Diagnosis Of Patients Research Articles

Diagnosis of functional strictures in patients with primary sclerosing cholangitis using hepatobiliary contrast-enhanced MRI: a proof-of-concept study

ObjectivesPSC strictures are routinely diagnosed on T2-MRCP as dominant- (DS) or high-grade stricture (HGS). However, high inter-observer variability limits their utility. We introduce the “potential functional stricture” (PFS) on T1-weighted hepatobiliary-phase images of gadoxetic acid-enhanced MR cholangiography (T1-MRC) to assess inter-reader agreement on diagnosis, location, and prognostic value of PFS on T1-MRC vs. DS or HGS on T2-MRCP in PSC patients, using ERCP as the gold standard.MethodsSix blinded readers independently reviewed 129 MRIs to diagnose and locate stricture, if present. DS/HGS was determined on T2-MRCP. On T1-MRC, PFS was diagnosed if no GA excretion was seen in the CBD, hilum or distal RHD, or LHD. If excretion was normal, “no functional stricture” (NFS) was diagnosed. T1-MRC diagnoses (NFS = 87; PFS = 42) were correlated with ERCP, clinical scores, labs, splenic volume, and clinical events. Statistical analyses included Kaplan–Meier curves and Cox regression.ResultsInterobserver agreement was almost perfect for NFS vs. PFS diagnosis, but fair to moderate for DS and HGS. Forty-four ERCPs in 129 patients (34.1%) were performed, 39 in PFS (92.9%), and, due to clinical suspicion, five in NFS (5.7%) patients. PFS and NFS diagnoses had 100% PPV and 100% NPV, respectively. Labs and clinical scores were significantly worse for PFS vs. NFS. PFS patients underwent more diagnostic and therapeutic ERCPs, experienced more clinical events, and reached significantly more endpoints (p < 0.001) than those with NFS. Multivariate analysis identified PFS as an independent risk factor for liver-related events.ConclusionT1-MRC was superior to T2-MRCP for stricture diagnosis, stricture location, and prognostication.Clinical relevance statementBecause half of PSC patients will develop clinically-relevant strictures over the course of the disease, earlier more confident diagnosis and correct localization of functional stricture on gadoxetic acid-enhanced MRI may optimize management and improve prognostication.Key Points• There is no consensus regarding biliary stricture imaging features in PSC that have clinical relevance.• Twenty-minute T1-weighted MRC images correctly classified PSC patients with potential (PFS) vs with no functional stricture (NFS).• T1-MRC diagnoses may reduce the burden of diagnostic ERCPs.Graphical abstract

COVID-19 Proactive Disease Management Using COVID Virtual Hospital in a Rural Community.

A community teaching hospital serving a rural population established an intensive "hospital at home" program for patients with COVID-19 utilizing disease risk stratification and pulse oximeter readings to dictate nurse and clinician contact. Herein, we report patient outcomes and provider experiences resulting from this "virtual" approach to triaging pandemic care. COVID-19-positive patients appropriate for outpatient management were enrolled in our COVID Virtual Hospital (CVH). Patients received pulse oximeters and instructions for home monitoring of vital signs. CVH nurses contacted the patient within 12-48 hours. The primary care provider was alerted of the patient's diagnosis and held a virtual visit with patient within 2-3 days. Nurses completed a triage form during each patient call; the resulting risk score determined timing of subsequent calls. CVH-relevant patient outcomes included emergency department (ED) visits, mortality, and disease-related hospitalization. Additionally, a survey of providers was conducted to assess CVH experience. From April 22, 2020, to December 21, 2020, 1916 patients were enrolled in the CVH, of which 195 (10.2%) had subsequent visits to the ED. Among those 195 ED visits, 102 (52.3%) were nurse-directed while 93 (47.7%) were patient self-directed; 88 (86.3%) nurse-directed ED visits were subsequently admitted to inpatient care and 14 were discharged home. Of the 93 self-directed ED visits, 3 (3.2%) were admitted. A total of 91 CVH patients (4.7%) were ultimately admitted to inpatient care. Seven deaths occurred among CVH patients, 5 of whom had been admitted for inpatient care. Among 71 providers (23%) who responded to the survey, 94% and 93% agreed that the CVH was beneficial to providers and patients, respectively. Proactive in-home triage of patients with COVID-19 utilizing a virtual hospital model minimized unnecessary presentations to ED and likely prevented our rural hospital from becoming overwhelmed during year one of the pandemic.

