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    Decision fatigue in hospital medicine: A scoping review
    (The Society for Hospital Medicine, 2024-04) Jones, Sarah; Perry, Kelsey; Stumpff, Julia C; Kruer, Rachel; Czosnowski, Lauren; Kara, Areeba
    BACKGROUND: Decision fatigue describes the erosion of decision-making capacity as a consequence of the repeated acts of decision making. The phenomenon has been detected in ambulatory settings with higher rates of inappropriate antimicrobial and opiate prescribing and lower rates of cancer screening associated with appointments that occur later in the day. As hospital medicine is acknowledged to be a cognitively intense specialty, we decided to explore decision fatigue in hospital medicine. METHODS: As a relatively unexplored concept, we undertook a scoping review to understand what is known about decision fatigue in hospital medicine. All studies including healthcare workers in acute care settings and exploring the concepts of decision fatigue, cognitive burden and/or fatigue were included. Conceptually related studies of sleep deprivation, shift work, Circadian disruption, and excessive workloads with actual or theoretical paths of causality related to patient outcomes were also included. RESULTS: Our preliminary search revealed fifteen studies that met our inclusion criteria. No study specifically included hospitalists. Most studies described the concept among nurses, residents, and/or emergency department physicians. The outcomes studied were diverse and included self reported perceptions (e.g. perceived impact on patient care) and validated scales to measure fatigue and psychomotor performance. Fewer studies investigated clinical decisions such as the use of consultations, imaging and disposition decisions through the emergency department. Mitigating circumstances such as age, experience, responsibilities outside the hospital (e.g. having children) were infrequently described. CONCLUSIONS: While hospital medicine's fast pace, multitasking, fragmentation between clinicians and interruptions make it susceptible to decision fatigue, the concept remains under-explored in hospital medicine. The lack of consistent terminology complicates the evaluation of a phenomenon which ultimately is the culmination of individual, patient, work system and work environment factors. There is a need to detect and defuse the impact of decision fatigue in hospital medicine.
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    Virtual Is the New Reality: How Are We Matching Up Postpandemic?
    (2024-03) Pfeifle, Dan; Bagley, Brent; Carlos, W Graham
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    Transitioning from One Electronic Health Record to Another: A Systematic Review
    (Springer, 2023) Miake‑Lye, Isomi M.; Cogan, Alison M.; Mak, Selene; Brunner, Julian; Rinne, Seppo; Brayton, Catherine E.; Krones, Ariella; Ross, Travis E.; Burton, Jason T.; Weiner, Michael; Medicine, School of Medicine
    Background: Transitioning to a new electronic health record (EHR) presents different challenges than transitions from paper to electronic records. We synthesized the body of peer-reviewed literature on EHR-to-EHR transitions to evaluate the generalizability of published work and identify knowledge gaps where more evidence is needed. Methods: We conducted a broad search in PubMed through July 2022 and collected all publications from two prior reviews. Peer-reviewed publications reporting on data from an EHR-to-EHR transition were included. We extracted data on study design, setting, sample size, EHR systems involved, dates of transition and data collection, outcomes reported, and key findings. Results: The 40 included publications were grouped into thematic categories for narrative synthesis: clinical care outcomes (n = 15), provider perspectives (n = 11), data migration (n = 8), patient experience (n = 4), and other topics (n = 5). Many studies described single sites that are early adopters of technology with robust research resources, switching from a homegrown system to a commercial system, and emphasized the dynamic effect of transitioning on important clinical care and other outcomes over time. Discussion: The published literature represents a heterogeneous mix of study designs and outcome measures, and while some of the stronger studies in this review used longitudinal approaches to compare outcomes across more sites, the current literature is primarily descriptive and is not designed to offer recommendations that can guide future EHR transitions. Transitioning from one EHR to another constitutes a major organizational change that requires nearly every person in the organization to change how they do their work. Future research should include human factors as well as diverse methodological approaches such as mixed methods and implementation science.
