Individualized prediction of critical illness in older adults: Validation of an elders risk assessment model.

BACKGROUND: The electronic health record (EHR) presents new opportunities for the timely identification of patients at high risk of critical illness and the implementation of preventive strategies. This study aims to externally validate an EHR-based Elders Risk Assessment (ERA) score to identify older patients at high risk of future critical illness during a primary care visit. METHODS: This historical cohort study included patients aged ≥65 years who had primary care visits at Mayo Clinic Rochester, MN, between July 2019 and December 2021. The ERA score at the time of the primary care visit was used to predict critical illness, defined as death or ICU admission within 1 year of the visit. RESULTS: A total of 12,885 patients were included in the analysis. The median age at the time of the primary care visit was 75 years, with 44.6% being male. 93.7% of participants were White, and 64.2% were married. The median (25th, 75th percentile) ERA score was 4 (0, 9). 11.3% of study participants were admitted to the ICU or died within 1 year of the visit. The ERA score predicted critical illness within 1 year of a primary care visit with an area under the receiver operating characteristic curve of 0.84 (95% CI 0.83-0.85), which indicates good discrimination. An ERA score of 9 was identified as optimal for implementing and testing potential preventive strategies, with the odds ratio of having the primary outcome in patients with ERA score ≥9 being 11.33 (95%CI 9.98-12.87). CONCLUSIONS: This simple EHR-based risk assessment model can predict critical illness within 1 year of primary care visits in older patients. The findings of this study can serve as a basis for testing and implementation of preventive strategies to promote the well-being of older adults at risk of critical illness and its consequences.

Innovative Research Methods: Using Simulation to Evaluate Health Care Policy.

Statement Health care policies have the potential to improve patient outcomes, access to care, and reduce health disparities. However, new policy is often tested in the field, where unintended consequences are paid for by patients. In this perspective, we argue that health care simulations, which can elucidate the potential for policy to hinder clinicians' ability to provide high-quality care, are a complement to large-scale policy evaluations in the field.

Development and validation of MRI-based radiomics signatures as new markers for preoperative assessment of EGFR mutation and subtypes from bone metastases.

BACKGROUND: This study aimed to develop and externally validate contrast-enhanced (CE) T1-weighted MRI-based radiomics for the identification of epidermal growth factor receptor (EGFR) mutation, exon-19 deletion and exon-21 L858R mutation from MR imaging of spinal bone metastasis from primary lung adenocarcinoma. METHODS: A total of 159 patients from our hospital between January 2017 and September 2021 formed a primary set, and 24 patients from another center between January 2017 and October 2021 formed an independent validation set. Radiomics features were extracted from the CET1 MRI using the Pyradiomics method. The least absolute shrinkage and selection operator (LASSO) regression was applied for selecting the most predictive features. Radiomics signatures (RSs) were developed based on the primary training set to predict EGFR mutations and differentiate between exon-19 deletion and exon-21 L858R. The RSs were validated on the internal and external validation sets using the Receiver Operating Characteristic (ROC) curve analysis. RESULTS: Eight, three, and five most predictive features were selected to build RS-EGFR, RS-19, and RS-21 for predicting EGFR mutation, exon-19 deletion and exon-21 L858R, respectively. The RSs generated favorable prediction efficacies for the primary (AUCs, RS-EGFR vs. RS-19 vs. RS-21, 0.851 vs. 0.816 vs. 0.814) and external validation (AUCs, RS-EGFR vs. RS-19 vs. RS-21, 0.807 vs. 0.742 vs. 0.792) sets. CONCLUSIONS: Radiomics features from the CE MRI could be used to detect the EGFR mutation, increasing the certainty of identifying exon-19 deletion and exon-21 L858R mutations based on spinal metastasis MR imaging.

A novel multimodal needs assessment to inform the longitudinal education program for an international interprofessional critical care team.