Metronidazole for Prevention of Pelvic Cellulitis and Abscess after Laparoscopic Hysterectomy: A Triple-blinded, Randomized, Placebo-controlled Clinical Trial

To determine whether a postoperative 5-day treatment schedule with vaginal metronidazole added to conventional antibiotic prophylaxis with 2 g cefazolin modifies the risk of pelvic cellulitis (PC) and pelvic abscess (PA) after total laparoscopic hysterectomy (TLH). A randomized, controlled, triple-blind, multicenter clinical trial. Two centers dedicated to minimally invasive gynecologic surgery in Colombia. A total of 574 patients were taken to TLH because of benign diseases. Patients taken to TLH were divided into 2 groups (treatment group, cefazolin 2 g intravenous single dose before surgery+metronidazole vaginal ovules for 5 days postoperatively, control group: cefazolin 2 g intravenous single dose+placebo vaginal ovules for 5 days postoperatively). The absolute frequency (AF) of PC and PA and their relationship with the presence of bacterial vaginosis (BV) were measured. There was no difference in AF of PC (AF, 2/285 [0.7%] vs 5/284 [1.7%] in the treatment and placebo groups, respectively; risk ratio, 1.75; 95% confidence interval, 0.54-5.65; p=.261), nor for PA (AF, 0/285 [0%] vs 2/289 [0.7%]; p=.159, in the treatment and placebo groups, respectively). The incidence of BV was higher in the metronidazole group than the placebo group (42.5% vs 33.4%, p=.026). The use of vaginal metronidazole ovules during the first 5 days in postoperative TLH added to conventional cefazolin prophylaxis does not prevent the development of PC or PA, regardless of the patient's diagnosis of BV.

POTENTIAL USE OF VIRTUAL REALITY IN TELEHEALTH USINGARTIFICIAL INTELLIGENCE

Healthcare has become important to live a prosperous life. Telehealth and telemedicine technology help patients to get healthy life at their convenient place. It has become easy for doctors, healthcare providers to assess their patients through telehealth technology. Virtual Reality helps us to be active and productive in our day-to- day life. It helps to reduce stress and cure illness by providing a fitness routine that reduces and heals pain.The automation allows the system to operate according to the patient's diagnosis. This system not only is helpful for patients but also for people who want to have a healthylife. It is time-consuming and cost-saving and it can provide efficient features to detect the cause and solutionto prevent it. The aim of this paper is to provide healthy life through virtual assessment and recovery through the issues people are facing to remain physically and mentally fit. The integration of VR and AI has the potential to enhance patient experiences, and healthcare outcomes, and increase access to quality healthcare services, particularly in remote or underserved areas.

1838-PUB: Impact of COVID-19 on New-Onset Pediatric Diabetes Diagnoses

Introduction: Global trends show an increased number of pediatric patients with newly diagnosed diabetes who present in severe diabetic ketoacidosis (DKA) during the COVID-19 pandemic. Methods: Medical records were reviewed for pediatric patients &amp;lt;18 years of age with new onset diabetes mellitus (DM) diagnosed two years pre-pandemic and two years during the COVID pandemic. Data collected included demographic, biochemical, and hospitalization data. Logistic regression was used to investigate the relationship between BMI, hemoglobin A1c, duration of hospital stay, DKA, and pandemic time frame. Results: A total of 175 cases of new onset DM were diagnosed during the study period; 54% post-pandemic. This represents a 16% increase in incident cases in the post-pandemic period. The sample was 55.4% male, 74.9% White/Caucasian, and 33.1% non-Hispanic. Type 1 DM comprised 136 cases. Inpatient diagnoses were the same in both the pre- and post-pandemic periods, n=75. Outpatient diagnoses during the pandemic period (n=19) were significantly higher than in the pre-pandemic period (n=6), X2(1) = 5.83, p &amp;lt; 0.05. The overall logistic regression model was statistically significant, X2(7) =18.35, p &amp;lt; 0.05. Hemoglobin A1c (p &amp;lt; 0.05, OR = 0.756, 95% CI [0.606, 0.945]) and length of hospital stay (p &amp;lt; 0.05, OR = 0.586, 95% CI [0.381, 0.902]) were significantly different between the two time periods, but BMI percentile (p = 0.869) and bicarbonate levels (p = 0.962) were not. Discussion: There was an increased incidence of new onset DM diagnosed in pediatric patients post-COVID. Surprisingly, outpatient cases accounted for the increased number. This study showed that during the pandemic, patients presented with a higher hemoglobin A1c and stayed longer in the hospital than prior to the pandemic. Disclosure K.Simms: None. S.Green: None. M.Shah: None. M.Sareini: None. C.Chin: None.

Six domains of health: a practical approach to identifying priorities in dementia care.