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    THU035 Impact Of Surgery Or Medical Treatment With The Selective Glucocorticoid Receptor Modulator Relacorilant On Hypercoagulopathy In Patients With Cushing Syndrome
    (The Endocrine Society, 2023-10-05) Simeoli, Chiara; Di Paola, Nicola; Stigliano, Antonio; Lardo, Pina; Kearney, Tara; Mezosi, Emese; Ghigo, Ezio; Giordano, Roberta; Mariash, Cary N.; Donegan, Diane; Feelders, Richard A.; Hand, Austin L.; Moraitis, Andreas G.; Pivonello, Rosario; Medicine, School of Medicine
    In patients with Cushing syndrome (CS), hypercoagulability represents a significant concern, leading to an elevated risk for thrombotic events. Hypercoagulability persists for several months (mos) after curative surgery, and current CS treatment guidelines recommend anticoagulation therapy for up to 3 mos after surgery. In patients with Cushing disease, hemostatic parameters may even worsen after surgery, independent of surgical outcome, with improvements beginning about 3 mos after successful surgery (Casonato et al. Blood Coagul Fibrinolysis 1999). This transient worsening may be due to increased inflammation as cortisol levels, and hence cortisol’s anti-inflammatory effects, are reduced after successful surgery, leading to increased activity in the coagulation cascade, which normalizes over time. Here, we evaluate the impact of surgery or treatment with the selective glucocorticoid receptor modulator relacorilant (RELA) on the coagulation state in patients with CS, reporting findings from a retrospective, longitudinal, monocentric, surgical cohort study and an open-label phase 2 study of RELA (NCT02804750). In the surgical study, coagulation markers were assessed in 30 patients before curative surgery and in remission. In the RELA study, patients received either RELA 100-200 mg for 12 weeks or RELA 250-400 mg for 16 weeks; coagulation markers were assessed in 34 patients throughout the study. In the surgical study, baseline (BL) mean 24-h urinary free cortisol (UFC) was 615.6 mcg/day (by immunoassay; 2.1x upper limit of normal [ULN]); mean and median time to hemostasis assessment after remission were 6.2 and 6 mos, respectively. Significant mean changes from BL were observed in activated partial thromboplastin time (aPTT; +2.0 sec, P=0.031), factor VIII (fVIII; -24.2%, P=0.044), and von Willebrand factor (vWF; -20.6%, P=0.018), whereas platelet count was unchanged. In the RELA study, BL mean UFC was 211.9 mcg/day (by tandem mass spectrometry; 4.2x ULN). Similar to the surgical study, significant mean changes from BL to last observed visit were reported in aPTT (+1.5 sec, P=0.046), fVIII (-18.9%, P=0.022), and platelet count (-68.8*109/L, P<0.0001), while vWF was unchanged. Significant improvements in other coagulation factors, eg, fIX and fX, were seen in patients with abnormal values at BL. These studies showed that coagulation markers in patients with CS improve 6 mos after curative surgery, and that treatment with RELA may have similar effects after 3-4 mos. The previously observed transient increase in fVIII immediately after surgery was absent with RELA, where negative mean changes from BL were seen throughout the study. This is presumably due to the less abrupt reduction of cortisol activity with RELA compared to surgery. RELA’s effects on hypercoagulopathy support further investigation of preoperative use and in patients with CS who are not eligible for surgery.
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    Neuropsychiatric adverse effects from CFTR modulators deserve a serious research effort
    (Wolters Kluwer, 2023) VanElzakker, Michael B.; Tillman, Emma M.; Yonker, Lael M.; Ratai, Eva-Maria; Georgiopoulos, Anna M.; Medicine, School of Medicine
    Purpose of review: This review highlights the problem of neuropsychiatric adverse effects (AEs) associated with elexacaftor/tezacaftor/ivacaftor (ETI), current suboptimal mitigation approaches, a novel testable mechanistic hypothesis, and potential solutions requiring further research. Recent findings: Studies show that a minority of persons with cystic fibrosis (PwCF) initiating cystic fibrosis transmembrane conductance regulator (CFTR) modulators experience neuropsychiatric AEs including worsening mood, cognition, anxiety, sleep, and suicidality. The GABA-A receptor is a ligand-gated chloride channel, and magnetic resonance spectroscopy neuroimaging studies have shown that reduced GABA expression in rostral anterior cingulate cortex is associated with anxiety and depression. Recent research details the impact of peripheral inflammation and the gut-brain axis on central neuroinflammation. Plasma ETI concentrations and sweat chloride have been evaluated in small studies of neuropsychiatric AEs but not validated to guide dose titration or correlated with pharmacogenomic variants or safety/efficacy. Summary: Although ETI is well tolerated by most PwCF, some experience debilitating neuropsychiatric AEs. In some cases, these AEs may be driven by modulation of CFTR and chloride transport within the brain. Understanding biological mechanisms is a critical next step in identifying which PwCF are likely to experience AEs, and in developing evidence-based strategies to mitigate them, while retaining modulator efficacy.
