Direct access from general practice to transvaginal ultrasound for early detection of ovarian cancer: a feasibility study

ObjectiveTo investigate the feasibility of providing general practitioners (GPs) direct and fast referral access to transvaginal ultrasound (TVUS).DesignA prospective cohort study.SettingA total of 232 Danish general practices in parts of the Central Denmark Region.SubjectsWomen aged ≥40 years who consulted their GP for vague and non-specific symptoms (n = 479).Main outcome measuresThe feasibility assessment included the GPs’ referral rate, indications for referral, management of test results, and findings from TVUS.ResultsA total of 479 women were referred to TVUS. The examinations revealed abnormalities in 104 (21.7%) women. Additional investigations were needed in 68 (14.2%) women of whom seven (1.5%) underwent major surgery. No case of ovarian cancer was diagnosed during the study period or the 6-month follow-up. However, three (0.6%) women with an abnormal transvaginal ultrasound were diagnosed with urogynecological cancer; this yielded a PPV of 4.4% (95% confidence interval: 1.5–12.2) and an NPV of 100.0% (95% confidence interval: 96.7–100.0) for urogynecological cancer.ConclusionProviding GPs with direct access to transvaginal ultrasound was feasible; 80% of the investigated women were referred back to the GP, 14% were further investigated, 0.6% were diagnosed with urogynecological cancer, and 1.5% had major procedures performed without complications.ImplicationsDirect access to TVUS could be an important pathway to ensure fast evaluation of women presenting with vague non-specific symptoms of potential ovarian cancer. Future studies should explore the patient experience, cancer outcomes, and health economics issues.

KEY POINTS

•    Current awareness  • GPs have no fast referral option for women presenting with vague non-specific symptoms that could indicate underlying ovarian cancer.   Key findings  • We offered GPs direct and fast referral access to TVUS; 51.7% of practices used the opportunity.  • The GPs referred 479 women to TVUS; 104 had an abnormal TVUS and 68 needed additional investigations.  • Seven women underwent major surgery, leading to three cases of urogynecological cancer. No woman had a false negative TVUS result.

     

Sexual Orientation Demographic Data in a Clinical Cohort of Transgender Patients

Background  There are specific issues regarding sexual orientation (SO) collection and analysis among transgender and nonbinary patients. A limitation to meaningful SO and gender identity (GI) data collection is their consideration as a fixed trait or demographic data point. Methods  A de-identified patient database from a single electronic health record (EHR) that allows for searching any discrete data point in the EHR was used to query demographic data (sex assigned at birth and current GI) for transgender individuals from January 2011 to March 2020 at a large urban tertiary care academic health center. Results  A cohort of transgender individuals were identified by using EHR data from a two-step demographic question. Almost half of male identified (46.70%, n  = 85) and female identified (47.51%, n  = 86) individuals had “heterosexual/straight” input for SO. Overall, male and female identified (i.e., binary) GI aggregate categories had similar SO responses. Assigned male at birth (AMAB) nonbinary individuals ( n  = 6) had “homosexual/gay” SO data input. Assigned female at birth (AFAB) nonbinary individuals ( n  = 56) had almost half “something else” SO data input (41.67%, n  = 15). Individuals with “choose not to disclose” for GI ( n  = 249) almost all had “choose not to disclose” SO data (96.27%, n  = 232). Conclusion  Current SO categories do not fully capture transgender individuals'' identities and experiences, and limit the clinical and epidemiological utility of collecting this data in the current form. Anatomical assumptions based on SO should be seen as a potential shortcoming in over-reliance on SO as an indicator of screening needs and risk factors.     