High-quality healthcare for people living with dementia encompasses both patients and care partners (CPs). A framework populated with simple assessment tools is needed to deconstruct this complexity into actionable domains that inform assessment and care planning for individuals and dyads, help differentiate care team roles, and can more fully estimate true population burden in health and social care systems. Researchers used a cross-sectional mixed-methods descriptive study to illustrate the use of an inductive Six Domain framework and simple assessment tools in a sample of dyads selected for complexity. Data was collected from three university-affiliated hospitals with a shared electronic medical record (EMR). Eighty-eight CPs for people living with dementia (care recipients) newly discharged home after an acute medical hospitalization participated. Care recipients' outpatient and inpatient diagnoses, medications, and care were extracted from the EMR. CPs completed an in-home semi-structured interview and study measures. Data were sorted into six domains: three care recipient-focused domains (cognition, emotion/behavior, general and functional health); a single CP-focused domain (mood, cognition, stress, and self-rated health); a health-related social needs domain (enrollment of persons with dementia in low-income insurance, CP-reported financial strain); and a care delivery domain (CP-reported engagement with clinicians in care recipients' care planning, and match between CP-reported knowledge of care recipients' medical care needs and medical records). As expected, all people living with dementia had significant cognitive, neurobehavioral, and medical complexity requiring extensive oversight and management at home. Over a third of CPs reported high stress, depression, or anxiety. A fifth screened positive for one or more indicators of poor health, cognitive impairment, and/or health-related social needs. CP reports and care recipients' medical records were discordant for chronic conditions in 68% of cases and for prescribed medications in 44%. In 85% of cases, there were gaps in indicators of CP-clinician collaboration in care management. The Six Domains of Health framework captures a broad array of challenges that are relevant to providing comprehensive dyadic care and setting individualized health and social care priorities. With further study, it could provide conceptual scaffolding for comparative population research and more equitable, fully integrated pathways for care.

1455-P: Developing Computable Phenotypes (CPs) for Identifying Children, Adolescents, and Young Adults with Diabetes Using Electronic Health Records in the DiCAYA Network

The DiCAYA Network, which is funded by the CDC and NIDDK, is working to create a nationwide electronic health record-based diabetes surveillance system. The feasibility and performance of existing diabetes computable phenotypes in this system were unknown, as they had only been tested in individual health systems. This study aimed to develop a DiCAYA-wide EHR-based computable phenotype (CP) to identify prevalent cases of diabetes by type. We conducted network-wide chart reviews for 1830 youth (age &amp;lt; 18y) and 1830 young adults (age 18 - &amp;lt;45y) among individuals with possible diabetes, identified as those with any potential indication of diabetes in the EHR (any diabetes-related diagnosis, medication, or abnormal lab test). We assessed the performance of the DiCAYA CP (two outpatient diagnoses or one inpatient diagnosis by type) for identifying diabetes and diabetes type in children and young adults in the reviewed sample, using chart review as the gold standard. (Table 1). We developed a highly accurate EHR-based CP for diabetes in children and young adults based on EHR data from the DiCAYA network. Our results support the feasibility of deploying a unified CP across a nationwide EHR network for diabetes surveillance, with consistently high accuracy across the participating sites. Disclosure H.Shao: Consultant; Lilly Diabetes. B.E.Dixon: Consultant; Merck &amp; Co., Inc. E.Lustigova: None. M.Rosenman: None. V.W.Zhong: None. S.Conderino: None. J.Divers: None. L.Thorpe: None. A.D.Liese: None. C.Rudisill: Stock/Shareholder; Pfizer Inc., Viatris Inc., Teladoc Health, Catalent. J.S.Obeid: None. Y.Guo: None. M.E.Pavkov: None. G.Imperatore: None. J.A.Ewing: None. J.Bian: None. P.Li: None. D.Dabelea: None. R.B.Conway: None. T.L.Crume: None. B.S.Schwartz: None. A.G.Hirsch: None. Funding Centers for Disease Control and Prevention (U18DP006512)

Rare Skin Eruption Caused by Paracetamol: A Case of Acute Generalized Exanthematous Pustulosis

Background: This case report aims to enhance clinicians' ability to identify and effectively manage rare skin eruptions, specifically focusing on Acute Generalized Exanthematous Pustulosis (AGEP) by providing valuable insights into the context of its diagnostic challenges and clinical implications.&#x0D; Presentation of Case: We present a case of AGEP in a 16-year-old Indian boy who developed generalized pustulosis after taking Paracetamol (Acetaminophen). The patient's diagnosis was initially delayed due to the resemblance of AGEP with other skin conditions. Furthermore, the inadvertent reintroduction of Paracetamol exacerbated the condition.&#x0D; Discussion: We discuss various treatment options and emphasize the importance of prompt and accurate diagnosis of AGEP by utilizing the AGEP validation. By employing this scoring system, clinicians can enhance their diagnostic accuracy and avoid unnecessary delays in treatment initiation.&#x0D; Conclusion: The prompt identification of AGEP using the AGEP validation score is crucial for timely management. This case report highlights the potential risks associated with common drugs like Paracetamol and emphasizes the need for vigilance in prescribing medications. Clinicians should be aware of the distinctive features of AGEP and consider it as a differential diagnosis in patients presenting with pustular skin eruptions following drug intake. Improved awareness and application of diagnostic tools can aid in better patient outcomes.

