Key interoperability Factors for patient portals and Electronic health Records: A scoping review.

AIM: To identify the key requirements and challenges to interoperability between patient portals and electronic health records (EHRs). INTRODUCTION: Patient portals provide patients with access to their health information directly from EHRs within hospitals, primary care centres and general practices (GPs). Patient portals offer many benefits to patients including improved communication with healthcare providers and care coordination. However, many challenges exist with the integration and automatic and secure sharing of information between EHRs and patient portals. It is critical that countries learn from international experiences to successfully develop interoperable national patient portals. METHODS: A scoping review methodology was undertaken. A search strategy using index terms and keywords was applied across four key databases, an additional grey literature search was also run. The identified studies were screened by two reviewers to determine eligibility against defined inclusion criteria. Data were abstracted from the eligible studies and reviewed to identify the key requirements and challenges to interoperability of patient portals with EHRs. RESULTS: After screening 3,462 studies, 34 were included across 11 countries. Of the 29 unique patient portals studied, few offered patients access to their entire healthcare record across multiple sites and a number of different functionalities were available. Key interoperability requirements and challenges identified were: Data Sharing Incentives & Supports; Heterogenous Organisations & Information Systems; Data Storage & Management; Available Information & Functionalities; Data Formats & Standards; Identification of Individuals; User Access, Control & Consent; and Security & Privacy. CONCLUSION: Seamless exchange of health information across patient portals and EHRs required organisational and individual factors, as well as technical considerations. Interorganisational collaboration and engagement of key stakeholders to determine standards and guidelines for consent and sharing of information, as well as technical standards and security measures were recommended.

[WITHDRAWN] Predicting breast cancer with AI for individual risk-adjusted MRI screening and early detection.

This paper has been withdrawn by Lukas Hirsch. Major revisions and rewriting in progress.

Contrast-Enhanced Mammography for Women with Palpable Breast Abnormalities.

RATIONALE AND OBJECTIVES: To examine the role of contrast-enhanced mammography (CEM) in the work-up of palpable breast abnormalities. MATERIALS AND METHODS: In this single-center combination prospective-retrospective study, women with palpable breast abnormalities underwent CEM evaluation prospectively, comprising the acquisition of low energy (LE) images and recombined images (RI) which depict enhancement, followed by targeted ultrasound (US). Two independent readers retrospectively reviewed the imaging and assigned BI-RADS assessment based on LE alone, LE plus US, RI with LE plus US (CEM plus US), and RI alone. Pathology results or 1-year follow-up imaging served as the reference standard. RESULTS: 237 women with 262 palpable abnormalities were included (mean age, 51 years). Of the 262 palpable abnormalities, 116/262 (44%) had no imaging correlate and 242/262 (92%) were benign. RI alone had better specificity compared to LE plus US (Reader 1, 94% versus 89% (p = 0.009); Reader 2, 93% versus 88% (p = 0.03)), better positive predictive value (Reader 1, 52% versus 42% (p = 0.04); Reader 2, 53% versus 42% (p = 0.04)), and better accuracy (Reader 1, 93% versus 89% (p = 0.05); Reader 2, 93% versus 90% (p = 0.06)). CEM plus US was not significantly different in performance metrics versus LE plus US. CONCLUSION: RI had better specificity compared to LE in combination with US. There was no difference in performance between CEM plus US and LE plus US, likely reflecting the weight US carries in radiologist decision-making. However, the results indicate that the absence of enhancement on RI in the setting of palpable lesions may help avoid benign biopsies.

Respiratory syncytial virus and its prophylaxis with palivizumab: exploring nurses' knowledge.

BACKGROUND: Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infections in children. Premature infants and infants with underlying health issues are at increased risk of developing severe RSV infection. Prophylactic treatment with palivizumab reduces their risk of hospitalisation. AIM: To measure nurses' knowledge of RSV and RSV prophylaxis and explore their perceived potential barriers to palivizumab administration to children in the acute hospital setting. METHOD: A non-experimental, quantitative fixed study design was adopted. A 17-item online questionnaire was used to survey nurses caring for children under the age of 1 year in an acute children's teaching hospital. RESULTS: Questionnaires were completed by 144 nurses, giving a response rate of 53%. Respondents demonstrated an adequate knowledge of RSV and its prophylaxis but also some knowledge deficits, notably about the eligibility criteria for palivizumab. The most cited perceived potential barriers to palivizumab administration were uncertainty about which infants are eligible for it, forgetting to check whether a patient is due to receive a dose, parental refusal for treatment because their child is ill, and not knowing the contraindications of palivizumab. CONCLUSION: Front-line hospital staff have a crucial role in identifying infants eligible for prophylactic RSV treatment, in initiating prophylaxis in a timely manner, in avoiding missed or delayed palivizumab doses during infants' hospital stays, and in educating families about the importance of RSV prevention.

