Implications of Diagnosis Through a Machine Learning Algorithm on Management of People With Familial Hypercholesterolemia.

Background: Familial hypercholesterolemia (FH) is an underdiagnosed genetic condition that leads to premature cardiovascular disease. Flag, Identify, Network, and Deliver (FIND) FH is a machine learning algorithm (MLA) developed by the Family Heart Foundation that identifies high-risk individuals in the electronic medical record for targeted FH screening. Objectives: The purpose of this study was to characterize the FH diagnostic coding status of patients detected by a MLA screening and assess for correlations with patterns in medical management and cardiovascular outcomes. Methods: We applied the FIND FH MLA to a retrospective, cross-sectional cohort within one large academic medical center. Individual patient charts were manually reviewed and stratified by diagnosis status. Variables including baseline characteristics, medical history, family history, laboratory values, medications, and cardiovascular outcomes were compared across diagnosis status. Results: The MLA identified 471 patients over 5.5 years with a high probability for FH. 121 (26%) previously undiagnosed patients met criteria for having "likely FH." Those with established FH diagnoses (n = 32) had significantly more lipid panel monitoring, prescriptions for non-statin or combination lipid-lowering agents, visits with a cardiologist, and frequency of coronary artery calcium score (CACS) testing or lipoprotein(a) testing than undiagnosed patients with likely FH. The 2 groups had no significant differences in having had prior major adverse cardiovascular events. The remaining 318 patients were classified as having "suspected FH." Conclusions: These findings suggest that implementation of a MLA approach such as FIND FH may be feasible for identifying undiagnosed individuals living with FH, as well as addressing treatment disparities in this population at increased cardiovascular risk.

The Museum as a Shared Space: Developing Contextual and Cross-Disciplinary Approaches to Arts-Based Education.

Introduction: Despite the growing evidence favoring use of context-based interdisciplinary pedagogies in medical education, museum learning remains underutilized as a low-cost, replicable tool for introducing such constructs. We describe a novel approach to museum-based education building off the existing pedagogy of Visual Thinking Strategies that heightens the role of context. Methods: Outside the Frame, an optional elective at Emory University School of Medicine, was piloted in two iterations for a total of 7 second-year medical students who voluntarily enrolled in the course for the fall 2022 and 2023 semesters. Participating students were transitioning from the preclinical classroom environment to clinical clerkships, a period associated with feelings of personal and professional instability that may particularly benefit from critical reflection. The course included didactic components, hands-on crafting activities, presentations, and discussion groups. Student feedback was collected through anonymous pre- and post-course surveys, as well as written narrative reflections. Results: All post-course responses ranked their experience of the course as being "valuable" or "very valuable". Narrative reflections were overall positive and highlighted the role of context and cross-disciplinary input in shaping metacognitive awareness and cultivating comfort with uncertainty. Discussion: This pilot innovation demonstrates that a methodical framework to arts-based learning can elevate the role of context in a standardized museum education curriculum. Future visual arts and medicine courses may incorporate this framework to chart more active collaborations with museum educators and humanities faculty, as well as engage a broader range of communities and professional disciplines beyond medicine.

Finding the Balance: Venous Thromboembolism Prophylaxis during Hematochezia in Crohn's Disease.

Introduction: Despite heightened risk of venous thromboembolism (VTE) in hospitalized patients with inflammatory bowel disease (IBD), pharmacologic prophylaxis remains underutilized, particularly in those presenting with hematochezia. Although placement of retrievable inferior vena cava filters (rIVCF) may be considered in those with contraindications to anticoagulation and VTE risk, current recommendations from clinical guidelines are incongruent, leading to wide variation in practice. Case Presentation: This report highlights a case of rIVCF used in the management of recurrent VTEs in a patient hospitalized for persistent gastrointestinal bleeding. Conclusion: Our case demonstrates the need for a lower threshold for initiating VTE prophylaxis in patients with active IBD, even when hematochezia is the presenting symptom. A small group of patients with recurrent VTE and clear contraindications to anticoagulation may require IVCFs, necessitating close follow-up and monitoring for filter complications.

Primary care clinician engagement in implementing a machine-learning algorithm for targeted screening of familial hypercholesterolemia.