Text Messaging Real-Time COVID-19 Clinical Guidance to Hospital Employees

Background  During the initial days of the coronavirus disease 2019 (COVID-19) pandemic, hospital-wide practices rapidly evolved, and hospital employees became a critical population for receiving consistent and timely communication about these changes. Objectives  We aimed to rapidly implement enterprise text messaging as a crisis communication intervention to deliver key COVID-related safety and practice information directly to hospital employees. Methods  Utilizing a secure text-messaging platform already routinely used in direct patient care, we sent 140-character messages containing targeted pandemic-related updates to on-duty hospital employees three times per week for 13 weeks. This innovation was evaluated through the analysis of aggregate “read” receipts from each message. Effectiveness was assessed by rates of occupational exposures to COVID-19 and by two cross-sectional attitudinal surveys administered to all text-message recipients. Results  On average, each enterprise text message was sent to 1,997 on-duty employees. Analysis of “read” receipts revealed that on average, 60% of messages were consistently read within 24 hours of delivery, 34% were read in 2 hours, and 16% were read in 10 minutes. Readership peaked and fell in the first week of messaging but remained consistent throughout the remainder of the intervention. A survey administered after 2 weeks revealed that 163 (79%) users found enterprise texts “valuable,” 152 (73%) users would recommend these texts to their colleagues, and 114 (55%) users preferred texts to email. A second survey at 9 weeks revealed that 109 (80%) users continued to find texts “valuable.” Enterprise messaging, in conjunction with the system''s larger communication strategy, was associated with a decrease in median daily occupational exposure events (nine events per day premessaging versus one event per day during messaging). Conclusion  Enterprise text messages sent to hospital-employee smartphones are an efficient and effective strategy for urgent communications. Hospitals may wish to leverage this technology during times of routine operations and crisis management.     

The Effect of WeChat on Parental Care Burden,Anxiety, and Depression in Children after CHD Surgery during COVID-19 Pandemic

Objectives  This study aimed to explore the effect of applying WeChat in the follow-up and health education of children after congenital heart disease (CHD) surgery during the coronavirus disease 2019 (COVID-19) epidemic. Methods  Data from 135 children were retrospectively analyzed. The care burden, anxiety, depression, and satisfaction of the parents of patients at home were analyzed and compared. Results  One month after discharge, the Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Zarit Burden Interview (ZBI), and Patient Satisfaction Questionnaire-18 scores of the WeChat follow-up group were significantly better than those of the outpatient follow-up group ( p  < 0.05). Compared with the discharge time, the SAS, SDS, and ZBI scores were significantly improved in the WeChat follow-up group but not in the outpatient follow-up group ( p  < 0.05). Conclusion  During the COVID-19 epidemic, the application of WeChat to the follow-up management of children after CHD surgery can effectively reduce care burden and relieve anxiety and depression in parents at home. It can also improve the satisfaction of parents with medical treatment.     

Leveraging American College of Obstetricians and Gynecologists Guidelines for Point-of-Care Decision Support in Obstetrics

Background  The American College of Obstetricians and Gynecologists (ACOG) provides numerous narrative documents containing formal recommendations and additional narrative guidance within the text. These guidelines are not intended to provide a complete “care pathway” for patient management, but these elements of guidance can be useful for clinical decision support (CDS) in obstetrical and gynecologic care and could be exposed within electronic health records (EHRs). Unfortunately, narrative guidelines do not easily translate into computable CDS guidance. Objective  This study aimed to describe a method of translating ACOG clinical guidance into clear, implementable items associated with specific obstetrical problems for integration into the EHR. Methods  To translate ACOG clinical guidance in Obstetrics into implementable CDS, we followed a set of steps including selection of documents, establishing a problem list, extraction and classification of recommendations, and assigning tasks to those recommendations. Results  Our search through ACOG clinical guidelines produced over 500 unique documents. After exclusions, and counting only sources relevant to obstetrics, we used 245 documents: 38 practice bulletins, 113 committee opinions, 16 endorsed publications, 1 practice advisory, 2 task force and work group reports, 2 patient education, 2 obstetric care consensus, 60 frequently asked questions (FAQ), 1 women''s health care guidelines, 1 Prolog series, and 9 others (non-ACOG). Recommendations were classified as actionable ( n  = 576), informational ( n  = 493), for in-house summary ( n  = 124), education/counseling ( n  = 170), policy/advocacy ( n  = 33), perioperative care ( n  = 4), delivery recommendations ( n  = 50), peripartum care ( n  = 13), and non-ACOG ( n  = 25). Conclusion  We described a methodology of translating ACOG narrative into a semi-structured format that can be more easily applied as CDS in the EHR. We believe this work can contribute to developing a library of information within ACOG that can be continually updated and disseminated to EHR systems for the most optimal decision support. We will continue documenting our process in developing executable code for decision support.     

