-
JAMA Health Forum Sep 2023The 21st Century Cures Act includes an information-blocking rule (IBR) that requires health systems to provide patients with immediate access to their health information...
IMPORTANCE
The 21st Century Cures Act includes an information-blocking rule (IBR) that requires health systems to provide patients with immediate access to their health information in the electronic medical record upon request. Patients accessing their health information before they receive an explanation from their health care team may experience confusion and may be more likely to share unsolicited patient complaints (UPCs) with their health care organization.
OBJECTIVE
To evaluate the quantity of UPCs about physicians before and after IBR implementation and to identify themes in UPCs that may identify patient confusion, fear, or anger related to the release of information.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study was conducted with an interrupted time-series analysis of UPCs spanning January 1, 2020, to June 30, 2022. The data were obtained from a single academic medical center, Vanderbilt University Medical Center, at which the IBR was implemented on January 20, 2021. Data analysis was performed from January 11 to July 15, 2023.
EXPOSURE
Implementation of the IBR on January 20, 2021.
MAIN OUTCOMES AND MEASURES
The primary outcome was the monthly rate of UPCs before and after IBR implementation. A qualitative analysis was performed for UPCs received after IBR implementation. The Wilcoxon rank-sum test was used to compare monthly complaints between the pre- and post-IBR groups. The Pearson χ2 test was used to compare proportions of complaints by UPC category between time periods.
RESULTS
The medical center received 8495 UPCs during the study period: 3022 over 12 months before and 5473 over 18 months after institutional IBR implementation. There was no difference in the monthly proportions of UPCs per 1000 patient encounters before (median, 0.81 [IQR, 0.75-0.88]) and after (median, 0.83 [IQR, 0.77-0.89]) IBR implementation (difference in medians, -0.02 [95% CI, -0.12 to 0.07]; P =.86). Segmented regression analysis revealed no difference in monthly UPCs (β [SE], 0.03 [0.09]; P =.72).
CONCLUSIONS AND RELEVANCE
In this cohort study, implementation of the Cures Act IBR was not associated with an increase in monthly rates of UPCs. These findings suggest that review of UPCs identified as IBR-specific complaints may allow clinicians and organizations to prepare patients that their test and procedure results may be available before clinicians are able to review them and respond.
Topics: Humans; Retrospective Studies; Cohort Studies; Physicians; Interrupted Time Series Analysis
PubMed: 37773508
DOI: 10.1001/jamahealthforum.2023.3244 -
Cephalalgia : An International Journal... Feb 2024Estimates of proportions of people with migraine who report premonitory symptoms vary greatly among previous studies. Our aims were to establish the proportion of...
BACKGROUND
Estimates of proportions of people with migraine who report premonitory symptoms vary greatly among previous studies. Our aims were to establish the proportion of patients reporting premonitory symptoms and its dependency on the enquiry method. Additionally, we investigated the impact of premonitory symptoms on disease burden using Headache Impact Test (HIT-6), Migraine Disability Assessment (MIDAS) and World Health Organization Disability Assessment 2.0 (WHODAS 2.0), whilst investigating how various clinical factors influenced the likelihood of reporting premonitory symptoms.
METHODS
In a cross-sectional study, premonitory symptoms were assessed among 632 patients with migraine. Unprompted enquiry was used first, followed by a list of 17 items (prompted). Additionally, we obtained clinical characteristics through a semi-structured interview.
RESULTS
Prompted enquiry resulted in a greater proportion reporting premonitory symptoms than unprompted (69.9% vs. 43.0%; < 0.001) and with higher symptom counts (medians 2, interquartile range = 0-6 vs. 1, interquartile range = 0-1; < 0.001). The number of symptoms correlated weakly with HIT-6 ( = 0.14; < 0.001) and WHODAS scores ( = 0.09; 0.041). Reporting postdromal symptoms or triggers increased the probability of reporting premonitory symptoms, whereas monthly migraine days decreased it.
CONCLUSIONS
The use of a standardized and optimized method for assessing premonitory symptoms is necessary to estimate their prevalence and to understand whether and how they contribute to disease burden.
