTD/motor neuron disease). A primary psychiatric disorder (PPD) was the next commonest diagnosis (15.5%), followed by vascular cognitive impairment (VCI, 10.6%), Alzheimer disease (AD, 9.9%), and other neurologic diagnoses (6.2%). A final diagnosis of bvFTD was associated with higher rates of medical comorbidities and more eating behavior abnormalities compared with a diagnosis of PPD. Screening cognitive tests and preexisting psychiatric history did not distinguish these 2 groups.

Discussion

A broad spectrum of neurologic and psychiatric disorders may present with impairments to frontal networks. Almost half of patients referred had a final FTD syndrome diagnosis, with bvFTD the commonest final diagnosis. People with PPD, VCI, and AD present with similar clinical profiles but are distinguishable using MRI and FDG-PET imaging. Medical and psychiatric comorbidities are common in people with bvFTD.

Opportunistic genomic screening has clinical utility: An interventional cohort study

PURPOSE

Practice is shifting toward genome-first approaches, such as opportunistic screening for secondary findings (SFs). Analysis of SFs could be extended beyond medically actionable results to include non-medically actionable monogenic disease risks, carrier status, pharmacogenomic variants, and risk variants for common complex disease. However, evidence on the clinical utility of returning these results is lacking. We assessed the outcomes of opportunistic screening for a broad spectrum of SFs by evaluating the yield, impact on clinical management, and consistency between SFs and participants' clinical features and family history.

METHODS

Adult cancer patients had exome sequencing with the option to learn multiple categories of SFs. Outcomes data were collected through chart review and participant-reported measures up to one year after return of results.

RESULTS

All participants (n = 139, 85.6% female, average 54.6 years old) who elected to learn SFs had ≥1 variant reported (100% [139/139]). The yield of reportable findings was highest for pharmacogenomic variants (97.8% [135/138] of participants), followed by common disease risk variants (89.4% [118/132]), carrier status (89.3% [117/131]), and variants related to Mendelian (27.2% [34/125]), medically actionable (15.2% [21/138]), and early-onset neurodegenerative (2.6% [3/117]) disease risks. SFs from the American College of Medical Genetics and Genomics list (v3.2, noncancer genes) were reported in 1.4% (2/138) of participants. SFs across all categories demonstrated clinical utility by prompting management changes in 28.1% (39/139) of participants. Moreover, a considerable proportion of participants had suggestive clinical features (49.0% (24/49)]) or family history (21.8% (27/124)) potentially related to their SFs.

CONCLUSION

Our findings indicate there are potential benefits from opportunistic screening for a broad range of SFs.

Racial disparities in gestational weight gain and adverse pregnancy outcomes among Black and White pregnant people with obesity

OBJECTIVE

This study of pregnant people with obesity examined two aims in testing the hypothesis that the COVID-19 pandemic widened racial disparity in maternal health in high-risk pregnancies; it compared by race both (1) gestational weight gain (GWG) patterns and (2) patterns of preexisting conditions and adverse pregnancy outcomes.

METHODS

This retrospective chart review included birth certificate and delivery records from a large women's specialty hospital in Louisiana between 2018 and 2022. Differences in preexisting conditions, GWG, and adverse pregnancy outcomes were explored across early-, peak-, and late-pandemic periods using log-linear regression and robust Poisson models.

RESULTS

Among 7431 deliveries (54% Black), Black pregnant people had higher rates of preexisting type 2 diabetes and chronic hypertension but lower rates of gestational diabetes and preeclampsia compared to White pregnant people across all periods. Black individuals had higher prepregnancy weight and lower GWG compared to White individuals across all periods. GWG differences were not significant in peak- and late-pandemic periods.

CONCLUSIONS

Black individuals with obesity started pregnancy with higher weight and more preexisting conditions but had lower GWG compared to White individuals. Exacerbated disparities in preexisting conditions demonstrate higher health risks for Black individuals during pregnancy.

Post-Acute Care Interventions in Patients Hospitalized Due to COPD Exacerbation Before and After Implementation of an Integrated Care Program

Purpose

In Switzerland, while the quality of acute inpatient care for patients with AECOPD is high, a lack of post-acute care interventions has been identified. To correct this shortfall, an integrated care program for patients with AECOPD was initiated at University Hospital Zurich. The study's aim was to compare defined post-acute care intervention implementation rates before and after the new program's implementation.

Methods

A retrospective medical chart review was performed regarding patients hospitalized due to AECOPD between July 2019 and March 2023. The control group (CG) had received usual care, while the intervention group (IG) received the newly implemented program. Implementation rates were compared with Pearson's chi-squared-test or Fisher's exact test.

Results

Charts of 107 participants (IG: 55, CG: 52) were evaluated. Implementation rates increased significantly in the IG for exacerbation management, dyspnea management, recommendation for rehabilitation, smoking cessation advice, evaluation of inhalation technique and recommendation of vaccination (p < 0.05) but not for physical activity, post-discharge medical follow-up or nutrition.

Conclusion

This study provides promising evidence that the introduction of a hospital-initiated integrated care program can significantly increase the implementation rate of post-acute care interventions in patients hospitalized due to AECOPD.

Impact of surgical specialization on long-term survival after emergent colon cancer resections

BACKGROUND

The impact of surgical specialization on long-term survival in patients undergoing emergent colon cancer resections remains unclear.

METHOD

A retrospective analysis was conducted on all patients who underwent emergent colon cancer resections at a secondary care hospital between 2010 and 2020. The most senior surgeon performing the procedures was classified as colorectal surgeon (CS) or non-colorectal surgeon (NCS). NCS was further divided into acute care surgeons (ACSs) or general surgeons (GSs). Overall survival (OS) and cancer-free survival (CFS) were compared in patients operated by surgeons with different specializations.

RESULTS

A total of 235 emergent resections were performed during the study period, of which 99 (42%) were performed by CS and 136 (58%) by NCS. In adjusted Cox regression analyses, OS and CFS were similar in patients operated on by CS and NCS (hazard ratio (HR) for OS: 1.02 (0.72-1.496), p = 0.899 and HR for CFS: 0.91 (0.61-1.397), p = 0.660). Similarly, OS and CFS were equivalent in patients operated by ACS and CS (HR for OS: 1.10 (0.75-1.62), p = 0.629 and HR for CFS: 1.24 (0.80-1.92), p = 0.343). However, patients operated by GS had significantly shorter OS and CFS (HR for OS: 1.78 (1.05-3.00), p = 0.031 and HR for CFS: 1.83 (1.02-3.26), p = 0.041) compared with those operated by ACS and CS.

CONCLUSION

Long-term survival after emergent colon cancer resections was similar in patients operated on by CS and NCS, and the subgroup of ACS, indicating equivalent comparable surgical quality. The less favorable poorer survival observed for patients operated on by GS may possibly be due to less frequent exposure to colorectal and emergent surgery.

CohortDiagnostics: Phenotype evaluation across a network of observational data sources using population-level characterization

OBJECTIVE

This paper introduces a novel framework for evaluating phenotype algorithms (PAs) using the open-source tool, Cohort Diagnostics.