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    Frequency of serrated polyposis syndrome recognition by community endoscopists
    (Thieme, 2023-10-06) McWhinney, Connor D.; Lahr, Rachel E.; Rex, Douglas K.; Medicine, School of Medicine
    Background and study aims: Some data indicate serrated polyposis syndrome (SPS) is underdiagnosed. We determined the frequency of SPS diagnosis by community endoscopists prior to referral to a tertiary center. Patients and methods: We performed a retrospective analysis of a prospectively collected database of SPS patients at a tertiary academic hospital. There were 212 patients who were referred to our center for resection of one or more lesions detected at a prior colonoscopy and who had records available that allowed determination of whether SPS was diagnosed before referral. Results: Only 25 of 212 patients (11.8%) had a diagnosis or suspicion of a polyposis syndrome prior to referral, and only 12 patients (5.7%) had a specific SPS diagnosis made prior to referral. Among 187 patients diagnosed at our center, 39 had sufficient serrated lesions removed and documented in outside records to meet SPS criteria prior to referral, but the diagnosis was not made by the referring physician despite adequate numbers of lesions resected. The remaining cases required lesions removed at our center to meet SPS diagnostic criteria. Limitations were a single center, single expert endoscopist. Conclusions: SPS is the most common colorectal polyposis syndrome, but it remains underdiagnosed by community endoscopists. Underdiagnosis may contribute to post-colonoscopy colorectal cancer in patients with SPS.
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    Bioinformatic analysis identified novel candidate genes with the potentials for diagnostic blood testing of primary biliary cholangitis
    (Public Library of Science, 2023-10-16) Pham, Hoang Nam; Pham, Linh; Sato, Keisaku; Medicine, School of Medicine
    Primary biliary cholangitis (PBC) is an autoimmune disorder characterized by intrahepatic bile duct destruction and cholestatic liver injury. Diagnosis of PBC is generally based on the existence of anti-mitochondrial antibody (AMA) in blood samples; however, some PBC patients are negative for serum AMA tests, and invasive liver histological testing is required in rare PBC cases. The current study seeks novel candidate genes that are associated with PBC status and have potentials for blood diagnostic testing. Human transcriptomic profiling data of liver and blood samples were obtained from Gene Expression Omnibus (GEO). Three GEO data series (GSE79850, GSE159676, and GSE119600) were downloaded, and bioinformatic analyses were performed. Various differentially expressed genes were identified in three data series by comparing PBC patients and control individuals. Twelve candidate genes were identified, which were upregulated in both liver tissues and blood samples of PBC patients in all three data series. The enrichment analysis demonstrated that 8 out of 12 candidate genes were associated with biological functions, which were closely related to autoimmune diseases including PBC. Candidate genes, especially ITGAL showed good potentials to distinguish PBC with other diseases. These candidate genes could be useful for diagnostic blood testing of PBC, although further clinical studies are required to evaluate their potentials as diagnostic biomarkers.
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    Multicenter evaluation of the BIOFIRE Joint Infection Panel for the detection of bacteria, yeast, and AMR genes in synovial fluid samples
    (American Society for Microbiology, 2023) Esteban, Jaime; Salar-Vidal, Llanos; Schmitt, Bryan H.; Waggoner, Amy; Laurent, Frédéric; Abad, Lelia; Bauer, Thomas W.; Mazariegos, Irving; Balada-Llasat, Joan-Miquel; Horn, Jared; Wolk, Donna M.; Jefferis, Alexa; Hermans, Mirjam; Verhoofstad, Irma; Butler-Wu, Susan M.; Umali-Wilcox, Minette; Murphy, Caitlin; Cabrera, Barbara; Craft, David; von Bredow, Benjamin; Leber, Amy; Everhart, Kathy; Dien Bard, Jennifer; Flores, Irvin Ibarra; Daly, Judy; Barr, Rebecca; Holmberg, Kristen; Graue, Corrin; Kensinger, Bart; Medicine, School of Medicine
    The bioMérieux BIOFIRE Joint Infection (JI) Panel is a multiplex in vitro diagnostic test for the simultaneous and rapid (~1 h) detection of 39 potential pathogens and antimicrobial resistance (AMR) genes directly from synovial fluid (SF) samples. Thirty-one species or groups of microorganisms are included in the kit, as well as several AMR genes. This study, performed to evaluate the BIOFIRE JI Panel for regulatory clearance, provides data from a multicenter evaluation of 1,544 prospectively collected residual SF samples with performance compared to standard-of-care (SOC) culture for organisms or polymerase chain reaction (PCR) and sequencing for AMR genes. The BIOFIRE JI Panel demonstrated a sensitivity of 90.9% or greater for all but six organisms and a positive percent agreement (PPA) of 100% for all AMR genes. The BIOFIRE JI Panel demonstrated a specificity of 98.5% or greater for detection of all organisms and a negative percent agreement (NPA) of 95.7% or greater for all AMR genes. The BIOFIRE JI Panel provides an improvement over SOC culture, with a substantially shorter time to result for both organisms and AMR genes with excellent sensitivity/PPA and specificity/NPA, and is anticipated to provide timely and actionable diagnostic information for joint infections in a variety of clinical scenarios.
