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Crowdsourced Assessment of Ureteroscopy with Laser Lithotripsy Video Feed Does Not Correlate with Trainee Experience.
Conti SL, Brubaker W, Chung BI, Sofer M, Hsi RS, Shinghal R, Elliott CS, Caruso T, Leppert JT
(2019) J Endourol 33: 42-49
MeSH Terms: Academic Medical Centers, California, Clinical Competence, Crowdsourcing, Hospitals, Veterans, Humans, Kidney Calculi, Lithotripsy, Laser, Reproducibility of Results, Ureteroscopy, Urology, Video Recording
Show Abstract · Added February 26, 2019
OBJECTIVES - We sought to validate the use of crowdsourced surgical video assessment in the evaluation of urology residents performing flexible ureteroscopic laser lithotripsy.
METHODS - We collected video feeds from 30 intrarenal ureteroscopic laser lithotripsy cases where residents, postgraduate year (PGY) two through six, handled the ureteroscope. The video feeds were annotated to represent overall performance and to contain parts of the procedure being scored. Videos were submitted to a commercially available surgical video evaluation platform (Crowd-Sourced Assessment of Technical Skills). We used a validated ureteroscopic laser lithotripsy global assessment tool that was modified to include only those domains that could be evaluated on the captured video. Videos were evaluated by crowd workers recruited using Amazon's Mechanical Turk platform as well as five endourology-trained experts. Mean scores were calculated and intraclass correlation coefficients (ICCs) were computed for the expert domain and total scores. ICCs were estimated using a linear mixed-effects model. Spearman rank correlation coefficients were calculated as a measure of the strength of the relationships between the crowd mean and expert average scores.
RESULTS - A total of 30 videos were reviewed 2488 times by 487 crowd workers and five expert endourologists. ICCs between expert raters were all below accepted levels of correlation (0.30), with the overall score having an ICC of <0.001. For individual domains, the crowd scores did not correlate with expert scores, except for the stone retrieval domain (0.60 p = 0.015). In addition, crowdsourced scores had a negative correlation with the PGY level (0.44, p = 0.019).
CONCLUSIONS - There is poor agreement between experts and poor correlation between expert and crowd scores when evaluating video feeds of ureteroscopic laser lithotripsy. The use of an intraoperative video of ureteroscopy with laser lithotripsy for assessment of resident trainee skills does not appear reliable. This is further supported by the lack of correlation between crowd scores and advancing PGY level.
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12 MeSH Terms
Rapid resolution of hyperammonemia in neonates using extracorporeal membrane oxygenation as a platform to drive hemodialysis.
Robinson JR, Conroy PC, Hardison D, Hamid R, Grubb PH, Pietsch JB, Lovvorn HN
(2018) J Perinatol 38: 665-671
MeSH Terms: Ammonia, Cohort Studies, Extracorporeal Membrane Oxygenation, Female, Hospitals, Pediatric, Humans, Hyperammonemia, Infant, Newborn, Logistic Models, Male, Peritoneal Dialysis, Prognosis, Referral and Consultation, Renal Dialysis, Retrospective Studies, Risk Assessment, Severity of Illness Index, Survival Rate, Treatment Outcome
Show Abstract · Added June 27, 2018
OBJECTIVE - We aimed to clarify the impact of extracorporeal membrane oxygenation (ECMO) as a platform to drive hemodialysis (HD) for ammonia clearance on outcomes of neonates with severe hyperammonemia.
STUDY DESIGN - All neonates treated for hyperammonemia at a single children's hospital between 1992 and 2016 were identified. Patient characteristics and outcomes were compared between those receiving medical management or ECMO/HD.
RESULT - Twenty-five neonates were treated for hyperammonemia, of which 13 (52%) received ECMO/HD. Peak ammonia levels among neonates treated with ECMO/HD were significantly higher than those medically managed (1041 [IQR 902-1581] μmol/L versus 212 [IQR 110-410] μmol/L; p = 0.009). Serum ammonia levels in the ECMO/HD cohort declined to the median of medically managed within 4.5 (IQR 2.9-7.0) hours and normalized within 7.3 (IQR 3.6-13.5) hours. All neonates survived ECMO/HD, and nine (69.2%) survived to discharge.