MATERIALS AND METHODS

The method is based on several diagnostic criteria to evaluate a patient cohort returned by a PA. Diagnostics include estimates of incidence rate, index date entry code breakdown, and prevalence of all observed clinical events prior to, on, and after index date. We test our framework by evaluating one PA for systemic lupus erythematosus (SLE) and two PAs for Alzheimer's disease (AD) across 10 different observational data sources.

RESULTS

By utilizing CohortDiagnostics, we found that the population-level characteristics of individuals in the cohort of SLE closely matched the disease's anticipated clinical profile. Specifically, the incidence rate of SLE was consistently higher in occurrence among females. Moreover, expected clinical events like laboratory tests, treatments, and repeated diagnoses were also observed. For AD, although one PA identified considerably fewer patients, absence of notable differences in clinical characteristics between the two cohorts suggested similar specificity.

DISCUSSION

We provide a practical and data-driven approach to evaluate PAs, using two clinical diseases as examples, across a network of OMOP data sources. Cohort Diagnostics can ensure the subjects identified by a specific PA align with those intended for inclusion in a research study.

CONCLUSION

Diagnostics based on large-scale population-level characterization can offer insights into the misclassification errors of PAs.

Enhancing suicidal behavior detection in EHRs: A multi-label NLP framework with transformer models and semantic retrieval-based annotation

BACKGROUND

Suicide is a leading cause of death worldwide, making early identification of suicidal behaviors crucial for clinicians. Current Natural Language Processing (NLP) approaches for identifying suicidal behaviors in Electronic Health Records (EHRs) rely on keyword searches, rule-based methods, and binary classification, which may not fully capture the complexity and spectrum of suicidal behaviors. This study aims to create a multi-class labeled dataset with annotation guidelines and develop a novel NLP approach for fine-grained, multi-label classification of suicidal behaviors, improving the efficiency of the annotation process and accuracy of the NLP methods.

METHODS

We develop a multi-class labeling system based on guidelines from FDA, CDC, and WHO, distinguishing between six categories of suicidal behaviors and allowing for multiple labels per data sample. To efficiently create an annotated dataset, we use an MPNet-based semantic retrieval framework to extract relevant sentences from a large EHR dataset, reducing annotation space while capturing diverse expressions. Experts annotate the extracted sentences using the multi-class system. We then formulate the task as a multi-label classification problem and fine-tune transformer-based models on the curated dataset to accurately classify suicidal behaviors in EHRs.

RESULTS

Lexical analysis revealed key themes in assessing suicide risk, considering an individual's history, mental health, substance use, and family background. Fine-tuned transformer-based models effectively identified suicidal behaviors from EHRs, with Bio_ClinicalBERT, BioBERT, and XLNet achieving the F1 scores (0.81), outperforming BERT and RoBERTa. The proposed approach, based on a multi-label classification system, captures the complexity of suicidal behaviors effectively particularly "Suicide Attempt" and "Family History" instances. The proposed approach, using task-specific NLP models and a multi-label classification system, captures the complexity of suicidal behaviors more effectively than traditional binary classification. However, direct comparisons with existing studies are difficult due to varying metrics and label definitions.

CONCLUSION

This study presents a robust NLP framework for detecting suicidal behaviors in EHRs, leveraging task-specific fine-tuning of transformer-based models and a semi-automated pipeline. Despite limitations, the approach demonstrates the potential of advanced NLP techniques in enhancing the identification of suicidal behaviors. Future work should focus on model expansion and integration to further improve patient care and clinical decision-making.

Planning for implementation success: insights from conducting an implementation needs assessment

AIM

The aim of this paper is to provide insights into conducting an implementation needs assessment using a case example in a less-research-intensive setting.

DESIGN AND METHODS

In the case example, an implementation needs assessment was conducted, including (1) an environmental scan of the organization's website and preliminary discussions with key informants to learn about the implementation context, and (2) a formal analysis of the evidence-practice gap (use of sedation interruptions) deploying a chart audit methodology using legal electronic reports.

RESULTS

Our needs assessment was conducted over 5 months and demonstrated how environmental scans reveal valuable information that can inform the evidence-practice gap analysis. A well-designed gap analysis, using suitable indicators of best practice, can reveal compliance rates with local protocol recommendations, even with a small sample size. In our case, compliance with the prescribed practices for sedation interruptions ranged from 65% (n=53) to as high as 84% (n=69).

CONCLUSIONS

Implementation needs assessments provide valuable information that can inform implementation planning. Such assessments should include an environmental scan to understand the local context and identify both current recommended best practices and local best practices for the intervention of interest. When addressing an evidence-practice gap, analyses should quantify the difference between local practice and desired best practice.

IMPACT

The insights gained from the case example presented in this paper are likely transferrable to implementation research or studies conducted in similar, less-research-intensive settings.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A257.

Quantifying diagnosis and treatment practices of opioid use disorder in primary care practices using chart review data

BACKGROUND

Opioid misuse is a significant public health crisis. The aim sought to identify potential gaps in opioid care in primary care practices.

METHODS

American Academy of Family Physicians (AAFP) offered a monthly online educational series to seven U.S. practices. Practices were asked to complete up to 50 chart reviews for visits during two periods: February-April, 2019, and February-April, 2022. Each chart had to have an ICD-10 diagnosis of opioid misuse, opioid dependence, or opioid use. Chart reviews consisted of 14 questions derived from an American Academy of Addiction Psychiatry (AAAP) Performance in Practice activity, and then, scored based on practices' responses. Descriptive statistics and binary logistic and multinomial regressions were used.

RESULTS

Both periods had 173 chart reviews (total: 346) from the six practices. Most chart reviews were for patients with a diagnosis of opioid dependence (2019: 90.2%; 2022: 83.2%). Three questions for assessing OUD treatment behaviors had high levels of documentation across both time periods (>85%): other drug use, treatment readiness, and treatment discussion.

DISCUSSION

Results show a gap in the treatment of patients with OUD in primary care across several clinical practice recommendations.

CONCLUSIONS

Expanding OUD treatment integration to primary care remains the most promising effort to combat the opioid crisis.

Factors Associated with Housing Stability Among Individuals with Co-Occurring Serious Mental Illness and Substance Use Disorders Receiving Assertive Community Treatment Services

Assertive Community Treatment (ACT) is a community-based, multidisciplinary mental health treatment model with improved housing stability as a treatment goal. We know little about factors contributing to housing stability among ACT participants with co-occurring serious mental illness and substance use disorders, who account for 30% of the ACT participant population. Informed by the behavioral model of health service use, the present study aimed to examine the relationship between housing stability and theoretically relevant factors. We retrospectively abstracted the data from two ACT teams' treatment service planning and tracking system. Stable housing was defined by living in a private residence or permanent supportive housing throughout the assessment periods; unstable housing was defined by having at least one unstable housing situation (e.g., jail or prison) throughout the assessment periods. The sample included 57 individuals with 272 assessment charts. Multivariate logistic regression results show that service engagement was associated with housing stability and that receiving housing supportive services was inversely associated with housing stability. The findings support prior literature in that service engagement remained a "critical ingredient" of the ACT model and highlights the importance of the supportive aspect of housing services in improving housing stability among individuals with co-occurring disorders.

