Evaluating Natural Language Processing Packages for Predicting Hospital-Acquired Pressure Injuries From Clinical Notes.

Incidence of hospital-acquired pressure injury, a key indicator of nursing quality, is directly proportional to adverse outcomes, increased hospital stays, and economic burdens on patients, caregivers, and society. Thus, predicting hospital-acquired pressure injury is important. Prediction models use structured data more often than unstructured notes, although the latter often contain useful patient information. We hypothesize that unstructured notes, such as nursing notes, can predict hospital-acquired pressure injury. We evaluate the impact of using various natural language processing packages to identify salient patient information from unstructured text. We use named entity recognition to identify keywords, which comprise the feature space of our classifier for hospital-acquired pressure injury prediction. We compare scispaCy and Stanza, two different named entity recognition models, using unstructured notes in Medical Information Mart for Intensive Care III, a publicly available ICU data set. To assess the impact of vocabulary size reduction, we compare the use of all clinical notes with only nursing notes. Our results suggest that named entity recognition extraction using nursing notes can yield accurate models. Moreover, the extracted keywords play a significant role in the prediction of hospital-acquired pressure injury.

Air quality and cancer risk in the All of Us Research Program.

INTRODUCTION: The NIH All of Us Research Program has enrolled over 544,000 participants across the US with unprecedented racial/ethnic diversity, offering opportunities to investigate myriad exposures and diseases. This paper aims to investigate the association between PM2.5 exposure and cancer risks. MATERIALS AND METHODS: This work was performed on data from 409,876 All of Us Research Program participants using the All of Us Researcher Workbench. Cancer case ascertainment was performed using data from electronic health records and the self-reported Personal Medical History questionnaire. PM2.5 exposure was retrieved from NASA's Earth Observing System Data and Information Center and assigned using participants' 3-digit zip code prefixes. Multivariate logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI). Generalized additive models (GAMs) were used to investigate non-linear relationships. RESULTS: A total of 33,387 participants and 46,176 prevalent cancer cases were ascertained from participant EHR data, while 20,297 cases were ascertained from self-reported survey data from 18,133 participants; 9,502 cancer cases were captured in both the EHR and survey data. Average PM2.5 level from 2007 to 2016 was 8.90 µg/m3 (min 2.56, max 15.05). In analysis of cancer cases from EHR, an increased odds for breast cancer (OR 1.17, 95% CI 1.09-1.25), endometrial cancer (OR 1.33, 95% CI 1.09-1.62) and ovarian cancer (OR 1.20, 95% CI 1.01-1.42) in the 4th quartile of exposure compared to the 1st. In GAM, higher PM2.5 concentration was associated with increased odds for blood cancer, bone cancer, brain cancer, breast cancer, colon and rectum cancer, endocrine system cancer, lung cancer, pancreatic cancer, prostate cancer, and thyroid cancer. CONCLUSIONS: We found evidence of an association of PM2.5 with breast, ovarian, and endometrial cancers. There is little to no prior evidence in the literature on the impact of PM2.5 on risk of these cancers, warranting further investigation.

Systematic Review and Meta-Analysis on the Incidence of Level-Specific Cervical Nodal Metastasis in Primary Parotid Malignancies.

OBJECTIVE: In primary parotid gland malignancies, the incidence of level-specific cervical lymph node metastasis in clinically node-positive necks remains unclear. This study aimed to determine the incidence of level-specific cervical node metastasis in clinically node-negative (cN0) and node-positive (cN+) patients who presented with primary parotid malignancies. DATA SOURCES: Electronic databases (MEDLINE, EMBASE, PubMed, Cochrane). REVIEW METHODS: Random-effects meta-analysis was used to calculate pooled estimate incidence of level-specific nodal metastasis for parotid malignancies with 95% confidence intervals (CIs). Subgroup analyses of cN0 and cN+ were performed. RESULTS: Thirteen publications consisting of 818 patients were included. The overall incidence of cervical nodal involvement in all neck dissections was 47% (95% CI, 31%-63%). Among those who were cN+, the incidence of nodal positivity was 89% (95% CI, 75%-98%). Those who were cN0 had an incidence of 32% (95% CI, 14%-53%). In cN+ patients, the incidence of nodal metastasis was high at all levels (level I 33%, level II 73%, level III 48%, level IV 39%, and level V 37%). In cN0 patients, the incidence of nodal metastasis was highest at levels II (28%) and III (11%). CONCLUSION: For primary parotid malignancies, the incidence of occult metastases was 32% compared to 89% in a clinically positive neck. It is recommended that individuals with a primary parotid malignancy requiring elective treatment of the neck have a selective neck dissection which involves levels II to III, with the inclusion of level IV based on clinical judgment. Those undergoing a therapeutic neck dissection should undergo a comprehensive neck dissection (levels I-V).

