Current Clinical Information Research Articles

A user‐friendly calculator to estimate length of time from initial presentation to need for full‐time care or death in individual patients with Alzheimer’s disease

AbstractBackgroundAlzheimer’s disease (AD) exhibits substantial variability in its initial presentation and rate of progression. Our goal was to understand AD progression well enough to create a calculator that uses presented clinical features to estimate the length of time from initial presentation to major disease outcomes in individual patients with AD.MethodThe variability in rate of AD progression is strongly related to the variability in specific disease signs and symptoms identified at initial presentation. We developed a longitudinal Grade of Membership prediction algorithm and demonstrated its ability, based on initial presentation of six fixed covariates and 73 time‐varying clinical signs and/or symptoms, to accurately predict time to need for full‐time care (FTC) and death in two groups: a mainly white, clinic‐based group of AD patients (N = 229), and a statistically representative community‐based sample of Hispanic (N = 211) and non‐Hispanic (N = 62) older adults with MCI or AD. We then created an online calculator for use by physicians, relatives, or patients to generate these predictions.ResultThe calculator is implemented as an online, freely available R Shiny web app: https://cnd‐columbia.shinyapps.io/AD_Calc/. The user is prompted for current clinical information about the patient. Most of this information can be gleaned from patient observation, healthcare providers, or medical records. Unknown items can be skipped or sensibly approximated. The calculator generates individual‐specific survival‐probability curves, including median survival time, over the next 10 years. It also generates conditional probabilities of need for FTC in a way that allows the overall survival time to be decomposed into time free of need for FTC and time in need of FTC. The calculator does not predict which specific individuals would die before the median versus after the median; that prediction cannot be done.ConclusionGiven the substantial variability over individuals in rate of disease progression, knowing the statistics of the individual‐specific survival times as well as the times to need for FTC can be of great value to patients with AD, their caregivers, and health care providers. The new calculator meets this need. In the future, the calculator also can be extended to predict time to other important disease milestones.

The alcohol biomarker phosphatidylethanol (PEth) – test performance and experiences from routine analysis and external quality assessment

Phosphatidylethanol (PEth) are membrane molecules formed from phosphatidylcholine and ethanol through transphosphatidylation catalyzed by phospholipase D. Measurement of the main PEth form 16:0/18:1 is used as a specific and sensitive alcohol biomarker, since its formation requires ethanol, it accumulates in the blood upon repeated ethanol exposure, and it is only slowly eliminated during abstinence. PEth formation correlates with alcohol intake at the population level, albeit with considerable inter-individual variation as for the half-life during withdrawal. Over the past decade, the use of PEth has increased significantly and the applications have broadened. In Sweden, routine decision limits and the interpretation of test results for PEth were harmonized in 2013, using < 0.05 µmol/L (∼35 µg/L) as the recommended lower reporting limit and values > 0.30 µmol/L (∼210 µg/L) to indicate regular high alcohol intake. Routine test results show a large variation with about half being < 0.05 µmol/L and some even exceeding 10 µmol/L. In 2013, an external quality assessment (EQA) scheme for PEth 16:0/18:1 measurement in whole blood was also started (Equalis, Uppsala, Sweden), presently involving 56 laboratories from 13 countries. The agreement of PEth results between the laboratories has gradually improved to a CV < 15%. The current clinical and scientific information suggests that PEth values below the lower reporting limit (typically ∼0.03–0.05 µmol/L, or ∼20–35 µg/L) indicates sobriety or only low or occasional alcohol consumption, while regular high alcohol intake at levels corresponding to harmful drinking is required in most cases to reach PEth values > 0.30 µmol/L.

Physical Therapist Management of Glenohumeral Joint Osteoarthritis: A Clinical Practice Guideline from the American Physical Therapy Association.

A clinical practice guideline on glenohumeral joint osteoarthritis was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists, an occupational therapist, and a physician. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for physical therapist management of glenohumeral joint osteoarthritis. This clinical practice guideline is available in Spanish; see Supplementary Appendix 8.