Objective: To assess the impact of a multi-pronged educational approach on the knowledge, attitudes, and behaviors regarding Familial Hypercholesterolemia (FH) management at a large academic medical center with the aim of empowering primary care clinicians (PCC) to diagnose and treat FH. Methods: A comprehensive educational program for PCCs on FH management was developed and piloted from July 2022 to March 2024. Components of our intervention included: 1. Implementation of a novel clinical decision support tool in the electronic medical record for FH management, 2. Development and dissemination of an interactive educational website focused on FH and its management, 3. Delivery of virtual instructional sessions to increase awareness of the tool, provide education on its use, and obtain support from institutional leadership, and 4. Direct outreach to a pilot subset of PCCs whose patients had been detected using the validated FIND FH® machine learning algorithm. Participating clinicians were surveyed at baseline before the intervention and after the educational session. Results: 70 PCC consented to participate in the study with a survey completion rate of 79 % (n = 55) and 42 % (n = 23) for the baseline and follow-up surveys, respectively. Objective PCC knowledge scores improved from 40 to 65 % of responders correctly responding to at least 2/3rds of survey questions. Despite the fact that 87 % identified PCC's as most effective for early detection of FH, 100 % of PCCs who received direct outreach chose to defer care to an outpatient cardiologist over pursuing workup in the primary care setting. Conclusion: Empowering PCCs in management of FH serves as a key strategy in addressing this underdiagnosed and undertreated potentially life-threatening condition. A systems-based approach to addressing these aims may include leveraging EMR-based clinical decision support models and cross-disciplinary educational partnerships with medical specialists.

Feasibility of recruiting adolescents into a prospective cohort study of the effects of social isolation during COVID-19.

BACKGROUND: Social connection and loneliness in adolescence are increasingly understood as critical influences on adult mental and physical health. The unique impact of the social isolation imposed by the COVID-19 lockdown on emerging adults is therefore expected to be especially profound. We sought to investigate the feasibility of using ecological momentary assessment (EMA) and wearable accelerometers to characterize the effects of social isolation and/or loneliness experienced by adolescents during the COVID-19 pandemic. METHODS: We recruited 19 participants aged 13-18 from an Adolescent Medicine practice in Atlanta, GA. Participants completed surveys at baseline and throughout a 2-week study period using EMA regarding their degree of social isolation, loneliness, family functioning, school climate, social media use, and COVID-19 experiences surrounding their physical, mental, and social domains. Six participants agreed to wear an activity tracker and heart rate measurement device for 14 days to monitor their emotional state and physical health. Participant feedback was collected via open-ended exit interviews. Feasibility of recruitment/retention, adherence, and outcome measures were investigated. Implementation was also assessed by evaluating the barriers and facilitators to study delivery. Associations between the social isolation and loneliness variables and all other variables were performed with univariate linear regression analysis with significance set at p < 0.05. The progression criteria were a recruitment rate of > 30% and a retention rate of > 80%. RESULTS: Progression criteria were met for recruitment (76%) of participants, but not retention (38%). Adherence to EMA survey completion was highly variable with only 54% completing ≥ 1 survey a day, and accelerometry use was not feasible. Social isolation was significantly correlated with lower school climate, higher COVID-19 experiences, higher depression scores, and lower sleep quality. Loneliness also showed a significant correlation with all these factors except COVID-19 experiences. CONCLUSIONS: EMA and wearable accelerometer use was not feasible in this longitudinal study of adolescents during the COVID-19 pandemic. Future research should further investigate barriers to conducting long-term research with adolescents and the potential effects of the pandemic on subject recruitment and retention.

Idiopathic remitting seronegative symmetrical synovitis with pitting edema syndrome with underlying history of malignancy.

Key Clinical Message: By reporting this case, we hope to emphasize the importance of maintaining a high index of clinical suspicion for the early recognition of RS3PE in patients presenting with atypical symptoms of PMR and underlying history of malignancy. Abstract: Remitting seronegative symmetrical synovitis with pitting edema is a rare rheumatic syndrome of unknown etiology. It shares qualities with many other common rheumatological disorders such as rheumatoid arthritis and polymyalgia rheumatica, making diagnosis especially challenging. RS3PE has been speculated to be a paraneoplastic syndrome, and those cases associated with underlying malignancy have shown to respond poorly to conventional treatment. Therefore, it is advisable to routinely screen patients with malignancy and presenting with RS3PE for cancer recurrence, even if in remission.

A Case of Cardiac Sarcoidosis Masquerading As Heart Failure With Ventricular Arrhythmia.

Sarcoidosis is a rare cause of cardiomyopathy that can easily be confused for acute heart failure when pulmonary manifestations are absent. We present the case of a 41-year-old female presenting with dyspnea found to have ventricular arrhythmia on arrival at the emergency department. Cardiac magnetic resonance and computed tomography of the chest with contrast were performed, confirming the systemic sarcoidosis diagnosis with cardiac involvement.