Ten-year trends in clinical characteristics and outcome of children hospitalized with severe wasting or nutritional edema in Malawi (2011-2021): Declining admissions but worsened clinical profiles

BACKGROUND

Severe acute malnutrition (SAM) constitutes a substantial burden in African hospitals. Despite adhering to international guidelines, high inpatient mortality rates persist and the underlying contributing factors remain poorly understood.

OBJECTIVE

We evaluated the 10-year trend (2011-2021) in clinical factors and outcomes among children with severe wasting and/or nutritional edema at Malawi's largest nutritional rehabilitation unit (NRU).

METHODS

This retrospective study analyzed trends in presentation and outcomes using generalized additive models. The association between clinical characteristics and mortality or readmission was examined and key features were also related to time to either mortality or discharge.

RESULTS

1497 children (53%, females) were included. Median age at admission (23 months, IQR 14, 34) or anthropometry (i.e., weight-for-age, height-for-age and weight-for-height) did not change over the 10-years. But the prevalence of edema decreased by 40% whereas dehydration, difficulty breathing, and pallor became more common. Yearly HIV testing increased but positive-detection remained around 11%. Reporting of complete vaccination dropped by 49%, and no reduction in 'watch' antibiotic usage was detected. Overall admissions declined but mortality remained around 23% [95%CI; 21, 25], and deaths occurred earlier (5.6 days [95%CI; 4.6, 6.9] in 2011 vs. 3.5 days [95%CI; 2.5, 4.7] in 2021; p<0.001). Duration of hospitalization was shortened and readmissions surged from 4.9% [95%CI; 3.3, 7.4] in 2011 to 25% [95%CI; 18, 33] in 2021 (p<0.001). Age, wasting, having both dehydration and diarrhea, or having vomiting, cough, or difficulty breathing were associated with mortality but these associations did not show any interaction over time.

CONCLUSION

Over 10 years, mortality risk remained high among hospitalized children with SAM and coincided with worsened clinical presentation at admission and increased readmission. Longitudinal data from major NRUs can identify shifts in clinical profiles or outcomes, and this information can be leveraged to promote earlier care-seeking, improved risk stratification, and implementation of more patient-centered treatments.

The Study of the Epidemiology of Pediatric Hypertension Registry (SUPERHERO): rationale and methods

Despite increasing prevalence of hypertension in youth and high adult cardiovascular mortality rates, the long-term consequences of youth-onset hypertension remain unknown. This is due to limitations of prior research, such as small sample sizes, reliance on manual record review, and limited analytic methods, that did not address major biases. The Study of the Epidemiology of Pediatric Hypertension (SUPERHERO) is a multisite, retrospective registry of youth evaluated by subspecialists for hypertension disorders. Sites obtain harmonized electronic health record data using standardized biomedical informatics scripts validated with randomized manual record review. Inclusion criteria are index visit for International Classification of Diseases, 10th Revision (ICD-10) code-defined hypertension disorder on or after January 1, 2015, and age < 19 years. We exclude patients with ICD-10 code-defined pregnancy, kidney failure on dialysis, or kidney transplantation. Data include demographics, anthropomorphics, US Census Bureau tract, histories, blood pressure, ICD-10 codes, medications, laboratory and imaging results, and ambulatory blood pressure. SUPERHERO leverages expertise in epidemiology, statistics, clinical care, and biomedical informatics to create the largest and most diverse registry of youth with newly diagnosed hypertension disorders. SUPERHERO's goals are to reduce CVD burden across the life course and establish gold-standard biomedical informatics methods for youth with hypertension disorders.

Examining the Early Academic Performance of Doctor of Physical Therapy Students After Holistic Review: A Retrospective Cohort Study

INTRODUCTION

A diverse health care workforce can help to address systemic health disparities. Holistic review and use of an expanded definition of underrepresented minority (URM) that includes factors beyond race and ethnicity are suggested methods to promote diversity in the physical therapist (PT) workforce and ultimately address societal health disparities.

REVIEW OF LITERATURE

Evidence suggests that holistic review can promote PT student diversity; however, limited evidence exists that describes the academic outcomes of holistic review that consider social determinants of learning (SDOL) factors in the review process. The purpose of this study was to examine the early academic outcomes of students after a holistic review and to examine relationships between SDOL factors and academic performance.

SUBJECTS

A convenience sample of 160 students admitted to a doctor of physical therapy (DPT) program from June 2020 to June 2022 was used.

METHODS

A secondary analysis of students' self-reported responses from their admissions application was used to categorize response data into SDOL groups. An independent-sample t -test was used to test group differences in academic performance, and regression modeling was used to test relationships between SDOL factors and academic performance.

RESULTS

The mean 6-month DPT program grade point average (GPA) of the sample was 3.32 ± .43. Nonstatistically significant differences appeared in early DPT GPA between URM and non-URM student groups. However, after controlling for undergraduate GPA, a history of educational disadvantage was the only SDOL factor that contributed to early DPT GPA variance (2.6%), P < .05.

DISCUSSION AND CONCLUSION

The similar academic performance of URM and non-URM students provides support for using an expanded URM definition in holistic review. Most of the educationally disadvantaged group were first-generation college students, which was associated with lower early GPA. These results provide emerging evidence that first-generation students in DPT programs may benefit from additional academic support.

Parenteral prostacyclin utilization in patients with pulmonary arterial hypertension in the intermediate-risk strata: a retrospective chart review and cross-sectional survey

BACKGROUND

Current clinical guidelines support use of parenteral prostacyclin therapy for patients with pulmonary arterial hypertension (PAH) at intermediate risk. The objective of this study was to assess parenteral prostacyclin therapy use among patients at intermediate risk according to the Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) 2.0 four-strata risk assessment model.

METHODS

This was a retrospective chart review and cross-sectional online survey of healthcare professionals (HCPs). Included patients were classified as intermediate-low or intermediate-high risk per COMPERA 2.0 between 2016 and 2020 (index visit), initiated on a parenteral prostacyclin any time following intermediate risk assessment, and had World Health Organization (WHO) Functional Class (FC), 6-minute walk distance (6MWD), and B-type natriuretic peptide/N-terminal pro B-type natriuretic peptide (BNP/NT-proBNP) assessments at index and first comprehensive follow-up visits (follow-up).

RESULTS

A total of 139 HCPs (53% community-based, 47% Pulmonary Hypertension Care Center-based) participated in the survey and provided 350 patient records; among these, mean age (SD) was 54.1 (15.3) years and 52% were female. Median (IQR) time from parenteral prostacyclin initiation to follow-up was 3.0 months (2.0, 7.0). At parenteral prostacyclin initiation for the 280 patient records with available COMPERA 2.0 assessments, 62% of patients were intermediate-high risk, 33% were intermediate-low risk and 3% were low risk, improving to 38%, 53%, and 8%, respectively, at follow-up.

CONCLUSIONS

Improvements were seen for the individual COMPERA 2.0 risk calculator parameters and for several other clinical parameters. Findings from this study substantiate recent guidelines suggesting earlier use of this treatment in intermediate-risk patients with PAH.