Phytotherapeutic alternatives for neurodegenerative dementias: Scientific review, discussion and therapeutic proposal.

The incidence and prevalence of age-related neurodegenerative dementias have been increasing. There is no curative therapy and conventional drug treatment can cause problems for patients. Medicinal plants traditionally used for problems associated with ageing are emerging as a therapeutic resource. The main aim is to give a proposal for use and future research based on scientific knowledge and tradition. A literature search was conducted in several searchable databases. The keywords used were related to neurodegenerative dementias, ageing and medicinal plants. Boolean operators and filters were used to focus the search. As a result, there is current clinical and preclinical scientific information on 49 species used in traditional medicine for ageing-related problems, including neurodegenerative dementias. There are preclinical and clinical scientific evidences on their properties against protein aggregates in the central nervous system and their effects on neuroinflammation, apoptosis dysregulation, mitochondrial dysfunction, gabaergic, glutamatergic and dopaminergic systems alterations, monoamine oxidase alterations, serotonin depletion and oestrogenic protection. In conclusion, the potential therapeutic effect of the different medicinal plants depends on the type of neurodegenerative dementia and its stage of development, but more clinical and preclinical research is needed to find better, safer and more effective treatments.

Monkeypox a Concern for Donor-derived Infection?

Monkeypox a Concern for Donor-derived Infection?

S2981 Drug-Induced Autoimmune-Like Hepatitis Due to HemoHIM in a 28-Year Old Pregnant Woman

Introduction: Drug-induced autoimmune-like hepatitis (DIAIH) is a pathologic immune response against proteins in the liver that can be triggered in susceptible individuals by drugs or herbal remedies. While any supplement can cause idiosyncratic hepatotoxicity, up to 16% of drug-induced liver injuries are attributable to herbal supplements. To date, there are still limited data on herbal medicine-related hepatotoxicity. This topic is particularly understudied in pregnant patients, with most current clinical information coming from case reports. While use of supplements is common during pregnancy, there is still limited information regarding their safety. Case Description/Methods: A previously healthy G4P2A1 28-year-old presented at 5 weeks of pregnancy with right upper quadrant pain and fevers, and was presumed to have acute cholecystitis resulting in a laparoscopic cholecystectomy. Despite this, her liver enzymes continued to worsen (AST 2893, ALT 2664, TBili 2.6, Alk Phos 460, INR 1.3). The patient also had laboratory evidence of AIH including Anti-Mi+ 34.5, U1-RNP/RNA-A68 2.4, Chromatin Abs 1.6. She underwent liver biopsy showing drug-induced liver injury and autoimmune hepatitis (AIH). Given that AIH often presents during pregnancy, it was unclear if this presentation represented DIAIH or AIH. Notably, the patient had recently started taking an herbal supplement with purported immune support called HemoHIM that was thought to be a possible driver of DIAIH, The supplement was discontinued and she was started on a 60mg prednisolone with subsequent clinical and laboratory improvement. Despite improvement, the patient suffered spontaneous abortion early in the treatment course and in retrospect underwent unnecessary cholecystectomy. Given concern for possible AIH and slow normalization of LFTs, she was started on azathioprine, but self-discontinued after 7 months. Her liver enzymes remained stable 6 months later; supporting a diagnosis of DIAIH due to HemoHIM rather than AIH which would have likely rebounded with such early treatment withdrawal. Discussion: While DIAILH is an underreported disease in pregnant women this case demonstrates the importance of early diagnosis and treatment. Additionally, it illustrates he challenges in distinguishing between DAILH and AIH especially in patients taking herbal supplements.