The My Diabetes Care Patient Portal Intervention: Usability and Pre-Post Assessment

Background  My Diabetes Care (MDC) is a novel, multifaceted patient portal intervention designed to help patients better understand their diabetes health data and support self-management. MDC uses infographics to visualize and summarize patients'' diabetes health data, incorporates motivational strategies, and provides literacy level–appropriate educational resources. Objectives  We aimed to assess the usability, acceptability, perceptions, and potential impact of MDC. Methods  We recruited 69 participants from four clinics affiliated with Vanderbilt University Medical Center. Participants were given 1 month of access to MDC and completed pre- and post-questionnaires including validated measures of usability and patient activation, and questions about user experience. Results  Sixty participants completed the study. Participants'' mean age was 58, 55% were females, 68% were Caucasians, and 48% had limited health literacy (HL). Most participants (80%) visited MDC three or more times and 50% spent a total of ≥15 minutes on MDC. Participants'' median System Usability Scale (SUS) score was 78.8 [Q1, Q3: 72.5, 87.5] and significantly greater than the threshold value of 68 indicative of “above average” usability ( p  < 0.001). The median SUS score of patients with limited HL was similar to those with adequate HL (77.5 [72.5, 85.0] vs. 82.5 [72.5, 92.5]; p  = 0.41). Participants most commonly reported the literacy level–appropriate educational links and health data infographics as features that helped them better understand their diabetes health data (65%). All participants (100%) intended to continue to use MDC. Median Patient Activation Measure® scores increased postintervention (64.3 [55.6, 72.5] vs. 67.8 [60.6, 75.0]; p  = 0.01). Conclusion  Participants, including those with limited HL, rated the usability of MDC above average, anticipated continued use, and identified key features that improved their understanding of diabetes health data. Patient activation improved over the study period. Our findings suggest MDC may be a beneficial addition to existing patient portals.     

An Analysis of Electronic Health Record Work to Manage Asynchronous Clinical Messages among Breast Cancer Care Teams

Objective  Asynchronous messaging is an integral aspect of communication in clinical settings, but imposes additional work and potentially leads to inefficiency. The goal of this study was to describe the time spent using the electronic health record (EHR) to manage asynchronous communication to support breast cancer care coordination. Methods  We analyzed 3 years of audit logs and secure messaging logs from the EHR for care team members involved in breast cancer care at Vanderbilt University Medical Center. To evaluate trends in EHR use, we combined log data into sequences of events that occurred within 15 minutes of any other event by the same employee about the same patient. Results  Our cohort of 9,761 patients were the subject of 430,857 message threads by 7,194 employees over a 3-year period. Breast cancer care team members performed messaging actions in 37.5% of all EHR sessions, averaging 29.8 (standard deviation [SD] = 23.5) messaging sessions per day. Messaging sessions lasted an average of 1.1 (95% confidence interval: 0.99–1.24) minutes longer than nonmessaging sessions. On days when the cancer providers did not otherwise have clinical responsibilities, they still performed messaging actions in an average of 15 (SD = 11.9) sessions per day. Conclusion  At our institution, clinical messaging occurred in 35% of all EHR sessions. Clinical messaging, sometimes viewed as a supporting task of clinical work, is important to delivering and coordinating care across roles. Measuring the electronic work of asynchronous communication among care team members affords the opportunity to systematically identify opportunities to improve employee workload.     

