Medical Encounters Research Articles

Risk factors associated with medical encounters in ultramarathon race starters – Data from 103,131 race starters over 90 km: SAFER XLI

ObjectivesTo identify the risk factors associated with all medical encounters (MEs) and serious/life-threatening MEs (SLMEs) during the Comrades Marathon. DesignProspective cohort study, with cross-sectional analyses. MethodsDuring the 2014–2019 Comrades Marathon, all MEs (including SLMEs) were recorded in 103,131 starters. For both all MEs and SLMEs, the following risk factors were explored: sex, age, route (“up” vs. “down” race), previous Comrades experience (yes/no), wet-blub globe temperature (WBGT) and race pace. Incidence (per 1000 starters; 95%CI), and the incidence ratio (IR; 95%CI) are presented. ResultsFor all MEs, being female was a significant risk factor (females vs. males IR = 1.47, p < 0.0001), and age was only marginally significant (p = 0.0167). Therefore factors for all MEs were adjusted for sex. Other factors significantly associated with all MEs were: higher WBGT (highest WBGT compared to lowest, IR = 1.33, p = 0.0003), race pace (highest risk for those who finish either among the first quarter [IR = 1.49] or last quarter [IR = 1.46] compared to middle pace; p < 0.0001) and the route (“down” vs. “up”: IR = 1.11; p = 0.0181). Factors associated with higher risk for SLMEs were: females (IR = 1.9; p = 0.0003), “down” vs. “up” route (IR = 1.37; p = 0.0306) and race pace (slower and faster runners vs. mid (6.4–7.1 min/km) race pace category (IR > 2.1, p < 0.0001)). ConclusionsIntrinsic (female, faster and slower race pace) and extrinsic (higher WBGT and the “down” route) are novel risk factors associated with all MEs at this event. These can be considered by the race organizers and the medical team to develop and implement prevention strategies.

Exploring the impact of a digital health tool on patients’ interaction with community pharmacists: A pilot randomized controlled study

BackgroundThe use of digital Patient- Reported Outcomes (PRO) tools has been shown to enhance the exchange of information and shared decision-making in medical encounters. However, their influence on patient-pharmacist interactions has not yet been explored. ObjectivesThis study aimed to examine the impact of RxTalk™, a digital PRO tool, in supporting the communication between patients and pharmacists compared to usual care. MethodsIntervention: RxTalk™ was developed to collect information about medication adherence and beliefs, using a tablet computer. Study designA pilot randomized controlled study was conducted at a community pharmacy in Wisconsin, USA. Sixty patients were randomized to either the intervention group who used RxTalk™ during medication pick-up or the control group who did not use the tool. Patients who used RxTalk™ received paper copies of their responses which were also shared with pharmacists. The consultation was audio-recorded for both groups and coded using the Active Patient Participation Coding scale. Follow-up phone interviews were conducted with both groups within one week of enrollment. ResultsPatient tapes were analyzed. In the unadjusted model, patients in the intervention group had a higher active participation rate (p = 0.004) and raised significantly more concerns during consultations (p < 0.001) compared to the control group. Pharmacists asked twice as many questions while counseling patients in the intervention group compared to the control group (p < 0.001). After controlling for patients' demographics and pharmacists’ questions, there was a statistical difference between the two patient groups in their odds of expressing at least one concern utterance. ConclusionThis pilot study suggests that collecting PRO from patients with chronic illnesses and providing results to pharmacists and patients can help patients express their health and medication concerns. RxTalk™ would be useful for pharmacists who wish to improve the recognition and management of medication-related problems.

Ascites with a Chance of Flooding: A Rare Complication of Cirrhosis

Flood Syndrome, characterized by ruptured umbilical hernias with ascitic fluid leakage in decompensated liver cirrhosis, presents a rare but potentially fatal complication of cirrhotic liver disease. We present a case study of a patient with decompensated cirrhosis who underwent multiple medical encounters before the severity of his condition, characterized by ascitic fluid leakage, was recognized. Flood Syndrome was ultimately identified on admission to the hospital, prompting multidisciplinary interventions and discussions, including antibiotics, surgical consultation, and optimization for hernia repair. Due to the patient’s complexity of his medical condition and surgical risks, a transjugular intrahepatic portosystemic shunt (TIPS) was performed to alleviate ascites before a planned umbilical hernia repair. This case underscores the importance of early recognition of umbilical hernias in cirrhotic patients and highlights the complexity of management decisions, balancing surgical risks with medical optimization to improve outcomes. Further research is warranted to refine treatment strategies and enhance patient care in Flood Syndrome cases.