CONCLUSION - ECMO/HD is an effective adjunct to rapidly clear severe hyperammonemia in newborns, reducing potential neurodevelopmental morbidity.
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19 MeSH Terms
The Need for Better Data Breach Statistics.
Fabbri D, Frisse ME, Malin B
(2017) JAMA Intern Med 177: 1696
MeSH Terms: Hospitals, Risk
Added April 10, 2018
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A technology-based patient and family engagement consult service for the pediatric hospital setting.
Jackson GP, Robinson JR, Ingram E, Masterman M, Ivory C, Holloway D, Anders S, Cronin RM
(2018) J Am Med Inform Assoc 25: 167-174
MeSH Terms: Adolescent, Child, Child, Preschool, Consumer Health Informatics, Consumer Health Information, Family, Female, Hospitals, Pediatric, Humans, Infant, Infant, Newborn, Information Seeking Behavior, Information Technology, Internet, Male, Mobile Applications, Patient-Centered Care, Referral and Consultation, Retrospective Studies, Tennessee
Show Abstract · Added November 8, 2017
Objective - The Vanderbilt Children's Hospital launched an innovative Technology-Based Patient and Family Engagement Consult Service in 2014. This paper describes our initial experience with this service, characterizes health-related needs of families of hospitalized children, and details the technologies recommended to promote engagement and meet needs.
Materials and Methods - We retrospectively reviewed consult service documentation for patient characteristics, health-related needs, and consultation team recommendations. Needs were categorized using a consumer health needs taxonomy. Recommendations were classified by technology type.
Results - Twenty-two consultations were conducted with families of patients ranging in age from newborn to 15 years, most with new diagnoses or chronic illnesses. The consultation team identified 99 health-related needs (4.5 per consultation) and made 166 recommendations (7.5 per consultation, 1.7 per need). Need categories included 38 informational needs, 26 medical needs, 23 logistical needs, and 12 social needs. The most common recommendations were websites (50, 30%) and mobile applications (30, 18%). The most frequent recommendations by need category were websites for informational needs (39, 50%), mobile applications for medical needs (15, 40%), patient portals for logistical needs (12, 44%), and disease-specific support groups for social needs (19, 56%).
Discussion - Families of hospitalized pediatric patients have a variety of health-related needs, many of which could be addressed by technology recommendations from an engagement consult service.
Conclusion - This service is the first of its kind, offering a potentially generalizable and scalable approach to assessing health-related needs, meeting them with technologies, and promoting patient and family engagement in the inpatient setting.
© The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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20 MeSH Terms
The Effects of Travel Burden on Outcomes After Resection of Extrahepatic Biliary Malignancies: Results from the US Extrahepatic Biliary Consortium.
O'Connor SC, Mogal H, Russell G, Ethun C, Fields RC, Jin L, Hatzaras I, Vitiello G, Idrees K, Isom CA, Martin R, Scoggins C, Pawlik TM, Schmidt C, Poultsides G, Tran TB, Weber S, Salem A, Maithel S, Shen P
(2017) J Gastrointest Surg 21: 2016-2024
MeSH Terms: Aged, Biliary Tract Neoplasms, Delivery of Health Care, Female, Hospitals, High-Volume, Humans, Income, Male, Middle Aged, Proportional Hazards Models, Retrospective Studies, Survival Rate, Tertiary Care Centers, Travel, Treatment Outcome, United States
Show Abstract · Added April 10, 2018
BACKGROUND - Surgical resection of extrahepatic biliary malignancies has been increasingly centralized at high-volume tertiary care centers. While this has improved outcomes overall, increased travel burden has been associated with worse survival for many other malignancies. We hypothesized that longer travel distances are associated with worse outcomes for these patients as well.
STUDY DESIGN - Data was analyzed from the US Extrahepatic Biliary Consortium database, which retrospectively reviewed patients who received resection of extrahepatic biliary malignancies at 10 high-volume centers. Driving distance to the patient's treatment center was measured for 1025 patients. These were divided into four quartiles for analysis: < 24.5, 24.5-57.2, 57.2-117, and < 117 mi. Cox proportional hazard models were then used to measure differences in overall survival.
