Clinical Care Research Articles

Collecting Sociodemographic Data in Pediatric Emergency Research: A Working Group Consensus.

Understanding and addressing health care disparities relies on collecting and reporting accurate data in clinical care and research. Data regarding a child's race, ethnicity, and language; sexual orientation and gender identity; and socioeconomic and geographic characteristics are important to ensure equity in research practices and reported outcomes. Disparities are known to exist across these sociodemographic categories. More consistent, accurate data collection could improve understanding of study results and inform approaches to resolve disparities in child health. However, published guidance on standardized collection of these data in children is limited, and given the evolving nature of sociocultural identities, requires frequent updates. The Pediatric Emergency Care Applied Research Network, a multi-institutional network dedicated to pediatric emergency research, developed a Health Disparities Working Group in 2021 to support and advance equitable pediatric emergency research. The working group, which includes clinicians involved in pediatric emergency medical care and researchers with expertise in pediatric disparities and the conduct of pediatric research, prioritized creating a guide for approaches to collecting race, ethnicity, and language; sexual orientation and gender identity; and socioeconomic and geographic data during the conduct of research in pediatric emergency care settings. Our aims with this guide are to summarize existing barriers to sociodemographic data collection in pediatric emergency research, highlight approaches to support the consistent and reproducible collection of these data, and provide rationale for suggested approaches. These approaches may help investigators collect data through a process that is inclusive, consistent across studies, and better informs efforts to reduce disparities in child health.

Symptom burden and quality of life among patient and family caregiver dyads in advanced cancer.

Symptom management among patients diagnosed with advanced cancer is a high priority in clinical care that often involves the support of a family caregiver. However, limited studies have examined parallel patient and caregiver symptom burden and associations with their own and each other's quality of life (QOL). This study seeks to identify patient and caregiver symptom clusters and investigate associations between identified clusters and demographic, clinical, and psychosocial factors (cognitive appraisals and QOL). This study was a secondary analysis of self-reported baseline survey data collected from a randomized clinical trial of 484 adult advanced cancer patients and their caregivers. Latent class analysis and factor analysis were used to identify symptom clusters. Bivariate statistics tested associations between symptom clusters and demographic, clinical, and psychosocial variables. The most prevalent symptom for patients was energy loss/fatigue and for caregivers, mental distress. Low, moderate, and high symptom burden subgroups were identified at the patient, caregiver, and dyad level. Age, gender, race, income, chronic conditions, cancer type, and treatment type were associated with symptom burden subgroups. Higher symptom burden was associated with more negative appraisals of the cancer and caregiving experience, and poorer QOL (physical, social, emotional, functional, and overall QOL). Dyads whose caregivers had more chronic conditions were more likely to be in the high symptom burden subgroup. Patient and caregiver symptom burden influence their own and each other's QOL. These findings reinforce the need to approach symptom management from a dyadic perspective.

Segmental deformity markers offer novel indicators of deformity progression risk in deformity-matched adolescent idiopathic scoliosis patients.

Identification of adolescent idiopathic scoliosis (AIS) patients with mild curvatures who pose significant risk of progressing to severe levels of curvatures is of paramount importance for clinical care. This study aimed to compare segmental deformity changes in AIS sub-cohorts that are dichotomised by progression status. Thirty-six female participants with Lenke 1 AIS curves were investigated with sequential MRIs during growth. Scans were reformatted to measure orthogonal segmental parameters, including sagittal/coronal wedging angles and axial rotation angles. Participants were dichotomised by progression. Two-tailed, independent sample t-tests were used to compare sub-cohort multi-segmental and segmental deformity parameters. Measurements were compared at each scan number and variable rates of change were determined using actual time between measures. AIS progression status sub-cohorts were comparable at scan 1 for multi-segmental deformity parameters (e.g. major thoracic curve angle, rib hump, kyphosis) (P > 0.05). However, apical measures of coronal IVD wedging, axial IVD rotation and axial vertebral rotation were segmental parameters at scan 1 which were larger for participants whose AIS would later go on to clinically progress (all P < 0.05). Measures of segmental hypokyphosis were comparable between groups. As development was tracked at each subsequent scan, coronal and axial plane differences between groups increased in both magnitude and number of differences. Initial disparity and then subsequent increasing magnitude of change of axial rotation may indicate a higher propensity to clinically progress in the future. This knowledge hopes to provide useful management information for AIS care providers and prognostic education for patients alike. II.