Comparison of postoperative complications in early versus delayed tracheostomy decannulation in patients undergoing oral cancer surgery with microvascular reconstruction.

The purpose of this study was to determine the relationship of early and delayed tracheostomy decannulation protocols on the length of stay, time to oral feeding and incidence of postoperative complications in patients undergoing microvascular reconstruction for oral cancer. A review of all patients who underwent surgical management of oral squamous cell carcinoma (OSCC) over the study period from 01/07/2017 to 31/06/2021 was performed. Patients who underwent elective tracheostomy as part of their microvascular reconstruction were included. Two cohorts were identified based on distinct postoperative tracheostomy decannulation protocols; early (Within 7 days) and delayed (≥7 days). Time to oral feeding, length of stay and complication rates was determined for both groups for statistical analysis. A total of 103 patients with OSCC were included in the study. The overall complication rate was 35.9% and were more likely in node positive patients (53.7% vs 23.2%; p = 0.003) and in cases where the geniohyoid muscle complex was disrupted during tumour resection (66.7% vs 31.9%; p = 0.026). Early decannulation was significantly associated with shorter length of hospital stay (10 days vs 15 days) and earlier removal of nasogastric feeding tubes (7 vs 10 days). There was no difference in the overall complication rate between the two groups (33.3% vs 37.5%; p = 0.833). Early decannulation in appropriately selected patients is recommended as it significantly reduces the length of hospital stay and aids in early resumption of oral intake. Furthermore, this approach is not associated with increased rates of complications.

Spindle cell lipoma of the epiglottis: a potential airway emergency.

Nil.

An Overview of Cancer in the First 315,000 All of Us Participants.

INTRODUCTION: The NIH All of Us Research Program will have the scale and scope to enable research for a wide range of diseases, including cancer. The program's focus on diversity and inclusion promises a better understanding of the unequal burden of cancer. Preliminary cancer ascertainment in the All of Us cohort from two data sources (self-reported versus electronic health records (EHR)) is considered. MATERIALS AND METHODS: This work was performed on data collected from the All of Us Research Program's 315,297 enrolled participants to date using the Researcher Workbench, where approved researchers can access and analyze All of Us data on cancer and other diseases. Cancer case ascertainment was performed using data from EHR and self-reported surveys across key factors. Distribution of cancer types and concordance of data sources by cancer site and demographics is analyzed. RESULTS AND DISCUSSION: Data collected from 315,297 participants resulted in 13,298 cancer cases detected in the survey (in 89,261 participants), 23,520 cancer cases detected in the EHR (in 203,813 participants), and 7,123 cancer cases detected across both sources (in 62,497 participants). Key differences in survey completion by race/ethnicity impacted the makeup of cohorts when compared to cancer in the EHR and national NCI SEER data. CONCLUSIONS: This study provides key insight into cancer detection in the All of Us Research Program and points to the existing strengths and limitations of All of Us as a platform for cancer research now and in the future.

Role of 3D Volumetric and Perfusion Imaging for Detecting Early Changes in Pancreatic Adenocarcinoma.

PURPOSE: There is a major shortage of reliable early detection methods for pancreatic cancer in high-risk groups. The focus of this preliminary study was to use Time Intensity-Density Curve (TIDC) and Marley Equation analyses, in conjunction with 3D volumetric and perfusion imaging to demonstrate their potential as imaging biomarkers to assist in the early detection of Pancreatic Ductal Adenocarcinoma (PDAC). EXPERIMENTAL DESIGNS: A quantitative retrospective and prospective study was done by analyzing multi-phase Computed Tomography (CT) images of 28 patients undergoing treatment at different stages of pancreatic adenocarcinoma using advanced 3D imaging software to identify the perfusion and radio density of tumors. RESULTS: TIDC and the Marley Equation proved useful in quantifying tumor aggressiveness. Perfusion delays in the venous phase can be linked to Vascular Endothelial Growth Factor (VEGF)-related activity which represents the active part of the tumor. 3D volume analysis of the multiphase CT scan of the patient showed clear changes in arterial and venous perfusion indicating the aggressive state of the tumor. CONCLUSION: TIDC and 3D volumetric analysis can play a significant role in defining the response of the tumor to treatment and identifying early-stage aggressiveness.