Implementation of Virtual Preoperative Evaluation During a Pandemic

<h3>Background Information</h3> Preadmission testing visits have historically been in-person and or via phone calls facilitated by nurse practitioners and registered nurses. Due to the pandemic, a change in process was required to address national and state social distancing recommendations. Project was conducted at a 171-bed community teaching hospital in the Northeast United States. <h3>Objectives of Project</h3> To implement a smooth transition from onsite preoperative evaluations via phone or in-person visit, to 100% virtual visit. <h3>Process of Implementation</h3> In October of 2020 the interdisciplinary leadership and Chief NP made the decision that all permanent RN staff would work from home and that all NP visits would become virtual. The Chief NP and Project Manager collaborated and created a Microsoft Teams account, revised paper resources, and uploaded them so that staff could access electronically. The Telecommunications team transferred existing telephone numbers and linked them with hospital provided laptops, head- sets and Jabber accounts for RN staff. They also provided cameras for the desktops utilized by the NPs. The Clinical Business Analysis team updated and created new appointment types to facilitate phone screens. The Chief NP updated the After Visit Summary which included, Covid screening, visitor restrictions and safe patient commitment. Education was provided to all staff regarding the change in process and available updated resources by the Chief NP and one staff NP. <h3>Statement of Successful Practice</h3> In November 2020 100% of all preoperative visits became remote or virtual. Staff are utilizing a messaging app for internal communication to communicate patient concerns, inquire with clinical questions, scheduling changes. Positive feedback from nursing staff regarding new process. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> High satisfaction and safety for patients and clinicians are the driving force behind these visits. To aid in addressing the long-standing concerns surrounding location and availability, telehealth provides greater flexibility to both patients and clinician while closing the service gap. Having local resources more broadly available via a common online resource, provides the clinician access to the most current clinical information while integrating care efforts that improve health outcomes.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association.

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease.The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

Unmet informatics needs of nurses regarding the use of personal smartphones in the workplace.

This study aimed to investigate the differences in practices, policies, and perceptions of nurses regarding work-related utilization of smartphones in acute-care settings. Mobile devices utilizing emerging technology are widely used in acute-care settings; however, concerns such as potential distraction, improper use, and negative impact on the nursing image in clinical practice remain valid. Nurse managers (n=8) and nurses (n=181) were enrolled from eight academic tertiary hospitals that have comprehensive electronic medical record systems and mobile versions. Between October 2018 and February 2019, participants completed a questionnaire designed to explore their use of smartphones. The reporting guide for self-administered surveys of clinicians was applied. Approximately 80% of nurses carried personal smartphones while working, with 70% using their devices for work. The prevalence of work-related smartphone use ranged from 3% to 43% by functionality, which was lower than that estimated by managers. Frequent uses included taking pictures/videos and internet browsing. Nurses were more positive than managers about the benefits of smartphone use and less burdened by related concerns. Novice and junior nurses were more optimistic than senior nurses. Only one hospital had a policy on nurses' use of personal devices at work. Two unmet needs in the current clinical information system were identified: information supporting task-related knowledge at the bedside and security of data capture and communication. The unintended perception gaps between nurses and managers regarding work-related smartphone use can be closed by nursing leadership. Unmet nursing informatics, particularly for information-seeking purposes, can be addressed in the context of quality assurance. Nurse leaders can advocate secure and proper use of smartphones in clinical practice.

Application of artificial intelligence in COVID-19 medical area: a systematic review.

BackgroundCoronavirus disease 2019 (COVID-19) has caused a large-scale global epidemic, impacting international politics and the economy. At present, there is no particularly effective medicine and treatment plan. Therefore, it is urgent and significant to find new technologies to diagnose early, isolate early, and treat early. Multimodal data drove artificial intelligence (AI) can potentially be the option. During the COVID-19 Pandemic, AI provided cutting-edge applications in disease, medicine, treatment, and target recognition. This paper reviewed the literature on the intersection of AI and medicine to analyze and compare different AI model applications in the COVID-19 Pandemic, evaluate their effectiveness, show their advantages and differences, and introduce the main models and their characteristics.MethodsWe searched PubMed, arXiv, medRxiv, and Google Scholar through February 2020 to identify studies on AI applications in the medical areas for the COVID-19 Pandemic.ResultsWe summarize the main AI applications in six areas: (I) epidemiology, (II) diagnosis, (III) progression, (IV) treatment, (V) psychological health impact, and (VI) data security. The ongoing development in AI has significantly improved prediction, contact tracing, screening, diagnosis, treatment, medication, and vaccine development for the COVID-19 Pandemic and reducing human intervention in medical practice.DiscussionThis paper provides strong advice for using AI-based auxiliary tools for related applications of human diseases. We also discuss the clinicians’ role in the further development of AI. They and AI researchers can integrate AI technology with current clinical processes and information systems into applications. In the future, AI personnel and medical workers will further cooperate closely.