Systemic and skin-limited delayed-type drug hypersensitivity reactions associate with distinct resident and recruited T cell subsets.

Delayed-type drug hypersensitivity reactions are major causes of morbidity and mortality. The origin, phenotype and function of pathogenic T cells across the spectrum of severity requires investigation. We leveraged recent technical advancements to study skin-resident memory T cells (TRM) versus recruited T cell subsets in the pathogenesis of severe systemic forms of disease, SJS/TEN and DRESS, and skin-limited disease, morbilliform drug eruption (MDE). Microscopy, bulk transcriptional profiling and scRNAseq + CITEseq + TCRseq supported in SJS/TEN clonal expansion and recruitment of cytotoxic CD8+ T cells from circulation into skin, along with expanded and non-expanded cytotoxic CD8+ skin TRM. Comparatively, MDE displayed a cytotoxic T cell profile in skin without appreciable expansion and recruitment of cytotoxic CD8+ T cells from circulation, implicating TRM as potential protagonists in skin-limited disease. Mechanistic interrogation in patients unable to recruit T cells from circulation into skin and in a parallel mouse model supported that skin TRM were sufficient to mediate MDE. Concomitantly, SJS/TEN displayed a reduced regulatory T cell (Treg) signature compared to MDE. DRESS demonstrated recruitment of cytotoxic CD8+ T cells into skin like SJS/TEN, yet a pro-Treg signature like MDE. These findings have important implications for fundamental skin immunology and clinical care.

Access to Psychotherapy Notes: Review of Legal Standards for Mental Health Clinicians.

Patients' access to their psychotherapy records may be assumed to be well protected; however, the matter is intricately regulated. In fact, the statutes and rights pertaining to patient access to psychotherapy notes vary across states. Taken together, federal and state laws indirectly and inconsistently delineate lawful access-as well as clinical exceptions to providing access-to psychotherapy notes. Federal law defers to state laws when the latter afford individuals greater access to their notes. Both federal and individual state levels vary in providing for possible conditions under which access may be restricted. Right of access to psychotherapy notes is a matter of importance for all mental health clinicians in the United States. Awareness and integration of pertinent laws and regulations allow clinicians to manage such matters without a negative impact on their clinical care. Further consideration of how clinical practice interacts with other dimensions of health care administration (clinical, ethical, and legal) may serve to enhance the integrity of a clinician's work and the ability to adapt to difficult clinical circumstances with confidence.

Piloting a Clinical Decision Support Tool to Identify Patients With Social Needs and Provide Navigation Services and Referral to Community-Based Organizations: Protocol for a Randomized Controlled Trial.

Social needs and social determinants of health (SDOH) significantly outrank medical care when considering the impact on a person's length and quality of life, resulting in poor health outcomes and worsening life expectancy. Integrating social needs and SDOH data along with clinical risk information within operational clinical decision support (CDS) systems built into electronic health records (EHRs) is an effective approach to addressing health-related social needs. To achieve this goal, applied research is needed to develop EHR-integrated CDS tools and closed-loop referral systems and implement and test them in the digital and clinical workflows at health care systems and collaborating community-based organizations (CBOs). This study aims to describe the protocol for a mixed methods study including a randomized controlled trial and a qualitative phase assessing the feasibility, acceptability, and effectiveness of an EHR-integrated digital platform to identify patients with social needs and provide navigation services and closed-loop referrals to CBOs to address their social needs. The randomized controlled trial will enroll and randomize adult patients living in socioeconomically challenged neighborhoods in Baltimore City receiving care at a single academic health care institution in the 3-month intervention (using the digital platform) or the 3-month control (standard-of-care assessment and addressing of social needs) arms (n=295 per arm). To evaluate the feasibility and acceptability of the digital platform and its impact on the clinical and digital workflow and patient care, we will conduct focus groups with the care teams in the health care system (eg, clinical providers, social workers, and care managers) and collaborating CBOs. The outcomes will be the acceptability, feasibility, and effectiveness of the CDS tool and closed-loop referral system. This clinical trial opened to enrollment in June 2023 and will be completed in March 2025. Initial results are expected to be published in spring 2025. We will report feasibility outcome measures as weekly use rates of the digital platform. The acceptability outcome measure will be the provider's and patient's responses to the truthfulness of a statement indicating a willingness to use the platform in the future. Effectiveness will be measured by tracking a 3-month change in identified social needs and provided navigation services as well as clinical outcomes such as hospitalization and emergency department visits. The results of this investigation are expected to contribute to our understanding of the use of digital interventions and the implementation of such interventions in digital and clinical workflows to enhance the health care system and CBO ability related to social needs assessment and intervention. These results may inform the construction of a future multi-institutional trial designed to test the effectiveness of this intervention across different health care systems and care settings. ClinicalTrials.gov NCT05574699; https://clinicaltrials.gov/study/NCT05574699. DERR1-10.2196/57316.