Topics: Humans; Cross-Sectional Studies; Migraine Disorders; Headache; Photophobia; Prevalence
PubMed: 38299579
DOI: 10.1177/03331024231223979 -
BMC Gastroenterology Jan 2024Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder characterized by abdominal pain, discomfort, and changes in bowel habits. The mechanism...
BACKGROUND
Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder characterized by abdominal pain, discomfort, and changes in bowel habits. The mechanism underlying IBS remains unclear, and little evidence exists for clarifying the causal relationship between blood metabolites and IBS.
METHODS
We conducted a Mendelian randomization (MR) study using two samples. Exposure data for 7824 Europeans were extracted from a genome-wide association study (GWAS) on metabolite levels. The IBS GWAS data from the GWAS database were used for the initial analysis. The primary analysis of causal relationships was conducted using inverse-variance weighting (IVW) with MR-Egger and weighted medians as supplementary analyses. Sensitivity analyses were performed using a combination of the Cochran's Q test, MR-Egger intercept test, Mendelian randomization pleiotropy residual sum and outlier, and leave-one-out analysis. For significant associations, replication and meta-analyses were performed using additional independent IBS case GWAS data released by the FinnGen Consortium R9. To identify the metabolites, score regression, confounding analysis, and reverse MR were performed to further assess the causal relationships between the metabolites.
RESULTS
After rigorous screening, we identified four known metabolites to be associated with IBS (stearate, odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.59-0.92; arginine, OR: 1.36, 95% CI: 1.07-1.74; 1-palmitoylglycerol, OR:1.49, 95% CI: 1.07-2.07; 1-palmitoylglycerophosphoinositol, OR: 0.84, 95% CI: 0.71-0.99).
CONCLUSIONS
MR analysis revealed a causal relationship between the four metabolites and IBS, providing preliminary evidence for the pathogenesis of IBS. Our results provide novel insights into the potential biomarkers of IBS.
Topics: Humans; Irritable Bowel Syndrome; Genome-Wide Association Study; Mendelian Randomization Analysis; Abdominal Pain; Causality
PubMed: 38182988
DOI: 10.1186/s12876-023-03111-9 -
AJNR. American Journal of Neuroradiology Aug 2023Automatic brain parcellation is typically performed on dedicated MR imaging sequences, which require valuable examination time. In this study, a 3D MR imaging...
BACKGROUND AND PURPOSE
Automatic brain parcellation is typically performed on dedicated MR imaging sequences, which require valuable examination time. In this study, a 3D MR imaging quantification sequence to retrieve R and R relaxation rates and proton density maps was used to synthesize a T1-weighted image stack for brain volume measurement, thereby combining image data for multiple purposes. The repeatability and reproducibility of using the conventional and synthetic input data were evaluated.
MATERIALS AND METHODS
Twelve subjects with a mean age of 54 years were scanned twice at 1.5T and 3T with 3D-QALAS and a conventionally acquired T1-weighted sequence. Using SyMRI, we converted the R, R, and proton density maps into synthetic T1-weighted images. Both the conventional T1-weighted and the synthetic 3D-T1-weighted inversion recovery images were processed for brain parcellation by NeuroQuant. Bland-Altman statistics were used to correlate the volumes of 12 brain structures. The coefficient of variation was used to evaluate the repeatability.
RESULTS
A high correlation with medians of 0.97 for 1.5T and 0.92 for 3T was found. A high repeatability was shown with a median coefficient of variation of 1.2% for both T1-weighted and synthetic 3D-T1-weighted inversion recovery at 1.5T, and 1.5% for T1-weighted imaging and 4.4% for synthetic 3D-T1-weighted inversion recovery at 3T. However, significant biases were observed between the methods and field strengths.
CONCLUSIONS
It is possible to perform MR imaging quantification of R, R, and proton density maps to synthesize a 3D-T1-weighted image stack, which can be used for automatic brain parcellation. Synthetic parameter settings should be reinvestigated to reduce the observed bias.