Racial discrimination and healthcare system trust among American adults with and without cancer.

Racial and ethnic minoritized groups report disproportionately lower trust in the healthcare system. Lower healthcare system trust is potentially related to increased exposure to racial discrimination in medical settings, but this association is not fully understood. We examined the association between racial discrimination in medical care and trust in the healthcare system among people with and without a personal cancer history. We examined racial discrimination and trust in a nationally representative American adult sample from the Health Information National Trends Survey 6. Racial discrimination was defined as any unfair treatment in healthcare based on race or ethnicity. Trust in the healthcare system (eg, hospitals and pharmacies) was grouped into low, moderate, and high trust. Multinomial logistic regression models were used to compare low and moderate trust relative to high trust in the healthcare system and estimate odds ratios (ORs) and 95% confidence intervals (CIs). A total of 5,813 respondents (15% with a personal cancer history) were included 92% (n = 5,355) reported no prior racial discrimination experience during medical treatment. Prior experiences of racial discrimination were positively associated with low (OR = 6.12, 95% CI: 4.22-8.86) and moderate (OR = 2.70, 95% CI: 1.96-3.72) trust in the healthcare system, relative to high trust. Similar associations were observed when stratifying by personal cancer history. Respondents who reported racial discrimination during medical encounters had lower trust in the healthcare system, especially respondents with a personal cancer history. Our findings highlight the need to address racial discrimination experiences during medical care to build patient trust and promote healthcare access.

Empowering Reflection and Reflective Writing in Medical Education

Reflection and reflective writing serve as integral components in medical education. They enable students to delve deeper into their experiences, fostering a profound understanding of clinical scenarios and patient interactions, nurturing self-awareness, critical thinking, and empathy. The term “reflection” carries multiple interpretations, all encapsulating the concept of understanding oneself and the surrounding environment to inform future behavior. In the realm of medical education, both students and medical teachers encounter challenges in navigating reflective practices, necessitating guidance and support throughout the process. Effective reflection between students and medical teachers in clinical settings requires adept navigation through potential difficulties in open discussions and managing the emotional impact. To address these challenges, medical teachers must possess heightened self-awareness and adaptability to cater to the diverse needs of individual students. Various models have offered frameworks to organize the reflective process, categorizing them into ‘iterative’ and ‘vertical’ approaches. Successful application involves a selective combination of elements from different models to customize reflective practices. Comprehending reflection and reflective writing is paramount for medical teachers as it empowers them to mentor students effectively, nurturing a culture of reflective practitioners. This fosters continual learning, ethical practice, and professional development among future healthcare professionals.

Comparison of emergency medical services and emergency department encounter trends for nonfatal opioid-involved overdoses, nine states, United States, 2020–2022

BackgroundOpioid-involved overdoses, especially those involving synthetic opioids like fentanyl, have driven increases in overdose morbidity and mortality. Emergency medical services (EMS) and emergency department (ED) data can each provide near real-time information on trends in nonfatal opioid-involved overdoses; however, minimal data exist on the comparability of trends in these two data sources. MethodsEMS data from biospatial© and ED data from CDC’s Drug Overdose Surveillance and Epidemiology system and National Syndromic Surveillance Program were queried for nine states. Counts of total encounters, opioid-involved overdose encounters, and rates of opioid-involved overdoses per 10,000 total encounters were calculated for each data source from 2020 to 2022. Trends in monthly counts and rates were assessed using Joinpoint regression. ResultsOn average, EMS data captured 1.8 times more monthly opioid-involved overdose encounters than ED data. Trends in the counts of opioid-involved overdose encounters were similar in both data sources with increases and decreases occurring during roughly the same periods. Overall, trends in rates of opioid-involved overdose encounters were also comparable. ConclusionsEMS and ED data provide complementary information for understanding overdose trends. Study findings underscore the importance of implementing post-overdose response protocols by both EMS and ED providers to ensure patients receive services irrespective of care setting.