Electronic documentation burden among outpatient rehabilitation therapists: a qualitative descriptive study and quality improvement initiative.

Outpatient rehabilitation (rehab) physical, occupational, and speech therapists use electronic health records (EHR), yet their documentation experiences, including any documentation burden, are not well researched. Therapists are a growing portion of the U.S. healthcare workforce, whose need is critical to the health of an aging population. We aimed to describe outpatient rehab therapists' documentation experiences and identify strategies for mitigating any documentation burden. We used qualitative descriptive methodology to conduct 4 focus groups with outpatient rehab therapists at Hospital for Special Surgery, a multi-site orthopedic institution. Transcripts were inductively coded to identify themes and actionable strategies for improving the therapists' documentation experiences. Therapists provided feedback and prioritization of proposed strategies. A total of 13 therapists were interviewed. Five themes and 10 subthemes characterize the therapists' documentation experience by a feeling that documentation inhibits clinical care and work/life balance, a perceived lack of support and efficiencies, the desire to document to communicate clinical care, and a design vision for improving the EHR. Top prioritized strategies for improvement included use of timesaving templates, expanding dictation, decluttering the EHR interface, and support for free texting over discrete data capture. Outpatient rehab therapists experience documentation burden similar to that documented of physicians and nurses. Manual data entry imposes burden on therapists' time and clinical care. A multi-faceted approach is needed for improving therapists' experiences including EHR redesign, technology supporting dictation and narrative to discrete data capture, and support from leadership and regulators.

Update on Genetic Counselor Practice and Recommendations for Pediatric Cancer Predisposition Evaluation and Surveillance.

In July 2023, the American Association for Cancer Research held the second Childhood Cancer Predisposition Workshop at which international experts in pediatric cancer predisposition met to update the previously published 2017 consensus statements on pediatric cancer predisposition syndromes. Since 2017, advances in tumor and germline genetic testing and increased understanding of cancer predisposition in pediatric cancer patients have led to significant changes in clinical care. Here, we provide an updated genetic counseling framework for pediatric oncology professionals. The framework includes: (1) referral indications and timing; (2) somatic and germline genetic testing options; (3) testing for adult-onset cancer predisposition syndromes in children with and without cancer; (4) evolving genetic counseling models to meet the increased demand for genetic testing; (5) barriers to cancer genetic testing and surveillance in children; and (6) psychosocial and equity considerations regarding cancer genetic testing and surveillance in children. Adaptable genetic counseling services are needed to provide support to pediatric oncology provider teams and diverse patients with pediatric cancer, cancer predisposition, and their families.

Human-AI Teaming in Critical Care: A Comparative Analysis of Data Scientists' and Clinicians' Perspectives on AI Augmentation and Automation.

