Novel methodology for the evaluation of symptoms reported by patients with newly diagnosed atrial fibrillation: Application of natural language processing to electronic medical records data.

INTRODUCTION: Understanding symptom patterns in atrial fibrillation (AF) can help in disease management. We report on the application of natural language processing (NLP) to electronic medical records (EMRs) to capture symptom reports in patients with newly diagnosed (incident) AF. METHODS AND RESULTS: This observational retrospective study included adult patients with an index diagnosis of incident AF during January 1, 2016 through June 30, 2018, in the Optum datasets. The baseline and follow-up periods were 1 year before/after the index date, respectively. The primary objective was identification of the following predefined symptom reports: dyspnea or shortness of breath; syncope, presyncope, lightheadedness, or dizziness; chest pain; fatigue; and palpitations. In an exploratory analysis, the incidence rates of symptom reports and cardiovascular hospitalization were assessed in propensity-matched patient cohorts with incident AF receiving first-line dronedarone or sotalol. Among 30 447 patients with an index AF diagnosis, the NLP algorithm identified at least 1 predefined symptom in 9734 (31.9%) patients. The incidence rate of symptom reports was highest at 0-3 months post-diagnosis and lower at >3-6 and >6-12 months (pre-defined timepoints). Across all time periods, the most common symptoms were dyspnea or shortness of breath, followed by syncope, presyncope, lightheadedness, or dizziness. Similar temporal patterns of symptom reports were observed among patients with prescriptions for dronedarone or sotalol as first-line treatment. CONCLUSION: This study illustrates that NLP can be applied to EMR data to characterize symptom reports in patients with incident AF, and the potential for these methods to inform comparative effectiveness.

Healthcare resource utilization in patients with newly diagnosed atrial fibrillation in the United States.

OBJECTIVES: To summarize healthcare resource utilization (HCRU) in patients with newly diagnosed (incident) paroxysmal or persistent atrial fibrillation (AF). METHODS: This retrospective, observational cohort study assessed HCRU among patients with incident paroxysmal or persistent AF using data from 1 January 2015 to 30 September 2019 in the IBM MarketScan® Research Databases. RESULTS: A total of 50,796 patients were identified in the overall incident AF cohort. Rates of all-cause inpatient hospital stays, all-cause emergency room visits, and all-cause outpatient visits in the overall incident cohort were 46.8, 114.7, and 2,752.7 events per 100 patient-years (PY), respectively. Rates of cardiovascular-related inpatient stays for the overall population were 11.3 events per 100 PY. During follow-up, 50.4% of the overall cohort filled prescriptions for direct-acting oral anticoagulants and 5.0% had catheter ablation. CONCLUSIONS: Advances in anticoagulation and ablation have been realized since previously published HCRU analyses of patients with atrial fibrillation. This update suggests that HCRU among patients with incident AF in the US remains high with some subgroups of patients receiving more specialized care.

Comparative Safety and Effectiveness of Sotalol Versus Dronedarone After Catheter Ablation for Atrial Fibrillation.

Background Atrial tachyarrhythmias are common after atrial fibrillation ablation, so adjunctive antiarrhythmic drug therapy is often used. Data on the effectiveness and safety of dronedarone and sotalol after AF ablation are limited. Here, we compared health outcomes of ablated patients treated with dronedarone versus sotalol. Methods and Results A comparative analysis of propensity score-matched retrospective cohorts was performed using IBM MarketScan Research Databases. Patients treated with dronedarone after atrial fibrillation ablation were matched 1:1 to patients treated with sotalol between January 1, 2013 and March 31, 2018. Outcomes of interest included cardiovascular hospitalization, proarrhythmia, repeat ablation, and cardioversion. This study was exempt from institutional review board review. Among 30 696 patients who underwent atrial fibrillation ablation, 2086 were treated with dronedarone and 3665 with sotalol after ablation. Propensity-score matching resulted in 1815 patients receiving dronedarone matched 1:1 to patients receiving sotalol. Risk of cardiovascular hospitalization was lower with dronedarone versus sotalol at 3 months (adjusted hazard ratio [aHR], 0.77 [95% CI, 0.61-0.97]), 6 months (aHR, 0.76 [95% CI, 0.63-0.93]), and 12 months after ablation (aHR, 0.70 [95% CI, 0.66-0.93]). Risk of repeat ablation and cardioversion generally did not differ between the 2 groups. A lower risk of proarrhythmia was associated with dronedarone versus sotalol at 3 months (aHR, 0.76 [95% CI, 0.64-0.90]), 6 months (aHR, 0.80 [95% CI, 0.70-0.93]), and 12 months (aHR, 0.83 [95% CI, 0.73-0.94]) after ablation. Conclusions These data suggest that dronedarone may be a more effective and safer alternative after ablation than sotalol.

US Antiarrhythmic Drug Treatment for Patients With Atrial Fibrillation: An Insurance Claims-Based Report.

Background Current American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines and European Society of Cardiology guidelines recommend antiarrhythmic drugs (AADs) for maintenance of sinus rhythm in patients with atrial fibrillation. We assessed the concordance between healthcare provider real-world practice and current guidelines with respect to first-line AAD rhythm management. Methods and Results Administrative claims data from the deidentified Optum Clinformatics Data Mart database were used. Patients were included if they were initiated on an AAD in 2015 to 2016, had 1 year of continuous data availability before their first AAD pharmacy claim, and had a diagnosis for atrial fibrillation within that period. Concordance was assessed by comparing the AAD initiated by the healthcare provider against guideline recommendations for first-line treatment, given the presence of heart failure, coronary artery disease, both, or neither (as determined by International Classification of Diseases, Ninth Revision and Tenth Revision [ICD-9 and ICD-10] codes). Concordance was also assessed by provider type using Medicare taxonomy codes. For the 15 445 patients included, 51% of healthcare providers initiated AAD treatments with amiodarone, 18% flecainide, 15% sotalol, 8% dronedarone, 5% propafenone, and 2% dofetilide. The overall rate of guideline concordance was 61%, with differences by provider type: 67% for electrophysiologists, 61% for cardiologists, and 60% for others (internal medicine, etc). Conclusions There continues to be a sizable gap in concordance between practice and guidelines in first-line rhythm management of patients with atrial fibrillation. Further research is needed to identify possible explanations for non-guideline-recommended use of AADs, in addition to enhanced AAD educational strategies for practitioners.