Development of the key performance indicators for digital health interventions: A scoping review.

Background: Digital health interventions offer new methods for delivering healthcare, with the potential to innovate healthcare services. Key performance indicators play a role in the evaluation, measurement, and improvement in healthcare quality and service performance. The aim of this scoping review was to identify current knowledge and evidence surrounding the development of key performance indicators for digital health interventions. Methods: A literature search was conducted across ten key databases: AMED - The Allied and Complementary Medicine Database, CINAHL - Complete, Health Source: Nursing/Academic Edition, MEDLINE, APA PsycINFO, EMBASE, EBM Reviews - Cochrane Database of Systematic Reviews, EBM Reviews - Database of Abstracts of Reviews of Effects, EBM Reviews - Health Technology Assessment, and IEEE Xplore. Results: Five references were eligible for the review. Two were articles on original research studies of a specific digital health intervention, and two were overviews of methods for developing digital health interventions (not specific to a single digital health intervention). All the included reports discussed the involvement of stakeholders in developing key performance indicators for digital health interventions. The step of identifying and defining the key performance indicators was completed using various methodologies, but all centred on a form of stakeholder involvement. Potential options for stakeholder involvement for key performance indicator identification include the use of an elicitation framework, a factorial survey approach, or a Delphi study. Conclusions: Few articles were identified, highlighting a significant gap in evidence-based knowledge in this domain. All the included articles discussed the involvement of stakeholders in developing key performance indicators for digital health interventions, which were performed using various methodologies. The articles acknowledged a lack of literature related to key performance indicator development for digital health interventions. To allow comparability between key performance indicator initiatives and facilitate work in the field, further research would be beneficial to develop a common methodology for key performance indicators development for digital health interventions.

Impact of COVID-19 on emergency medicine resident procedure performance.

Background: As a result of the COVID-19 pandemic, patterns of patient presentations and medical education have changed, potentially resulting in fewer and different types of patient encounters. Procedural proficiency is a cornerstone of emergency medicine (EM) training, and residents must meet Accreditation Council for Graduate Medical Education (ACGME) requirements to graduate. It is feared there may have been a pandemic-induced decrease in opportunities for residents to perform procedures. This study investigates the change in procedures performed by EM residents during the initial year of the pandemic. Methods: This study utilized a multicenter retrospective design. Across three EM residency programs, logs of 14 ACGME-required procedures performed by residents were reviewed. For each procedure, counts were compared prepandemic year (March 2019 to February 2020) to during pandemic year (March 2020 to February 2021). Procedures were further grouped into 4-month periods: March to June, July to October, and November to February. Results: A total of 113 EM resident physicians were included in this study. Procedures performed by EM residents tended to decrease during the COVID-19 pandemic. There were statistically significant decreases in number of annual cricothyrotomies (2.4 vs. 0.9, p < 0.001) and pediatric trauma resuscitations (5.7 vs. 3.9, p = 0.024). Comparing the first 4-month periods of each year, there were significant decreases in cardiac pacing (6.3 vs. 5.4, p = 0.038), chest tubes (2.2 vs. 1.0, p < 0.001), cricothyrotomies (0.6 vs. 0.1, p = 0.001), intubations (8.2 vs. 4.4, p = 0.002), and pericardiocenteses (1.7 vs. 0.2, p < 0.001). Conclusions: The COVID-19 pandemic has led to a decrease in the number of procedures performed per EM resident in many of the domains required by the ACGME. Although only some procedures had statically significant decreases, it remains to be seen if this will lead to decreased resident procedural competency. Further research may be required in this area to determine any such effect.

Oral ENT-01 Targets Enteric Neurons to Treat Constipation in Parkinson Disease : A Randomized Controlled Trial.

