Amitriptyline for Refractory Idiopathic Intractable Hiccups: A Case Report.

Clinicians usually intend to get overall health status as well as specific health care information from patient's electronic health record (EHR). However, the amount of EHR data can be incredibly large, which makes it a very tedious and inefficient work for clinicians to extract valuable information. This paper first investigates the clinical relevance of EHR data content. Then it presents a Level of Detail (LOD) information navigation model, which classified patient's whole EHR into different detail levels according to their clinical relevance. A novel navigation and visualization method is brought forward based on this model. Finally, an application is designed and implemented based on this method. It can guide clinicians from summarized overview to detailed contents of the EHR smoothly. Both the evolution of specific health problems and other related EHR information can be visualized and located quickly.

IntroductionHiccups are involuntary, spasmodic contractions of the diaphragm and intercostal muscles that cause inspiration and are interrupted by closure of the glottis. Most sources define the term “persistent hiccups” as lasting more than 2 days and “intractable” as lasting more than 1 month. Both are most likely associated with a pathologic process. “Intractable hiccups” should lead to investigation of organic pathology. If it does not improve, it can interfere with the patient’s ability to eat, socialize and sleep, leading to a significant worsening of quality of life. “Intractable hiccups” are more frequent in men (91%), over 50 years of age. Women suffer from psychogenic hiccups more frequently than men. Anxiety or stress can trigger hiccups. Multiple neurotransmitters are involved.ObjectivesWe present a theoretical review on the topic.MethodsA bibliographic review on the topic.ResultsIn recent years, new trials and case series have been published, and regulatory agencies have issued new recommendations on the use of pharmacologic agents for this indication. The literature has described the efficacy of several pharmacologic agents in the empiric treatment of persistent and intractable hiccups. Most of these target dopaminergic and GABAergic receptors.Based on limited efficacy and safety data, Baclofen and Gabapentin can be considered as first-line treatment for intractable and persistent hiccups, as they suggest efficacy and are less likely to cause long-term side effects than standard neuroleptic agents. Dopamine blocking agents such as Metoclopramide, Chlorpromazine, and Haloperidol, could be used as second line. In one study, withdrawal of Benzodiazepines or addition of Pregabalin was found to help reduce hiccups.The patient we consulted came for persistent hiccups or singultus of 2 years of evolution. Organic pathology was ruled out. She related the onset of the symptoms to different stressors that had caused her anxiety. We administered Escitalopram and Gabapentin and indicated withdrawal of Bromazepam, which she started taking months ago. In follow-up appointments she reported a decrease in the intensity and frequency of the symptoms, with a notable improvement in her quality of life.ConclusionsConsidering all available evidence, a treatment algorithm with Baclofen is recommended as first-line therapy for persistent and intractable hiccups. Gabapentin may also be safe and effective in the long-term treatment of this condition, especially for patients with CNS disease. Metoclopramide is no longer recommended for long-term treatment of hiccups. Clinical experience also supports the use of Chlorpromazine and other neuroleptics for acute, but not long-term, treatment. Going forward, large multicenter studies will be needed to create an adequate evidence base for the treatment of persistent and intractable hiccups. Until then, guidelines will continue to be based on unreliable data and clinical experience.Disclosure of InterestNone Declared

Introduction: Hiccups are common and typically resolve spontaneously. However, in rare cases, they can continue for days, weeks or even years, causing significant morbidity and discomfort in patients. In the setting of intractable hiccups, vagal nerve stimulation has been reported in two cases.Objectives: This is a case report and review of the literature regarding the use of vagal nerve stimulators for intractable hiccups. Specifically, this report highlights a case where this therapy was not effective, as two prior case reports have reported positive results.Case report: A 52-year-old man presented with multiple years of intractable hiccups. A workup revealed no identifiable aetiology, and he had failed multiple medical therapies. A phrenic nerve block was attempted, which was not beneficial. Vagal maneuvers, specifically the induction of emesis, did consistently provide transient relief of his symptoms, and, therefore, the decision was made to proceed with a trial of vagal nerve stimulation after review of the literature supported the therapy. Despite 8 months with multiple stimulation parameters, the patient did not have any significant benefit from vagal nerve stimulation.Conclusions: Intractable idiopathic hiccups continue to present a significant challenge for physicians and patients. While vagal nerve stimulation is a potentially beneficial therapy, it is not effective in all patients with central idiopathic intractable hiccups.