Predictors of progression through the cascade of care to a cure for hepatitis C patients using decision trees and random forests.

BACKGROUND: This study uses machine learning techniques to identify sociodemographic and clinical predictors of progression through the hepatitis C (HCV) cascade of care for patients in the 1945-1965 birth cohort in the Southern United States. METHODS: We compared sociodemographic and clinical variables between groups of patients for three care outcomes: linkage to care, initiation of antiviral treatment, and virologic cure. A decision tree model and random forest model were built for each outcome. RESULTS: Patients were primarily male, African American/Black or Caucasian/White, non-Hispanic or Latino, and insured. The average age at first HCV screening was 60 years old, and common medical diagnoses included chronic kidney disease, fibrosis and/or cirrhosis, transplanted liver, diabetes mellitus, and liver cell carcinoma. Variables used in predicting linkage to care included age at first HCV screening, insurance at first HCV screening, race, fibrosis and/or cirrhosis, other liver disease, ascites, and transplanted liver. Variables used in predicting initiation of antiviral treatment included insurance at first HCV screening, gender, other liver cancer, steatosis, and liver cell carcinoma. Variables used in predicting virologic cure included insurance at first HCV screening, transplanted liver, and ethnicity. CONCLUSION: These patients have a high hepatic health burden, likely reflecting complications of untreated HCV and highlighting the urgency to cure HCV in this birth cohort. We found differences in HCV care outcomes based on sociodemographic and clinical variables. More work is needed to understand the mechanisms of these differences in care outcomes and to improve HCV care.

Comparative analysis of three-dimensional volume rendering and maximum intensity projection for preoperative planning in liver cancer.

Three-dimensional imaging is a useful tool to evaluate liver structure and surrounding vessels for preoperative planning. In this study, we compared two methods of visualizing vascular maps on computed tomography including maximum intensity projection (MIP) and 3D volume rendered (VR) imaging. We compiled important imaging components of pre-surgical planning, and developed criteria for comparison. The imaging techniques were compared based on colorization, volume quantification, rotation, vessel delineation, small vessel clarity, and segmental liver isolation. MIP had more overall limitations due to reduced differentiation of superimposed structures, motion artifact, and interference from calcifications. We determined that because 3D quantitative volume rendered imaging can provide more detail and perspective than MIP imaging, it may be more useful in preoperative planning for patients with liver malignancy. Advanced 3D imaging is a useful tool that can have profound clinical implications on cancer detection and surgical planning.

Use of Purastat, a novel haemostatic matrix based on self-assembling peptides in the prevention of nasopharyngeal adhesion formation.

INTRODUCTION: Purastat is a novel haemostatic agent that has recently been used effectively in nasal procedures, specifically in functional endoscopic endonasal surgery in the prevention of post-operative epistaxis while minimising adhesion formation. This study presents a case of successful application of Purastat following division of a nasopharyngeal/palatal stenosis following radiotherapy. PRESENTATION OF CASE: A 49-year-old male developed severe nasopharyngeal stenosis following concurrent chemoradiotherapy with curative intent a HPV positive base of tongue squamous cell carcinoma. Following treatment, while the patient experienced excellent metabolic response, he began to progressive nasal obstruction which he reported to be significantly affecting his quality of life. Following multidisciplinary team discussion, division of the stenosis was considered appropriate. Under general anaesthesia, the patient was positioned lying supine with the neck extended. A Boyle-Davis gag with lip and teeth protection was placed and a Y-suction catheter inserted to lift the palate from the posterior pharyngeal wall. Coblation using a PDW wand was used to divide the area of fibrosis bilaterally toward the superior tonsillar pillar until palatopharyngeus musculature was visible. Injection of 4 mg of Dexamethasone with a hypodermic needle was then performed followed by application of 4 ml of topical Purastat onto the raw surfaces after haemostasis was confirmed. The patient was discharged the same day on simple analgesia and instructions to avoid exertion for two weeks. He attended follow-up in the outpatient department two months later and reported persisting resolution of his nasal obstructive symptoms. No evidence of recurrence or residual adhesion tissue was noted.