Topics: Humans; Middle Aged; Reproducibility of Results; Protons; Imaging, Three-Dimensional; Brain; Magnetic Resonance Imaging
PubMed: 37414454
DOI: 10.3174/ajnr.A7937 -
Blood Coagulation & Fibrinolysis : An... Jan 2024The aim of this study was to evaluate the activated partial thromboplastin time (APTT) and prothrombin time (PT)-based clot waveform analysis (CWA) in patients diagnosed...
The aim of this study was to evaluate the activated partial thromboplastin time (APTT) and prothrombin time (PT)-based clot waveform analysis (CWA) in patients diagnosed with acute promyelocytic leukemia (APL). APTT-based and PT-based CWA parameters of patients diagnosed with APL were analyzed and compared with healthy volunteers. Four APTT-CWA parameters were noted, maximum velocity corresponding to the first peak of the first derivative (max1), maximum acceleration corresponding to the first peak of the second derivative (max2) and the corresponding peak times of max1 and max2 (Tmax1, Tmax2). For the PT-CWA, two PT-CWA parameters were noted, maximum velocity (max1') and the corresponding timing (Tmax1'). The results were expressed in medians. Mann-Whitney U test was used to compare the CWA parameters. Correlations were examined using the Spearman correlation test. Tmax1 and Tmax2 were significantly prolonged in patients with APL in comparison with healthy volunteers. Although max1 and max2 were lower in APL patients compared with healthy volunteers, no significant difference was noted. There was a strong and significant correlation between the DIC score and the parameters max1, max2 and max1' and a very strong and significant correlation between fibrinogen levels and max1, max2 and max1'. When comparing DIC patients with hypofibrinogenemia and DIC without hypofibrinogenemia, a significant difference was noted in max1, max2, Tmax1 and Tmax2. The APTT and PT-based CWA analysis is a good tool to evaluate the bleeding tendency in APL, as it offers a novel approach for evaluating global hemostasis, predicting the bleeding risk and delivering improvements to APL patients management.
Topics: Humans; Leukemia, Promyelocytic, Acute; Afibrinogenemia; Blood Coagulation Tests; Prothrombin Time; Partial Thromboplastin Time; Thrombosis
PubMed: 37994627
DOI: 10.1097/MBC.0000000000001265 -
Environment International Apr 2024Evidence suggests that exposure to per- and polyfluoroalkyl substances (PFAS) increases risk of high blood pressure (BP) during pregnancy. Prior studies did not examine...
BACKGROUND
Evidence suggests that exposure to per- and polyfluoroalkyl substances (PFAS) increases risk of high blood pressure (BP) during pregnancy. Prior studies did not examine associations with BP trajectory parameters (i.e., overall magnitude and velocity) during pregnancy, which is linked to adverse pregnancy outcomes.
OBJECTIVES
To estimate associations of multiple plasma PFAS in early pregnancy with BP trajectory parameters across the second and third trimesters. To assess potential effect modification by maternal age and parity.
METHODS
In 1297 individuals, we quantified six PFAS in plasma collected during early pregnancy (median gestational age: 9.4 weeks). We abstracted from medical records systolic BP (SBP) and diastolic BP (DBP) measurements, recorded from 12 weeks gestation until delivery. BP trajectory parameters were estimated via Super Imposition by Translation and Rotation modeling. Subsequently, Bayesian Kernel Machine Regression (BKMR) was employed to estimate individual and joint associations of PFAS concentrations with trajectory parameters - adjusting for maternal age, race/ethnicity, pre-pregnancy body mass index, income, parity, smoking status, and seafood intake. We evaluated effect modification by age at enrollment and parity.
RESULTS
We collected a median of 13 BP measurements per participant. In BKMR, higher concentration of perfluorooctane sulfonate (PFOS) was independently associated with higher magnitude of overall SBP and DBP trajectories (i.e., upward shift of trajectories) and faster SBP trajectory velocity, holding all other PFAS at their medians. In stratified BKMR analyses, participants with ≥ 1 live birth had more pronounced positive associations between PFOS and SBP velocity, DBP magnitude, and DBP velocity - compared to nulliparous participants. We did not observe significant associations between concentrations of the overall PFAS mixture and either magnitude or velocity of the BP trajectories.