A Mobile Game Platform for Improving Social Communication in Children with Autism: A Feasibility Study

Background  Many children with autism cannot receive timely in-person diagnosis and therapy, especially in situations where access is limited by geography, socioeconomics, or global health concerns such as the current COVD-19 pandemic. Mobile solutions that work outside of traditional clinical environments can safeguard against gaps in access to quality care. Objective  The aim of the study is to examine the engagement level and therapeutic feasibility of a mobile game platform for children with autism. Methods  We designed a mobile application, GuessWhat , which, in its current form, delivers game-based therapy to children aged 3 to 12 in home settings through a smartphone. The phone, held by a caregiver on their forehead, displays one of a range of appropriate and therapeutically relevant prompts (e.g., a surprised face) that the child must recognize and mimic sufficiently to allow the caregiver to guess what is being imitated and proceed to the next prompt. Each game runs for 90 seconds to create a robust social exchange between the child and the caregiver. Results  We examined the therapeutic feasibility of GuessWhat in 72 children (75% male, average age 8 years 2 months) with autism who were asked to play the game for three 90-second sessions per day, 3 days per week, for a total of 4 weeks. The group showed significant improvements in Social Responsiveness Score-2 (SRS-2) total (3.97, p <0.001) and Vineland Adaptive Behavior Scales-II (VABS-II) socialization standard (5.27, p  = 0.002) scores. Conclusion  The results support that the GuessWhat mobile game is a viable approach for efficacious treatment of autism and further support the possibility that the game can be used in natural settings to increase access to treatment when barriers to care exist.     

eHealth Literacy of Medical and Health Science Students and Factors Affecting eHealth Literacy in an Ethiopian University: A Cross-Sectional Study

Background  eHealth literacy is individual''s ability to look for, understand, and evaluate health information from electronic sources. Integrating eHealth literacy to the health system could help lower health care costs and ensure health equity. Despite its importance, the eHealth literacy level in Ethiopia has not been studied on medical and health science students, who are important parties in the health system. Understanding their level of eHealth literacy augments practice of health care, efficiency in education, and use of eHealth technologies. Objective  This research study aims to determine eHealth literacy level and identify its associated factors among medical and health science students in University of Gondar (UoG). Methods  An institution-based cross-sectional study was conducted from March to May 2019 among undergraduate medical and health science students in the UoG. Stratified multistage sampling was used. The eHealth literacy scale was used to measure eHealth literacy. A binary logistic regression model was fitted to measure association between eHealth literacy and the independent variables. Results  A total of 801 students participated in this study with a 94.6% of response rate. The majority (60%) were male and previously lived-in urban areas (68%). The mean eHealth literacy score was 28.7 and 60% of the participants possessed high eHealth literacy. Using health-specific Web sites (adjusted odds ratio [AOR] = 2.84, 95% confidence interval [CI]: 1.86–4.33), having higher Internet efficacy (AOR = 2.26, 95% CI: 1.56–3.26), perceived usefulness of the Internet (AOR = 3.33, 95% CI: 1.95–5.69), medical app use (AOR = 1.70, 95% CI: 1.13–2.55), being female (AOR = 1.55, 95% CI: 1.08–2.22), and being health informatics student (AOR = 2.02, 95% CI: 1.149–3.148) affect a high eHealth literacy level. Conclusion  The level of eHealth literacy in this study was moderate. Using specific reputable health Web sites, using smartphone medical applications, and Internet efficacy determine eHealth literacy significantly.     

