RESUMO
BACKGROUND: A potential benefit of electronic health records (EHRs) is that they could potentially save clinician time and improve documentation by auto-generating the history of present illness (HPI) in partnership with patients prior to the clinic visit. We developed an online patient portal called AEGIS (Automated Evaluation of Gastrointestinal [GI] Symptoms) that systematically collects patient GI symptom information and then transforms the data into a narrative HPI that is available for physicians to review in the EHR prior to seeing the patient. OBJECTIVE: This study aimed to compare whether use of an online GI symptom history taker called AEGIS improves physician-centric outcomes vs usual care. METHODS: We conducted a pragmatic controlled trial among adults aged ≥18 years scheduled for a new patient visit at 4 GI clinics at an academic medical center. Patients who completed AEGIS were matched with controls in the intervention period who did not complete AEGIS as well as controls who underwent usual care in the pre-intervention period. Of note, the pre-intervention control group was formed as it was not subject to contamination bias, unlike for post-intervention controls. We then compared the following outcomes among groups: (1) documentation of alarm symptoms, (2) documentation of family history of GI malignancy, (3) number of follow-up visits in a 6-month period, (4) number of tests ordered in a 6-month period, and (5) charting time (difference between appointment time and time the encounter was closed). Multivariable regression models were used to adjust for potential confounding. RESULTS: Of the 774 patients who were invited to complete AEGIS, 116 (15.0%) finished it prior to their visit. The 116 AEGIS patients were then matched with 343 and 102 controls in the pre- and post-intervention periods, respectively. There were no statistically significant differences among the groups for documentation of alarm symptoms and GI cancer family history, number of follow-up visits and ordered tests, or charting time (all P>.05). CONCLUSIONS: Use of a validated online HPI-generation portal did not improve physician documentation or reduce workload. Given universal adoption of EHRs, further research examining how to optimally leverage patient portals for improving outcomes are needed.
RESUMO
BACKGROUND: The incidence of recurrent laryngeal nerve injury (RLNI) after heart transplantation has not been well studied. This can manifest as vocal cord dysfunction causing dysphonia. Previous research is limited to aortic, coronary bypass, and valvular surgery. Identifying RLNI after heart transplantation is important in order to more accurately detail complications associated with this major surgery. METHODS: This is a retrospective study assessing 972 adult patients who underwent orthotopic heart transplantation between 2010-2019. Primary outcome was incidence of RLNI. Secondary outcomes were 1-year mortality and length of stay. Cardiology and otolaryngology notes were examined. Key word searches were used to identify possible RLNI in patients' health care record. RESULTS: 2.9% (29/972) of patients developed new RLNI confirmed by laryngoscopy during hospitalization. Patients with RLNI had a significantly increased risk of 1-year mortality (P = .015) and length of stay (P = .006) compared to those without RLNI. 68.9% (20/29) of RLNI was left-sided (68.9%). CONCLUSIONS: Recurrent laryngeal nerve injury is a recognizable adverse outcome following heart transplantation. This study supports that RLNI is associated with increased 1-year mortality and length of stay. Early otolaryngology evaluation may be warranted to evaluate vocal cord mobility and address potential management.
Assuntos
Transplante de Coração , Traumatismos do Nervo Laríngeo , Traumatismos do Nervo Laríngeo Recorrente , Adulto , Transplante de Coração/efeitos adversos , Humanos , Incidência , Traumatismos do Nervo Laríngeo Recorrente/etiologia , Estudos RetrospectivosRESUMO
JC virus-associated nephropathy is rare in kidney transplant recipients, and even rarer in recipients of other solid organ transplants. We present a case of JC virus-associated nephropathy in a heart-kidney transplant recipient, which to our knowledge is the first case reported in the literature. We discuss the findings on renal biopsy for JC virus nephropathy and our management approach to this rare complication.
Assuntos
Transplante de Coração/efeitos adversos , Vírus JC/patogenicidade , Nefropatias/virologia , Transplante de Rim/efeitos adversos , Rim/virologia , Infecções por Polyomavirus/etiologia , Idoso , Biópsia , Rejeição de Enxerto , Humanos , Rim/patologia , MasculinoRESUMO
BACKGROUND: The generation of vascular progenitors (VPs) from human induced pluripotent stem cells (hiPSCs) has great potential for treating vascular disorders such as ischemic retinopathies. However, long-term in vivo engraftment of hiPSC-derived VPs into the retina has not yet been reported. This goal may be limited by the low differentiation yield, greater senescence, and poor proliferation of hiPSC-derived vascular cells. To evaluate the potential of hiPSCs for treating ischemic retinopathies, we generated VPs from a repertoire of viral-integrated and nonintegrated fibroblast and cord blood (CB)-derived hiPSC lines and tested their capacity for homing and engrafting into murine retina in an ischemia-reperfusion model. METHODS AND RESULTS: VPs from human embryonic stem cells and hiPSCs were generated with an optimized vascular differentiation system. Fluorescence-activated cell sorting purification of human embryoid body cells differentially expressing endothelial/pericytic markers identified a CD31(+)CD146(+) VP population with high vascular potency. Episomal CB-induced pluripotent stem cells (iPSCs) generated these VPs with higher efficiencies than fibroblast-iPSC. Moreover, in contrast to fibroblast-iPSC-VPs, CB-iPSC-VPs maintained expression signatures more comparable to human embryonic stem cell VPs, expressed higher levels of immature vascular markers, demonstrated less culture senescence and sensitivity to DNA damage, and possessed fewer transmitted reprogramming errors. Luciferase transgene-marked VPs from human embryonic stem cells, CB-iPSCs, and fibroblast-iPSCs were injected systemically or directly into the vitreous of retinal ischemia-reperfusion-injured adult nonobese diabetic-severe combined immunodeficient mice. Only human embryonic stem cell- and CB-iPSC-derived VPs reliably homed and engrafted into injured retinal capillaries, with incorporation into damaged vessels for up to 45 days. CONCLUSIONS: VPs generated from CB-iPSCs possessed augmented capacity to home, integrate into, and repair damaged retinal vasculature.