The role of genotoxicity in asbestos-induced mesothelioma: an explanation for the differences in carcinogenic potential among fiber types.

The mechanism(s) underlying asbestos toxicity associated with the pathogenesis of mesothelioma has been a challenge to unravel for more than 60 years. A significant amount of research has focused on the characteristics of different fiber types and their potential to induce mesothelioma. These mechanistic studies of fiber toxicity have proceeded along two lines: those demonstrating biochemical mechanisms by which fibers induce disease and those investigating human susceptibility. Most recent studies focused on in vitro genotoxic effects induced by asbestos as the mechanism responsible for asbestos-induced disease. Although asbestos exerts a genotoxic effect at certain concentrations in vitro, a positive response in these tests does not indicate that the chemical is likely to produce an increased risk of carcinogenesis in exposed human populations. Thus far, findings from studies on the effects of fiber type in mesothelial cells are seriously flawed by a lack of a dose response relationship. The common limitation of these in vitro experiments is the lack of attention paid to the complexities of the human anatomy, biochemistry and physiology, which make the observed effects in these experimental systems difficult to extrapolate to persons in the workplace. Mechanistic differences between carcinogenic and genotoxic processes indicate why tests for genotoxicity do not provide much insight regarding the ability to predict carcinogenic potential in workers exposed to asbestos doses in the post-Occupational Safety and Health Administration era. This review discusses the existing literature on asbestos-induced genotoxicity and explains why these studies may or may not likely help characterize the dose-response curve at low dose.

Evaluation of pulmonary function within a cohort of flavorings workers.

OBJECTIVES: We present a re-analysis of a recent Health Hazard Evaluation (HHE) that was performed by the US National Institute for Occupational Safety and Health (NIOSH) regarding the pulmonary status of workers at a flavorings manufacturing facility. This facility has used acetaldehyde, acetoin, benzaldehyde, butyric acid, diacetyl and many other flavoring chemicals for many years. METHODS: Ten years of spirometry testing and job descriptions data on 112 workers were analyzed by the authors and by NIOSH. Using NIOSH's exposure assessment criteria, we compared the prevalence of restrictive findings (as determined by spirometry testing) in production workers to an internal control group that had reduced or no potential for exposure to flavoring chemicals. NIOSH used multiple linear regression to evaluate changes in pulmonary function by the exposure group. After our review of the NIOSH findings, we evaluated associations between longitudinal changes in pulmonary health and workplace exposures through the use of generalized estimating equations. We then compared our results to those obtained by NIOSH. RESULTS: We found that the prevalence of pulmonary restriction was similar in production workers and internal controls. We found no relationship between the magnitude of exposure to flavorings chemicals and observed decrements in pulmonary function. Our findings were contrary to those reported by NIOSH, most likely because of how we accounted for the longitudinal nature of the spirometric data. CONCLUSION: Many years of exposures to flavoring chemicals in this workplace, including diacetyl, were not found to produce an increased risk of abnormal spirometric findings.

Is renovation riskier than new construction?: an observational comparison of risk factors for stepladder-related falls.

BACKGROUND: Stepladder-related injuries at construction sites have increased in recent years. We aimed to quantify the prevalence of stepladder-related fall hazards in general construction and to compare the risks on renovation worksites to new construction build sites. METHODS: Eighteen worksites were visited, resulting in the observation of 771 stepladders. Eight of the sites were new builds and ten were renovation projects. RESULTS: High compliance with best practices was not observed for several factors, including having hands free while climbing (46%) and using minimum forces (72%). There was a notable trend toward more hazards on renovation build projects than on new construction sites; however, these differences were not statistically significant. CONCLUSIONS: There was not sufficient evidence to show that stepladder fall hazards are more prevalent on renovation projects than on new build projects. Having hands free while climbing and using minimum forces were two practices needing more wide-scale adoption regardless of construction job type.

Portable ladder assessment tool development and validation-quantifying best practices in the field.

Many causes for falls from ladders in construction are related to the user's activities; however, the extent to which users comply with ladder use best practices is unknown and has not been well quantified before. We developed and tested an audit tool that assesses compliance with best practices guidelines for portable ladder use designed for applications in the construction industry. Implemented on a hand-held computer, the assessment tool consisted of a series of checklists categorized in four groups; ladder condition, setup, moving on a ladder, and completing tasks from a ladder. For these four observational categories, the resulting tool contained 31 and 33 questions for step and extension ladders, respectively. Three individuals trained to use the tool scored a set of photographs and videos depicting 25 ladder conditions, 20 ladder setups, 10 users moving on ladders, and 13 users completing tasks from a ladder for a total of 78 observations. The assessment tool had good agreement across and within raters. For the three raters, agreement ranged from 79% to 97% across the questions. Within one subject, kappa coefficients for the intrarater reliability ranged from 0.67 to 0.91. The tool offers a practical method to quantify best practices associated with ladder use that can ultimately inform targeted intervention efforts.