Artificial intelligence (AI) holds immense potential for enhancing clinical and administrative health care tasks. However, slow adoption and implementation challenges highlight the need to consider how humans can effectively collaborate with AI within broader socio-technical systems in health care. In the example of intensive care units (ICUs), we compare data scientists' and clinicians' assessments of the optimal utilization of human and AI capabilities by determining suitable levels of human-AI teaming for safely and meaningfully augmenting or automating 6 core tasks. The goal is to provide actionable recommendations for policy makers and health care practitioners regarding AI design and implementation. In this multimethod study, we combine a systematic task analysis across 6 ICUs with an international Delphi survey involving 19 health data scientists from the industry and academia and 61 ICU clinicians (25 physicians and 36 nurses) to define and assess optimal levels of human-AI teaming (level 1=no performance benefits; level 2=AI augments human performance; level 3=humans augment AI performance; level 4=AI performs without human input). Stakeholder groups also considered ethical and social implications. Both stakeholder groups chose level 2 and 3 human-AI teaming for 4 out of 6 core tasks in the ICU. For one task (monitoring), level 4 was the preferred design choice. For the task of patient interactions, both data scientists and clinicians agreed that AI should not be used regardless of technological feasibility due to the importance of the physician-patient and nurse-patient relationship and ethical concerns. Human-AI design choices rely on interpretability, predictability, and control over AI systems. If these conditions are not met and AI performs below human-level reliability, a reduction to level 1 or shifting accountability away from human end users is advised. If AI performs at or beyond human-level reliability and these conditions are not met, shifting to level 4 automation should be considered to ensure safe and efficient human-AI teaming. By considering the sociotechnical system and determining appropriate levels of human-AI teaming, our study showcases the potential for improving the safety and effectiveness of AI usage in ICUs and broader health care settings. Regulatory measures should prioritize interpretability, predictability, and control if clinicians hold full accountability. Ethical and social implications must be carefully evaluated to ensure effective collaboration between humans and AI, particularly considering the most recent advancements in generative AI.

Equivalence of Alcohol Use Disorder Symptom Assessments in Routine Clinical Care When Completed Remotely via Online Patient Portals Versus In Clinic via Paper Questionnaires: Psychometric Evaluation.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends the paper-based or computerized Alcohol Symptom Checklist to assess alcohol use disorder (AUD) symptoms in routine care when patients report high-risk drinking. However, it is unknown whether Alcohol Symptom Checklist response characteristics differ when it is administered online (eg, remotely via an online electronic health record [EHR] patient portal before an appointment) versus in clinic (eg, on paper after appointment check-in). This study evaluated the psychometric performance of the Alcohol Symptom Checklist when completed online versus in clinic during routine clinical care. This cross-sectional, psychometric study obtained EHR data from the Alcohol Symptom Checklist completed by adult patients from an integrated health system in Washington state. The sample included patients who had a primary care visit in 2021 at 1 of 32 primary care practices, were due for annual behavioral health screening, and reported high-risk drinking on the behavioral health screen (Alcohol Use Disorder Identification Test-Consumption score ≥7). After screening, patients with high-risk drinking were typically asked to complete the Alcohol Symptom Checklist-an 11-item questionnaire on which patients self-report whether they had experienced each of the 11 AUD criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) over a past-year timeframe. Patients could complete the Alcohol Symptom Checklist online (eg, on a computer, smartphone, or tablet from any location) or in clinic (eg, on paper as part of the rooming process at clinical appointments). We examined sample and measurement characteristics and conducted differential item functioning analyses using item response theory to examine measurement consistency across these 2 assessment modalities. Among 3243 patients meeting eligibility criteria for this secondary analysis (2313/3243, 71% male; 2271/3243, 70% White; and 2014/3243, 62% non-Hispanic), 1640 (51%) completed the Alcohol Symptom Checklist online while 1603 (49%) completed it in clinic. Approximately 46% (752/1640) and 48% (764/1603) reported ≥2 AUD criteria (the threshold for AUD diagnosis) online and in clinic (P=.37), respectively. A small degree of differential item functioning was observed for 4 of 11 items. This differential item functioning produced only minimal impact on total scores used clinically to assess AUD severity, affecting total criteria count by a maximum of 0.13 criteria (on a scale ranging from 0 to 11). Completing the Alcohol Symptom Checklist online, typically prior to patient check-in, performed similarly to an in-clinic modality typically administered on paper by a medical assistant at the time of the appointment. Findings have implications for using online AUD symptom assessments to streamline workflows, reduce staff burden, reduce stigma, and potentially assess patients who do not receive in-person care. Whether modality of DSM-5 assessment of AUD differentially impacts treatment is unknown.

Suitability and Usefulness of a Flexible Dosing Timing of Oral Semaglutide to Maximize Benefit in Clinical Practice: An Expert Panel.