Swarna Prashana - faith in the embrace of research.

Childhood needs diverse nutritional requirements. Poor appetite, lifestyle changes, and poor digestion affects child immunity and make them prone to diseases. Kaumarabhritya, a branch of Ayurveda which deals in child and adolescent health care, has a unique concept of Swarna Prashana (SP) to promote generalized immunity and intellect. SP is commonly recommended to children between 0 and 12 years of age and given as a general health promoter to improve intellect, digestion, strength, immunity, longevity, and complexion. Multiple benefits of SP are mentioned in different Samhitas which needs to be explored on scientific background. Authors have highlighted content variabilities, plausible mechanisms, research tasks and potentials, lacunae, and future prospects about SP. This manuscript is a spotlight on current social, clinical, marketing, and scientific information of Swarna Prashana. SP can be a cost-effective, safe, infrastructure compatible, and prevention-centric approach to improve children's overall health status and has the potential to serve as a positive health care program for children.

Conflicts of interest (COI) among the UpToDate oncology management authors.

e13573 Background: UpToDate is an evidence based clinical resource designed to provide current clinical information. It is a widely used clinical practice tool providing evidenced based recommendations for diagnosis, management, and therapy. The extent of COI among the UpToDate authors has not been well studied. Our study evaluated the extent of COI of UpToDate authors involved in medical management recommendations for the 10 most common cancers in United States. Methods: We examined the latest November 2020 version of the UpToDate clinical management recommendations for 10 most common cancers. Using disclosure lists, we catalogued COIs for participants in each work group. The categories included: Category I- Grant/Research/Clinical Trial Support; Category II- Consultant/Scientific Advisory Boards/Expert witness; Category III- Speakers Bureau; Category IV- Equity Ownership/Stock Options/Patent holder/Employment/Other Financial Interest; and Category V- Spouse/Domestic Partner/Dependent Potential Conflict. We cataloged the companies/institutions involved in each disclosure. An “episode” describes 1 instance of participation of an individual in 1 company in 1 category for each cancer section. Results: There was a total of 207 authors including section and deputy editors of oncology management section. All authors completed their COI disclosures (100%). 128 (62%) of a total of 207 individuals reported COIs. A total of 1343 episodes were disclosed. We found that each author had an average of 10.49 episodes overall. Authors involved in Category I, II, III, IV &amp; V were 6.3%, 13.5%, 3.2%, 4.7% and 1.6% respectively. 29.36% authors were involved both in Category I and II. A total of 672 company affiliations were associated with COI disclosure. AstraZeneca (6.10%), Merck (4.31%) and Novartis (2.68%) were the companies most frequently reported. The guideline with the maximum episodes (223) was prostate cancer. Conclusions: COIs are prevalent among authors of UpToDate clinical management recommendations. More than ½ of the participants disclosed at least 1 COI, but there appears to be a substantial number of experienced experts without COIs. Further research studies are necessary to determine the impact of these COIs on clinical practice patterns and resource utilization. Distribution of COI and total episodes.[Table: see text]

Professionally responsible coronavirus disease 2019 vaccination counseling of obstetrical and gynecologic patients