BACKGROUND: The current global pandemic has caused unprecedented strain on critical care resources, creating an urgency for global critical care education programs. Learning needs assessment is a core element of designing effective, targeted educational interventions. In theory, multimodal methods are preferred to assess both perceived and unperceived learning needs in diverse, interprofessional groups, but a robust design has rarely been reported. Little is known about the best approach to determine the learning needs of international critical care professionals. METHOD: We conducted multimodal learning needs assessment in a pilot group of critical care professionals in China using combined quantitative and qualitative methods. The assessments consisted of three phases: 1) Twenty statements describing essential entrustable professional activities (EPAs) were generated by a panel of critical care education experts using a Delphi method. 2) Eleven Chinese critical care professionals participating in a planned education program were asked to rank-order the statements according to their perceived learning priority using Q methodology. By-person factor analysis was used to study the typology of the opinions, and post-ranking focus group interviews were employed to qualitatively explore participants' reasoning of their rankings. 3) To identify additional unperceived learning needs, daily practice habits were audited using information from medical and nursing records for 3 months. RESULTS: Factor analysis of the rank-ordered statements revealed three learning need patterns with consensual and divergent opinions. All participants expressed significant interest in further education on organ support and disease management, moderate interest in quality improvement topics, and relatively low interest in communication skills. Interest in learning procedure/resuscitation skills varied. The chart audit revealed suboptimal adherence to several evidence-based practices and under-perceived practice gaps in patient-centered communication, daily assessment of antimicrobial therapy discontinuation, spontaneous breathing trial, and device discontinuation. CONCLUSIONS: We described an effective mixed-methods assessment to determine the learning needs of an international, interprofessional critical care team. The Q survey and focus group interviews prioritized and categorized perceived learning needs. The chart audit identified additional practice gaps that were not identified by the learners. Multimodal methods can be employed in cross-cultural scenarios to customize and better target medical education curricula.

Intra- and peritumoral radiomics on assessment of breast cancer molecular subtypes based on mammography and MRI.

PURPOSE: This study aimed to investigate the efficacy of digital mammography (DM), digital breast tomosynthesis (DBT), diffusion-weighted (DW) and dynamic contrast-enhanced (DCE) MRI separately and combined in the prediction of molecular subtypes of breast cancer. METHODS: A total of 241 patients were enrolled and underwent breast MD, DBT, DW and DCE scans. Radiomics features were calculated from intra- and peritumoral regions, and selected with least absolute shrinkage and selection operator (LASSO) regression to develop radiomics signatures (RSs). Prediction performance of intra- and peritumoral regions in the four modalities were evaluated and compared with area under the receiver-operating characteristic (ROC) curve (AUC), specificity and sensitivity as comparison metrics. RESULTS: The RSs derived from combined intra- and peritumoral regions improved prediction AUCs compared with those from intra- or peritumoral regions alone. DM plus DBT generated better AUCs than the DW plus DCE on predicting Luminal A and Luminal B in the training (Luminal A: 0.859 and 0.805; Luminal B: 0.773 and 0.747) and validation (Luminal A: 0.906 and 0.853; Luminal B: 0.807 and 0.784) cohort. For the prediction of HER2-enriched and TN, the DW plus DCE yielded better AUCs than the DM plus DBT in the training (HER2-enriched: 0.954 and 0.857; TN: 0.877 and 0.802) and validation (HER2-enriched: 0.974 and 0.907; TN: 0.938 and 0.874) cohort. CONCLUSIONS: Peritumoral regions can provide complementary information to intratumoral regions for the prediction of molecular subtypes. Compared with MRI, the mammography showed higher AUCs for the prediction of Luminal A and B, but lower AUCs for the prediction of HER2-enriched and TN.

Checklist for Early Recognition and Treatment of Acute Illness and Injury: An Exploratory Multicenter International Quality-Improvement Study in the ICUs With Variable Resources.

OBJECTIVES: To determine whether the "Checklist for Early Recognition and Treatment of Acute Illness and Injury" decision support tool during ICU admission and rounding is associated with improvements in nonadherence to evidence-based daily care processes and outcomes in variably resourced ICUs. DESIGN, SETTINGS, PATIENTS: This before-after study was performed in 34 ICUs (15 countries) from 2013 to 2017. Data were collected for 3 months before and 6 months after Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation. INTERVENTIONS: Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation using remote simulation training. MEASUREMENTS AND MAIN RESULTS: The coprimary outcomes, modified from the original protocol before data analysis, were nonadherence to 10 basic care processes and ICU and hospital length of stay. There were 1,447 patients in the preimplementation phase and 2,809 patients in the postimplementation phase. After adjusting for center effect, Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation was associated with reduced nonadherence to care processes (adjusted incidence rate ratio [95% CI]): deep vein thrombosis prophylaxis (0.74 [0.68-0.81), peptic ulcer prophylaxis (0.46 [0.38-0.57]), spontaneous breathing trial (0.81 [0.76-0.86]), family conferences (0.86 [0.81-0.92]), and daily assessment for the need of central venous catheters (0.85 [0.81-0.90]), urinary catheters (0.84 [0.80-0.88]), antimicrobials (0.66 [0.62-0.71]), and sedation (0.62 [0.57-0.67]). Analyses adjusted for baseline characteristics showed associations of Checklist for Early Recognition and Treatment of Acute Illness and Injury implementation with decreased ICU length of stay (adjusted ratio of geometric means [95% CI]) 0.86 [0.80-0.92]), hospital length of stay (0.92 [0.85-0.97]), and hospital mortality (adjusted odds ratio [95% CI], 0.81 (0.69-0.95). CONCLUSIONS: A quality-improvement intervention with remote simulation training to implement a decision support tool was associated with decreased nonadherence to daily care processes, shorter length of stay, and decreased mortality.