RESULTS - No difference was found between the groups in severity of disease or post-operative complications. The median overall survival in each quartile was as follows: 1st = 1.91, 2nd = 1.60, 3rd = 1.30, and 4th = 1.39 years. Patients in the 3rd and 4th quartile had a significantly lower median household income (p = 0.0001) and a greater proportion Caucasian race (p = 0.0001). However, neither of these was independently associated with overall survival. The two furthest quartiles were found to have decreased overall survival (HR = 1.39, CI = 1.12-1.73 and HR = 1.3, CI = 1.04-1.62), with quartile 3 remaining significant after multivariate analysis (HR = 1.45, CI = 1.04-2.0, p = 0.028).
CONCLUSIONS - Longer travel distances were associated with decreased overall survival, especially in the 3rd quartile of our study. Patients traveling longer distances also had a lower household income, suggesting that these patients have significant barriers to care.
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16 MeSH Terms
Acute kidney injury is a risk factor for subsequent proteinuria.
Parr SK, Matheny ME, Abdel-Kader K, Greevy RA, Bian A, Fly J, Chen G, Speroff T, Hung AM, Ikizler TA, Siew ED
(2018) Kidney Int 93: 460-469
MeSH Terms: Acute Kidney Injury, Aged, Angiotensin II Type 1 Receptor Blockers, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Blood Pressure, Comorbidity, Databases, Factual, Diabetes Mellitus, Diabetic Nephropathies, Disease Progression, Female, Glomerular Filtration Rate, Hospitalization, Hospitals, Veterans, Humans, Hypertension, Kidney, Male, Middle Aged, Prevalence, Prognosis, Proteinuria, Renal Insufficiency, Chronic, Retrospective Studies, Risk Factors, Severity of Illness Index, Time Factors, United States
Show Abstract · Added November 29, 2018
Acute kidney injury (AKI) is associated with subsequent chronic kidney disease (CKD), but the mechanism is unclear. To clarify this, we examined the association of AKI and new-onset or worsening proteinuria during the 12 months following hospitalization in a national retrospective cohort of United States Veterans hospitalized between 2004-2012. Patients with and without AKI were matched using baseline demographics, comorbidities, proteinuria, estimated glomerular filtration rate, blood pressure, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (ACEI/ARB) use, and inpatient exposures linked to AKI. The distribution of proteinuria over one year post-discharge in the matched cohort was compared using inverse probability sampling weights. Subgroup analyses were based on diabetes, pre-admission ACEI/ARB use, and AKI severity. Among the 90,614 matched AKI and non-AKI pairs, the median estimated glomerular filtration rate was 62 mL/min/1.73m. The prevalence of diabetes and hypertension were 48% and 78%, respectively. The odds of having one plus or greater dipstick proteinuria was significantly higher during each month of follow-up in patients with AKI than in patients without AKI (odds ratio range 1.20-1.39). Odds were higher in patients with Stage II or III AKI (odds ratios 1.32-1.81) than in Stage I AKI (odds ratios 1.18-1.32), using non-AKI as the reference group. Results were consistent regardless of diabetes status or baseline ACEI/ARB use. Thus, AKI is a risk factor for incident or worsening proteinuria, suggesting a possible mechanism linking AKI and future CKD. The type of proteinuria, physiology, and clinical significance warrant further study as a potentially modifiable risk factor in the pathway from AKI to CKD.
Published by Elsevier Inc.
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29 MeSH Terms
An Innovative Approach to Addressing the HIV Care Continuum: Implementation of a Clinical Pharmacy Resident in a Veterans Affairs HIV Specialty Clinic.
Bagwell A, McFarland MS, Hulgan T
(2018) J Pharm Pract 31: 422-428
MeSH Terms: Adult, Aged, Ambulatory Care Facilities, Anti-HIV Agents, Cohort Studies, HIV Infections, Hospitals, Veterans, Humans, Male, Middle Aged, Organizational Innovation, Pharmacy Residencies, Pharmacy Service, Hospital, Pilot Projects, United States, United States Department of Veterans Affairs, Veterans, Viral Load
Show Abstract · Added December 11, 2019
PURPOSE - Engagement of patients in the HIV care continuum and adherence to antiretroviral therapy (ART) continue to limit successful viral suppression. Innovative practices to improve this continuum and ameliorate potential physician shortages are needed. The objective of this evaluation was to determine the clinical benefits of incorporating pharmacy resident involvement on a multidisciplinary team in caring for patients with HIV.