From clinical trials and observational data, oral semaglutide has proven to be the most effective second-line oral therapy for the management of patients with type 2 diabetes. This review aims to describe the perspective of an Italian expert panel that addressed the potential challenges arising during the use of oral semaglutide in the free-living conditions of routine clinical care. A group of Italian experts discussed and generated insights into the use of oral semaglutide in clinical practice. Key topics included the effectiveness of oral semaglutide in clinical practice, the positioning of the agent to optimize the treatment benefits, the possibility to adopt flexibility in the administration schedule, critical issues encountered, the role of patient communication and information in the importance of dose escalation and management of adverse events. Available data on efficacy and effectiveness of oral semaglutide from randomized clinical trials and real-world studies were reported, along with factors that determine tolerability and persistence on treatment. The debate over a fixed versus a flexible dosing schedule was critically addressed, providing anecdotical clues from a small case series and a real-world database. Additionally, a set of recommendations for clinicians to consider when prescribing oral semaglutide and during the process of patient monitoring were provided.

Leadership and Followership Dynamics in Interprofessional Health Care Teams: Attending Physician Perspectives.

Effective interprofessional health care team (IHT) members collaborate to reduce medical errors, use resources effectively, and improve patient outcomes, making interprofessional collaboration imperative. Because physicians are often designated as the positional leaders of IHTs, understanding their perspectives on collaboration within IHTs could help to mitigate the disconnects between what is suggested in theory and what is happening in practice. This study aimed to explore leader-follower dynamics within medical teams that are commonly working in clinical care contexts. Using a constructivist approach, the authors conducted 12 individual, semistructured interviews from November 2022 to September 2023 with attending physicians who have led IHTs in perioperative (i.e., preoperative clinic, operating room, postoperative and recovery unit) or emergency department settings. The transcripts were analyzed from December 2022 to December 2023 using inductive thematic analysis. Three themes explained the physician perceptions of IHT leadership-followership dynamics: (1) physicians are comfortable sharing leadership intraprofessionally, (2) the clinical culture and environment constrain interprofessional followership and shared leadership, and (3) hierarchical models hold true even while active followers are appreciated, when appropriate. The data in this study suggest that, in perioperative and emergency department settings, shared leadership largely may not occur interprofessionally but occurs intraprofessionally. Participants suggested that the clinical culture and environment (i.e., legal concerns, hierarchical assumption, patient care ownership responsibilities) constrained interprofessional followership and shared leadership. On the basis of the study's findings and how they align with previous research, future research into interprofessional collaboration and followership roles should focus on what factors enable and constrain active followership and shared leadership. Such collaboration can only be achieved when active followership and shared leadership are allowed and promoted. These findings and others suggest that not all contexts are enabling such types of interprofessional collaboration due to legal concerns, hierarchical traditions, and patient ownership considerations.

Enhancing Laryngoscopy Mastery: The Impact of Autonomous Practice with Feedback-Providing Simulators.

Mastery learning with fixed end points and variable training time leads to more consistent expertise but is difficult to implement. Here we piloted mastery learning of laryngoscopy with independent practice. 35 learners participated in independent mastery learning on a manikin that provides automated performance feedback. A pre- and postpractice assessment of intubation skills was completed. After an average of 21 minutes of open practice, the percentage of subjects that met mastery criteria improved from 24% to 89% (P < .05). Independent intubation practice with manikin feedback facilitated mastery learning, enhanced procedural education, and may impact clinical care.

Insights into the clinical, immunologic, and genetic underpinnings of food allergy.

The last few decades have seen striking changes in the field of food allergy. The prevalence of the disease has risen dramatically in many parts of the globe, and management of the condition has undergone major revision. While delayed introduction of common allergenic foods during infancy was advised for many years, the learning early about peanut allergy (LEAP) trial and other studies led to a major shift in infant feeding practices, with deliberate early introduction of these foods now recommended. Additionally, the Food and Drug Administration approved the first treatment for food allergy in 2020-a peanut oral immunotherapy (OIT) product that likely represents just the beginning of new immunotherapy-based and other treatments for food allergy. Our knowledge of the environmental and genetic factors contributing to the pathogenesis of food allergy has also undergone transformational advances. Here, we will discuss our efforts to improve the clinical care of patients with food allergy and our understanding of the immunological mechanisms contributing to this common disease.

Misinterpretations about CT numbers, material decomposition, and elemental quantification.