Analisis Penerapan Lean Six Sigma dalam Meningkatkan Efektifitas Laboratorium Rumah Sakit: A Literature Review

Hospital quality must be improved for the benefit of patients because the main task of a hospital or health care facility is to provide medical services to patients. The laboratory is part of the medical service that provides services such as making a diagnosis, providing treatment, monitoring the results of treatment, and establishing a patient's diagnosis. This article was prepared using the literature review method by outlining the contents of the research results that already existed and in accordance with the topic of discussion regarding the analysis of the application of lean six sigma in increasing the effectiveness of hospital laboratories with the lean method using Google Scholar, Emerald, and Pubmed with the keywords lean six sigma, laboratory, and hospital or lean six sigma, laboratory, and hospital. Based on the results of the literature review, it was found that the activities carried out in the laboratory still show activities that do not generate added value or waste. This is because the technique for handling examination specimens sent from inpatients and the emergency room has not been effective, and the mechanism for handing over specimens between health workers has not been effective. Research (Ibrahim et al., 2022) shows the implementation of lean six sigma can improve the timeliness of inpatients for routine CBC tests in the laboratory and minimize patient dissatisfaction.

Designing a minimum data set of laboratory data for the electronic summary sheet of pediatric ward in Iran: A cross-sectional study.

Iranian hospitals are provided with hospital information systems (HISs) from different vendors, which make it hardly possible to summarize laboratory data in an consistent manner. Therefore, there is a need to design a minimum data set of laboratory data that will define standard criteria and reduce potential medical errors. The purpose of this study was to design a minimum data set (MDS) of laboratory data for an electronic summary sheet to be used in the pediatric ward of Iranian hospitals. This study consists of three phases. In the first phase, out of 3997 medical records from the pediatric ward, 604 summary sheets were chosen as sample. The laboratory data of these sheets were examined and the recorded tests were categorized. In the second phase, based on the types of diagnosis we developed a list of tests. Then we asked the physicians of the ward to select which ones should be documented for each patient's diagnosis. In the third phase, the tests that were reported in 21%-80% of the records, and were verified by the same percentage of physicians, were evaluated by the experts' panel. In the first phase, 10,224 laboratory data were extracted. Of these, 144 data elements reported in more than 80% of the records, and more than 80% of experts approved them to be included in the MDS for patients' summary sheet. After data elements were investigated in the experts' panel, 292 items were chosen for the final list of the data set. This MDS was designed such that, if implemented in hospital information systems, it could automatically enable registering data in the summary sheet when patient's diagnosis is registered.

PRESCRIPTION COST ANALYSIS IN PATIENTS OF TYPE 2 DM AND HYPERTENSION JOINING CHRONIC DISEASE MANAGEMENT PROGRAM (PROLANIS) AT PUSKESMAS AFTER THE IMPLEMENTATION OF NATIONAL HEALTH INSURANCE

To improve the status of public health and carry out social security programs in the health sector, the government started to implement the National Health Insurance. This program covers the participants’ medical care expenses using the capitation system applied in health centers as the First-Level Health Facilities. BPJS Kesehatan has allocated some budget in the form of a capitation rate to first-level health facilities for hypertension and type 2 diabetes mellitus patients after the implementation of National Health Insurance. This research was carried out in 4 health centers, namely Lamper Tengah Health Center, Mangkang Health Center, Mijen Health Center, and Karanganyar Health Center. The data were collected retrospectively from the medical records of 800 patients. The data were analyzed descriptively to determine the prescription cost and Spearman's rho test was used to find the factors that influence the prescription cost. It was revealed that the average prescription cost for type 2 DM patients was IDR 142,293, and for hypertensive patients was IDR 112,735. The prescribing pattern in patients covered by Prolanis program for type 2 DM patients is a combination of glimepiride, metformin with a drug price of IDR 20,670. Factors that have an influence on prescription costs are diagnosis p= 0.033, type of drug (p= 0.000) and drug item (p= 0.000). This study concludes that the factors to influence the drug costs of Prolanis patients at the health centers of Semarang City were the patient's diagnosis, the type of drug given, and the number of drug items given.