Illness is more prevalent than injury in trail runners participating in a mountainous ultra trail race

ABSTRACT Objectives Trail running is a popular off-road sport involving running in natural environments over various terrains, often in remote locations. This study aims to investigate the epidemiology and risk factors of injuries and illnesses, i.e. medical encounters, on race day among trail runners in a high-altitude ultra trail race. Methods This descriptive cross-sectional study on an ultra trail race (38 km, 65 km and 100 km) in South Africa, included participants 18 years or older. Of the 331 race participants, 285(86.1%) consented to participate in the study. Data collection included demographic details, injuries (body region, specific body area, tissue type, pathology) and illnesses (organ system, symptom cluster, etiology). Risk factor analysis includes sex, age, weight, height, race distance, illness and injury history, training and running experience. Frequency (n, %), prevalence (%) and odds ratios (OR; 95%CI) are reported. Results Eighty-nine (31.2%) individuals reported 131 medical encounters [49 injuries (37.4%); 82 illnesses (62.6%)]. Injuries were sustained by 14.7% of athletes, and 22.5% reported illnesses. For injuries, the lower limb was mainly involved (n = 41; 83.7%). Most injuries affected the foot (n = 18; 36.7%), ankle (n = 10; 20.4%) and knee (n = 7; 14.3%). Tissue types mainly involved skin (n = 21; 42.8%), ligament (n = 7; 14.3%) and muscle (n = 7; 14.3%). Multiple (n = 45; 54.9%) and gastrointestinal (n = 17; 20.7%) organ systems were mainly involved in illnesses. Only 100 km runners reported dehydration (n = 28; 31.5%), and one in every six of these runners (n = 5; 17.9%) did not finish. Runners reporting fatigue (n = 21; 23.6%) had a high (n = 8; 38.1%) did not finish rate. Two in every five participants (n = 36; 40.4%) with a medical encounter, did not finish. No medical encounter-associated risk factors were identified. Conclusions Illnesses were more common than injuries during the mountainous ultra trail race. Sustaining a medical encounter increased the chance of not completing the race. Further research on the epidemiology of race day medical encounters in trail running is required.

Cannabis, Tobacco Use, and COVID-19 Outcomes

It is unclear whether cannabis use is associated with adverse health outcomes in patients with COVID-19 when accounting for known risk factors, including tobacco use. To examine whether cannabis and tobacco use are associated with adverse health outcomes from COVID-19 in the context of other known risk factors. This retrospective cohort study used electronic health record data from February 1, 2020, to January 31, 2022. This study included patients who were identified as having COVID-19 during at least 1 medical visit at a large academic medical center in the Midwest US. Current cannabis use and tobacco smoking, as documented in the medical encounter. Health outcomes of hospitalization, intensive care unit (ICU) admission, and all-cause mortality following COVID-19 infection. The association between substance use (cannabis and tobacco) and these COVID-19 outcomes was assessed using multivariable modeling. A total of 72 501 patients with COVID-19 were included (mean [SD] age, 48.9 [19.3] years; 43 315 [59.7%] female; 9710 [13.4%] had current smoking; 17 654 [24.4%] had former smoking; and 7060 [9.7%] had current use of cannabis). Current tobacco smoking was significantly associated with increased risk of hospitalization (odds ratio [OR], 1.72; 95% CI, 1.62-1.82; P < .001), ICU admission (OR, 1.22; 95% CI, 1.10-1.34; P < .001), and all-cause mortality (OR, 1.37, 95% CI, 1.20-1.57; P < .001) after adjusting for other factors. Cannabis use was significantly associated with increased risk of hospitalization (OR, 1.80; 95% CI, 1.68-1.93; P < .001) and ICU admission (OR, 1.27; 95% CI, 1.14-1.41; P < .001) but not with all-cause mortality (OR, 0.97; 95% CI, 0.82-1.14, P = .69) after adjusting for tobacco smoking, vaccination, comorbidity, diagnosis date, and demographic factors. The findings of this cohort study suggest that cannabis use may be an independent risk factor for COVID-19-related complications, even after considering cigarette smoking, vaccination status, comorbidities, and other risk factors.