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    Clinical approach to indeterminate biliary strictures: Clinical presentation, diagnosis, and workup
    (Baishideng, 2023) Yadlapati, Sujani; Mulki, Ramzi; Sánchez-Luna, Sergio A.; Ahmed, Ali M.; Kyanam Kabir Baig, Kondal Rao; Peter, Shajan; Medicine, School of Medicine
    Despite advances in cross-sectional imaging and endoscopic technology, bile duct strictures remain a challenging clinical entity. It is crucial to make an early determination of benign or malignant nature of biliary strictures. Early diagnosis not only helps with further management but also minimizes mortality and morbidity associated with delayed diagnosis. Conventional imaging and endoscopic techniques, particularly endoscopic retrograde cholangiopancreatography (ERCP) and tissue sampling techniques play a key in establishing a diagnosis. Indeterminate biliary strictures (IDBSs) have no definite mass on imaging or absolute histopathological diagnosis and often warrant utilization of multiple diagnostics to ascertain an etiology. In this review, we discuss possible etiologies, clinical presentation, diagnosis, and management of IDBSs. Based on available data and expert opinion, we depict an evidence based diagnostic algorithm for management of IDBSs. Areas of focus include use of traditional tissue sampling techniques such as ERCP with brush cytology, intraductal biopsies, fluorescence in situ hybridization and flow cytometry. We also describe the role of endoscopic ultrasound (EUS)-guided fine needle aspiration and biopsies, cholangioscopy, confocal laser endomicroscopy, and intraductal EUS in management of IDBSs.
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    Development of a population‐level prediction model for intensive care unit (ICU) survivorship and mortality in older adults: A population‐based cohort study
    (Wiley, 2023-10-19) Khan, Sikandar H.; Perkins, Anthony J.; Fuchita, Mikita; Holler, Emma; Ortiz, Damaris; Boustani, Malaz; Khan, Babar A.; Gao, Sujuan; Medicine, School of Medicine
    Background and aims: Given the growing utilization of critical care services by an aging population, development of population-level risk models which predict intensive care unit (ICU) survivorship and mortality may offer advantages for researchers and health systems. Our objective was to develop a risk model for ICU survivorship and mortality among community dwelling older adults. Methods: This was a population-based cohort study of 48,127 patients who were 50 years and older with at least one primary care visit between January 1, 2017, and December 31, 2017. We used electronic health record (EHR) data to identify variables predictive of ICU survivorship. Results: ICU admission and mortality within 2 years after index primary care visit date were used to divide patients into three groups of "alive without ICU admission", "ICU survivors," and "death." Multinomial logistic regression was used to identify EHR predictive variables for the three patient outcomes. Cross-validation by randomly splitting the data into derivation and validation data sets (60:40 split) was used to identify predictor variables and validate model performance using area under the receiver operating characteristics (AUC) curve. In our overall sample, 92.2% of patients were alive without ICU admission, 6.2% were admitted to the ICU at least once and survived, and 1.6% died. Greater deciles of age over 50 years, diagnoses of chronic obstructive pulmonary disorder or chronic heart failure, and laboratory abnormalities in alkaline phosphatase, hematocrit, and albumin contributed highest risk score weights for mortality. Risk scores derived from the model discriminated between patients that died versus remained alive without ICU admission (AUC = 0.858), and between ICU survivors versus alive without ICU admission (AUC = 0.765). Conclusion: Our risk scores provide a feasible and scalable tool for researchers and health systems to identify patient cohorts at increased risk for ICU admission and survivorship. Further studies are needed to prospectively validate the risk scores in other patient populations.