Impact of COVID-19 pandemic on lung cancer diagnosis in a community hospital.

e18634 Background: Coronavirus disease 2019 (COVID 19) pandemic saw its first case in the United States in 2020. Although lung imaging for COVID-19 patients theoretically increased chances of detecting cancerous lung nodules, strict quarantine measures disrupting routine cancer screening was a concern. Real-world data on lung cancer diagnosis during the pandemic at community level is less known. Methods: We conducted a retrospective chart review on patients newly diagnosed of lung cancer from 2018- 2022 in our community hospital. Demographic details, year of diagnosis, type and stage of cancer, inpatient or outpatient diagnosis and mode of diagnosis (surveillance, incidental or symptomatic) was noted. Descriptive analysis of the above parameters was conducted across three eras- 2018 and 2019 as pre-COVID era (PreCo), 2020 and 2021 as COVID era (Cov) and 2022 as post-COVID era (PosCo) irrespective of COVID-19 diagnosis. Results: Out of 287 patients included, 40% (116) were diagnosed during PreCo, 27.5% (79) during Cov and 32% (92) during PosCo. In the PreCo, 16% (19) were incidentally detected, 21% (24) were ISym, 48% (56) on surveillance, and 15% (17) were OSym. In Cov, 13.9% (11) were incidentally detected, 53.3% (42) were ISym 13.9% (11) on surveillance, and 18.9% (15) were OSym. In PosCo, 11.3% (11) were incidentally detected, 19% (18) were ISym, 44% (41) on surveillance, and 24% (22) were OSym. Stage IV cancers among new lung cancer diagnoses were noted to be highest in PosCo (43.4%) followed by PreCo (31.9%) and Cov (26.6%). Conclusions: Cov saw a decrease in the annual rate of new lung cancer diagnosis compared to PreCo likely secondary to reduced routine screening. A staggering increase in new and stage IV cancers were noted in PosCo which could stem from missed screening as well as rapid progression of undiagnosed cancers during the pandemic. In Cov, there was a dramatic increase in symptomatic inpatient lung cancer cases (53.3%) as symptoms of COVID-19 and lung cancer overlap. Comparable rates of cancer diagnosis via surveillance in PosCo (44%) and PreCo (48%) hints at possible restoration of access to outpatient cancer care. [Table: see text]

Information and decisional needs of patients (pts) with newly diagnosed advanced cancer in the hospital: A multi-level, mixed-methods study.

e24177 Background: Pt informed decision-making (IDM) is crucial in cancer care. Little is known about the informational and decisional needs of pts with newly diagnosed advanced cancer in the hospital, for whom unique IDM challenges may exist. Methods: A single-center, mixed-methods study of hospitalized pts with a newly diagnosed, treatment-naïve advanced solid malignancy; their caregivers; and outpatient medical oncologists was conducted from June to November 2022. At discharge, pts were surveyed for cancer type/stage knowledge, treatment knowledge &amp; decisional conflict using the informed subscale &amp; total Decisional Conflict Scale (DCS; scored 0-100, higher = more conflict) respectively, and information timing preferences. Post-discharge semi-structured interviews exploring information/decisional needs were conducted with pts or pt-caregiver dyads. Oncologists were surveyed about the knowledge of the most recent pt they saw who met aforementioned criteria. Quantitative data were analyzed using descriptive statistics and qualitative data using thematic analysis. Results: Of 25 pts approached, 20 (80%) completed the survey. Interviews were halted after 12 pts and 4 caregivers due to saturation. Fifteen (75%) pts knew their cancer type and 10 (50%) their stage. For the DCS, 13 (65%) scored &gt; 37.5, which is linked with decision delay/regret; median informed subscale score was 66.7. Pts reported wanting to be informed as soon as possible (vs. later) about cancer type (90%), stage (85%), treatment options (80%) and prognosis (70%). Interview themes were cancer knowledge, cancer decisions, information needs/uncertainty, barriers/facilitators to information gathering during/post-hospitalization, decision-making barriers/facilitators, locus of control in decision-making, and goals. Of 46 oncologists approached, 32 (70%) completed the survey. Twenty-four (75%) reported that the pt was somewhat/very well-informed about cancer type, 15 (47%) stage, 18 (57%) treatment options and 9 (28%) prognosis. Themes from open-ended questions were inpatient information processing, outpatient care navigation/expectations, and low expectations of pt cancer knowledge. Oncologists recommended pt education, supportive care referrals, and inpatient-outpatient communication at discharge. Conclusions: Pts with an inpatient diagnosis of advanced cancer experience high decisional conflict and are not well-informed about cancer treatment and prognosis. Pts, caregivers, and oncologists identified numerous information/decisional needs and barriers/facilitators. Though some needs were due to barriers unique to hospitalization, pts did not perceive hospitalization as a barrier to IDM. Further studies should explore transitional interventions such as enhanced pt education, supportive care, and standardized, tailored handoffs to the outpatient team.