A Green HPLC Method for Determination of Nine Sulfonamides in Milk and Beef, and Its Greenness Assessment with Analytical Eco-Scale and Greenness Profile.

BACKGROUND: Sulfonamides have been widely used in the prevention and clinical treatment of bacterial diseases in livestock and poultry. The use of sulfonamides increases the risk of veterinary drug residues in animal derived foods. The traditional reversed phase liquid chromatography methods for sulfonamides residues detection in animal derived foods have the problem of high consumption of organic solvents. OBJECTIVE: The aim of this study was to establish a green high-performance liquid chromatography method for the detection of sulfonamides residues in different animal-origin foods. METHOD: The sample extraction solutions were purified by the Agela Cleanert PEP-2 cartridge and analyzed by the high-performance liquid chromatography method using ethanol as the green alternative solvent. RESULTS: The proposed method was validated in terms of linear range (20-1000 µg/kg), limit of detection (3.0-12.3 µg/kg), limit of quantitation (10-43 µg/kg), accuracy (80.7-101.3%), and repeatability and reproducibility (RSD <5.9% and RSD <8.5% respectively). CONCLUSIONS: The proposed method is an environmentally friendly, sensitive and reliable high-performance liquid chromatography method for simultaneous determination of sulfonamide residues in animal-origin foods. HIGHLIGHTS: In this work, we firstly developed a green high-performance liquid chromatography method for simultaneous determination of the residues of nine sulfonamides in milk and beef with ethanol as the green alternative solvent.

Integrated assessment of CDK1 upregulation in thyroid cancer.

Cyclin-dependent kinase 1 (CDK1) has a unique role in cell cycle regulation, as it is crucial for cell cycle progression and cell division. The aim of the present study was to use a combination of various detection methods to examine the expression and clinical significance of CDK1 in thyroid cancer (THCA). We used in-house tissue microarrays, immunohistochemistry, public RNA-sequencing, gene microarrays, and meta-analyses to conduct a comprehensive analysis of the role of CDK1 in the occurrence and development of THCA. CDK1 protein expression was notably higher in THCA tissues than in non-cancer tissues as evidenced by the in-house tissue microarrays. The expression of CDK1 protein was also significantly higher in pathologic T3-T4 than in T1-T2 samples. The pooled standardized mean difference (SMD) for CDK1 was 0.71 (95% CI, 0.46-0.95) including a total of 931 THCA and 585 non-cancerous thyroid tissue samples. An aggregation of the immunohistochemistry results and the RNA-sequencing/microarray findings gave a pooled SMD for CDK1 expression of 2.13 (95% CI, 1.30-2.96). The final area under curve (AUC) for the summarized receiver operating characteristic (sROC) was 0.7941 using all 1102 cases of THCA and 672 cases of controls. KEGG analysis with the co-expressed genes of CDK1 in THCA demonstrated the top enriched pathways to be the cell cycle, thyroid hormone synthesis, autoimmune thyroid disease, etc. In summary, we reveal the overexpression of CDK1 in THCA based on multiple detection methods that combine independent cohorts. However, further studies are required to elucidate the molecular mechanisms of CDK1 that promotes the biological aggressiveness of THCA cells.

Development and validation of clinical performance assessment in simulated medical emergencies: an observational study.

BACKGROUND: Critical illness is a time-sensitive process which requires practitioners to process vast quantities of data and make decisions rapidly. We have developed a tool, the Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN), aimed at enhancing care delivery in such situations. To determine the efficacy of CERTAIN and similar cognitive aids, we developed rubric for evaluating provider performance in a simulated medical resuscitation environments. METHODS: We recruited 18 clinicians with current valid ACLS certification for evaluation in three simulated medical scenarios designed to mimic typical medical decompensation events routinely experienced in clinical care. Subjects were stratified as experienced or novice based on prior critical care training. A checklist of critical actions was designed using face validity for each scenario to evaluate task completion and performance. Simulation sessions were video recorded and scored by two independent raters. Construct validity was assessed under the assumption that experienced clinicians should perform better than novice clinicians on each task. Reliability was assessed as percentage agreement, kappa statistics and Bland-Altman plots as appropriate. RESULTS: Eleven experts and seven novices completed evaluation. The overall agreement on common checklist item completion was 84.8 %. The overall model achieved face validity and was consistent with our construct, with experienced clinicians trending towards better performance compared to novices for accuracy and speed of task completion. CONCLUSIONS: A standardized video assessment tool has potential to provide a valid and reliable method to assess 12 performances of clinicians facing simulated medical emergencies.