Disparities in Telemedicine Access: A Cross-Sectional Study of a Newly Established Infrastructure during the COVID-19 Pandemic

Background  The COVID-19 pandemic led to dramatic increases in telemedicine use to provide outpatient care without in-person contact risks. Telemedicine increases options for health care access, but a “digital divide” of disparate access may prevent certain populations from realizing the benefits of telemedicine. Objectives  The study aimed to understand telemedicine utilization patterns after a widespread deployment to identify potential disparities exacerbated by expanded telemedicine usage. Methods  We performed a cross-sectional retrospective analysis of adults who scheduled outpatient visits between June 1, 2020 and August 31, 2020 at a single-integrated academic health system encompassing a broad range of subspecialties and a large geographic region in the Upper Midwest, during a period of time after the initial surge of COVID-19 when most standard clinical services had resumed. At the beginning of this study period, approximately 72% of provider visits were telemedicine visits. The primary study outcome was whether a patient had one or more video-based visits, compared with audio-only (telephone) visits or in-person visits only. The secondary outcome was whether a patient had any telemedicine visits (video-based or audio-only), compared with in-person visits only. Results  A total of 197,076 individuals were eligible (average age = 46 years, 56% females). Increasing age, rural status, Asian or Black/African American race, Hispanic ethnicity, and self-pay/uninsured status were significantly negatively associated with having a video visit. Digital literacy, measured by patient portal activation status, was significantly positively associated with having a video visit, as were Medicaid or Medicare as payer and American Indian/Alaskan Native race. Conclusion  Our findings reinforce previous evidence that older age, rural status, lower socioeconomic status, Asian race, Black/African American race, and Hispanic/Latino ethnicity are associated with lower rates of video-based telemedicine use. Health systems and policies should seek to mitigate such barriers to telemedicine when possible, with efforts such as digital literacy outreach and equitable distribution of telemedicine infrastructure.     

Automated image processing pipeline for adaptive optics scanning light ophthalmoscopy

To mitigate the substantial post-processing burden associated with adaptive optics scanning light ophthalmoscopy (AOSLO), we have developed an open-source, automated AOSLO image processing pipeline with both “live” and “full” modes. The live mode provides feedback during acquisition, while the full mode is intended to automatically integrate the copious disparate modules currently used in generating analyzable montages. The mean (±SD) lag between initiation and montage placement for the live pipeline was 54.6 ± 32.7s. The full pipeline reduced overall human operator time by 54.9 ± 28.4%, with no significant difference in resultant cone density metrics. The reduced overhead decreases both the technical burden and operating cost of AOSLO imaging, increasing overall clinical accessibility.     

Health Information Exchange between Specialists and General Practitioners Benefits Rural Patients

Background  Health information exchange (HIE) may improve diagnostic accuracy, treatment efficacy, and safety by providing treating physicians with expert advice. However, most previous studies on HIE have been observational in nature. Objectives  To examine whether collaboration between specialists and general practitioners (GPs) in rural areas via HIE can improve outcomes among patients at low-to-moderate risk of cardiovascular disease, kidney disease, and stroke. Methods  In this randomized controlled trial, the Miyagi Medical and Welfare Information Network was used for HIE. We evaluated the clinical data of 1,092 patients aged ≥65 years living in the rural areas of the Miyagi Prefecture and receiving care from GPs only. High-risk patients were immediately referred to specialists, whereas low-to-moderate risk patients were randomly assigned to an intervention group in which GPs were advised by specialists through HIE ( n  = 518, 38% male, mean age = 76 ± 7 years) or a control group in which GPs received no advice by specialists ( n  = 521, 39% male, mean age = 75 ± 7 years). Results  In the intention-to-treat analysis, all-cause mortality and cumulative incidence of serious adverse events (e.g., hospital admission or unexpected referral to specialists) did not differ between the groups. However, per-protocol analysis controlling for GP adherence with specialist recommendations revealed significantly reduced all-cause mortality ( p  = 0.04) and cumulative serious adverse event incidence ( p  = 0.04) in the intervention group compared with the control group. Conclusion  HIE systems may improve outcomes among low-to-moderate risk patients by promoting greater collaboration between specialists and GPs, particularly in rural areas with few local specialists.     