The development of coronavirus disease 2019 vaccines in the current and planned clinical trials is essential for the success of a public health response. This paper focuses on how physicians should implement the results of these clinical trials when counseling patients who are pregnant, planning to become pregnant, breastfeeding or planning to breastfeed about vaccines with government authorization for clinical use. Determining the most effective approach to counsel patients about coronavirus disease 2019 vaccination is challenging. We address the professionally responsible counseling of 3 groups of patients—those who are pregnant, those planning to become pregnant, and those breastfeeding or planning to breastfeed. We begin with an evidence-based account of the following 5 major challenges: the limited evidence base, the documented increased risk for severe disease among pregnant coronavirus disease 2019-infected patients, conflicting guidance from government agencies and professional associations, false information about coronavirus disease 2019 vaccines, and maternal mistrust and vaccine hesitancy. We subsequently provide evidence-based, ethically justified, practical guidance for meeting these challenges in the professionally responsible counseling of patients about coronavirus disease 2019 vaccination. To guide the professionally responsible counseling of patients who are pregnant, planning to become pregnant, and breastfeeding or planning to breastfeed, we explain how obstetrician-gynecologists should evaluate the current clinical information, why a recommendation of coronavirus disease 2019 vaccination should be made, and how this assessment should be presented to patients during the informed consent process with the goal of empowering them to make informed decisions. We also present a proactive account of how to respond when patients refuse the recommended vaccination, including the elements of the legal obligation of informed refusal and the ethical obligation to ask patients to reconsider. During this process, the physician should be alert to vaccine hesitancy, ask patients to express their hesitation and reasons for it, and respectfully address them. In contrast to the conflicting guidance from government agencies and professional associations, evidence-based professional ethics in obstetrics and gynecology provides unequivocal and clear guidance: Physicians should recommend coronavirus disease 2019 vaccination to patients who are pregnant, planning to become pregnant, and breastfeeding or planning to breastfeed. To prevent widening of the health inequities, build trust in the health benefits of vaccination, and encourage coronavirus disease 2019 vaccine and treatment uptake, in addition to recommending coronavirus disease 2019 vaccinations, physicians should engage with communities to tailor strategies to overcome mistrust and deliver evidence-based information, robust educational campaigns, and novel approaches to immunization.

Allergische Reaktionen auf COVID-19-Impfungen – Was HNO-Ärzte wissen sollten – Teil 1: Allgemeine Aspekte von Allergien auf Impfstoffe, immunologische Grundlagen von Allergien auf Impfstoffe, Immunmechanismen von allergischen und pseudoallergischen Reaktionen, Teil 2: Charakteristiken der mRNA-Impfstoffe BNT162b2 und mRNA-1273 zur Prophylaxe von COVID-19 und assoziierte Immunphänomene, Teil 3: Praktische Aspekte der Prophylaxe, Diagnostik und Therapie von Allergien auf COVID-19-Impfstoffe

With BNT162b2 (approved in the EC on 27th of December 2020) and mRNA-1273 (approved in the EC on 6th of January 2021) for the first time ever two RNA-vaccines received conditional approval within the EC in order to effectively combat the SARS-COV2 pandemic. The emergence of sporadic cases of anaphylaxis following vaccination with these new compounds and the identification of PEGs (polyethylenglycols) as potential, widely used but yet usually unknown culprits have led to uncertainty among treating physicians and patients. The aim of this article series is to summarize current available pathophysiological and clinical information (part 1), to describe the characteristics of the vaccines (part 2) and to provide practical solutions for diagnosis and treatment of potential allergy against mRNACovid19 vaccines.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia.

(Reprinted with permission from The American Journal of Psychiatry 2020; 177:868-872).

Hepatitis B reactivation and immune check point inhibitors

Background: Liver toxicity during immune checkpoint inhibitor treatment is mostly due to immune mediated hepatitis. Viral hepatitis, as well as auto-immune or metabolic hepatitis, are considered as exclusion criteria for ICI induced immune hepatitis diagnosis. However, considering the high prevalence of viral hepatitis B infection and the increasing prescription of immune checkpoint inhibitors, their use in patients with HBV chronic viral infection may be common, even more if patients are treated for hepatocellular carcinoma. Few clinical studies directly deal with the risk of HBV reactivation during ICI therapy and real-life data is currently based on five reported cases of HBV reactivation, one with fatal outcome.In this review, we summarize the current available clinical information about HBV reactivation risk during ICI treatment, its hypothetic mechanism, and propose practical recommendations about verifying and monitoring HBV status throughout the treatment.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia

Physical Therapist Management of Total Knee Arthroplasty.

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.