BACKGROUND: Parkinson disease (PD) is associated with α-synuclein (αS) aggregation within enteric neurons. ENT-01 inhibits the formation of αS aggregates and improved constipation in an open-label study in patients with PD. OBJECTIVE: To evaluate the safety and efficacy of oral ENT-01 for constipation and neurologic symptoms in patients with PD and constipation. DESIGN: Randomized, placebo-controlled phase 2b study. (ClinicalTrials.gov: NCT03781791). SETTING: Outpatient. PATIENTS: 150 patients with PD and constipation. INTERVENTION: ENT-01 or placebo daily for up to 25 days. After baseline assessment of constipation severity, daily dosing was escalated to the prokinetic dose, the maximum dose (250 mg), or the tolerability limit, followed by a washout period. MEASUREMENTS: The primary efficacy end point was the number of complete spontaneous bowel movements (CSBMs) per week. Neurologic end points included dementia (assessed using the Mini-Mental State Examination [MMSE]) and psychosis (assessed using the Scale for the Assessment of Positive Symptoms adapted for PD [SAPS-PD]). RESULTS: The weekly CSBM rate increased from 0.7 to 3.2 in the ENT-01 group versus 0.7 to 1.2 in the placebo group (P < 0.001). Improvement in secondary end points included SBMs (P = 0.002), stool consistency (P < 0.001), ease of passage (P = 0.006), and laxative use (P = 0.041). In patients with dementia, MMSE scores improved by 3.4 points 6 weeks after treatment in the ENT-01 group (n = 14) versus 2.0 points in the placebo group (n = 14). Among patients with psychosis, SAPS-PD scores improved from 6.5 to 1.7 six weeks after treatment in the ENT-01 group (n = 5) and from 6.3 to 4.4 in the placebo group (n = 6). ENT-01 was well tolerated, with no deaths or drug-related serious adverse events. Adverse events were predominantly gastrointestinal, including nausea (34.4% [ENT-01] vs. 5.3% [placebo]; P < 0.001) and diarrhea (19.4% [ENT-01] vs. 5.3% [placebo]; P = 0.016). LIMITATION: Longer treatment periods need to be investigated in future studies. CONCLUSION: ENT-01 was safe and significantly improved constipation. PRIMARY FUNDING SOURCE: Enterin, Inc.

Support Staff Take an Essential Role in Research Services.

The profound transformation of medical libraries over the last twenty years reflects the advancements in medical education and health care delivery, increased expectations of users, and accelerated evolution of technology. The Harvey Cushing/John Hay Whitney Medical Library (CWML) used this opportunity to rethink how staffing could be redeployed to accommodate these new developments. After assessing processes, workflows, and individual responsibilities, library administration devised a novel team approach that would allow clerical & technical (C&T) staff to work across departmental lines to provide a broader variety of in-depth and frontline services. This paper will share how the C&T staff at the CWML developed a broader skill set, while providing library services to users in the rapidly changing field of medical education and health care services.

Are Digital Oral Thermometer Readings Accurate in Adult Emergency Department Patients?

Background Inaccurate vital signs may lead to inadequate treatment and skew the differential diagnosis in patients presenting to the emergency department (ED), and thus could cause a delay in diagnosis and treatment. Our study sought to evaluate and compare oral and rectal temperatures in patients with medical conditions that may have fever as part of their presentation to the ED. Objectives To determine if oral and rectal temperatures correlate in patients with medical conditions who have a fever, dry mucous membranes, and are warm to the touch on exam. To identify which patient presentations are more likely to have incongruous temperatures. Our hypothesis is that digital oral thermometers are inaccurate and understate the temperature in patients who present with dry mucous membranes and tactile warmth. Methods A prospective cohort of adult patients in the ED was asked to consent to the comparison of rectal temperature if they presented with a medical condition that could result in a fever. Oral and rectal (core) temperatures were obtained, along with demographic data, chief complaint, current medications, recent ingestion of warm or cold liquids, use of antipyretics, and the treating physician's assessment of mucous membrane dryness and tactile warmth. Results A total of 111 patients were enrolled in the study. 55.8% of patients were male, and the mean age was 61 years. The most common presenting complaint was lower respiratory tract related; 87% had dry mucous membranes, and 85.5% were warm to the touch. Fever or hypothermia was missed in 55 patients (49.5%) if only oral temperatures were obtained. Patients were more likely to consent if their doctor was concerned about a fever and requested a rectal temperature as part of their workup. Conclusions This is one of the first studies to evaluate the difference between oral and rectal routes of obtaining body temperature in the ED in adult patients. Our data reveal that many fevers are "missed" if only oral temperatures are used in medical decision-making in patients with dry mouths and with tactile warmth. Our study is limited by the small sample size and the potential for selection bias.

Radiologist-Level Performance by Using Deep Learning for Segmentation of Breast Cancers on MRI Scans.

