Impact of an Online Gastrointestinal Symptom History Taker on Physician Documentation and Charting Time: Pragmatic Controlled Trial.

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.

Kaposi sarcoma-associated herpesvirus/human herpesvirus 8-associated extracavitary primary effusion lymphoma presenting as multiple lymphomatous polyposis.

Primary effusion lymphoma (PEL) is a distinct clinicopathological entity usually characterized by presentation as a lymphomatous body cavity effusion in the absence of solid tumor mass or dissemination during its clinical course. PEL can also rarely occur as a solid lymphoma involving nodal and extranodal sites and is referred to as extracavitary PEL. Here we report a unique case of extracavitary PEL in a 49-year-old HIV-seropositive patient who presented with vague abdominal pain and 20-lb weight loss. Esophagogastroduodenoscopy and colonoscopy revealed more than 100 broad-based intestinal polyps ranging from 2 mm to 3 cm in size, spreading from the duodenum to the rectum as a typical impression of "intestinal polyposis syndrome." Multiple biopsies demonstrated sheets of large lymphoid cells with characteristic features of extracavitary PEL with strong Kaposi sarcoma-associated herpesvirus/human herpesvirus 8 virus positivity by immunohistochemistry. Extracavitary PEL presenting as distinctive multiple lymphomatous polyposis as manifested in the case has not been described previously.

Ten-year outcome after saphenous vein patch angioplasty in males and females after carotid endarterectomy.

Many surgeons use a vein-patch angioplasty after endarterectomy of small (< 4 mm) diameter carotid arteries in males and females. Because evidence suggests that females may have a poorer outcome than males after revascularization, the long-term success of carotid endarterectomy may be different among the genders. The 10-year outcome after a saphenous vein-patch angioplasty in females was studied. Endarterectomies were performed on 708 carotid arteries of 615 patients, who had evidence of symptomatic disease or had asymptomatic greater than 80% stenosis. A segment of proximal greater saphenous vein was harvested for the patch. The 247 females had a mean age of 69.1 +/-9.8 (SD) years and a follow-up time of 4.0 +/-4.0 (SD) years. The 368 males had a mean age of 69.2 +/-8.8 (SD) years and a follow-up time of 4.4 +/-4.0 (SD) years. After endarterectomy, survival, the ipsilateral stroke-free rates and the restenosis-free rates were determined by life table analyses with 73 endarterectomies in 66 patients being at risk at 10 years. The 5- and 10-year survival rates in males were 81.9% and 62.2%, respectively. The 5- and 10-year survival rates in females were 82.6% and 73.0%, respectively. The 5- and 10-year ipsilateral stroke-free rates after carotid endarterectomy were 98.3% and 93.9% in males and 96.7% and 95.6% in females. The respective 5- and 10-year restenosis-free rates were 96.7% and 93.3% in males and 88.6% and 82.8% in females; p < 0.0002, by the Mantel-Cox test. Although survival and the incidence of an ipsilateral stroke were similar in females and males, the hemodynamic restenosis rate was higher in females. It is especially important to use routine duplex scanning to follow the post-endarterectomy health of the carotid artery in females.