Systematic Review of Approaches to Preserve Machine Learning Performance in the Presence of Temporal Dataset Shift in Clinical Medicine

Objective  The change in performance of machine learning models over time as a result of temporal dataset shift is a barrier to machine learning-derived models facilitating decision-making in clinical practice. Our aim was to describe technical procedures used to preserve the performance of machine learning models in the presence of temporal dataset shifts. Methods  Studies were included if they were fully published articles that used machine learning and implemented a procedure to mitigate the effects of temporal dataset shift in a clinical setting. We described how dataset shift was measured, the procedures used to preserve model performance, and their effects. Results  Of 4,457 potentially relevant publications identified, 15 were included. The impact of temporal dataset shift was primarily quantified using changes, usually deterioration, in calibration or discrimination. Calibration deterioration was more common ( n  = 11) than discrimination deterioration ( n  = 3). Mitigation strategies were categorized as model level or feature level. Model-level approaches ( n  = 15) were more common than feature-level approaches ( n  = 2), with the most common approaches being model refitting ( n  = 12), probability calibration ( n  = 7), model updating ( n  = 6), and model selection ( n  = 6). In general, all mitigation strategies were successful at preserving calibration but not uniformly successful in preserving discrimination. Conclusion  There was limited research in preserving the performance of machine learning models in the presence of temporal dataset shift in clinical medicine. Future research could focus on the impact of dataset shift on clinical decision making, benchmark the mitigation strategies on a wider range of datasets and tasks, and identify optimal strategies for specific settings.     

Designing and Implementing an IT Architecture for a Digital Multicenter Dementia Registry: digiDEM Bayern

Background  Registries are an essential research tool to investigate the long-term course of diseases and their impact on the affected. The project digiDEM Bayern will set up a prospective dementia registry to collect long-term data of people with dementia and their caregivers in Bavaria (Germany) supported by more than 300 research partners. Objective  The objective of this article is to outline an information technology (IT) architecture for the integration of a registry and comprehensive participant management in a dementia study. Measures to ensure high data quality, study governance, along with data privacy, and security are to be included in the architecture. Methods  The architecture was developed based on an iterative, stakeholder-oriented process. The development was inspired by the Twin Peaks Model that focuses on the codevelopment of requirements and architecture. We gradually moved from a general to a detailed understanding of both the requirements and design through a series of iterations. The experience learned from the pilot phase was integrated into a further iterative process of continuous improvement of the architecture. Results  The infrastructure provides a standardized workflow to support the electronic data collection and trace each participant''s study process. Therefore, the implementation consists of three systems: (1) electronic data capture system for Web-based or offline app-based data collection; (2) participant management system for the administration of the identity data of participants and research partners as well as of the overall study governance process; and (3) videoconferencing software for conducting interviews online. First experiences in the pilot phase have proven the feasibility of the framework. Conclusion  This article outlines an IT architecture to integrate a registry and participant management in a dementia research project. The framework was discussed and developed with the involvement of numerous stakeholders. Due to its adaptability of used software systems, a transfer to other projects should be easily possible.     