Bedside education in the art of medicine (BEAM): A learner's perspective on arts-based teaching.

In today's culture of the medical profession, it is fairly unusual for students to actually witness physicians talking with patients about anything outside scientific explanation. That other side of medicine - the one that goes beyond explanation to understanding - goes unexplored, and the patient's personal narrative is consequently less understood. Meanwhile, though reflective writing is the most frequently used didactic method to promote introspection and deeper consolidation of new ideas for medical learners, there is robust evidence that other art forms - such as storytelling, dance, theatre, literature and the visual arts - can also help deepen reflection and understanding of the human aspect of medical practice. The overall goal of the Bedside Education in the Art of Medicine (BEAM) project is to redress these issues through early interventions within the culture of the medical profession. By creating an arts-based humanities curriculum, we hope to broaden medical learners' understanding and shine a light on what it means - for patients and clinicians - to be human, live well, experience loss, encounter disease, and engage in a therapeutic relationship. BEAM is envisioned as a modular, online resource of "third things" that any clinician anywhere will be able to access via a smartphone application to deliver brief, focused, humanistic clinical teaching in either hospital or ambulatory care settings. This commentary foregrounds a learner's perspective to model BEAM's usage in an in-depth manner; it examines the relation of a painting by Edward Hopper to medical education through the lens of a poem by Victoria Chang, in the context of the BEAM web-based app educational resource. By assessing the poignancy of the painting via the poem, I demonstrate the capacity of the arts and humanities in medical education, with a specific focus on the development of interpretative skills and tolerance for ambiguity that all authentic, engaged physicians need.

Two Distinct Types of Sweat Profile in Healthy Subjects While Exercising at Constant Power Output Measured by a Wearable Sweat Sensor.

Wearable sweat sensors have enabled real-time monitoring of sweat profiles (sweat concentration versus time) and could enable monitoring of electrolyte loss during exercise or for individuals working in extreme environments. To assess the feasibility of using a wearable sweat chloride sensor for real-time monitoring of individuals during exercise, we recorded and analyzed the sweat profiles of 50 healthy subjects while spinning at 75 Watts for 1 hour. The measured sweat chloride concentrations were in the range from 2.9-34 mM. The sweat profiles showed two distinct sweat responses: Type 1 (single plateau) and Type 2 (multiple plateaus). Subjects with Type 2 profiles had higher sweat chloride concentration and weight loss, higher maximum heart rate, and larger changes in heart rate and rating of perceived exertion during the trial compared to subjects with Type 1 profiles. To assess the influence of level of effort, we recorded sweat profiles for five subjects at 75 W, 100 W, and 125 W. While all five subjects showed Type 1 sweat profiles at 75 W, four of the subjects had Type 2 profiles at 125 W, showing an increase in sweat chloride with exercise intensity. Finally, we show that sweat profiles along with other physiological parameters can be used to predict fluid loss.

Sweat test for cystic fibrosis: Wearable sweat sensor vs. standard laboratory test.

BACKGROUND: Sweat chloride testing for diagnosis of cystic fibrosis (CF) involves sweat induction, collection and handling, and measurement in an analytical lab. We have developed a wearable sensor with an integrated salt bridge for real-time measurement of sweat chloride concentration. Here, in a proof-of-concept study, we compare the performance of the sensor to current clinical practice in CF patients and healthy subjects. METHOD: Sweat was induced on both forearms of 10 individuals with CF and 10 healthy subjects using pilocarpine iontophoresis. A Macroduct sweat collection device was attached to one arm and sweat was collected for 30 min and then sent for laboratory analysis. A sensor was attached to the other arm and the chloride ion concentration monitored in real time for 30 min using a Bluetooth transceiver and smart phone app. RESULTS: Stable sweat chloride measurements were obtained within 15 min following sweat induction using the wearable sensor. We define the detection time as the time at which the standard deviation of the real-time chloride ion concentration remained below 2 mEq/L for 5 min. The sweat volume for sensor measurements at the detection time was 13.1 ±â€¯11.4 µL (SD), in many cases lower than the minimum sweat volume of 15 µL for conventional testing. The mean difference between sweat chloride concentrations measured by the sensor and the conventional laboratory practice was 6.2 ±â€¯9.5 mEq/L (SD), close to the arm-to-arm variation of about 3 mEq/L. The Pearson correlation coefficient between the two measurements was 0.97 highlighting the excellent agreement between the two methods. CONCLUSION: A wearable sensor can be used to make real-time measurements of sweat chloride within 15 min following sweat induction, requiring a small sweat volume, and with excellent agreement to standard methods.