CLINICAL TRIAL NUMBER

Not applicable.

Clinical and audiological characteristics in adults with tinnitus in South Africa

BACKGROUND

 In South Africa, the prevalence of tinnitus and its associated clinical and audiological characteristics remain underexplored, posing challenges in the assessment and management of the condition. This knowledge gap affects clinician preparedness and effectiveness in treating tinnitus.

OBJECTIVES

 This study aimed to explore the clinical and audiological characteristics of adult patients reporting tinnitus at a tertiary academic hospital in South Africa.

METHOD

 A quantitative, non-experimental, retrospective review of 129 patient audiological records from the Audiology Department at Helen Joseph Hospital was conducted. Among these, 71 records were of patients who reported experiences of tinnitus.

RESULTS

 Tinnitus was reported by 55% of patients, with a higher prevalence in females (76%). The mean age of patients was 51.9 years. Unilateral tinnitus was present in 28% of cases, while 78% of patients had hearing loss, predominantly sensorineural. Common audiological characteristics included vertigo (24%), otalgia (14%), otorrhea (17%) and perforated tympanic membrane (15%). Clinical conditions associated with tinnitus included hypertension (32%), heart disease (28%), diabetes (9%) and head trauma (9%). Findings regarding age and gender differences in the clinical and audiological manifestations of tinnitus are presented.

CONCLUSION

 Further research with larger, diverse samples and prospective designs is necessary to confirm these findings and explore possible underlying causes.Contribution: The findings highlight the significant prevalence of tinnitus and its association with various clinical and audiological conditions in the South African context. Understanding these characteristics will enhance the clinician's ability to accurately assess, diagnose and manage tinnitus, leading to improved treatment outcomes.

A window of opportunity for ICU end-of-life care-A retrospective multicenter cohort study

BACKGROUND

The "window of opportunity" for intensive care staff to deliver end-of-life (EOL) care lies in the timeframe from "documenting the diagnosis of dying" to death. Diagnosing the dying can be a challenging task in the ICU. We aimed to describe the trajectories for dying patients in Danish intensive care units (ICUs) and to examine whether physicians document that patients are dying in time to perform EOL care and, if so, when a window of opportunity for EOL care exists.

METHODS

From the Danish Intensive Care Database, we identified patients ≥18 years old admitted to Danish ICUs between January and December 2020 with an ICU stay of >96 h (four days) and who died during the ICU stay or within 7 days after ICU discharge. A chart review was performed on 250 consecutive patients admitted from January 1, 2020, to ICUs in the Central Denmark Region.

RESULTS

In most charts (223 [89%]), it was documented that the patient was dying. Of those patients who received mechanical ventilation, 171 (68%) died after abrupt discontinuation of mechanical ventilation, and 63 (25%) died after gradual withdrawal. Patients whose mechanical ventilation was discontinued abruptly died after a median of 1 h (interquartile range [IQR]: 0-15) and 5 h (IQR: 2-15) after a diagnosis of dying was recorded. In contrast, patients with a gradual withdrawal died after a median of 108 h (IQR: 71-189) and 22 h (IQR: 5-67) after a diagnosis of dying was recorded.

CONCLUSIONS

EOL care hinges on the ability to diagnose the dying. This study shows that there is a window of opportunity for EOL care, particularly for patients who are weaned from mechanical ventilation. This highlights the importance of intensifying efforts to address EOL care requirements for ICU patients and those discharged from ICUs who are not eligible for readmission.

Cannabis Use and Inhalational Anesthesia Administration in Older Adults: A Propensity-matched Retrospective Cohort Study

BACKGROUND

Cannabis use is associated with higher intravenous anesthetic administration. Similar data regarding inhalational anesthetics are limited. With rising cannabis use prevalence, understanding any potential relationship with inhalational anesthetic dosing is crucial. Average intraoperative isoflurane or sevoflurane minimum alveolar concentration equivalents between older adults with and without cannabis use were compared.

METHODS

The electronic health records of 22,476 surgical patients 65 yr or older at the University of Florida Health System between 2018 and 2020 were reviewed. The primary exposure was cannabis use within 60 days of surgery, determined via (1) a previously published natural language processing algorithm applied to unstructured notes and (2) structured data, including International Classification of Diseases codes for cannabis use disorders and poisoning by cannabis, laboratory cannabinoids screening results, and RxNorm codes. The primary outcome was the intraoperative time-weighted average of isoflurane or sevoflurane minimum alveolar concentration equivalents at 1-min resolution. No a priori minimally clinically important difference was established. Patients demonstrating cannabis use were matched 4:1 to non-cannabis use controls using a propensity score.

RESULTS

Among 5,118 meeting inclusion criteria, 1,340 patients (268 cannabis users and 1,072 nonusers) remained after propensity score matching. The median and interquartile range age was 69 (67 to 73) yr; 872 (65.0%) were male, and 1,143 (85.3%) were non-Hispanic White. The median (interquartile range) anesthesia duration was 175 (118 to 268) min. After matching, all baseline characteristics were well-balanced by exposure. Cannabis users had statistically significantly higher average minimum alveolar concentrations than nonusers (mean ± SD, 0.58 ± 0.23 vs. 0.54 ± 0.22, respectively; mean difference, 0.04; 95% confidence limits, 0.01 to 0.06; P = 0.020).

CONCLUSION

Cannabis use was associated with administering statistically significantly higher inhalational anesthetic minimum alveolar concentration equivalents in older adults, but the clinical significance of this difference is unclear. These data do not support the hypothesis that cannabis users require clinically meaningfully higher inhalational anesthetics doses.

EDITOR’S PERSPECTIVE

Electronic health record data extraction: Physical therapists' documentation of physical activity assessments and prescriptions for patients with chronic low back pain

BACKGROUND

Despite physical activity being a major component of managing chronic low back pain, < 50% of patients receive physical activity interventions. Electronic Health Records can deepen our understanding about this clinical gap.

OBJECTIVE

We aimed to: 1) develop and test a data abstraction form that captures physical activity documentation; and 2) explore physical therapists' documentation of physical activity assessments and interventions.

METHODS

We developed a data abstraction form using previously published practice guidelines. After identifying the forms' inter-rater reliability, we used it to explore physical therapists' documentation related to physical activity assessments and interventions for patients with chronic low back pain.

RESULTS

The final data abstraction form included information about physical activity history, assessments, interventions, general movement discussion, and plan. Our inter-rater reliability was high. Of the 18 patients, 66.7% had documentation about their PA history. Across the 56 encounters, 14 (25.0%) included an assessment, 18 (32.1%) an intervention, 18 (32.1%) a general movement discussion, and 12 (21.4%) included a plan.

CONCLUSION

Using our reliable data abstraction form we identified a lack of documentation about physical activity assessments and interventions among patients with chronic low back pain. A larger study is needed to examine the generalizability of these results.

