Evaluation of Documentation Patterns of Trainees and Supervising Physicians Using Data Mining.

BACKGROUND: The electronic health record (EHR) includes a rich data set that may offer opportunities for data mining and natural language processing to answer questions about quality of care, key aspects of resident education, or attributes of the residents' learning environment. OBJECTIVE: We used data obtained from the EHR to report on inpatient documentation practices of residents and attending physicians at a large academic medical center. METHODS: We conducted a retrospective observational study of deidentified patient notes entered over 7 consecutive months by a multispecialty university physician group at an urban hospital. A novel automated data mining technology was used to extract patient note-related variables. RESULTS: A sample of 26 802 consecutive patient notes was analyzed using the data mining and modeling tool Healthcare Smartgrid. Residents entered most of the notes (33%, 8178 of 24 787) between noon and 4 pm and 31% (7718 of 24 787) of notes between 8 am and noon. Attending physicians placed notes about teaching attestations within 24 hours in only 73% (17 843 of 24 443) of the records. Surgical residents were more likely to place notes before noon (P < .001). Nonsurgical faculty were more likely to provide attestation of resident notes within 24 hours (P < .001). CONCLUSIONS: Data related to patient note entry was successfully used to objectively measure current work flow of resident physicians and their supervising faculty, and the findings have implications for physician oversight of residents' clinical work. We were able to demonstrate the utility of a data mining model as an assessment tool in graduate medical education.

Bedside external ventricular drain placement: can multiple passes be predicted on the computed tomography scan before the procedure?

OBJECTIVE: Bedside external ventricular drain (EVD) placement is less than perfect and often requires multiple passes to achieve cerebrospinal fluid flow. We conducted this prospective study to understand why multiple passes are necessary and whether this affects the incidence of hemorrhage. METHODS: We compared the number of passes in 47 EVD placement procedures to the incidence of hemorrhage after the procedure. We also analyzed computed tomography scans before the procedure to identify variables that correlate with multiple passes. RESULTS: Of the procedures analyzed, 72% (34/47) were single pass whereas 28% (13/47) required multiple passes. Average number of passes was 1.85 (± 1.8), but average number of passes when multiple passes were made was 4.1 (± 2.29; range, 2-9). Incidence of tract hemorrhage was 10.6% (5/47). Of those, 11.8% (4/34) were in the single-pass group and 7.7% (1/13) from the multiple-pass group. There was no statistical relationship between the number of passes and hemorrhage (P > 0.99). Subarachnoid hemorrhage, intraventricular hemorrhage, and midline shift were not found to be statistically significant in relation to the number of passes. The presence of midline rostral hematoma significantly correlated with multiple passes. One of 34 patients (2.9%) needed a single pass and 5/13 (38.5%) needed multiple passes in the presence of midline rostral hematoma (P = 0.0011). The average targeted frontal horn volume was larger in patients who needed single pass EVD (12.4 ± 6.3 cm(2) vs. 8.0 ± 4.7 cm(2); P = 0.035). CONCLUSIONS: Multiple passes are inherent to the bedside EVD procedure, but did not increase the rate of intracranial hemorrhage.

Gamma Knife radiosurgery in the management of brainstem metastases.

BACKGROUND: Metastases to the brainstem portend a poor prognosis and present a challenge in clinical management. Surgical resection is rarely a viable option. METHODS: Post-treatment MRI scans of patients with brainstem metastases treated with radiosurgery were used to determine local control and disease progression. Median survival was calculated using Kaplan-Meier analysis. Univariate and multivariate analyses were performed using log-rank test and Cox proportional hazards model, respectively. RESULTS: Thirty-two consecutive patients with brainstem metastasis underwent Gamma Knife radiosurgery. Median age was 50 years. Median tumor volume was 0.71 cm3 and median tumor margin dose was 13 Gy. Seventeen of 32 patients received WBRT prior to stereotactic radiosurgery. Median survival was 5.2 months. There was a statistically significant difference in survival based on RTOG recursive partition analysis (RPA) class. Median survival of patients categorized as RPA class I was 19.2 months, RPA class II was 8.4 months, and RPA class III was 1.9 months. The overall local tumor control rate was 87.5%. There were no acute complications following stereotactic radiosurgery and no evidence of radiation necrosis noted on post-treatment MRI scans. CONCLUSION: Stereotactic radiosurgery is an effective treatment for brainstem metastases and should be considered especially for patients with good performance status.

Endometriosis causing lower extremity deep vein thrombosis - case report and review of the literature.

Endometriosis is a medical condition in women wherein endometrial cells deposited in the area outside the uterine cavity are influenced by hormonal changes, and produce symptoms depending on the site of implantation. A unique case of retroperitoneal endometriosis causing deep vein thrombosis from extrinsic compression of the right iliac vein is described. Clinical presentation with cyclical leg swelling, coincidental with menstruation and culminating with deep vein thrombosis, although very suggestive, has not been previously reported.