METHODS - A single-center pre-post cohort pilot evaluation was conducted at the Tennessee Valley Healthcare Systems VA Medical Center. Patients were enrolled in an HIV pharmacotherapy clinic implemented by an ambulatory care pharmacy resident. The primary end point of the evaluation was the percentage of patients achieving an undetectable plasma HIV viral load after enrollment. Secondary end points included change from baseline in CD4 T-cell count and self-reported adherence.
RESULTS - A total of 55 patients were seen in the HIV pharmacotherapy clinic over a 28-week evaluation period. Of those patients with detectable viral load at enrollment, 70% reached viral suppression during follow-up, with a significant 0.75 log10 decrease in the median viral load ( P < .0001 for both). The median CD4 T-cell count increased from 464 to 525 cells/mm ( P = .01). Reported adherence, assessed using the Visual Analogue adherence Scale (VAS) increased significantly ( P = .0001).
CONCLUSION - After enrollment in an HIV pharmacotherapy clinic, a significant decrease in viral load was seen, as were improvements in secondary end points of CD4 T cells and adherence. These data demonstrate the clinical benefits of pharmacy resident involvement on a multidisciplinary team in caring for patients with HIV.
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Impact of an Integrated Antibiotic Allergy Testing Program on Antimicrobial Stewardship: A Multicenter Evaluation.
Trubiano JA, Thursky KA, Stewardson AJ, Urbancic K, Worth LJ, Jackson C, Stevenson W, Sutherland M, Slavin MA, Grayson ML, Phillips EJ
(2017) Clin Infect Dis 65: 166-174
MeSH Terms: Aged, Anti-Bacterial Agents, Antimicrobial Stewardship, Australia, Drug Hypersensitivity, Drug-Related Side Effects and Adverse Reactions, Female, Hospitals, Humans, Inappropriate Prescribing, Male, Microbial Sensitivity Tests, Middle Aged, Penicillins, Skin Tests
Show Abstract · Added March 30, 2020
Background - Despite the high prevalence of patient-reported antibiotic allergy (so-called antibiotic allergy labels [AALs]) and their impact on antibiotic prescribing, incorporation of antibiotic allergy testing (AAT) into antimicrobial stewardship (AMS) programs (AAT-AMS) is not widespread. We aimed to evaluate the impact of an AAT-AMS program on AAL prevalence, antibiotic usage, and appropriateness of prescribing.
Methods - AAT-AMS was implemented at two large Australian hospitals during a 14-month period beginning May 2015. Baseline demographics, AAL history, age-adjusted Charlson comorbidity index, infection history, and antibiotic usage for 12 months prior to testing (pre-AAT-AMS) and 3 months following testing (post-AAT-AMS) were recorded for each participant. Study outcomes included the proportion of patients who were "de-labeled" of their AAL, spectrum of antibiotic courses pre- and post-AAT-AMS, and antibiotic appropriateness (using standard definitions).
Results - From the 118 antibiotic allergy-tested patients, 226 AALs were reported (mean, 1.91/patient), with 53.6% involving 1 or more penicillin class drug. AAT-AMS allowed AAL de-labeling in 98 (83%) patients-56% (55/98) with all AALs removed. Post-AAT, prescribing of narrow-spectrum penicillins was more likely (adjusted odds ratio [aOR], 2.81, 95% confidence interval [CI], 1.45-5.42), as was narrow-spectrum β-lactams (aOR, 3.54; 95% CI, 1.98-6.33), and appropriate antibiotics (aOR, 12.27; 95% CI, 5.00-30.09); and less likely for restricted antibiotics (aOR, 0.16; 95% CI, .09-.29), after adjusting for indication, Charlson comorbidity index, and care setting.
Conclusions - An integrated AAT-AMS program was effective in both de-labeling of AALs and promotion of improved antibiotic usage and appropriateness, supporting the routine incorporation of AAT into AMS programs.