Quantitative CT imaging, particularly iodine and calcium quantification, is an important CT-based biomarker. This study quantifies sources of errors in quantitative CT imaging in both single-energy and spectral CT. This work examines the theoretical relationship between CT numbers, linear attenuation coefficient, and material quantification. We derive four understandings: (1) CT numbers are not proportional with element mass in vivo, (2) CT numbers are proportional with element mass only when contained in a voxel of pure water, (3) iodine-water material decomposition is never accurate in vivo, and (4) for error-free material decomposition a voxel must only consist of the basis decomposition vectors. Misinterpretation-based errors are calculated using the National Institute of Standards and Technology (NIST) XCOM database for: tissue chemical compositions, clinical concentrations of hydroxyapatite (HAP), and iodine. Quantification errors are also demonstrated experimentally using phantoms. In single-energy CT, misinterpretation-induced errors for HAP density in adipose, muscle, lung, soft tissue, and blood ranged from 0-132%, i.e., a mass error of 0-749 mg/cm3. In spectral CT, errors with iodine in the same tissues resulted in a range of < 0.1-33% error, resulting in a mass error of < 0.1-1.2 mg/mL. Our work demonstrates material quantification is fundamentally limited when measured in vivo due to measurement conditions differing from assumed and the errors are at or above detection limits for bone mineral density (BMD) and spectral iodine quantification. To define CT-derived biomarkers, the errors we demonstrate should either be avoided or built into uncertainty bounds. Improving error bounds in quantitative CT biomarkers, specifically in iodine and BMD quantification, could lead to improvements in clinical care aspects based on quantitative CT. CT numbers are only proportional with element mass only when contained in a voxel of pure water, therefore iodine-water material decomposition is never accurate in vivo. Misinterpretation-induced errors ranged from 0-132% for HAP density and < 0.1-33% in spectral CT with iodine. For error-free material decomposition, a voxel must only consist of the basis decomposition vectors.

The Basel model of principle-oriented clinical ethics consultation 2.0 : An introduction for psychiatry

The effectiveness of clinical ethics counselling in medicine in terms of satisfaction of the participants, support of ethical decision-making, perceived impact on clinical care, moral competence and quality of communication is now empirically well validated. In psychiatry, more and more institutions have structures for clinical ethics consultation as well; however, there is still alack of evaluative accompanying research on the benefits and differential indications of the various forms and models of clinical ethics counselling in psychiatry. The article presents the principles and the step by step application of the principle-oriented clinical ethics consultation according to the Basel model2.0. The article is based on material and procedures developed at the Clinical Ethics Unit of the University Hospital Basel and the University Psychiatric Clinics Basel for the principle-oriented clinical ethics consultation according to the Basel model2.0. Principle-oriented clinical ethics consultation according to the Basel model2.0 is suitable for dealing with moral issues and conflicts in psychiatric practice and for their ethical reflection; however, further evaluative accompanying research is needed on the benefits and differential indications of this and other models of clinical ethics support in psychiatry.

Identifying barriers and facilitators for the effective diagnosis and provision of primary health care for otitis media from the perspective of carers of Aboriginal children.

To identify the barriers and facilitators for timely detection and optimal management of otitis media (OM) in Aboriginal children in a primary care setting from the perspective of carers of Aboriginal children. A qualitative, Aboriginal co-designed, participatory action research study with interviews and focus groups in a large town in the Kimberley, Western Australia. The Consolidated Framework for Implementation Research informed stakeholder group identification and interview framework development. Data underwent thematic analysis using NVivo software. Thirty-two carers of Aboriginal children participated. Key barriers identified for the detection of OM were limited information about OM provided to carers and carers feeling disempowered to express their concerns. Key facilitators identified were the provision of health information through health promotion and the use of culturally secure resources. Having a culturally secure clinical environment was identified as essential, with Aboriginal Health Workers playing a vital role in clinical care. No barriers to management of OM in primary care were reported. Facilitators included health care practitioners (HCPs) emphasising the importance of completing antibiotic course and the clinic providing necessary medications. A culturally secure health promotion strategy with health promotion teams, campaigns and resources is needed to increase community awareness of OM signs and symptoms and facilitate appropriate health seeking. It is essential that the local Aboriginal community co-lead and co-develop these initiatives to ensure the unique wisdom and knowledge of Aboriginal people are captured. HCPs and the clinic effectively facilitate management of OM by providing medications and emphasising completion of antibiotics.