Current chemoprevention approaches in Lynch syndrome and Familial adenomatous polyposis: a global clinical practice survey.

International chemoprevention preferences and approaches in Lynch syndrome (LS) and APC-associated polyposis, including Familial adenomatous polyposis (FAP) and attenuated FAP (AFAP) have not been previously explored. To describe current chemoprevention strategies for patients with LS or FAP/AFAP (referred to collectively as FAP) practiced by members of four international hereditary cancer societies through administration of a survey. Ninety-six participants across four hereditary gastrointestinal cancer societies responded to the survey. Most respondents (91%, 87/96) completed information regarding their demographics and practice characteristics relating to hereditary gastrointestinal cancer and chemoprevention clinical practices. Sixty-nine percent (60/87) of respondents offer chemoprevention for FAP and/or LS as a part of their practice. Of the 75% (72/96) of survey respondents who were eligible to answer practice-based clinical vignettes based off of their responses to ten barrier questions regarding chemoprevention, 88% (63/72) of those participants completed at least one case vignette question to further characterize chemoprevention practices in FAP and/or LS. In FAP, 51% (32/63) would offer chemoprevention for rectal polyposis, with sulindac - 300 mg (18%, 10/56) and aspirin (16%, 9/56) being the most frequently selected options. In LS, 93% (55/59) of professionals discuss chemoprevention and 59% (35/59) frequently recommend chemoprevention. Close to half of the respondents (47%, 26/55) would recommend beginning aspirin at time of commencement of the patient's first screening colonoscopy (usually at age 25yrs). Ninety-four percent (47/50) of respondents would consider a patient's diagnosis of LS as an influential factor for aspirin use. There was no consensus on the dose of aspirin (≤100 mg, >100 mg - 325 mg or 600 mg) to offer patients with LS and there was no agreement on how other factors, such as BMI, hypertension, family history of colorectal cancer, and family history of heart disease, would affect the recommendation for aspirin use. Possible harm among older patients (>70 years) was identified as the most common reason to discourage aspirin use. Although chemoprevention is widely discussed and offered to patients with FAP and LS by an international group of hereditary gastrointestinal cancer experts, there is significant heterogeneity in how it is applied in clinical practice.

Clinical and Economic Burden in Patients With Systemic Lupus Erythematosus During the First Year After Initiating Oral Corticosteroids: A Retrospective US Database Study.

To characterize health care resource utilization (HCRU), health care costs, and adverse events (AEs) among patients with systemic lupus erythematosus (SLE) initiating oral corticosteroids (OCS) versus patients without OCS use. In this retrospective cohort study (GSK Study 213061), eligible patients (aged ≥5 years at first OCS claim) with SLE from the IQVIA Real-World Data Adjudicated Claims-US database (January 2006 to July 2019) had continuous enrollment during the 6-month preindex (baseline) and 12-month postindex (observation) periods and one or more inpatient or emergency department SLE diagnosis codes or two or more outpatient SLE diagnosis codes during baseline. The "OCS-initiator cohort" comprised patients with one or more OCS pharmacy claims during the study period and no evidence of preindex OCS use and was classified into three exposure categories based on the number of 6-month periods of more than 5 mg/day of OCS use (0, 1, 2). The "no-OCS-use cohort" comprised patients without OCS claims, although patients may have received OCS prior to the study period. Clinical and economic outcomes were reported over the observation period. Adjusted health care costs differed significantly ($6542 [95% confidence interval (CI): $5761-$7368], $19,149 [95% CI: $16,954-$21,471], $28,985 [95% CI: $25,546-$32,885]). HCRU incidence rates were significantly greater for all OCS-initiator exposure categories (n=16,216) versus the no-OCS-use cohort (n=11,137; adjusted incidence rate ratios [95% CI]: 1.22 [1.19-1.24], 1.39 [1.34-1.43], 1.66 [1.60-1.73]). OCS-related AEs were experienced by 67.1% to 74.1% of patients with OCS initiation, most commonly affecting the immune system. Within 12 months of OCS initiation, patients with SLE experienced substantial clinical and economic burden, which may imply a need to minimize OCS use.