Safety and adherence of early oral immunotherapy for peanut allergy in a primary care setting: a retrospective cross-sectional study

BACKGROUND

Peanut allergy is a common food allergy with potentially life-threatening implications. Early oral immunotherapy for peanut allergy (P-EOIT) has been shown to be effective and safe in research and specialty clinic settings. Provision of P-EOIT in primary care would make it available to more patients. We sought to assess the safety of P-EOIT in a primary care setting by documenting the rates of peanut-related allergic reactions leading to emergency department (ED) visits and use of epinephrine. We also examined adherence by assessing the percentage of patients reaching maintenance phase and continuing ingestion after one year of P-EOIT.

METHODS

This retrospective study included all patients aged less than 36 months who started P-EOIT at a primary care allergy clinic in New Brunswick, Canada, from 2016 to 2020. The population included patients who (1) had a history of an allergic reaction to peanuts with a positive skin prick test or positive peanut specific IgE level (ps-IgE) or (2) no history of ingestion and a baseline ps-IgE ≥5 kU/L. Patients had biweekly clinic visits with graded increases in peanut protein up to a maintenance dose of 300 mg of peanut protein daily. A blinded retrospective review of paper charts and electronic medical records was conducted along with phone interviews regarding ED visits and epinephrine use.

RESULTS

All 69 consented patients reached maintenance dose over a median of 29 weeks, and 66 patients (95.7%) were still regularly consuming peanut protein after 1 year of maintenance. One patient had a peanut ingestion-related ED visit requiring epinephrine during the escalation phase of peanut protein dosing (1.4%). During the first year of maintenance phase, no patients had peanut ingestion-related ED visits nor required epinephrine.

CONCLUSION

Early oral immunotherapy for peanut allergy in a primary care setting appears to be safe and our findings suggest that it does not lead to an increased burden of emergency department visits. Our population had high adherence rates, with the majority achieving maintenance dose and staying on this dose for one year.

Automated Identification of Postoperative Infections to Allow Prediction and Surveillance Based on Electronic Health Record Data: Scoping Review

BACKGROUND

Postoperative infections remain a crucial challenge in health care, resulting in high morbidity, mortality, and costs. Accurate identification and labeling of patients with postoperative bacterial infections is crucial for developing prediction models, validating biomarkers, and implementing surveillance systems in clinical practice.

OBJECTIVE

This scoping review aimed to explore methods for identifying patients with postoperative infections using electronic health record (EHR) data to go beyond the reference standard of manual chart review.

METHODS

We performed a systematic search strategy across PubMed, Embase, Web of Science (Core Collection), the Cochrane Library, and Emcare (Ovid), targeting studies addressing the prediction and fully automated surveillance (ie, without manual check) of diverse bacterial infections in the postoperative setting. For prediction modeling studies, we assessed the labeling methods used, categorizing them as either manual or automated. We evaluated the different types of EHR data needed for the surveillance and labeling of postoperative infections, as well as the performance of fully automated surveillance systems compared with manual chart review.

RESULTS

We identified 75 different methods and definitions used to identify patients with postoperative infections in studies published between 2003 and 2023. Manual labeling was the predominant method in prediction modeling research, 65% (49/75) of the identified methods use structured data, and 45% (34/75) use free text and clinical notes as one of their data sources. Fully automated surveillance systems should be used with caution because the reported positive predictive values are between 0.31 and 0.76.

CONCLUSIONS

There is currently no evidence to support fully automated labeling and identification of patients with infections based solely on structured EHR data. Future research should focus on defining uniform definitions, as well as prioritizing the development of more scalable, automated methods for infection detection using structured EHR data.

Association of Homelessness with Before Medically Advised Discharge After Surgery

BACKGROUND

Before medically advised (BMA) discharge, which refers to patients leaving the hospital at their own discretion, is associated with higher rates of readmission and death in other settings. It is not known if housing status is associated with this phenomenon after surgery.

METHODS

We identified all admitted adults who underwent an operation by one of 11 different surgical services at a single tertiary care hospital between January 2013 and June 2022. Chi-square tests and t-tests were used to compare demographic and clinical features between BMA discharges and standard discharges. Multivariable logistic regression was used to evaluate the association between housing status and BMA discharge, adjusting for demographic and admission characteristics. Documented reasons for BMA discharge were also abstracted from the medical record.

RESULTS

Of 111,036 patient admissions, 242 resulted in BMA discharge (0.2%). After adjusting for observable confounders, patients experiencing homelessness had substantially higher odds of BMA discharge after surgery (adjusted odds ratio 4.4, 95% confidence interval 3.0-6.4; p < 0.001) when compared to housed. Patients who underwent emergency surgery, patients with a documented substance use disorder, and those insured by Medicaid also had significantly higher odds of BMA discharge. System- or provider-related reasons (including patient frustration with the hospital environment, challenges in managing substance dependence, and perceived inadequacy of paint control) were documented in 96% of BMA discharges for patients experiencing homelessness (vs. 66% in housed patients).

CONCLUSION

BMA discharge is more common in patients experiencing homelessness after surgery even after adjusting for observable confounding characteristics. Deeper understanding of the drivers of BMA discharge in patients experiencing homelessness through qualitative methods are critical to promote more equitable and effective care.

Sternal Morphologic Characteristics of U.S. Military Males by Computed Tomography: Implications for Intraosseous Access

INTRODUCTION

Sternal intraosseous (IO) access has advantages over humeral and tibial access for fluid resuscitation in military medical settings due to superior flow rates and pharmacokinetics. However, the morphology of the young adult manubrial cortical and medullary bone as it relates to IO catheter tips of currently available FDA-approved IO access devices is unclear.

MATERIALS AND METHODS

Computed tomography manubrium images of active duty service members (N = 93) aged 18 to 30 were assessed by radiologists, including manubrial height, width, and cortical thickness, as well as total thickness and medullary thickness at the thickest (superior) and thinnest (inferior) parts of the manubrium. Inference regarding medullary or cortical IO catheter tip placement rates were made for FAST1 (5.5 mm catheter depth) and TALON (4.5 mm catheter depth) sternal IO devices. Data were analyzed using ANOVA, non-parametric, and correlational statistics at P < 0.05.

RESULTS

As inferred from case-specific CT-derived manubrium dimensions and maximal catheter tip penetration depths, both FAST1 and TALON would be placed in the target medullary space on 100% of opportunities if properly applied in the superior manubrium and on 99% of opportunities if properly applied in the inferior manubrium. Age was not significantly related to IO-relevant manubrial dimensions.

CONCLUSIONS

Present findings suggest that both FAST1 and TALON sternal IO catheter tips can be successfully placed into the target medullary bone with high accuracy in male military members aged 18 to 30 who require rapid resuscitation.

Guidance of development, validation, and evaluation of algorithms for populating health status in observational studies of routinely collected data (DEVELOP-RCD)

BACKGROUND

In recent years, there has been a growing trend in the utilization of observational studies that make use of routinely collected healthcare data (RCD). These studies rely on algorithms to identify specific health conditions (e.g. diabetes or sepsis) for statistical analyses. However, there has been substantial variation in the algorithm development and validation, leading to frequently suboptimal performance and posing a significant threat to the validity of study findings. Unfortunately, these issues are often overlooked.