CONCLUSION
Early pregnancy plasma PFOS concentrations were associated with altered BP trajectory in pregnancy, which may impact future cardiovascular health of the mother.
Topics: Humans; Female; Pregnancy; Adult; Fluorocarbons; Blood Pressure; Environmental Pollutants; Pregnancy Trimester, Third; Pregnancy Trimester, First; Pregnancy Trimester, Second; Young Adult; Maternal Exposure; Alkanesulfonic Acids
PubMed: 38583297
DOI: 10.1016/j.envint.2024.108628 -
Academic Medicine : Journal of the... Apr 2024This study uses a large national legal database to analyze characteristics of malpractice claims involving U.S. medical students.
PURPOSE
This study uses a large national legal database to analyze characteristics of malpractice claims involving U.S. medical students.
METHOD
The Westlaw database was searched in September 2023 for malpractice cases involving medical students from January 1, 1900, through September 1, 2023. Each case was independently reviewed by 2 authors, abstracting each variable. Categorical data were summarized as frequency of occurrence (i.e., number and percentage), and continuous data were summarized with means, medians, and ranges. All authors independently reviewed the dataset to identify potential themes and codes.
RESULTS
There were 65 cases that met the inclusion criteria. Reported patient outcomes were death (19, 29%), pain (25, 38%), and disability (36, 55%). The most common specialties involved were emergency medicine (16, 25%), general surgery (14, 22%), and obstetrics and gynecology (13, 20%). The most common primary alleged errors attributed to students related to medical decision-making (30, 46%), procedural complication (24, 37%), and poor communication (11, 17%). Among 23 (35%) cases reporting year of training, 1 (4%) included a second-year student, 13 (57%) included third-year students, and 9 (39%) included fourth-year students. Of the 65 lawsuits, 28 (43%) resulted in a settlement or verdict against the medical student. The total amount paid in these cases was $78,192,612, with a mean (median) of $3,007,408 ($1,050,000) per case. Of these 28 cases, 14 (50%) cited minimal or no physician supervision.
CONCLUSIONS
Medical malpractice claims involving medical students are rare but commonly relate to medical decision-making, procedural complication, and poor communication, with a lack of supervision being frequently cited. These results can be used to guide students and supervising physicians on how to avoid scenarios that may increase vulnerability to medical malpractice lawsuits.
PubMed: 38669133
DOI: 10.1097/ACM.0000000000005746 -
Journal of Special Operations Medicine... Dec 2023The purpose of this study was to evaluate the effectiveness of the physical domain (PD) to improve performance in all the POTFF domains (physical, psychological,...
BACKGROUND
The purpose of this study was to evaluate the effectiveness of the physical domain (PD) to improve performance in all the POTFF domains (physical, psychological, social/family, and spiritual) among Special Forces (SF) Operators.
METHODS
This was a cross-sectional study of active SF Operators assigned to the United States Army Special Operations Command (USASOC). Recruitment began in October 2016. Testing began on 1 January 2017, and concluded on 28 February 2020. Participants completed physical testing, blood draws, and questionnaires to determine domain metrics. Means, medians, and proportions were compared by level of participation in the PD.
RESULTS
A total of 231 Soldiers participated; n=63 in the control group, n=93 in the <4 days PD/week (PD <4) group, and n=66 in the >4 days PD/week (PD =4) group. The average age was 31 years (range 21-47 y). The average time in the Special Operations Forces (SOF) was 4 years (range 0-19 y). The PD =4 group showed significantly greater overall upper (p=.01) and lower (p=0) body strength, power (p=.01), and positive affect (p=.04). The PD =4 group also had significantly lower anxiety (p=.03), stress (p=.04), and depression (p=.02) than the control group.
CONCLUSION
The PD and psychological domain metrics were most associated with PD participation. This finding is consistent with the goals of the PD, which are to increase physical and mental capabilities and decrease injury recovery time.
