Effectiveness of an Electronic Medical Record-Based Recognition Tool for the Identification of Incidental Pulmonary Nodules.

BACKGROUND: Incidental pulmonary nodules (IPNs) are lung nodules detected on imaging studies performed for an unrelated reason. Approximately 1.6 million IPNs are detected in the United States every year. Unfortunately, close to 1.1 million (69%) of these IPNs are not managed with appropriate follow-up care. The goal of this study was to assess the utility of a noncommercial electronic medical record (EMR)-based IPN keyword recognition program in identifying IPNs and the ability of lung navigators to communicate these findings to patients. METHODS: This is a observational, implementation study aimed identify IPNs using an EMR-based protocol and to relay results of findings to patients. The patient population included patients 16 and older undergoing computed tomography (CT) chest, CT chest/abdomen, CT angiogram chest, CT chest/abdomen/pelvis, and chest radiography through the radiology department within a large community tertiary medical campus between June 2019 and August 2020. EPIC EMR were queried using criteria designed to find IPNs. A lung navigator reviewed these cases and sorted them into categories based on their size and risk status. After identification of risk factors, actions were taken to directly communicate results to patients. RESULTS: Seven hundred and fifty-three patients were found to have true IPNs without a history of active malignancy involving the lung. On the basis of radiographic measurements, 60% of the nodules identified were <6 mm, 17% were between 6 and 8 mm, 22% were >8 mm, and 12% were deemed nodular opacities. Lung navigators were able to contact a total of 637 (87%) individuals with IPNs and results were directly communicated. Of the 637 patients identified to have an IPN, a total of 12 (2%) cancers were diagnosed. CONCLUSION: We have here demonstrated that the development of an EMR-based keyword recognition platform for the identification of IPNs is a useful and successful tool for communication of IPN findings to patients using lung navigators.

On first looking into auriculo-ventricular asynchrony.

Walter Gaskell's demonstration in 1882 that it was possible to block the passage of contraction from auricle to ventricle in the frog heart by means of a clamp spurred Joseph Erlanger (1906) to prevent, by similar means, impulse conduction through the bundle of (Wilhelm) His jun. (1893) in the mammalian heart. With a miniaturized polygraph to record the jugular and arterial pulsation, James Mackenzie (1902) displayed various grades of heart block in the human heart. His results were confirmed by Thomas Lewis using Willem Einthoven's (1903) ECG in 1911. But without instrumental help, Robert Spittal (1804-1852) recounted a case of reversible auriculo-ventricular block in 1830.

Thomas Wrigley Grimshaw (1839-1900). Registrar general 1879-1900.

Thomas Wrigley Grimshaw was born in Whitehouse, County Antrim, in 1839, and learned his medicine at the Dublin School of Medicine when its reputation was at its highest. If his teachers strayed from the art of bedside medicine into science it was into meteorology that had been revived by Thomas Sydenham, the 'English Hippocrates' in the seventeenth century. When Grimshaw was appointed Registrar General for Ireland in 1879 he diverted attention from the acute epidemics of zymotic diseases to chronic pulmonary affections that numerically were far more deadly. Cartography became an obsession with him, and he used it to show that Ireland was divided by phthisis into east and west. Koch's 'great discovery' in 1882 that tuberculosis is an infection not a 'constitutional' disease made him change his long-held views, and in the decade before his death in 1900 at Carrickmines, County Dublin, he became an active advocate of the new knowledge, distressed by the fact that thriving Belfast and its hinterland had the highest mortality from phthisis in Ireland. His concern for the health of young girls employed in large numbers in the linen factories was matched by his landmark advocacy of young ladies anxious to gain the licence to practise medicine in Great Britain and Ireland.

Intensive care 1650: the revival of Anne Greene (c. 1628-59).

On a cold December day in 1650, 22-year-old Anne Greene was hanged in Oxford. When taken down after half an hour, she was found to show signs of life and over the next few days William Petty (1623-87), Thomas Willis (1621-75), Ralph Bathurst (1620-74) and Henry Clerke (1622-87) ministered to her full recovery. She was later pardoned of the charge of infanticide and, with the coffin wherein she had lain as a trophy, went into the country, became the subject not only of a prose and poetic narrative but also of a woodcut. Anne married happily, bore three children and lived until 1659. A combination of low-body temperature and external (pedal) cardiac massage after her failed execution, it is suggested, helped to keep her alive until the arrival of the physicians who had come to make an anatomical dissection but serendipitously won golden opinions.