METHODS

We systematically developed guidance for the development, validation, and evaluation of algorithms designed to identify health status (DEVELOP-RCD). Our initial efforts involved conducting both a narrative review and a systematic review of published studies on the concepts and methodological issues related to algorithm development, validation, and evaluation. Subsequently, we conducted an empirical study on an algorithm for identifying sepsis. Based on these findings, we formulated specific workflow and recommendations for algorithm development, validation, and evaluation within the guidance. Finally, the guidance underwent independent review by a panel of 20 external experts who then convened a consensus meeting to finalize it.

RESULTS

A standardized workflow for algorithm development, validation, and evaluation was established. Guided by specific health status considerations, the workflow comprises four integrated steps: assessing an existing algorithm's suitability for the target health status; developing a new algorithm using recommended methods; validating the algorithm using prescribed performance measures; and evaluating the impact of the algorithm on study results. Additionally, 13 good practice recommendations were formulated with detailed explanations. Furthermore, a practical study on sepsis identification was included to demonstrate the application of this guidance.

CONCLUSIONS

The establishment of guidance is intended to aid researchers and clinicians in the appropriate and accurate development and application of algorithms for identifying health status from RCD. This guidance has the potential to enhance the credibility of findings from observational studies involving RCD.

Positive PTSD Screening and Its Health Correlates in Patients With HIV in Urban Primary Care Settings

Posttraumatic stress disorder (PTSD) is underdiagnosed and undertreated in primary care, especially among African American individuals. The current study assessed documentation rates of PTSD and clinical health correlates among 135 predominantly African American patients with HIV and positive PTSD screens in a primary care unit. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) and a retrospective chart review of 135 patients with HIV were conducted. On the PCPTSD-5 (cut point of 3), approximately one half of patients (49.6%; n = 67) had probable PTSD; however, only 11.9% of patients (n = 16) had a chart diagnosis of PTSD. A positive PTSD screen was associated with higher rates of depression and insomnia, but not anxiety, alcohol use, drug use, or pain in patients with HIV. Multi-morbidity of HIV, major depression, and positive PTSD screens was associated with increased risk for asthma, number of medical diagnoses, depression, insomnia, and anxiety. Findings highlight the need for trauma-informed care in primary care settings for people with PTSD and HIV. Larger samples are warranted to further explore health correlates of PTSD. [Journal of Psychosocial Nursing and Mental Health Services, 62(8), 25-36.].

Higher risk of traumatic intracranial hemorrhage with antiplatelet therapy compared to oral anticoagulation-a single-center experience

PURPOSE

Traumatic brain injury is the main reason for the emergency department visit of up to 3% of the patients and a major worldwide cause for morbidity and mortality. Current emergency management guidelines recommend close attention to patients taking oral anticoagulation but not patients on antiplatelet therapy. Recent studies have begun to challenge this. The aim of this study was to determine the impact of antiplatelet therapy and oral anticoagulation on traumatic intracranial hemorrhage.

METHODS

Medical records of adult patients triaged with "head injury" as the main reason for emergency care were retrospectively reviewed from January 1, 2017, to December 31, 2017, and January 1, 2020, to December 31, 2021. Patients ≥ 18 years with head trauma were included. Odds ratio was calculated, and multiple logistic regression was performed.

RESULTS

A total of 4850 patients with a median age of 70 years were included. Traumatic intracranial hemorrhage was found in 6.2% of the patients. The risk ratio for traumatic intracranial hemorrhage in patients on antiplatelet therapy was 2.25 (p < 0.001, 95% confidence interval 1.73-2.94) and 1.38 (p = 0.002, 95% confidence interval 1.05-1.84) in patients on oral anticoagulation compared to patients without mediations that affect coagulation. In binary multiple regression, antiplatelet therapy was associated with intracranial hemorrhage, but oral anticoagulation was not.

CONCLUSION

This study shows that antiplatelet therapy is associated with a higher risk of traumatic intracranial hemorrhage compared to oral anticoagulation. Antiplatelet therapy should be given equal or greater consideration in the guidelines compared to anticoagulation therapy. Further studies on antiplatelet subtypes within the context of head trauma are recommended to improve the guidelines' diagnostic accuracy.

A Descriptive Analysis of Nasal Polyposis in HIV Positive Versus HIV Negative Patients

Nasal polyposis (NP) represents a benign proliferation of soft tissue tumors within the nasal cavity and paranasal sinuses, characterized by chronic inflammation of the sinonasal mucosa. This phenomenon, attributed to various environmental and physiological factors, presents clinically as semi-transparent masses with variable morphology, often obstructing nasal passages and causing respiratory compromise, olfactory dysfunction, and recurrent infections. Predominantly associated with chronic rhinosinusitis (CRS), NP poses significant challenges in diagnosis and management, particularly in the context of comorbid conditions such as human immunodeficiency virus (HIV) infection. HIV infection, known for its debilitating effects on the immune system, is theorized to exacerbate NP development and manifestation through mechanisms involving CD4 cell depletion and dysregulation of immune responses. Despite extensive research, elucidating potential pathways linking HIV infection to NP, comprehensive understanding remains elusive. This study aims to address this knowledge gap by conducting a retrospective chart review of patients presenting with NP at Charlotte Maxeke Johannesburg Academic Hospital between January 2016 and December 2020. The primary objective is to investigate the influence of HIV status on the clinical, radiological, and histological features of NP. Data collection, encompassing patient demographics, HIV status, clinical presentations, radiological findings, and histopathological characteristics, will be conducted between March 2021 and August 2022. Preliminary analysis of collected data reveals a cohort of 41 patients meeting inclusion criteria, with notable exclusions based on undisclosed HIV status and incomplete documentation. Initial findings suggest a nuanced interplay between genetic predisposition, environmental factors, and HIV status in NP pathogenesis, underscoring the need for further research to validate these observations. In conclusion, this study underscores the importance of elucidating the complex relationship between HIV infection and NP to optimize diagnostic and therapeutic approaches, particularly in regions with a high HIV prevalence such as South Africa. By comprehensively assessing the clinical, radiological, and histological features of NP in HIV-positive and HIV-negative populations, this research endeavours to enhance our understanding of NP pathophysiology and improve patient outcomes.

Using natural language processing in emergency medicine health service research: A systematic review and meta-analysis

OBJECTIVES

Natural language processing (NLP) represents one of the adjunct technologies within artificial intelligence and machine learning, creating structure out of unstructured data. This study aims to assess the performance of employing NLP to identify and categorize unstructured data within the emergency medicine (EM) setting.

METHODS

We systematically searched publications related to EM research and NLP across databases including MEDLINE, Embase, Scopus, CENTRAL, and ProQuest Dissertations & Theses Global. Independent reviewers screened, reviewed, and evaluated article quality and bias. NLP usage was categorized into syndromic surveillance, radiologic interpretation, and identification of specific diseases/events/syndromes, with respective sensitivity analysis reported. Performance metrics for NLP usage were calculated and the overall area under the summary of receiver operating characteristic curve (SROC) was determined.

RESULTS

A total of 27 studies underwent meta-analysis. Findings indicated an overall mean sensitivity (recall) of 82%-87%, specificity of 95%, with the area under the SROC at 0.96 (95% CI 0.94-0.98). Optimal performance using NLP was observed in radiologic interpretation, demonstrating an overall mean sensitivity of 93% and specificity of 96%.