© The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.
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Calibration drift in regression and machine learning models for acute kidney injury.
Davis SE, Lasko TA, Chen G, Siew ED, Matheny ME
(2017) J Am Med Inform Assoc 24: 1052-1061
MeSH Terms: Acute Kidney Injury, Aged, Bayes Theorem, Clinical Decision-Making, Decision Support Techniques, Female, Hospitals, Veterans, Humans, Logistic Models, Machine Learning, Male, Middle Aged, United States
Show Abstract · Added April 7, 2017
Objective - Predictive analytics create opportunities to incorporate personalized risk estimates into clinical decision support. Models must be well calibrated to support decision-making, yet calibration deteriorates over time. This study explored the influence of modeling methods on performance drift and connected observed drift with data shifts in the patient population.
Materials and Methods - Using 2003 admissions to Department of Veterans Affairs hospitals nationwide, we developed 7 parallel models for hospital-acquired acute kidney injury using common regression and machine learning methods, validating each over 9 subsequent years.
Results - Discrimination was maintained for all models. Calibration declined as all models increasingly overpredicted risk. However, the random forest and neural network models maintained calibration across ranges of probability, capturing more admissions than did the regression models. The magnitude of overprediction increased over time for the regression models while remaining stable and small for the machine learning models. Changes in the rate of acute kidney injury were strongly linked to increasing overprediction, while changes in predictor-outcome associations corresponded with diverging patterns of calibration drift across methods.
Conclusions - Efficient and effective updating protocols will be essential for maintaining accuracy of, user confidence in, and safety of personalized risk predictions to support decision-making. Model updating protocols should be tailored to account for variations in calibration drift across methods and respond to periods of rapid performance drift rather than be limited to regularly scheduled annual or biannual intervals.
© The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com
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Impact of a National Guideline on Antibiotic Selection for Hospitalized Pneumonia.
Williams DJ, Hall M, Gerber JS, Neuman MI, Hersh AL, Brogan TV, Parikh K, Mahant S, Blaschke AJ, Shah SS, Grijalva CG, Pediatric Research in Inpatient Settings Network
(2017) Pediatrics 139:
MeSH Terms: Adolescent, Anti-Bacterial Agents, Child, Child, Preschool, Databases, Factual, Female, Guideline Adherence, Hospitals, Pediatric, Humans, Infant, Inpatients, Male, Pneumonia
Show Abstract · Added July 27, 2018
BACKGROUND - We evaluated the impact of the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pneumonia guideline and hospital-level implementation efforts on antibiotic prescribing for children hospitalized with pneumonia.
METHODS - We assessed inpatient antibiotic prescribing for pneumonia at 28 children's hospitals between August 2009 and March 2015. Each hospital was also surveyed regarding local implementation efforts targeting antibiotic prescribing and organizational readiness to adopt guideline recommendations. To estimate guideline impact, we used segmented linear regression to compare the proportion of children receiving penicillins in March 2015 with the expected proportion at this same time point had the guideline not been published based on a projection of a preguideline trend. A similar approach was used to estimate the short-term (6-month) impact of local implementation efforts. The correlations between organizational readiness and the impact of the guideline were estimated by using Pearson's correlation coefficient.
RESULTS - Before guideline publication, penicillin prescribing was rare (<10%). After publication, an absolute increase in penicillin use was observed (27.6% [95% confidence interval: 23.7%-31.5%]) by March 2015. Among hospitals with local implementation efforts ( = 20, 71%), the median increase was 29.5% (interquartile range: 19.6%-39.1%) compared with 20.1% (interquartile rage: 9.5%-44.5%) among hospitals without such activities ( = .51). The independent, short-term impact of local implementation efforts was similar in magnitude to that of the national guideline. Organizational readiness was not correlated with prescribing changes.
CONCLUSIONS - The publication of the Pediatric Infectious Diseases Society/Infectious Diseases Society of America guideline was associated with sustained increases in the use of penicillins for children hospitalized with pneumonia. Local implementation efforts may have enhanced guideline adoption and appeared more relevant than hospitals' organizational readiness to change.
Copyright © 2017 by the American Academy of Pediatrics.
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