Evaluation of the New South Wales ambulance T1 major trauma transport protocol: A state-wide data linkage study

IntroductionPrehospital triage and transport protocols are critical components of the trauma systems. Still, there have been limited studies evaluating the performance of trauma protocols in New South Wales, such as the NSW ambulance major Trauma transport protocol (T1). ObjectivesDetermine the performance of a major trauma transport protocol in a cohort of ambulance road transports MethodsA data-linkage study using routine ambulance and hospital datasets across New South Wales Australia. Adult patients (age > 16 years) where any trauma protocol was indicated by paramedic crews and transported to any emergency department in the state were included. Major injury outcome was defined as an Injury Severity Score >8 based on coded in-patient diagnoses, or admission to intensive care unit or death within 30 days due to injury. Multivariable logistic regression was used to determine ambulance predictors of major injury outcome. ResultsThere were 168,452 linked ambulance transports analysed. Of the 9,012 T1 protocol activations, 2,443 cases had major injury [positive predictive value (PPV) = 27.1%]. There were 16,823 major injuries in total giving a sensitivity of the T1 protocol of 2,443/16,823 (14.5%), specificity of 145,060/151,629 (95.7%) and a negative predictive value (NPV) of 145,060/159,440 (91%). Overtriage rate associated with T1 protocol was 5,697/9,012 (63.2%) and undertriage rate was 5,509/159,440 (3.5%). The most important predictor of major injury was the activation of more than one trauma protocol by ambulance paramedics. DiscussionOverall, the T1 was associated with low undertriage and high specificity. The protocol may be improved by considering age and the number of trauma protocols activated by paramedics for any given patient.

Association of Race and Neighborhood Socioeconomic Disadvantage with Incident Peripheral Artery Disease and Chronic Limb-threatening Ischemia

There are disparities in peripheral artery disease (PAD) outcomes according to both race and socioeconomic disadvantage separately. However, few studies have investigated the association of race and socioeconomic deprivation together with risk of PAD. We aimed to investigate the association of race and socioeconomic disadvantage with risk of incident PAD and incident chronic limb-threatening ischemia (CLTI). We included all non-Hispanic white and non-Hispanic Black adults in the Maryland Health Services Cost Review Commission from January 2013 through December 2019 without prevalent PAD or CLTI at their index visit. PAD and CLTI were defined by inpatient and outpatient diagnosis codes. Socioeconomic disadvantage was determined by the area deprivation index (ADI), a comprehensive measure of socioeconomic deprivation, using nine-digit zip codes. Patients living in neighborhoods with greater socioeconomic deprivation (ADI 3 and 4) were categorized as high ADI, while patients living in neighborhoods with lower socioeconomic deprivation (ADI 1 and 2) were categorized as low ADI. We estimated the cumulative incidence of PAD and CLTI and quantified hazard ratios (HR) using multivariable Cox proportional hazards models across four race and ADI groups after correcting for traditional demographic and cardiovascular risk factors. A total of 5,592,650 adult patients without PAD or CLTI at baseline (51.6% ≥65 years of age, 37.9% Black, 31.2% with high ADI) were followed for a median of 10.71 years (interquartile range, 5-31 years). The overall cumulative incidence of PAD and CLTI was 22% and 6%, respectively, and varied significantly by race and ADI (Figs 1 and 2). After adjusting for baseline differences between groups, the risk of incident PAD was highest for the Black-high ADI group (hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.38-1.43), followed by White-high ADI (HR, 1.22; 95% CI, 1.20-1.24) and Black-low ADI (HR, 1.00; 95% CI, 0.99- 1.01) compared to White-low ADI (Table). Similarly, the risk of incident CLTI was highest for the Black-high ADI group (HR, 1.52; 95% CI, 1.48-1.57), followed by White-high ADI (HR, 1.38; 95% CI, 1.33-1.42), then Black-low ADI (HR, 1.14; 95% CI, 1.11-1.17) compared to White-low ADI. Previously reported racial differences in risk of PAD and CLTI are largely explained by socioeconomic deprivation, as characterized by ADI. Adults living in areas with higher socioeconomic deprivation are at higher risk of incident PAD and CLTI than their less socioeconomically deprived counterparts.Fig 2Cumulative Incidence Function Curves of Incident CLTI in health Services Cost Review Commission Database from 2013 through 2019 Stratified by Race and ADI.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Thromboembolic events, bleeding, and mortality in patients with cerebral venous thrombosis: a nationwide cohort study.