An econometric analysis of changes in arable land utilization using multinomial logit model in Pinggu district, Beijing, China.

Arable land in China has been decreasing as a result of rapid population growth and economic development as well as urban expansion, especially in developed regions around cities where quality farmland quickly disappears. This paper analyzed changes in arable land utilization during 1993-2008 in the Pinggu district, Beijing, China, developed a multinomial logit (MNL) model to determine spatial driving factors influencing arable land-use change, and simulated arable land transition probabilities. Land-use maps, as well as social-economic and geographical data were used in the study. The results indicated that arable land decreased significantly between 1993 and 2008. Lost arable land shifted into orchard, forestland, settlement, and transportation land. Significant differences existed for arable land transitions among different landform areas. Slope, elevation, population density, urbanization rate, distance to settlements, and distance to roadways were strong drivers influencing arable land transition to other uses. The MNL model was proved effective for predicting transition probabilities in land use from arable land to other land-use types, thus can be used for scenario analysis to develop land-use policies and land-management measures in this metropolitan area.

Assessment of the cytotoxicity and genotoxicity of haloacetic acids using microplate-based cytotoxicity test and CHO/HGPRT gene mutation assay.

Haloacetic acids (HAAs) are the second most prevalent class of disinfection byproducts found in drinking water. The implications of HAAs presence in drinking water are a public health concern due to their potential mutagenic and carcinogenic effects. In the present study, we examined the cytotoxic and genotoxic effects of six common HAAs using a microplate-based cytotoxicity test and a hypoxanthine-guanine phosphoribosyltransferase (HGPRT) gene mutation assay in Chinese hamster ovary K1 (CHO-K1) cells. We found that their chronic cytotoxicities (72h exposure) to CHO-K1 cells varied, and we ranked their levels of toxicity in the following descending order: iodoacetic acid (IA)>bromoacetic acid (BA)>dibromoacetic acid (DBA)>chloroacetic acid (CA)>dichloroacetic acid (DCA)>trichloroacetic acid (TCA). The toxicity of IA is 1040-fold of that of TCA. All HAAs except TCA were shown to be mutagenic to CHO-K1 cells in the HGPRT gene mutation assay. The mutagenic potency was compared and ranked as follows: IA>DBA>BA>CA>DCA>TCA. There was a statistically significant correlation between cytotoxicity and mutagenicity of the HAAs in CHO-K1 cells. The microplate-based cytotoxicity assay and HGPRT gene mutation assay were suitable methods to monitor the cytotoxicity and genotoxicity of HAAs, particularly for comparing the toxic intensities quantitatively.

Simulation-based objective assessment discerns clinical proficiency in central line placement: a construct validation.

BACKGROUND: Central venous catheterization (CVC) is associated with patient risks known to be inversely related to clinician experience. We developed and evaluated a performance assessment tool for use in a simulation-based central line workshop. We hypothesized that instrument scores would discriminate between less experienced and more experienced clinicians. METHODS: Participants included trainees enrolled in an institutionally mandated CVC workshop and a convenience sample of faculty attending physicians. The workshop integrated several experiential learning techniques, including practice on cadavers and part-task trainers. A group of clinical and education experts developed a 15-point CVC Proficiency Scale using national and institutional guidelines. After the workshop, participants completed a certification exercise in which they independently performed a CVC in a part-task trainer. Two authors reviewed videotapes of the certification exercise to rate performance using the CVC Proficiency Scale. Participants were grouped by self-reported CVC experience. RESULTS: One hundred and five participants (92 trainees and 13 attending physicians) participated. Interrater reliability on a subset of 40 videos was 0.71, and Cronbach a was 0.81. The CVC Proficiency Scale Composite score varied significantly by experience: mean of 85%, median of 87% (range 47%-100%) for low experience (0-1 CVCs in the last 2 years, n = 27); mean of 88%, median of 87% (range 60%-100%) for moderate experience (2-49 CVCs, n = 62); and mean of 94%, median of 93% (range 73%-100%) for high experience (> 49 CVCs, n = 16) (P = .02, comparing low and high experience). CONCLUSIONS: Evidence from multiple sources, including appropriate content, high interrater and internal consistency reliability, and confirmation of hypothesized relations to other variables, supports the validity of using scores from this 15-item scale for assessing trainee proficiency following a central line workshop.