Retrospective analysis of interpretable machine learning in predicting ICU thrombocytopenia in geriatric ICU patients

We developed an interpretable machine learning algorithm that prospectively predicts the risk of thrombocytopenia in older critically ill patients during their stay in the intensive care unit (ICU), ultimately aiding clinical decision-making and improving patient care. Data from 2286 geriatric patients who underwent surgery and were admitted to the ICU of Dongyang People’s Hospital between 2012 and 2021 were retrospectively analyzed. Integrated algorithms were developed, and four machine-learning algorithms were used. Selected characteristics included common demographic data, biochemical indicators, and vital signs. Eight key variables were selected using the Least Absolute Shrinkage and Selection Operator and Random Forest Algorithm. Thrombocytopenia occurred in 18.2% of postoperative geriatric patients, with a higher mortality rate. The C5.0 model showed the best performance, with an area under the receiver operating characteristic curve close to 0.85, along with unparalleled accuracy, precision, specificity, recall, and balanced accuracy scores of 0.88, 0.98, 0.89, 0.98, and 0.85, respectively. The support vector machine model excelled at predictively assessing thrombocytopenia severity, demonstrating an accuracy rate of 0.80 in the MIMIC database. Thus, our machine learning-based models have considerable potential in effectively predicting the risk and severity of postoperative thrombocytopenia in geriatric ICU patients for better clinical decision-making and patient care.

Phenotypic variability related to dominant UCHL1 mutations: about three families with optic atrophy and ataxia.

Ubiquitin C-terminal hydrolase L1 (UCHL1) has been associated with a severe, complex autosomal recessive spastic paraplegia (HSP79) [1] [2] [3][4]. More recently, UCHL1 loss of function (LoF) variants have been associated to an autosomal dominant disease characterized by late-onset spastic ataxia, neuropathy, and frequent optic atrophy [5]. Routine clinical care whole-genome (WGS) and exome (ES) sequencing. We present three families with autosomal dominant UCHL1-related disorder. The clinical phenotype mainly associated optic atrophy, mixed cerebellar and sensory ataxia, and possible hearing loss. We delineated two major phenotypes, even within the same family: (1) juvenile severe optic atrophy followed by a later-onset ataxia, or (2) late-onset ataxia with asymptomatic or mild optic atrophy. The families harboured three novel heterozygous variants in UCHL1: two loss of function (p.Lys115AsnfsTer40; c.171_174 + 7del11), and one missense (p.Asp176Asn) involving the catalytic site of the protein and potentially altering the adjacent splice site. We confirm the existence of dominantly inherited UCHL1 pathogenic variants. We describe a considerable intrafamilial phenotypic variability, with two main phenotypes. Optic atrophy was consistently present, but with varying degrees of severity. Neither delayed motor or intellectual development, nor dysmorphic features were part of the dominant phenotype in comparison with the autosomal recessive form. The molecular mechanism appears to be haploinsufficiency. UCHL1 monoallelic variants should therefore be considered in any case of early-onset optic atrophy or in late-onset complex ataxic syndrome with asymptomatic optic atrophy.

Impact of Clinical Pharmacists in the Inflammatory Bowel Disease Clinic.

Background: Limited evidence exists regarding pharmacist involvement and impact in inflammatory bowel disease (IBD) interdisciplinary clinic care models. The purpose is to describe pharmacist utilization in an interdisciplinary IBD clinic and evaluate clinical impact on patient quality of life. Methods: This was a retrospective cohort study comparing outcomes in patients with Crohn's disease initiated on therapy when the implementation of pharmacy services began (Early Phase) to the expansion of pharmacy services (Recent Phase). The primary outcome compared the proportion of patients referred to a pharmacist and those achieving a Harvey-Bradshaw Index (HBI) reduction of ≥3 points after therapy initiation. Results: 50 patients were included in the Early Phase and 43 patients in the Recent Phase. Utilization in pharmacy referrals increased from 48% (n = 24) in the Early Phase to 72% (n = 31) in the Recent Phase (P = 0.03). The proportion of patients achieving a HBI reduction of ≥3 points increased from 35% (n = 14) in the Early Phase to 51% (n = 18) in the Recent Phase (P = 0.23). Results also found a greater proportion of patients remaining steroid free in the Recent Phase compared to the Early Phase (50% vs 63%; P = 0.01) and C-reactive protein (CRP) improved significantly in the Recent Phase (-11) compared to (-3) in the Early Phase (P = 0.006). Conclusion: The utilization of pharmacists in an interdisciplinary IBD clinic increased and showed to impact patient care through improving symptom relief as seen by the achievement rate of the HBI score reduction, reducing steroid use after therapy initiation, and making clinically significant interventions.