Attitudes and experiences of cancer patients toward the provision of audio recordings of their own medical encounter: a cross-sectional online survey.

The provision of audio recordings of their own medical encounters to patients, termed consultation recordings, has demonstrated promising benefits, particularly in addressing information needs of cancer patients. While this intervention has been explored globally, there is limited research specific to Germany. This study investigates the attitudes and experiences of cancer patients in Germany toward consultation recordings. We conducted a nationwide cross-sectional quantitative online survey, informed by semi-structured interviews with cancer patients. The survey assessed participants' attitudes, experiences and desire for consultation recordings in the future. The data was analyzed using descriptive statistics and subgroup analyses. A total of 287 adult cancer patients participated. An overwhelming majority (92%) expressed a (very) positive attitude. Overall, participants strongly endorsed the anticipated benefits of the intervention, such as improved recall and enhanced understanding. Some participants expressed concerns that physicians might feel pressured and could become more reserved in their interactions with the use of such recordings. While a small proportion (5%) had prior experience with audio recording medical encounters, the majority (92%) expressed interest in having consultation recordings in the future. We observed positive attitudes of cancer patients in Germany toward consultation recordings, paralleling international research findings. Despite limited experiences, participants acknowledged the potential benefits of the intervention, particularly related to recalling and comprehending information from medical encounters. Our findings suggest that the potential of the intervention is currently underutilized in German cancer care. While acknowledging the possibility of a positive bias in our results, we conclude that this study represents an initial exploration of the intervention's potential within the German cancer care context, laying the groundwork for its further evaluation.

On the utility of using the All of Us Research Program as a resource to study military service members and veterans.

To illustrate the utility of the All of Us Research Program for studying military and veteran health. Results were derived from the All of Us Researcher Workbench Controlled Tier v7. Specific variables examined were family history of post-traumatic stress disorder (PTSD), medical encounters, and body mass index/body size. There are 37363 military and veteran participants enrolled in the All of Us Research Program. The population is older (M = 63.3 years), White (71.3%), and male (83.2%), consistent with military and veteran populations. Participants reported a high prevalence of PTSD (13.4%), obesity (40.2%), and abdominal obesity (77.1%). The breadth and depth of health data from service members and veterans enrolled in the All of Us Research Program allow researchers to address pressing health questions in these populations. Future enrollment and data releases will make this an increasingly powerful and useful study for understanding military and veteran health.

“The oncologist told me”: Reported speech as a patients’ resource to volunteer concerns in oncological visits

Based on the “patient centered approach”, growing emphasis within policies has been put on patients' active participation in medical encounters. Consistently, research has investigated patients' initiatives during medical visits in a wide array of settings and specialties. Among these, oncological care constitutes a setting where patient participation is particularly crucial as well as challenging. However, previous studies in this setting have focused mainly on doctors' interactional work, with few works exploring patients' expressions of fears, uncertainties, and hopes. The present study contributes to this underexplored line of inquiry by showing how oncological patients take the initiative and make relevant their concerns through reported speech (RS). Based on a corpus of 106 video-recorded oncological visits collected in Italy and adopting conversation analysis, the article shows how patients use RS to volunteer some information they have previously been told by other, non-present physicians. Through RS, patients cautiously make relevant specific aspects of their case that have not been addressed in the ongoing interaction and appear to constitute a concern for them (e.g., presence of metastases, treatment side effects, hospitalization length). In response, the physician addresses the patient's concern, either by confirming the reported information or by distancing themselves from it, thus providing their opinion on the matter.