Development and Evaluation of an Intravenous Infusion Sequence Annotation System

Objectives  The sequence of intravenous infusions may impact the efficacy, safety, and cost of intravenous medications. The study describes and assesses a computerized clinical decision support annotation system capable of analyzing the sequence of intravenous infusions. Methods  All intravenous medications on the hospital formulary were analyzed based on factors that impact intravenous infusion sequence. Eight pharmacy infusion knowledge databases were constructed based on Hospital Infusion Standards. These databases were incorporated into the computerized sequence annotation module within the electronic health record system. The annotation process was changed from pharmacists'' manual annotation (phase 1) to computer-aided pharmacist manual annotation (phase 2) to automated computer annotation (phase 3). Results  Comparing phase 2 to phase 1, there were significant differences in sequence annotation with regards to the percentage of hospital wards annotated (100% vs. 4.65%, chi-square  = 180.95, p  < 0.001), percentage of patients annotated (64.18% vs. 0.52%, chi-square = 90.46, p  < 0.001), percentage of intravenous orders annotated (75.67% vs. 0.77%, chi-square = 118.78, p  < 0.001), and the number of tubing flushes per ward per day (118.51 vs. 2,115.00, p  < 0.001). Compared with phase 1, there were significant cost savings in tubing flushes in phase 2 and phase 3. Compared with phase 1, there was significant difference in the time nurses spent on tubing flushes in phase 2 and phase 3 (1,244.94 vs. 21,684.8 minutes, p  < 0.001; 1,369.51 vs. 21,684.8 minutes, p  < 0.001). Compared with phase 1, significantly less time was required for pharmacist annotation in phase 2 and phase 3 (90.6 vs. 4,753.57 minutes, p  < 0.001; 0.05 vs. 4,753.57 minutes, p  < 0.001). Conclusion  A computerized infusion annotation system is efficient in sequence annotation and significant savings in tubing flushes can be achieved as a result.     

Recognition of fasting or overall hyperglycaemia when starting insulin treatment in patients with type 2 diabetes in general practice

Background

One of the long-term effects in childhood cancer survivors (CCS) is the development of second cancers. In a cohort of CCS, this study describes how second cancers were presented, the way they were diagnosed, and the knowledge CCS had about their increased risk to develop a second cancer.

Patients and methods

Selected participants were all adult five-year CCS (n = 1275) who were treated at the University Medical Center Groningen since 1965. Of these, 84 (6.6%) had developed a second cancer, of which 27 had died. The 57 survivors were asked to participate in a telephone interview.

Results

Of the 57 CCS, 35 (61%) participated. Together they had developed 45 second cancers. Most participants (97%) were seen at the long-term follow-up clinic. Of all second cancers, 89% caused symptoms. Of all second cancers, the majority (56%) were first presented at the general practitioner''s (GP''s) office and 20% at follow-up testing. Of these CCS, only 28% were aware of their increased risk of developing a second cancer.

Conclusions

It is important to inform CCS continuously regarding their increased risk, as a relatively small percentage are aware of this. Since most of these patients first reported their symptoms to the GP, all GPs should be aware of this increased risk, in particular because this concerns cancer at a younger age than normally expected. A survivor care plan might be an effective way of communication with both CCS and GPs.Key Words: Childhood cancer survivors, general practice, general practitioner, long-term follow-up, second cancers, The Netherlands

• Childhood cancer survivors are at risk of late effects such as development of second cancers.
• Follow-up testing for late effects is advised in long-term effects clinics, but is still debated with regard to second cancers.
• Awareness is advised among GPs about the risk of second cancers as most are diagnosed by the GP.

     

Searching the PDF Haystack: Automated Knowledge Discovery in Scanned EHR Documents

Background  Clinicians express concern that they may be unaware of important information contained in voluminous scanned and other outside documents contained in electronic health records (EHRs). An example is “unrecognized EHR risk factor information,” defined as risk factors for heritable cancer that exist within a patient''s EHR but are not known by current treating providers. In a related study using manual EHR chart review, we found that half of the women whose EHR contained risk factor information meet criteria for further genetic risk evaluation for heritable forms of breast and ovarian cancer. They were not referred for genetic counseling. Objectives  The purpose of this study was to compare the use of automated methods (optical character recognition with natural language processing) versus human review in their ability to identify risk factors for heritable breast and ovarian cancer within EHR scanned documents. Methods  We evaluated the accuracy of the chart review by comparing our criterion standard (physician chart review) versus an automated method involving Amazon''s Textract service (Amazon.com, Seattle, Washington, United States), a clinical language annotation modeling and processing toolkit (CLAMP) (Center for Computational Biomedicine at The University of Texas Health Science, Houston, Texas, United States), and a custom-written Java application. Results  We found that automated methods identified most cancer risk factor information that would otherwise require clinician manual review and therefore is at risk of being missed. Conclusion  The use of automated methods for identification of heritable risk factors within EHRs may provide an accurate yet rapid review of patients'' past medical histories. These methods could be further strengthened via improved analysis of handwritten notes, tables, and colloquial phrases.     