PURPOSE: To develop a deep network architecture that would achieve fully automated radiologist-level segmentation of cancers at breast MRI. MATERIALS AND METHODS: In this retrospective study, 38 229 examinations (composed of 64 063 individual breast scans from 14 475 patients) were performed in female patients (age range, 12-94 years; mean age, 52 years ± 10 [standard deviation]) who presented between 2002 and 2014 at a single clinical site. A total of 2555 breast cancers were selected that had been segmented on two-dimensional (2D) images by radiologists, as well as 60 108 benign breasts that served as examples of noncancerous tissue; all these were used for model training. For testing, an additional 250 breast cancers were segmented independently on 2D images by four radiologists. Authors selected among several three-dimensional (3D) deep convolutional neural network architectures, input modalities, and harmonization methods. The outcome measure was the Dice score for 2D segmentation, which was compared between the network and radiologists by using the Wilcoxon signed rank test and the two one-sided test procedure. RESULTS: The highest-performing network on the training set was a 3D U-Net with dynamic contrast-enhanced MRI as input and with intensity normalized for each examination. In the test set, the median Dice score of this network was 0.77 (interquartile range, 0.26). The performance of the network was equivalent to that of the radiologists (two one-sided test procedures with radiologist performance of 0.69-0.84 as equivalence bounds, P < .001 for both; n = 250). CONCLUSION: When trained on a sufficiently large dataset, the developed 3D U-Net performed as well as fellowship-trained radiologists in detailed 2D segmentation of breast cancers at routine clinical MRI.Keywords: MRI, Breast, Segmentation, Supervised Learning, Convolutional Neural Network (CNN), Deep Learning Algorithms, Machine Learning AlgorithmsPublished under a CC BY 4.0 license. Supplemental material is available for this article.

MRI Screening of BRCA Mutation Carriers: Comparison of Standard Protocol and Abbreviated Protocols With and Without T2-Weighted Images.

BACKGROUND. Increasing evidence supports the role of abbreviated MRI protocols for breast cancer detection. However, abbreviated protocols have been poorly studied in patients who are BRCA1 or BRCA2 mutation carriers. Furthermore, the need for T2-weighted sequences in abbreviated protocols remains controversial. OBJECTIVE. The purpose of this study was to compare, in the evaluation of patients with BRCA mutations, the diagnostic performance of a standard full breast MRI protocol with the performance of abbreviated protocols that included and did not include a T2-weighted sequence. METHODS. This retrospective study included 292 patients (mean age, 47.9 years) who were BRCA1 or BRCA2 mutation carriers who underwent 427 screening breast MRI examinations according to a standard full protocol who could be classified as having benign (n = 407) or malignant (n = 20) findings based on histopathology or imaging follow-up. Four readers independently assessed examinations in three separate sessions (theoretic abbreviated protocol, which included the first postcontrast acquisition; theoretic abbreviated protocol with addition of a T2-weighted sequence; and the standard full protocol) and assigned BI-RADS categories. Categories 3-5 were considered to represent positive examinations. Interreader agreement was assessed, and diagnostic performance was compared by use of pooled reader data. RESULTS. Interreader agreement on BI-RADS category, expressed as kappa values, was 0.55 for the standard, 0.45 for the abbreviated, and 0.57 for the abbreviated plus T2-weighted protocols. Pooled sensitivity was 94% for the standard, 92% for the abbreviated, and 90% for the abbreviated plus T2-weighted protocols (all p > .001). Pooled specificity was 80% for the standard, 71% for the abbreviated, and 83% for the abbreviated plus T2-weighted protocols (p < .001 for abbreviated plus T2-weighted compared with both standard and abbreviated). Pooled PPV was 19% for the standard, 14% for the abbreviated, and 20% for the abbreviated plus T2-weighted protocols (p < .001 for abbreviated compared with both standard and abbreviated). Pooled NPV was 100% for the standard, 99% for the abbreviated, and 99% for the abbreviated plus T2-weighted (all p > .001) protocols. Pooled accuracy was 80% for the standard, 73% for the abbreviated, and 83% for the abbreviated plus T2-weighted protocols (p < .001 for abbreviated compared with both standard and abbreviated plus T2-weighted). CONCLUSION. The abbreviated protocol without T2-weighted imaging had suboptimal performance. However, addition of the T2-weighted sequence yielded comparable sensitivity and accuracy and a small increase in specificity compared with the full protocol. CLINICAL IMPACT. The findings support implementation of abbreviated MRI with T2-weighted imaging for breast cancer screening of patients with BRCA mutations.