(086) MEDICAL GASLIGHTING AND VULVOVAGINAL PAIN DISORDERS

Abstract Introduction Gaslighting is a form of epistemic injustice that involves testimonial injustice, in which patient’s experiences are discounted by others. The incidence of epistemic injustice has been described in a number of pain conditions including chronic fatigue syndrome and fibromyalgia, as well as in marginalized obstetric populations. Little research has been directed towards epistemic injustice in populations seeking treatment for benign gynecologic conditions or the unique context of vulvovaginal pain conditions. Additionally, little is known about the consequence of this type of injustice on patient’s perception of their care or willingness to seek care. Objective The purpose of this study was to develop a patient-validated instrument to measure patient experience of epistemic injustice in their past gynecologic care and to use the instrument to explore patient experiences in a vulvovaginal pain referral center. Methods An instrument was designed by the study team to quantify the incidence and distressed caused by gaslighting in patients seek care for vulvovaginal pain conditions. This was created based on common themes from written testimonials of patients available from National Vulvodynia Association. After construction, the instrument was submitted for feedback to officers from two vulvovaginal pain disorder patient societies. The survey was modified to include the feedback from these sources. The survey was then completed by patients establishing care with the clinic prior to their first appointment. Results 187 patients completed the survey in part or in full. Patients reported having seen an average of 5.7 providers prior to presentation. Patients felt supported by only 42% of past providers. Patients felt belittled by 27% of past providers. Patients felt 21% of past providers did not believe their symptoms. 45% of patients were told they “just needed to relax more”; 18% percent were recommended to drink alcohol to improve their condition; 55% considered giving up seeking care because they felt their concerns were not being addressed; 31% were told their symptoms were caused by high levels of anxiety; 22% were referred to psychiatry without other medical treatment for their symptoms; 19% felt unsafe during a medical encounter. 39% percent of patients were made to feel they were “crazy” and this was the most distressing of the questions asked (average 7.3/10 on a likert scale for distress for patients who had experienced this). Conclusions A survey based on patient concerns and validated by patients affected by vulvovaginal pain conditions has not been previously reported. This instrument was applied to a patient population at a large referral center for vulvovaginal pain conditions and the results showed that patients commonly experienced many forms of epistemic injustice, and greater than half of patients consider cessation of care for their condition because of these experiences. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Dr. Jill Krapf is a medical advisor for Evvy. Dr. Andrew Goldstein is a part time Employee of Daré Bioscience. He is a member of the board of directors of The Gynecologic Cancers Research Foundation. He is an advisor for: AbbVie, Incyte, and the National Vulvodynia Association. He has received research funding from Incyte.

Time to diagnosis among young patients with cancer.

Sociodemographic and clinical factors associated with diagnostic delays in pediatric, adolescent, and young adult cancers are poorly understood. Using the Optum Labs Data Warehouse's de-identified claims data for commercial health plan enrollees, we identified children (0-14years) and adolescents/young adults (AYAs) (15-39years) diagnosed with one of 10 common cancers from 2001 to 2017, who were continuously enrolled for 6months preceding diagnosis. Time to diagnosis was calculated as days between first medical encounter with possible cancer symptoms and cancer diagnosis date. Median times from first symptom to diagnosis were compared using Wilcoxon rank sum test. Multivariable unconditional logistic regression identified sociodemographic factors associated with longer time (>3months) to cancer diagnosis (from symptom onset). Of 47,296 patients, 87% presented prior to diagnosis with symptoms. Patients with central nervous system (CNS) tumors were most likely to present with symptoms (93%), whereas patients with cervical cancer were least likely (70%). Symptoms varied by malignancy. Of patients with symptoms, thyroid (105days [range: 50-154]) and cervical (104days [range: 41-151]) cancer had the longest median time to diagnosis. Females and patients at either end of the age spectrum were more likely to experience diagnosis delays of more than 3months. In a commercially insured population, time to diagnosis varies by cancer type, age, and sex. Further work is needed to understand the patient, provider, and health system-level factors contributing to time from symptom onset to diagnosis, specifically in the very young children and the young adult patient population going forward.