A case of acute unilateral maxillary atelectasis following endoscopic pituitary surgery.

INTRODUCTION: Chronic maxillary atelectasis (CMA) is traditionally described as a rare, acquired condition of persistent and progressive antral wall collapse causing a reduction in maxillary sinus volume. In a handful of cases, CMA has been identified in patients with previously normal computed tomography (CT) imaging. However, maxillary atelectasis occurring rapidly after pituitary surgery, despite a normal pre-operative CT scan, has not previously been described in the literature. PRESENTATION OF CASE: A 29-year-old male presented two months post endoscopic transnasal, transsphenoidal excision of a Rathke's cleft cyst with facial pain and pressure, unresponsive to medical treatment. CT of the paranasal sinuses at five months post-operatively demonstrated evidence of a left CMA, which was not present on pre-operative imaging. He underwent endoscopic uncinectomy and middle meatal antrostomy with complete resolution of symptoms. DISCUSSION: To our knowledge, this is the first case in the literature describing acute development of maxillary atelectasis. While lateralisation of the middle turbinate causing ostiomeatal obstruction may lead to sinus atelectasis, it is typically a slow process and often seen in the context of chronic disease. Review of the literature demonstrates six cases of documented rapid-onset atelectasis of maxillary sinuses. Four of these cases were post-operative, with one involving direct surgery on the affected sinus. CONCLUSION: This case represents the first in the literature of acute, post-operative unilateral maxillary atelectasis following pituitary surgery, where the affected sinus was not directly involved in the initial operation. Consideration should be made to incorporate acute cases into the current classification system.

Chondro-Osseous Respiratory Epithelial Adenomatoid Hamartoma (COREAH): Case Report and Literature Review.

Chondro-osseous respiratory epithelial adenomatoid hamartoma (COREAH) is an extremely rare lesion of the nasal cavity with only 11 reported cases in the literature. COREAH is of interest as it may be easily mistaken for other diseases of the nasal cavity with higher morbidity, which require significantly different management strategies. We report, to the best of our knowledge, the oldest documented case of COREAH in the literature: an 83-year-old female who presented with headaches and was found to have a posterior nasal septal lesion. Uniquely, the patient had sequential scans performed 1 year apart demonstrating only minor interval growth. We describe our experience in managing a patient with COREAH and review the world literature, to better define aspects of the history, presentation, and investigations that may allow differentiation from more sinister disease.

A Dysregulated Balance of Proinflammatory and Anti-Inflammatory Host Cytokine Response Early During Therapy Predicts Persistence and Mortality in Staphylococcus aureus Bacteremia.

OBJECTIVES: The contribution of individual immune response to Staphylococcus aureus bacteremia on outcome has not been well studied. The objective was to relate the host cytokine response to outcome of Staphylococcus aureus bacteremia. DESIGN: Prospective observational study. SETTING: Three U.S. university-affiliated medical centers. PATIENTS: Adult patients infected with Staphylococcus aureus bacteremia hospitalized between July 2012 and August 2014. INTERVENTIONS: Blood specimens were obtained at Staphylococcus aureus bacteremia onset and 72 hours after therapy initiation. Levels of tissue necrosis factor, interleukin-6, interleukin-8, interleukin-17A, and interleukin-10 were measured by enzyme-linked immunosorbent assay at each time point and compared between those with persistent bacteremia (≥ 4 d) and resolving bacteremia. Primary outcome was persistent bacteremia after 4 days of effective therapy. Secondary outcomes were 30-day mortality and 30-day recurrence. MEASUREMENTS AND MAIN RESULTS: A total of 196 patients were included (mean age, 59 yr); of them, 33% had methicillin-resistant Staphylococcus aureus bacteremia. Forty-seven percent of the methicillin-resistant Staphylococcus aureus strains were staphylococcal cassette chromosome mec IV. Persistent bacteremia occurred in 24% of patients (47/196); they were more likely to die than resolving bacteremia group (28% vs 5%; p < 0.001). Compared with resolving bacteremia group, persistent bacteremia patients had higher initial median levels of tissue necrosis factor (44.73 vs 21.68 pg/mL; p < 0.001), interleukin-8 (124.76 vs 47.48 pg/mL; p = 0.028), and interleukin-10 (104.31 vs 29.72 pg/mL; p < 0.001). Despite 72 hours of treatment, levels remained higher for the persistent bacteremia group than for the resolving bacteremia group (tissue necrosis factor: 26.95 vs 18.38 pg/mL, p = 0.02; interleukin-8: 70.75 vs 27.86 pg/mL, p = 0.002; interleukin-6: 67.50 vs 21.81 pg/mL, p = 0.005; and interleukin-10: 30.98 vs 12.60 pg/mL, p < 0.001). Interleukin-17A levels were similar between groups at both time points. After controlling for confounding variables by multivariate analysis, interleukin-10/tissue necrosis factor ratio at 72 hours most significantly predicted persistence (odds ratio, 2.98; 95% CI, 1.39-6.39; p = 0.005) and mortality (odds ratio, 9.87; 95% CI, 2.64-36.91; p < 0.001) at values more than 1.00 and more than 2.56, respectively. CONCLUSIONS: Sustained elevation of interleukin-10/tissue necrosis factor ratio at 72 hours suggests a dysregulated immune response and may be used to guide management to improve outcomes.