Successful treatment of idiopathic intractable hiccup with baclofen and supportive treatment: a case report.

Assessing concordance between patient recall and health record documentation of medication discussions in Veterans Affairs primary care: A brief report.

Lance-Adams syndrome is a rare and debilitating disorder characterized by successful cardiopulmonary resuscitation resulting in myoclonus activity. Alcohol withdrawal seizures from alcohol use disorder may further exacerbate Lance-Adams syndrome. We aim to present a case of Lance-Adams syndrome complicated by alcohol withdrawal seizures and successfully treated with a combination of valproate, clonazepam, and gabapentin. The patient's electronic medical record, direct patient care experiences, and a comprehensive literature search were used for this case report. We report a 41-year-old male patient with Lance-Adams syndrome with concurrent alcohol use disorder. Treatment was improved when adding gabapentin for alcohol use disorder treatment, alongside combination antiepileptic therapy. A PubMed search was conducted to examine Lance-Adams syndrome case reports of successful combination antiepileptic therapy, with a secondary evaluation of patients with concurrent alcohol use disorder. The literature search yielded 18 articles, which resulted in 21 individual cases in which combination antiepileptic drug therapy was successful in treating myoclonus secondary to Lance-Adams syndrome; however, none of the case reports utilized gabapentin synergistically. One case described Lance-Adams syndrome complicated by alcohol consumption and similar to our patient, the patient used alcohol to abolish myoclonic activity. To the best of our knowledge, this is the first case report documenting a patient with Lance-Adams syndrome and concurrent alcohol use disorder, with a positive effect of gabapentin use. Gabapentin, when used for alcohol use disorder treatment, may be an appropriate adjunct agent in the management of patients receiving combination antiepileptic therapy for the treatment of Lance-Adams syndrome.

BackgroundHiccup (Singultus) is a sudden and involuntary contraction of the diaphragm followed by a sharp closure of the epiglottis which results in the production of a specific “hic” sound. Normally, hiccups are treated without intervention. Intractable hiccups occur rarely but are a disturbing symptom underlying other health related disorders.Case presentationWe report the clinical case of a 67-year-old male patient with myocardial infarction accompanied by intractable hiccups during the course of 8 months, and who was non-responsive to chlorpromazine or metoclopramide, and baclofen; drugs routinely used to treat this condition. This sustained hiccup had severely restricted the patient's ability to intake food and sleep. To explore alternative treatments, we investigated the adjuvant administration of lansoprazole, dimenhydrinate and clonazepam in this patient. We discovered that this drug combination was capable of successfully terminating his intractable hiccups, with no further evidence of recurrence. No similar treatment is previously reported for intractable hiccups. We further suggest a hypothesis concerning a potential mechanism on the anti-hiccup effect of dimenhydrinate.ConclusionWe identified that the adjuvant use of lansoprazole, clonazepam and dimenhydrinate was capable of attenuating the symptoms of our patient with intractable hiccups.