Impact of pharmacist‐led discharge medication reconciliation on error and patient harm prevention at a large academic medical center

AbstractIntroductionMedication errors during hospital discharge can lead to adverse outcomes, medication‐related readmissions, and increased health care costs. Pharmacist‐led medication reconciliation at discharge is a potential solution to mitigate poor outcomes and optimize medication safety.ObjectivesThis study aimed to quantify medication errors identified at discharge and characterize the severity of patient harm prevented following pharmacist‐led discharge medication reconciliation. Cost avoidance analysis was conducted to determine its associated financial impact.MethodsPatients, who were discharged from an adult internal medicine service during October 2022, were included in this one‐month pilot prospective quality improvement study. The number of errors at discharge were documented, categorized by type, and adjudicated for severity of potential harm. Error severity was classified based on a modified National Coordinating Council for Medication Error Reporting and Prevention Medication Error Index. Cost avoidance was calculated based on whether each error would have resulted in additional medical encounters and length of stay.ResultsThirty‐one patients were included in the analysis. Forty errors were identified by pharmacist‐led medication reconciliation at discharge, with a mean of 1.3 ± 1.9 errors per patient and 68% of patients having at least one error. The most common errors were duplication of therapy (25%) and medication access barriers at discharge (25%). The severity of errors included low (22.5%), serious (75%), and life‐threatening harm (2.5%). Thirty‐five percent of errors could have led to emergency visits or hospital readmissions. The estimated total cost for errors was $25 600. Pharmacist labor cost for reconciliation was $816. Cost avoidance was $24 784 from the 14 errors at discharge that could have resulted in additional emergency or inpatient visits.ConclusionPharmacist‐led medication reconciliation at discharge may prevent harm from reaching patients, decrease cost from unnecessary health encounters, and stop the error from continuing across transitions of care.

Effects of HPV vaccination on the development of HPV-related cancers: A retrospective analysis of a United States-based cohort.

10507 Background: Several studies have shown the efficacy of the Human Papillomavirus (HPV) vaccine in reducing the risk of cervical cancer. Given the recent introduction of the HPV vaccine, there has been limited evidence linking vaccination to a decreased likelihood of developing other HPV-related cancers. Methods: A retrospective cohort study was conducted using a patient population selected from the TriNetX United States Collaborative Network. Patients 9-39 years old attending medical encounters where any vaccine was administered between 1/1/2010 and 12/31/2023 were divided into two cohorts: patients vaccinated for HPV at least five years prior and those no history of HPV vaccination. Outcomes were malignancies at the following sites: Head and Neck (HNC), Cervix, Anus &amp; Anal Canal, Penis, Vulva, and Vagina. Patients with no prior history of cervical dysplasia undergoing Pap smear were observed for atypical cytology. Propensity score matching was performed to match cohorts for age, race/ethnicity, tobacco use, and BMI. Results: Males vaccinated for HPV (n = 760,540) were at decreased odds for HPV-related cancers (odds ratio (OR) = 0.46, 95 % confidence interval (CI) = 0.29-0.72, p-value = 0.001). This finding was primarily driven by a significant reduction in HNC (OR = 0.44, CI = 0.26-0.73, p = 0.0016). Females vaccinated for HPV (n = 945,999) had lower odds for cervical (OR = 0.71, CI = 0.52-0.96, p-value = 0.027) cancers and HPV-related cancers overall (OR = 0.73, CI = 0.57-0.94, p = 0.013). Odds of HNC (OR = 0.67, CI = 0.42-1.1, p = 0.10) and Vulvar/Vaginal cancer (OR = 1.67, CI = 0.81-3.41, p = 0.16) were not significantly different in vaccinated females compared to controls. Vaccinated females were less likely to develop High Grade Squamous Intraepithelial Lesions (HGSIL), (OR = 0.44, CI = 0.30-0.65, p &lt; 0.0001), and Carcinoma In-Situ(OR = 0.422, CI = 0.25-0.72, p = 0.002). Conclusions: These results suggest early evidence of efficacy in the vaccine in preventing the development of several types of malignancies and pre-malignant dysplasia caused by HPV. [Table: see text]

Comparative effectiveness of the bivalent COVID-19 mRNA vaccines, mRNA1273-222 and BNT162b2, in immunocompromised adults in the US.