Sign and pseudo-sign of Leser-Trélat: case reports and a review of the literature.

BACKGROUND: Leser-Trélat is distinguished by a rare paraneoplastic sign that is characterized by the sudden eruption of multiple seborrheic keratoses (SKs), associated with underlying internal malignancies. Similar non-malignancy-associated SK eruptions are referred to as the "pseudo-sign of Leser-Trélat" (PLT). OBJECTIVE: Two cases of rapid SK eruptions, one the sign of Leser-Trélat (SLT) and one PLT, are presented, and the literature on SLT and PLT is reviewed. METHODS: A literature review of SLT/PLT was performed by searching the PubMed database for all related English published cases. RESULTS: We identified 109 cases of SLT and 12 cases of PLT, with a mean patient age of 61.8 years. SK eruptions were observed before (68.3%), after (22.1%), and at the time of (9.6%) malignancy diagnosis. The malignancy most frequently associated with SLT was gastric adenocarcinoma. The most common anatomical location of SK eruptions was the trunk (18.9%). Frequently reported associated signs and symptoms included pruritus (52%) and acanthosis nigricans (38.7%). The most common treatment included surgery (35.8%), chemotherapy (26.9%), and radiation therapy (26.9%). Treatment resulted in clinical improvement (45%), no change (30%), exacerbation (15%), or initial improvement followed by exacerbation of SKs. Patient outcomes included disease stability/ improvement (48.4%), recurrence (9.7%), exacerbation/metastasis/new malignancy (4.8%), and death (37.1%). LIMITATIONS: This was a retrospective study and excluded non-English published cases. CONCLUSION: This review updates the existing SLT literature and emphasizes the presence of PLT. Clinicians should be aware that SK eruptions may be early manifestations of an internal malignancy or other pathology. To our knowledge, this is the first review examining both SLT and PLT.

Short- and long-term outcomes of intracorporeal versus extracorporeal ileocolic anastomosis in laparoscopic right hemicolectomy for colon cancer.

BACKGROUND: We assessed the short- and long-term outcomes of intracorporeal ileocolic anastomosis (IA) in laparoscopic right hemicolectomy for colon cancer compared with extracorporeal anastomosis (EA). METHODS: A retrospective chart review of 86 consecutive patients who underwent laparoscopic right hemicolectomy for colon cancer from March 2005 to June 2010 was performed. RESULTS: There were 51 and 35 patients who underwent intracorporeal and extracorporeal anastomosis, respectively. The two groups were demographically comparable. The conversion rate to open surgery was 8.6 % in the EA group, but none in the IA group (p = 0.064). There was no significant difference in operative time, estimated blood loss, complications (intra-abdominal abscess, anastomotic leak, ileus, and wound infection), and length of hospital stay between the groups. There was no perioperative mortality in both groups. There was no significant difference in median number of retrieved lymph node. The overall survival and the disease-free survival at 3 years were not different between the groups. CONCLUSIONS: Compared with the extracorporeal anastomosis technique, intracorporeal ileocolic anastomosis produces comparable short- and long-term outcomes in laparoscopic right hemicolectomy for colon cancer.