CONCLUSIONS

Our analysis revealed a generally favorable performance accuracy in using NLP within EM research, particularly in the realm of radiologic interpretation. Consequently, we advocate for the adoption of NLP-based research to augment EM health care management.

Clinical characterization of Co-morbid autoimmune disease and eating disorders: a retrospective chart review

Research suggests a link between autoimmune illnesses (AI) and eating disorders (ED). We retrospectively reviewed charts of adolescent patients presenting for eating disorder treatment. We compared the presentation and treatment course for those with an ED and comorbid AI [with (GI-AI, N = 59) or without (non-GI, N = 21) gastrointestinal inflammation] with matched ED-only cases. The sample was overwhelmingly female, with an average age of 15.40. Weight gain trajectories differed across groups, with similar rates of weight gain between controls and non GI-AI cases and with a lower rate of weight gain for individuals with comorbid GI-AI. Over half (56%) of patients reported an AI diagnosis prior to ED; 38% reported an AI diagnosis following ED, and 6% reported ED and AI simultaneous diagnosis. On presentation, ED-only controls had higher rates of comorbid anxiety than cases in either AI group, while those with non-GI AI were more likely to report depression. Mean total GI symptoms, % goal weight at presentation, vital sign instability, and markers of refeeding syndrome did not differ across groups. Health care professionals treating patients with either condition should have a low threshold for asking additional questions to identify the presence of the other condition.

Experiences and observations from a care point for displaced Ukrainians: a community case study in Antwerp, Belgium

Background

A total of 7,307 Ukrainian refugees moved to Antwerp, Belgium, during the study period (01 April 2022 to 31 December 2022). The city's administration set up three care centers where these people were introduced to the Belgian primary care system, a medical file was created, and acute/preventive/chronic care was delivered. This community case study analyzes the organization and contents of care and reflects upon its meaning for the mainstream healthcare system.

Methods

This is an observational study using routine electronic medical record data to measure the uptake of care. For a sample of 200 subjects, a retrospective chart review was conducted.

Participants

All refugees with a medical file at one of the three participating care centers were included.

Main outcomes

For the observational study, 2,261 patients were reached (30% of the potential users), and 6,450 contacts were studied. The nurses (including midwives) conducted 4,929 out of 6,450 (76%) of all consultations, while the general practitioners (GPs) conducted 1,521 out of 6,450 (24%). Of the nurse consultations, 955 (19%) were followed by another nurse consultation and 866 (18%) by a GP consultation. In the structured case reviews, most contacts were concerned with acute problems (609 out of 1,074, 57%). The most prevalent reasons for encounters and diagnoses were typical primary care issues. The nurses were able to manage half of the cases independently (327, 55%), referred 37% (217) of cases to the GP, and consulted a GP (live, by telephone, or a dedicated app) for 8% (48) of cases. GPs mostly prescribed drugs, referred to a medical specialist, and advised over-the-counter drugs, while nurses more often advised over-the-counter drugs (mostly paracetamol, nose sprays, and anti-inflammatory drugs), provided non-medical advice, or ordered laboratory tests.

Discussion

The medical care points delivered mostly typical acute primary care in this first phase, with a key role for nurses. The care points did not sufficiently take up chronic diseases and mental health problems. These results will inform policymakers on the use of primary care centers for newly arriving patients in times of a large influx. A nurse-first model seems feasible and efficient, but evaluation of safety and quality of care is needed. Once the acute phase of this crisis fades away, questions about the comprehensiveness, continuity, and integration of care for migrants remain relevant.

Outcomes of different pulmonary rehabilitation protocols in patients under mechanical ventilation with difficult weaning: a retrospective cohort study

BACKGROUND

The endeavor of liberating patients from ventilator dependence within respiratory care centers (RCCs) poses considerable challenges. Multiple factors contribute to this process, yet establishing an effective regimen for pulmonary rehabilitation (PR) remains uncertain. This retrospective study aimed to evaluate existing rehabilitation protocols, ascertain associations between clinical factors and patient outcomes, and explore the influence of these protocols on the outcomes of the patients to shape suitable rehabilitation programs.

METHODS

Conducted at a medical center in northern Taiwan, the retrospective study examined 320 newly admitted RCC patients between January 1, 2015, and December 31, 2017. Each patient received a tailored PR protocol, following which researchers evaluated weaning rates, RCC survival, and 3-month survival as outcome variables. Analyses scrutinized differences in baseline characteristics and prognoses among three PR protocols: protocol 1 (routine care), protocol 2 (routine care plus breathing training), and protocol 3 (routine care plus breathing and limb muscle training).

RESULTS

Among the patients, 28.75% followed protocol 1, 59.37% protocol 2, and 11.88% protocol 3. Variances in age, body-mass index, pneumonia diagnosis, do-not-resuscitate orders, Glasgow Coma Scale scores (≤ 14), and Acute Physiology and Chronic Health Evaluation II (APACHE) scores were notable across these protocols. Age, APACHE scores, and abnormal blood urea nitrogen levels (> 20 mg/dL) significantly correlated with outcomes-such as weaning, RCC survival, and 3-month survival. Elevated mean hemoglobin levels linked to increased weaning rates (p = 0.0065) and 3-month survival (p = 0.0102). Four adjusted models clarified the impact of rehabilitation protocols. Notably, the PR protocol 3 group exhibited significantly higher 3-month survival rates compared to protocol 1, with odds ratios (ORs) ranging from 3.87 to 3.97 across models. This association persisted when comparing with protocol 2, with ORs between 3.92 and 4.22.

CONCLUSION

Our study showed that distinct PR protocols significantly affected the outcomes of ventilator-dependent patients within RCCs. The study underlines the importance of tailored rehabilitation programs and identifies key clinical factors influencing patient outcomes. Recommendations advocate prospective studies with larger cohorts to comprehensively assess PR effects on RCC patients.

Extraction of Unstructured Electronic Health Records to Evaluate Glioblastoma Treatment Patterns

PURPOSE

Data on lines of therapy (LOTs) for cancer treatment are important for clinical oncology research, but LOTs are not explicitly recorded in electronic health records (EHRs). We present an efficient approach for clinical data abstraction and a flexible algorithm to derive LOTs from EHR-based medication data on patients with glioblastoma multiforme (GBM).

METHODS

Nonclinicians were trained to abstract the diagnosis of GBM from EHRs, and their accuracy was compared with abstraction performed by clinicians. The resulting data were used to build a cohort of patients with confirmed GBM diagnosis. An algorithm was developed to derive LOTs using structured medication data, accounting for the addition and discontinuation of therapies and drug class. Descriptive statistics were calculated and time-to-next-treatment (TTNT) analysis was performed using the Kaplan-Meier method.