e23057 Background: Despite the decline in COVID-19–related hospitalizations and mortality during the period of omicron predominance, immunocompromised individuals, including those with cancer, remain at an increased risk for severe COVID-19 outcomes. A subanalysis of a retrospective observational cohort study assessed the relative vaccine effectiveness (rVE) of 2 previously approved bivalent vaccines targeting the ancestral SARS-CoV-2 and the omicron BA.4/BA.5 variant, mRNA-1273.222 (Moderna, Inc., Cambridge, MA, USA) and BNT162b2 bivalent (Pfizer Inc., New York, NY, USA; BioNTech GmbH, Mainz, Germany), in immunocompromised adults in the United States. Methods: The study used a US electronic health record dataset (Veradigm) linked with medical and pharmacy claims data of adults aged ≥18 years with at least 1 underlying medical condition associated with increased risk of severe COVID-19 who received a dose of mRNA-1273.222 or BNT162b2 bivalent vaccines between August 31, 2022, and February 28, 2023. A subgroup analysis was conducted among an immunocompromised population, encompassing cancer patients, organ or stem cell transplant recipients, individuals with primary immunodeficiency, individuals with HIV, and individuals receiving immunosuppressing medications. Comorbid conditions were based on prior medical encounters in the 365 days before vaccination. The outcomes measured were rVE of the two bivalent mRNA vaccines against COVID-19-related hospitalizations (primary outcome) and outpatient visits (secondary outcome). Follow-up started 7 days after vaccination until May 31, 2023 (end of available claims data). Propensity score weighting was used to adjust for baseline differences between groups. Results: The subanalysis included 427,260 immunocompromised individuals, of which 250,573 (58.6%) were identified as having cancer. In the overall weighted immunocompromised population, 169,509 individuals received mRNA-1273.222, and 257,751 received BNT162b2 bivalent. The adjusted rVEs of mRNA-1273.222 versus BNT162b2 bivalent vaccine against COVID-19–related hospitalizations and outpatient visits were 15.0% (95% CI, 7.2%-22.0%; P&lt; 0.001) and 4.8% (95% CI, 1.8%-7.7%; P= 0.002), respectively. Conclusions: In this study, the mRNA-1273.222 vaccine offered greater protection against COVID-19–related hospitalization compared with the BNT162b2 bivalent vaccine among immunocompromised individuals. This study emphasizes the importance of assessing COVID-19 vaccine formulations and optimizing protection, especially in immunocompromised adults, including those with cancer.

Lessons learned from patients’ weight-related medical encounters: Results from 34 interviews

ObjectivesHow to best care for larger-bodied patients is a complicated issue in modern medicine. The present study seeks to inform current medical practices to ensure the delivery of high-quality and evidence-based care through the examination of higher-weight patients’ experiences with weight-related care. MethodsHigher-weight patients (N = 34) completed semi-structured interviews about their experiences and recommendations for weight-related care. Interviews were coded by two independent coders and harmonized. Findings were organized into broad domains of 1) negative care experiences and 2) positive care experiences and recommendations. ResultsPatients described a range of negative care experiences, including stigmatization from providers (e.g., rude, attacking, or insulting communication about weight), while concurrently expressing insufficient weight management support from providers. Positive care experiences and recommendations included patient-centered care (e.g., physician humility and empathy) and attending to the patient’s weight, which conveyed concern for the patient. ConclusionsOur findings reflect patients’ ambivalent attitudes toward weight-related care: while weight-focused provider communication can be highly stigmatizing, patients simultaneously desire more weight-management support from providers. Practice ImplicationsProviders who wish to move their practices from a weight-loss focus to one targeting healthy living should provide a rationale for these shifts to inform patients’ perceptions of high-quality care.

Common Data Elements and Databases Essential for the Study of Musculoskeletal Injuries in Military Personnel.