Daily management of neurodegenerative diseases by electrical neuromodulation techniques requires an integrated health care system for the continuous assistance to the patient. In this scenario, a direct bi-directional exchange of information between the patient's electronic health record (EHR) and patient's personal mobile health apps (mHealth) can boost the active contribution of patients and caregivers to safe homecare management. Grounding on a recently proposed standards-based architecture, we describe here a prototype implementing the mHealth App/EHR bi-directional health information exchange for supporting homecare transcranial Direct Current Stimulation (tDCS) therapy. We first modeled the tDCS case study using the Unified Modeling Language (UML) and, then, we developed the mHealth app for the patient side in order to implement the exchange architecture. We then connected the app to an EHR system developed using a web-based platform (Web Bio Bank) based on a framework for EHR management. The neurologist, using the EHR system, can configure the patient's homecare plan sent to the mHealth App, and can see the patient's monitoring reports sent from the mHealth App to the EHR. The integration architecture is implemented by CDA-2 compliant XML encrypted files. The current prototype proves that direct information exchange between mHealth Apps and EHR systems is possible by a standards-based architecture and can be effectively used to improve patient-neurologist communication as well as to support tDCS home therapy.

Electronic Health Records (EHRs) have many clinical, financial, and logistical benefits, yet the extent of their accuracy is unknown. We compared patient self-reported data at emergency department (ED) presentations with the corresponding EHR, focusing on key demographics, physical characteristics, and social history. Emphasis was placed on understanding whether major life stressors were noted on patients’ charts and how that could impact quality of care. Life stressors are defined as life-altering and emotionally demanding or traumatic events. We enrolled a convenience sample of 357 ambulatory, English speaking, adult patients at the Vanderbilt University Medical Center Emergency Department, an urban, academic, tertiary care ED (annual census 70,000). We compared the EHR with self-reported data from bedside patient interviews, including information on demographics (age, sex, race, ethnicity), physical characteristics (height, weight), and life history (smoking, life stressors). Data was described using median and percent frequency, and it was analyzed using Cohen kappa statistics and Bland-Altman plots. Between EHR and patient-reports, sex and age matched in 99%, and race/ethnicity matched in 90%. Race was more discordant when the patient self-identified as multiple races, as it was only reflected in 24% of those patients’ EHRs. Weight, height, and smoking were similar between patient interviews and EHR. Of 281 self-reported life stressors, only 75 were recorded in the EHR. Although most demographic and clinical data were concordant, life stressors were frequently absent from the EHR which suggests a discrepancy in data collection and maintenance.

<strong>Background:</strong> Neuroblastoma is a rare pediatric cancer that affects thousands of children worldwide. Information stored in electronic health records can be a useful source of data forin silicoscientific studies about this disease, carried out both by humans and by computational machines. Several open datasets derived from electronic health records of anonymized patients diagnosed with neuroblastoma are available in the internet, but they were released on different websites or as supplementary information of peer-reviewed scientific publications, making them difficult to find. <strong>Methods:</strong> To solve this problem, we present here this survey of five open public datasets derived from electronic health records of patients diagnosed with neuroblastoma, all collected in a single website called Neuroblastoma Electronic Health Records Open Data Repository. <strong>Results:</strong> The five open datasets presented in this survey can be used by researchers worldwide who want to carry on scientific studies on neuroblastoma, including machine learning and computational statistics analyses. <strong>Conclusions:</strong> We believe our survey and our open data resource can have a strong impact in oncology research, allowing new scientific discoveries that can improve our understanding of neuroblastoma and therefore improve the conditions of patients. We release the five open datasets reviewed here publicly and freely on our Neuroblastoma Electronic Health Records Open Data Repository under the CC BY 4.0 license at: <a href="https://davidechicco.github.io/neuroblastoma_EHRs_data" target="_blank">https://davidechicco.github.io/neuroblastoma_EHRs_data</a> or at <a href="https://doi.org/10.5281/zenodo.6915403" target="_blank">https://doi.org/10.5281/zenodo.6915403</a>