Cigarette butts may have low toxicity to soil-dwelling invertebrates: Evidence from a land snail.

Cigarette butts are a common form of litter that is often deposited on soil, where toxins from butts may affect soil-dwelling organisms. We examined possible toxicity of cigarette butts to the woodland snail Anguispira alternata using a toxicity study with cigarette butt effluent and a lab-based habitat choice experiment in which snails could feed or rest on areas with different butt densities. No mortality occurred during the 32-day toxicity study, which used six effluent concentrations ranging from 0 to 4butts/l (0 to 0.92butts/kg of soil). Neither food consumption nor snail growth differed among the effluent concentrations. When provided a choice among four habitats with 0 to 4 cigarette butts, snails selected to preferentially rest in the 0-butt habitat and avoided the 4-butt habitat. This distribution pattern was strong during the first wk. but became weaker over time and largely disappeared by the end of the 3-wk experiment. Snails did not discriminate among butt densities when feeding. This is the first toxicity test using cigarette butts on soil-dwelling invertebrates. Declining aversion to cigarette butts over a 3-wk period may indicate declining toxicity of terrestrially deposited butts as they age, but further testing is needed.

Interrater Reliability of Hospital Readmission Evaluations for Surgical Patients.

Value-based purchasing initiatives have helped shift attention to the accuracy of hospital readmission information at the most clinically detailed level. The purpose of this study was to determine the interrater reliability (IRR) of surgical experts in assessing surgical inpatient readmissions for categorical causes, relation to index procedure, and potential preventability. Cases were selected from the American College of Surgeons National Surgical Quality Improvement Program local database. Of 1840 cases, 156 patients (8.5%) were readmitted within 30 days of the procedure. Surgical site infection was the most common readmission cause (32%), followed by obstruction or ileus (17%). IRR was moderate for readmission cause (60% agreement, κ = 0.51), substantial for readmission in relation to surgical procedure (92%, κ = 0.70), and lowest for potential preventability of readmissions (57%, κ = 0.18). Results suggest that readmission cause and relation to surgical procedure can be determined with moderate to high degree of IRR, while preventability of readmissions may require stricter definitions to improve IRR.

Joseph Erlanger (1874-1965): the cardiovascular investigator who won a Nobel Prize in neurophysiology.

Born in San Francisco in 1874 into the family of German immigrants in which he was the only one to proceed beyond elementary education, Joseph Erlanger graduated from the University of California (Berkeley) in 1894. He was about to enter the local Cooper Medical School when he was told that the new medical school in Johns Hopkins University (Baltimore) aimed to surpass all others, and there he graduated and was later coached for a career in academic life by William H Howell (1860-1945). In due course he held the Chairs of Physiology in the University of Wisconsin (Madison) and Washington University at St Louis, Missouri. He showed that the Bundle of His is indeed the functional link between the atria and the ventricles in the mammalian heart and that the Korotkoff sounds are produced by a 'breaker' phenomenon resulting from instability of the pulse wave in a partially occluded artery. With Herbert S Gasser (1888-1963) he was awarded the Nobel Prize in 1944 for their work on action currents in peripheral nerve fibres. The history of science occupied him during his retirement. He died at St Louis in 1965.

Using NSQIP to investigate SCIP deficiencies in surgical patients with a high risk of developing hospital-associated urinary tract infections.

The study objectives were to identify risk factors for surgical patients who develop postoperative urinary tract infections (UTIs) and to characterize urethral catheter practices at the study hospital. Patients from the 2006-2010 institutional National Surgical Quality Improvement Program database were evaluated. Patients with UTIs within 30 postoperative days (n = 116) were compared to patients without UTIs (n = 8685) using multivariable logistic regression. A nested case-control study evaluated the effects of catheter practices on postoperative UTI using conditional logistic regression. Independent predictors of UTI were sex, age, inpatient stay, functional status, renal failure, preoperative transfusion, and preoperative hospital stay. Compared with controls, patients with UTI more often maintained catheters for >2 postoperative days (66% vs 43%, P < .001) and had longer mean catheter duration (11.6 vs 5.1 days, P < .001). Study findings led to institutional recommendations to reduce catheter-associated UTIs. Quality improvement initiatives can increase awareness of performance enhancement opportunities and encourage collaborative, interdisciplinary improvement through shared objectives.