Topics: Humans; United States; Young Adult; Adult; Middle Aged; Cross-Sectional Studies; Physical Examination; Military Personnel
PubMed: 38109229
DOI: 10.55460/YKHX-E4YA -
Hand (New York, N.Y.) Nov 2023Forearm stiffness can be caused by distal radioulnar joint (DRUJ) capsular contractures, which can occur after trauma such as a distal radius fracture. In this setting,...
BACKGROUND
Forearm stiffness can be caused by distal radioulnar joint (DRUJ) capsular contractures, which can occur after trauma such as a distal radius fracture. In this setting, a DRUJ capsular release may help improve forearm rotation, but the long-term functional outcomes remain unknown. The purpose of this case series is to investigate the short-term improvement in total pronosupination arc range of motion and long-term patient-reported outcomes (PROs) after DRUJ capsular release.
METHODS
We performed a retrospective review of consecutive patients who underwent DRUJ capsular release. Range of motion prior to surgery and at final short-term follow-up was collected and analyzed with a Wilcoxon signed-rank test. Patient-reported outcomes including QuickDASH and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) scores were obtained as medians with interquartile range (IQR), while patient satisfaction was measured on a 4-point Likert scale.
RESULTS
Five patients met the inclusion criteria with a median short-term follow-up of 5.5 (IQR: 4.3-10.3) months. The median preoperative supination was 25° (IQR: 0°-35°), and the median postoperative supination was 50° (IQR: 40°-60°; = .03). The median preoperative pronation was 45° (IQR: 10°-60°), and the median postoperative pronation was 70° (IQR: 60°-80°; = .04). After the long-term median follow-up of 10.9 (IQR 9.7-11.2) years, all the patients were satisfied or very satisfied with the results of the surgery. The median QuickDASH score was 13.6 (IQR: 9.1-20.5), and the median PROMIS UE score was 46.5 (IQR: 43.8-47.7).
CONCLUSIONS
Distal radioulnar joint capsular release can improve pronation and supination in patients with posttraumatic forearm stiffness and is associated with high long-term patient satisfaction.
PubMed: 37946511
DOI: 10.1177/15589447231207911 -
The Journal of Allergy and Clinical... Dec 2023The major problem at the Cleveland Allergy and Asthma Center was the need for additional therapy for severe eosinophilic asthma patients who were steroid-dependent or... (Review)
Review
BACKGROUND
The major problem at the Cleveland Allergy and Asthma Center was the need for additional therapy for severe eosinophilic asthma patients who were steroid-dependent or required frequent bursts of prednisone.
OBJECTIVES
The objectives of this study were to determine the efficacy of monthly mepolizumab (MP) injections up to 6½ years using Asthma Control Quesitonnaire-7 (ACQ-7), forced expiratory volume in 1 second (FEV), forced expiratory flow at 25% to 75% (FEF) overall and among super-responders, and to understand whether FEF is an effective parameter to evaluate MP efficacy.
METHODS
We reviewed the charts of 67 patients with severe eosinophilic asthma and compared the results between 47 super-responders and the rest of the cohort regarding ACQ-6, ACQ-7, eosinophils, FEV, and FEF. The groups of super-responders and all other patients were described with respect to initial and current values of the study end points using medians and 25th and 75th percentiles. Changes from the initial to the current values in the study end points were measured using percent changes. The Wilcoxon signed rank test was used within each group to test the null hypothesis of 0 median percent change.
RESULTS
After 6½ years, there were no significant changes in FEV. The FEF, had a significant median percent increase of 40% among the super-responders (P < .001), which was substantially higher (P = .026) than the median percent increase of 13.8% observed among all other patients.
CONCLUSIONS
The use of MP up to 6½ years was safe and effective, with significant changes to ACQ-7 and FEF associated with MP treatment, but not the FEV. A higher magnitude of changes was observed among super-responders than the rest of the cohort. Changes in FEF were more meaningful than changes in FEV in evaluating pulmonary function responsiveness of severe eosinophilic asthma to MP.
Topics: Humans; Anti-Asthmatic Agents; Asthma; Antibodies, Monoclonal, Humanized; Pulmonary Eosinophilia; Forced Expiratory Volume; Treatment Outcome
PubMed: 37572752
DOI: 10.1016/j.jaip.2023.08.010