RESULTS

Treating clinicians as the gold standard, nonclinicians abstracted GBM diagnosis with a sensitivity of 0.98, specificity 1.00, positive predictive value 1.00, and negative predictive value 0.90, suggesting that nonclinician abstraction of GBM diagnosis was comparable with clinician abstraction. Of 693 patients with a confirmed diagnosis of GBM, 246 patients contained structured information about the types of medications received. Of them, 165 (67.1%) received a first-line therapy (1L) of temozolomide, and the median TTNT from the start of 1L was 179 days.

CONCLUSION

We described a workflow for extracting diagnosis of GBM and LOT from EHR data that combines nonclinician abstraction with algorithmic processing, demonstrating comparable accuracy with clinician abstraction and highlighting the potential for scalable and efficient EHR-based oncology research.

Short- and long-term outcome after colon cancer resections performed by male and female surgeons: A single-center retrospective cohort study

BACKGROUND AND OBJECTIVE

To assess the effect of surgeon sex on short- and long-term outcomes after colon cancer resections.

METHODS

Clinical data of patients who underwent colon cancer resections between 2010 and 2020 at Helsingborg Hospital, Sweden, were retrospectively obtained from medical records. The sex of the surgeon of each procedure was recorded. Morbidity, mortality, and long-term survival were compared in patients operated by male and female surgeons.

RESULTS

Colon cancer resections were performed by 23 male and 9 female surgeons in 1113 patients (79% elective, 21% emergent). After elective surgery, there was no difference in postoperative complications, 30-day mortality, or long-term survival between patients operated by male and female surgeons. Following emergent resections, the complication rate was significantly lower in patients operated by female surgeons (41.3% vs 58.1%, p = 0.019). Similarly, the rates of R1-resections (0% vs 5.2%, p = 0.039), reoperations (3.8% vs 14.2%, p = 0.014), and intensive care unit (ICU) care (6.3% vs 17.4%, p = 0.018) were significantly lower for patients operated by female surgeons, but there was no difference in 30-day mortality (6.3% vs 5.2%, p = 0.767). Cox regression analysis showed that long-term and cancer-free survival in patients emergently operated by male surgeons was significantly shorter than that of patients operated by female surgeons (hazard ratio = 1.9 (95% confidence interval (CI) = 1.3-2.8), p = 0.001 and hazard ratio = 1.7 (95% CI = 1.1-2.7), p = 0.016).

CONCLUSIONS

The short- and long-term outcome after elective colon cancer resections were similar in patients operated by male and female surgeons. The outcome following emergent resections performed by female surgeons compared favorably with that of male surgeons, with fewer complications and reoperations and better long-term survival.

Retrospective charts for reporting, analysing, and evaluating disaster emergency response: a systematic review

OBJECTIVE

Given the frequency of disasters worldwide, there is growing demand for efficient and effective emergency responses. One challenge is to design suitable retrospective charts to enable knowledge to be gained from disasters. This study provides comprehensive understanding of published retrospective chart review templates for designing and updating retrospective research.

METHODS

We conducted a systematic review and text analysis of peer-reviewed articles and grey literature on retrospective chart review templates for reporting, analysing, and evaluating emergency responses. The search was performed on PubMed, Cochrane, and Web of Science and pre-identified government and non-government organizational and professional association websites to find papers published before July 1, 2022. Items and categories were grouped and organised using visual text analysis. The study is registered in PROSPERO (374,928).

RESULTS

Four index groups, 12 guidelines, and 14 report formats (or data collection templates) from 21 peer-reviewed articles and 9 grey literature papers were eligible. Retrospective tools were generally designed based on group consensus. One guideline and one report format were designed for the entire health system, 23 studies focused on emergency systems, while the others focused on hospitals. Five papers focused specific incident types, including chemical, biological, radiological, nuclear, mass burning, and mass paediatric casualties. Ten papers stated the location where the tools were used. The text analysis included 123 categories and 1210 specific items; large heterogeneity was observed.

CONCLUSION

Existing retrospective chart review templates for emergency response are heterogeneous, varying in type, hierarchy, and theoretical basis. The design of comprehensive, standard, and practicable retrospective charts requires an emergency response paradigm, baseline for outcomes, robust information acquisition, and among-region cooperation.

The accuracy of prehospital triage decisions in English trauma networks - a case-cohort study

BACKGROUND

Care for injured patients in England is provided by inclusive regional trauma networks. Ambulance services use triage tools to identify patients with major trauma who would benefit from expedited Major Trauma Centre (MTC) care. However, there has been no investigation of triage performance, despite its role in ensuring effective and efficient MTC care. This study aimed to investigate the accuracy of prehospital major trauma triage in representative English trauma networks.

METHODS

A diagnostic case-cohort study was performed between November 2019 and February 2020 in 4 English regional trauma networks as part of the Major Trauma Triage Study (MATTS). Consecutive patients with acute injury presenting to participating ambulance services were included, together with all reference standard positive cases, and matched to data from the English national major trauma database. The index test was prehospital provider triage decision making, with a positive result defined as patient transport with a pre-alert call to the MTC. The primary reference standard was a consensus definition of serious injury that would benefit from expedited major trauma centre care. Secondary analyses explored different reference standards and compared theoretical triage tool accuracy to real-life triage decisions.

RESULTS

The complete-case case-cohort sample consisted of 2,757 patients, including 959 primary reference standard positive patients. The prevalence of major trauma meeting the primary reference standard definition was 3.1% (n=54/1,722, 95% CI 2.3 - 4.0). Observed prehospital provider triage decisions demonstrated overall sensitivity of 46.7% (n=446/959, 95% CI 43.5-49.9) and specificity of 94.5% (n=1,703/1,798, 95% CI 93.4-95.6) for the primary reference standard. There was a clear trend of decreasing sensitivity and increasing specificity from younger to older age groups. Prehospital provider triage decisions commonly differed from the theoretical triage tool result, with ambulance service clinician judgement resulting in higher specificity.

CONCLUSIONS

Prehospital decision making for injured patients in English trauma networks demonstrated high specificity and low sensitivity, consistent with the targets for cost-effective triage defined in previous economic evaluations. Actual triage decisions differed from theoretical triage tool results, with a decreasing sensitivity and increasing specificity from younger to older ages.

Social Determinants of Health Impacting the Experience of Young Adults With Cancer at a Single Community Urban Hospital: A Retrospective Cohort Study

Adolescent and young adult (AYA) cancer patients receive palliative medicine consultation at a late stage and face diagnostic delays. Failure to address social determinants of health (SDOH) and AYA-specific needs can adversely impact patient experience. This retrospective observational cohort study used data from chart review to assess the frequency of SDOH impacting AYA patients and setting of initial diagnosis at a US urban safety-net hospital. The association of SDOH variables with delays in treatment, loss of follow-up, and no-shows was tested using Chi-square and t-tests. One hundred seventy five patient charts were reviewed. Sixty-two percent were diagnosed in acute care settings. Substance use disorders, financial, employment, and insurance issues were associated with delayed treatment, with weak to moderate effect sizes. Mental health diagnoses, substance use disorder, homelessness, and financial burdens were associated with patient no-shows, with moderate to large effect sizes. Twenty-five percent of patients received palliative medicine consultation; 70% of these occurred at end of life. This study demonstrates the impact of SDOH on AYA cancer care and the need for policy allowing for intervention on SDOH.