Cerebral venous thrombosis (CVT) predominantly affects young to middle-aged women. Scarce data exist regarding the long-term prognosis. We examined the clinical course of patients with CVT overall and according to their age and sex. Using Danish registries, we identified all patients with a first-time primary inpatient diagnosis of CVT from 1996-2018 (N= 653; median age, 41 years; 67% women) and individuals from the general population matched for age, sex, and calendar year (N= 65 300). Patients with CVT were at an increased risk of venous thromboembolism (VTE) at other sites, ischemic stroke, major bleeding, and mortality. For both sexes, the increased risks of VTE at other sites were most prominent among younger patients (18-54 years), whereas the increased risks of ischemic stroke, major bleeding, and mortality were most prominent among older patients (≥55 years). Among young women, the 10-year risks of VTE at other sites for patients with CVT compared with members of the matched cohort were 2.2% vs 0.4% (risk difference, 1.8%; 95% confidence interval [CI], 0.0-3.6). Among older women, compared with members of the matched cohort, the 10-year risks were 12.8% vs 3.1% (risk difference, 9.7%; 95% CI, 1.6-17.9) for ischemic stroke, 11.1% vs 4.6% (risk difference, 6.5%; 95% CI,-1.0 to 14.1) for major bleeding, and 43.1% vs 26.7% (risk difference, 16.4%; 95% CI, 3.7-29.1) for all-cause mortality. The risk of myocardial infarction was not elevated. Clinicians should be aware of the importance of age and sex heterogeneity in the prognosis of CVT.

An Algorithm Addressing the Problem of Overdiagnosis of Clostridioides difficile Infections in Hematopoietic Stem Cell Transplantation Recipients: Effects on C. difficile Infection Rates and Patient Outcomes

Diarrhea of other causes and Clostridioides difficile colonization are common in patients hospitalized for hematopoietic stem cell transplantation (HSCT). It has been well recognized that these issues tend to decrease the specificity of stool testing for C. difficile infection (CDI). The best way to address this problem is uncertain. In September 2018, we initiated a project with the goal of addressing the apparent problem of overdiagnosis of CDIs in our HSCT population. Using the quality improvement tool Model for Improvement, we introduced a C. difficile stool testing and CDI diagnosis algorithm with the aim of decreasing unnecessary inpatient CDI diagnoses and treatments. In this study, we examined the effects of the algorithm. We reviewed all HSCT admissions for the 2 years before introduction of the algorithm and the subsequent 3 years, recording all stool submissions for C. difficile determination and CDI. At the close of the study, we recruited our advanced practice providers (APPs) to review all CDIs following algorithm initiation and provide feedback on the ease of use of the algorithm and potential improvements to the overall process. Stool submissions for C. difficile determination decreased from 38.0/1000 to 20.6/1000 inpatient days (P < .001) and CDI diagnoses decreased from 5.5/1000 to 2.4/1000 days (P=.007). Patients admitted for a first allogeneic HSCT, first autologous HSCT, or HSCT readmission showed similar proportionate reductions. No detrimental effects on hospital length of stay, overall survival, progression-free survival, rate of readmission post-HSCT, incidence of acute graft-versus-host disease, or incidence of recurrent CDI were noted following algorithm introduction. A strategy of education, monitoring/feedback, and ease of algorithm access proved effective in inducing provider compliance. APPs rated the algorithm high on ease of use. We conclude that the use of an algorithm defining criteria for C. difficile testing, diagnosis, and treatment was associated with significantly decreased CDI diagnoses on a HSCT inpatient unit without apparent adverse effects.

An interpretable diagnostic approach for lung cancer: Combining maximal clique and improved BERT

AbstractThe lung cancer incidence and mortality in China have always been high. Moreover, due to the limited level of professional technology, misdiagnosis and missed diagnosis of lung cancer often occur. To improve the accuracy of diagnosis, this paper proposes an interpretable diagnostic method for lung cancer based on Chinese electronic medical records (EMRs). First, to overcome the difficulty in word segmentation of clinical texts in Chinese EMRs, a dictionary construction method is proposed based on the idea of maximal clique, and 730 medical professional terms related to lung diseases are identified. Then, the ProbSparse self‐attention mechanism and self‐attention distilling operation in Informer are used to improve the Bidirectional Encoder Representations from Transformer (BERT) to realize the representation of long clinical texts with lower time complexity and memory consumption. Finally, the convolutional neural network with an attention mechanism is employed to process the representation results to realize the interpretable prediction of lung cancer. This method is applied to the lung cancer diagnosis of inpatients in a tertiary hospital in Hunan Province, obtaining excellent results of about 0.9 for area under the receiver operating characteristic curve (AUROC) and area under the precision‐recall curve (AUPRC). In addition, the results of the comparative analysis with existing dictionaries, word embedding methods and diagnostic methods further confirm the superiority of the proposed method. Specifically, the proposed method improves the precision by at least 6%, the recall by at least 2.6%, the F1 score by at least 5.2%, AUROC by at least 7.3% and AUPRC by at least 7.7% compared with all these state‐of‐the‐art methods.