Interest and use of mental health and specialty behavioral medicine counseling in US primary care patients.

BACKGROUND: Counseling interventions have the potential to improve health and quality of life for primary care patients, but there are few studies describing the interest in and utilization of counseling among this patient population in the USA. PURPOSE: The purpose of the study was to evaluate interest in mental health and specialty behavioral medicine counseling and predictors of utilization over 1 year among US primary care patients. METHOD: Participants in this two-survey longitudinal study included 658 primary care patients in an urban US academic medical center (461 females, age M = 51.05, SD = 15.46 years). Retention rate was 61.2% at survey 2. Patient demographics, depression, anxiety, and interest in counseling services were assessed through a survey mailed 1 week following an outpatient appointment. Respondents to survey 1 were re-contacted 1 year later to assess. Interest and use of the following counseling services were evaluated in the relevant subgroups: mental health (the entire sample and patients with elevated anxiety and/or depression), health/lifestyle (overweight and obese participants), smoking cessation (current and occasional smokers), and pain management (participants with elevated daily pain ratings). RESULTS: At survey 1, 45.7% of the sample reported interest in mental health counseling, and 58.9% of the sample reported interest in behavioral medicine counseling. Among overweight or obese participants, 59.9% were interested in health/lifestyle counseling. Among smokers, 55.3% were interested in smoking cessation, and among participants with chronic pain, 33.8% were interest in pain management. Rates of utilization of services at survey 2 were 21.3% for mental health, 7.7% for health/lifestyle, 6.7% for smoking cessation, and 6.6% for pain management. Interest in receiving services at survey 1 was the strongest predictor of utilization. CONCLUSION: Results demonstrate high interest but low utilization over 1 year among US primary care patients. Identifying patients interested in counseling services and reducing barriers may help facilitate receipt of services for those with interest and need for behavioral treatments.

Gene polymorphisms predict toxicity to neoadjuvant therapy in patients with rectal cancer.

BACKGROUND: Toxicity from neoadjuvant chemoradiation therapy (NT) increases morbidity and limits therapeutic efficacy in patients with rectal cancer. The objective of this study was to determine whether specific polymorphisms in genes associated with rectal cancer response to NT were correlated with NT-related toxicity. METHODS: One hundred thirty-two patients with locally advanced rectal cancer received NT followed by surgery. All patients received 5-fluorouracil (5-FU) and radiation (RT), and 80 patients also received modified infusional 5-FU, folinic acid, and oxaliplatin chemotherapy (mFOLFOX-6). Grade ≥3 adverse events (AEs) that occurred during 5-FU/RT and during combined 5-FU/RT + mFOLFOX-6 were recorded. Pretreatment biopsy specimens and normal rectal tissues were collected from all patients. DNA was extracted and screened for 22 polymorphisms in 17 genes that have been associated with response to NT. Polymorphisms were correlated with treatment-related grade ≥3 AEs. RESULTS: Overall, 27 of 132 patients (20%) had grade ≥3 AEs; 18 patients had a complication associated only with 5-FU/RT, 3 patients experienced toxicity only during mFOLFOX-6, and 6 patients had grade ≥3 AEs associated with both treatments before surgery. Polymorphisms in the genes x-ray repair complementing defective repair in Chinese hamster cells 1 (XRCC1), xeroderma pigmentosum group D (XPD), and tumor protein 53 (TP53) were associated with grade ≥3 AEs during NT (P < .05). Specifically, 2 polymorphisms-an arginine-to-glutamine substitution at codon 399 (Q399R) in XRCC1 and a lysine-to-glutamine substitution at codon 751 (K751Q) in XPD-were associated with increased toxicity to 5-FU/RT (P < .05), and an arginine-to-proline substitution at codon 72 (R72P) in TP53 was associated with increased toxicity to mFOLFOX-6 (P = .008). CONCLUSIONS: Specific polymorphisms in XRCC1, XPD, and TP53 were associated with increased toxicity to NT in patients with rectal cancer. The current results indicated that polymorphism screening may help tailor treatment for patients by selecting therapies with the lowest risk of toxicity, thus increasing patient compliance.