Injuries are the leading cause of medical encounters with over 2 million medical encounters for musculoskeletal (MSK) conditions and over 700,000 acute injuries per year. Musculoskeletal injuries (MSKIs) are by far the leading health and readiness problem of the U.S. Military. The Proceedings of the International Collaborative Effort on Injury Statistics published a list of 12 data elements deemed necessary for injury prevention in the civilian population; however, there are no standardized list of common data elements (CDEs) across the DoD specifically designed to study MSKIs in the Military Health System (MHS). This study aims to address this gap in knowledge by defining CDEs across the DoD for MSKIs, establishing a CDE dictionary, and compiling other necessary information to quantify MSKI disease burden in the MHS. Between November 2022 and March 2023, we conducted an environmental scan of current MSKI data metrics across the DoD. We used snowball sampling with active engagement of groups housing datasets that contained MSKI data elements to determine CDEs as well as information on readiness databases across the DoD containing up-to-date personnel information on disease, hospitalizations, limited duty days (LDDs), and deployability status for all military personnel, as well as MSKI-specific measures from the MHS Dashboard which tracks key performance measures. We identified 8 unique databases: 5 containing demographic and diagnostic information (Defense Medical Surveillance System, Medical Assessment and Readiness Systems, Military Health System Data Repository, Person-Data Environment, and Soldier Performance, Health, and Readiness Database); and 3 containing LDD information (Aeromedical Services Information Management System, eProfile, and Limited Duty Sailor Marines Readiness Tracker). Nine CDEs were identified: DoD number, sex, race, ethnicity, branch of service, rank, diagnosis, Common Procedural Terminology coding, and cause codes, as they may be captured in any database that is a derivative of the Military Health System Data Repository. Medical Assessment and Readiness Systems contained most variables of interest, excluding injury/place of region and time in service. The Limited Duty Sailor Marines Readiness Tracker contains a variable corresponding to "days on limited duty." The Aeromedical Services Information Management System uses the "release date" and "profile date" to calculate LDDs. The eProfile system determines LDDs by the difference between the "expiration date" and "approved date." In addition, we identified 2 measures on the MHS Dashboard. One measures the percentage of service members (SMs) who are on limited duty for longer than 90 days because of an MSKI and the other tracks the percentage of SMs that are not medically ready for deployment because of a deployment-limiting medical condition. This article identifies core data elements needed to understand and prevent MSKIs and where these data elements can be found. These elements should inform researchers and result in evidence-informed policy decisions supporting SM health to optimize military force readiness.

Parent and oncologist perspectives on prognostic disclosure in advanced childhood cancer: communication pearls and pitfalls.

For children with advanced cancer and their families, communication about prognosis is critical. Unfortunately, data demonstrate that prognostic communication occurs infrequently and inconsistently across advancing illness. Prior to developing an intervention to improve prognostic communication, we aimed to (1) characterize parent and oncologist perspectives on "best" approaches for prognostic communication, and (2) explore similarities and differences between parent and oncologist perspectives. Children with poor-prognosis solid tumors, their parents, and oncologists were followed prospectively for 24months or until death. Matched semi-structured interviews were conducted with parents and oncologists 0-7days after medical encounters at timepoints of disease progression or relapse. Reflexive thematic analysis was conducted to describe parent and oncologist impressions of communication quality. A total of 68 interviews were conducted following serial disease reevaluation encounters involving 13 parents and five oncologists. Nine main themes were identified as "best" approaches: (1) speaking with honesty and clarity, (2) leaving room for hope, (3) leaning into a long-standing relationship, (4) personalizing language, (5) empowering the patient and family, (6) collaborating with the multidisciplinary team, (7) providing anticipatory guidance, (8) setting the scene, and (9) creating a therapeutic space. Parents and oncologists generally agreed on themes related to helpful communication approaches, while parents more explicitly described communication pitfalls. Parents and oncologists described clear recommendations for helpful communication strategies and pitfalls to avoid during difficult prognostic disclosure. Future work should integrate patient perspectives in the design and testing of an intervention to improve prognostic communication in advanced childhood cancer.

Prospects for artificial intelligence-enhanced electrocardiogram as a unified screening tool for cardiac and non-cardiac conditions: an explorative study in emergency care.

Current deep learning algorithms for automatic ECG analysis have shown notable accuracy but are typically narrowly focused on singular diagnostic conditions. This exploratory study aims to investigate the capability of a single deep learning model to predict a diverse range of both cardiac and non-cardiac discharge diagnoses based on a single ECG collected in the emergency department. In this study, we assess the performance of a model trained to predict a broad spectrum of diagnoses. We find that the model can reliably predict 253 ICD codes (81 cardiac and 172 non-cardiac) in the sense of exceeding an AUROC score of 0.8 in a statistically significant manner. The model demonstrates proficiency in handling a wide array of cardiac and non-cardiac diagnostic scenarios, indicating its potential as a comprehensive screening tool for diverse medical encounters.