Shared-Task Worklists Improve Clinical Trial Recruitment Workflow in an Academic Emergency Department

Background  Clinical trials performed in our emergency department at Barnes-Jewish Hospital utilize a centralized infrastructure for alerting, screening, and enrollment with rule-based alerts sent to clinical research coordinators. Previously, all alerts were delivered as text messages via dedicated cellular phones. As the number of ongoing clinical trials increased, the volume of alerts grew to an unmanageable level. Therefore, we have changed our primary notification delivery method to study-specific, shared-task worklists integrated with our pre-existing web-based screening documentation system. Objective  To evaluate the effects on screening and recruitment workflow of replacing text-message delivery of clinical trial alerts with study-specific shared-task worklists in a high-volume academic emergency department supporting multiple concurrent clinical trials. Methods  We analyzed retrospective data on alerting, screening, and enrollment for 10 active clinical trials pre- and postimplementation of shared-task worklists. Results  Notifications signaling the presence of potentially eligible subjects for clinical trials were more likely to result in a screen ( p  < 0.001) with the implementation of shared-task worklists compared with notifications delivered as text messages for 8/10 clinical trials. The change in workflow did not alter the likelihood of a notification resulting in an enrollment ( p  = 0.473). The Director of Research reported a substantial reduction in the amount of time spent redirecting clinical research coordinator screening activities. Conclusion  Shared-task worklists, with the functionalities we have described, offer a viable alternative to delivery of clinical trial alerts via text message directly to clinical research coordinators recruiting for multiple concurrent clinical trials in a high-volume academic emergency department.     

Unattended compared to traditional blood pressure measurement in patients with rheumatoid arthritis: a randomised cross-over study

BackgroundHypertension is characterised by a high prevalence, low awareness and poor control among rheumatoid arthritis (RA) patients. Correct blood pressure (BP) measurement is highly important in these subjects. The “unattended” BP measurement aims to reduce the “white-coat effect,” a phenomenon associated with cardiovascular risk. Data on “unattended” BP measurement in RA and its impact on hypertensive organ damage are very limited.MethodsBP was measured in the same patient both traditionally (“attended” BP) and by the “unattended” protocol (3 automated office BP measurements, at 1-min intervals, after 5 min of rest, with patient left alone) by a randomised cross-over design. Patients underwent clinical examination, 12-lead electrocardiography and trans-thoracic echocardiography to evaluate cardiac damage.ResultsSixty-two RA patients (mean age 67 ± 9 years, 87% women) were enrolled. Hypertension was diagnosed in 79% and 66% of patients according to ACC/AHA and ESC/ESH criteria, respectively. Concordance correlation coefficients between the two techniques were 0.55 (95%, CI 0.38–0.68) for systolic BP and 0.73 (95%, CI 0.60–0.82) for diastolic BP. “Unattended” (121.7/68.6 mmHg) was lower than “attended” BP (130.5/72.8 mmHg) for systolic and diastolic BP (both p < .0001). Among the two techniques, only “unattended” systolic BP showed a significant association with left ventricular mass (r = 0.11; p = .40 for “attended” BP; r = 0.27; p = .036 for unattended BP; difference between slopes: z = 3.92; p = .0001).ConclusionsIn RA patients, “unattended” BP is lower than traditional (“attended”) BP and more closely associated with LV mass. In these patients, the “unattended” automated BP measurement is a promising tool which requires further evaluation.

KEY MESSAGES

• “Unattended” automated blood pressure registration, aimed to reduce the “white-coat effect” is lower than “attended” value in rheumatoid arthritis patients.
• “Unattended” blood pressure is more closely associated with left ventricular mass than “attende” registration.