James Alexander Lindsay (1856-1931), and his clinical axioms and aphorisms.

John Alexander Lindsay was born at Fintona, county Tyrone in 1856, and at the age of 23 he graduated in medicine at the Royal University of Ireland. After two years in London and Europe he returned to Belfast to join the staff at the Royal Victoria Hospital and in 1899 he was appointed to the professorship of medicine. He was valued by the students for his clarity and by his colleagues for his many extracurricular contributions to the medical profession in the positions entrusted to him. He published monographs on Diseases of the Lungs, and the Climatic Treatment of Consumption, but his later Medical Axioms show his deep appreciation of studied clinical observation. Although practice was changing in the new century Lindsay displayed an ability to change with the new requirements, as evidenced by his lecture on electrocardiography as president of the section of medicine of the Royal Academy of Medicine in Ireland in 1915. He was impressed by the way the string galvanometer changed attention from stenosis and incompetence of the valves to the cardiac musculature, but rightly suspected that there was more to be told about the state of the myocardium than Einthoven's three leads revealed. His death occurred in Belfast in 1931.

The frustration of Lady Aberdeen in her crusade against tuberculosis in Ireland.

When in his Annual Report for 1905 the Registrar General for Ireland pointed out to the lately arrived Lord Lieutenant, The Earl of Aberdeen, that annually in every 100 deaths in Ireland 16 were victims of tuberculosis, Lady Aberdeen took notice. In March 1907 she founded the WNHA with the clear duty of taking part in the fight against the appalling ravages of that disease, and organised a Tuberculosis Exhibition the following October. And so began a campaign that led to the building of Peamount Sanatorium in county Dublin, the Allan Ryan Hospital at Ringsend, and the Collier Dispensary in the city centre. However, the Irish parliamentarians at Westminster emasculated the Tuberculosis Prevention (Ireland) Act 1908 by ensuring that notification was not made compulsory. Passage of the National Health Insurance Act (1911) necessitated changes that resulted in the Tuberculosis Prevention (Ireland) Act (1913), but the crucial shortcomings of the earlier Act were not rectified: notification was necessary but still not compulsory. Lady Aberdeen recognised this serious flaw she was powerless to correct, and turned to propaganda, editing Sláinte, a monthly magazine founded in January 1909 by the WNHA, and editing a three-volume account of Ireland's Crusade Against Tuberculosis (1908-1909).

Archibald Billing (1791-1881) MD FRCP FRS: bedside teaching at the London Hospital (1822).

After graduation at Trinity College Dublin in 1814 Archibald Billing, who was born in County Dublin, settled in London. His Dublin MD (1818) was incorporated at Oxford and he taught at the London Hospital where, when appointed Senior Physician in 1822, he introduced teaching at the patients' bedsides. He ceased to lecture in 1836 when he was invited to become a member of the Senate of the University of London. He published papers on a variety of clinical subjects but is remembered for First Principles of Medicine (1831) that went through six editions. His friends among the operatic artists included Niccolo Paganini, and The Science of Jems, Jewels, Coins and Medals (1867) was the work of a connoisseur. He lived in retirement for many years before he died at the age of 90 at 34 Park Lane, London, on 2 September 1881.

Brice Clarke (1895-1975) and the control of tuberculosis in Northern Ireland.

Among the problems facing Northern Ireland after its foundation in 1920, one of the most daunting was the prevalence of tuberculosis, a chronic communicable disease with highest mortality among young women and men in the prime of life. Over a quarter of a century, legislative changes tardily responded, and in spite of, or because of its magnitude, Brice Clarke (1895-1975) devoted himself to the challenge. After decorated service in the Great War of 1914-19 he returned to finish his medical studies in Queen's University Belfast and held hospital appointments until he became Chief Tuberculosis Officer for Belfast and soon afterwards Director of Tuberculosis Services in Northern Ireland. For twenty years he was an enthusiastic proponent of collapse therapy, and even before the new chemotherapy hastened the natural decline in the tuberculosis epidemic he trumpeted the value of properly equipped chest clinics and generously funded welfare schemes. His garden at Hillsborough could not contain him in retirement; he set off on a slow boat to Japan in 1962, and returned to pen biographical sketches of famous consumptives until his death in 1975 at the age of 80.