Constant interruptions and continual data flow result in information overload for clinicians and become barriers to identification and extraction of relevant patient data and its correct interpretation. The aim of the study was to describe the types, frequencies, and impact of intensive care unit (ICU) interruptions on patient safety event occurrences and electronic health records (EHR) use. We conducted a live observational study for 6 weeks, observing critical care physicians' and other providers' communication while recording interruptions, patient safety events, and EHR use. Across 55 hours, the researchers observed 7515 ICU tasks, 15.7% of which were interrupted. We found that technological interruptions directly influences the occurrence of patient safety events: an increase in technological interruptions directly contributes to patient safety event occurrence (P = 0.004). Technological interruptions had a direct effect on human interruptions, as the frequency of technological interruptions increase, human interruptions also increase (P = 0.02). A prospective, observational study was conducted to understand the relationship between interruptions and patient safety events and EHR use, in a time-sensitive, activity-based study in a large academic medical center with a certified EHR system. We found that technological interruptions were statistically correlated to the occurrence of patient safety events, and human interruptions significantly affected the level of EHR use. This study recommends that ICUs adopt a safety culture that promotes minimizing unnecessary interruptions, such as side conversations during rounds, for improved quality of care.

Successful Restoration of Fecal Continence Using Sacral Nerve Stimulation Following Chemoradiation and Transanal Excision of an Anal Melanoma With Partial Internal Anal Sphincter Resection: A Case Report

Treatment of Intractable Hiccups With Olanzapine Following Recent Severe Traumatic Brain Injury

Solid phase red cell adherence is a sensitive platform for blood group antibody detection, but non-specific reactions may occur. The aim of this study was to define the clinical characteristics of patients with these reactions and their associated laboratory findings. An 8-month retrospective review of a regional blood bank database was performed. One hundred and seventy-three patients were identified with apparent nonspecific solid phase (NSP) reactivity. Serologic findings were recorded, and each patient's electronic health record was interrogated. NSP reactivity was the most common positive finding in the laboratory. Of 173 patients with NSP, 167 had documented concurrent tube testing. Of these, 165 were negative, one demonstrated nonspecific reactivity, and one anti-Lea was identified. Most positive solid phase antibody screens had negative panel testing, with fewer cases of pan-reactivity or sporadic reactivity. Follow-up testing was either negative (85.5%) or demonstrated NSP reactivity (14.5%). No new blood group antibodies were identified. Most patients were female (72.8%), with pregnancy being the leading diagnosis (35.8%); however, this mirrored the distribution of cases received in the laboratory. When pregnant patients were excluded, female and male patients had the same average age, and the gender distribution and the primary diagnoses of NSP patients mirrored those of all patients evaluated. Solid phase antibody detection is known to be sensitive, but nonspecific reactions are relatively common. Compared to other studies, the evolution of NSP to clinically significant antibodies was not seen, female patients did not have a predilection for NSP reactivity, and NSP was not associated with certain diagnoses.

Patient portals provide patients and their caregivers online access to limited health results. Health care employees with electronic health record (EHR) access may be able to view their health information not available in the patient portal by looking in the EHR. In this study, we examine how employees use the patient portal when they also have access to the tethered EHR. We obtained patient portal and EHR usage logs corresponding to all employees who viewed their health data at our institution between January 1, 2013 and November 1, 2017. We formed three cohorts based on the systems that employees used to view their health data: employees who used the patient portal only, employees who viewed health data in the EHR only, and employees who used both systems. We compared system accesses and usage patterns for each employee cohort. During the study period, 35,172 employees accessed the EHR as part of patients' treatment and 28,631 employees accessed their health data: 25,193 of them used the patient portal and 13,318 accessed their clinical data in EHR. All employees who accessed their records in the EHR viewed their clinical notes at least once. Among EHR accesses, clinical note accesses comprised more than 42% of all EHR accesses. Provider messaging and appointment scheduling were the most commonly used functions in the patient portal. Employees who had access to their health data in both systems were more likely to engage with providers through portal messages. Employees at a large medical center accessed clinical notes in the EHR to obtain information about their health. Employees also viewed other health data not readily available in the patient portal.