The experiences of adolescents living with a central venous access device: A qualitative analysis.

Background: Central venous access devices are used in paediatric populations for specific chronic conditions requiring long-term treatment. Very little isknown about how young people experience living with such devices. Aim: To gain a deep understanding of adolescents' (aged 12-17 years) experiences of living with a central venous access device from the perspective of the adolescents themselves, and of one of their parents. Design: A descriptive phenomenological design was chosen. Methods: The sample comprised 20 participants, 10 adolescents with a central venous access device who were purposefully selected from a paediatric unit in Ireland, along with one of each adolescent's parents. Five of the adolescents had a skin tunnelled catheter that partly sits outside the body; and five a totally implanted port contained within the body. Participants were interviewed in adolescent-parent dyads, and data were analysed using an established phenomenological method. Results: Findings are presented around three themes: (i) The process of receiving treatment; (ii) managing skin tunnelled catheters and totally implanted ports day-to-day; and (iii) activities of daily living with a skin tunnelled catheter or a totally implanted port. Participants tended to compare their current device with previously negative experiences of multiple needle punctures associated with peripheral cannula insertions. Participants were largely positive about the type of device the adolescent currently had. However, in terms of daily management of the device itself and engaging in daily activities, totally implanted ports were more favourable than skin tunnelled catheters. Participants with a totally implanted port tended to minimise the needle-stick experience to access to the totally implanted port's reservoir. Discussion: Findings from the present study on adolescents concur with those of previous studies on adults that found that individuals with a central venous access device were largely positively disposed to their device and tended to compare their experiences of it to previously negative experiences with peripheral cannula insertions. Findings also reflect existing research that has reported a favourable disposition to self-management of a central venous access device, and a greater freedom to engage in everyday activities for those with a totally implanted port compared to those with a skin tunnelled catheter. Conclusion: We conclude that the type of central venous access device may have a pervasive and important impact on the everyday lives of adolescents and this needs to be given appropriate weight in formal guidelines for clinicians.

Acute and Delayed Intracranial Hemorrhage in Head-Injured Patients on Warfarin versus Direct Oral Anticoagulant Therapy.

INTRODUCTION: Direct oral anticoagulant (DOAC) use for thrombosis treatment and prophylaxis is a popular alternative to warfarin. This study compares rates of traumatic intracranial hemorrhage (ICH) for patients on anticoagulant therapies and the effect of combined anticoagulant and antiplatelet therapies. METHODS: A retrospective observational study of trauma patients was conducted at two level I trauma centers. Patients aged ≥18 years with preinjury use of an anticoagulant (warfarin, rivaroxaban, apixaban, or dabigatran) who sustained a blunt head injury within the past day were included. Patients were evaluated by head CT to evaluate for ICH. RESULTS: Three hundred and eighty-eight patients were included (140 on warfarin, 149 on a DOAC, and 99 on combined anticoagulant and antiplatelet therapies). Seventy-nine patients (20.4%) had an acute ICH, while 16 patients (4.1%) had a delayed ICH found on routine repeat CT. Those on combination therapy were not at increased risk of acute ICH (relative risk [RR] 0.90, confidence interval [CI]: 0.56-1.44; P > 0.5) or delayed ICH (RR 2.19, CI: 0.84-5.69; P = 0.10) compared to anticoagulant use only. Those on warfarin were at increased risk of acute ICH (RR 1.75, CI: 1.10-2.78, P = 0.015), but not delayed ICH (RR 0.99, CI 0.27-3.59, P > 0.5), compared to those on DOACs. No delayed ICH patients died or required neurosurgical intervention. CONCLUSION: Patients on warfarin had a higher rate of acute ICH, but not delayed ICH, compared to those on DOACs. Given the low rate of delayed ICH with no resultant morbidity or mortality, routine observation and repeat head CT on patients with no acute ICH may not be necessary.

Mortality in Pulmonary Embolism According to Risk Category at Presentation in Emergency Department: Impact of Cardiac Arrest.

In this investigation we explore whether assessment of the risk of mortality can be refined by stratifying high-risk patients with pulmonary embolism (PE) according to whether they had cardiac arrest. We stratified high-risk patients according to whether they had shock but no cardiac arrest, or cardiac arrest diagnosed in the emergency department (ED). This was a retrospective cohort study based on administrative data from the Nationwide Emergency Department Sample (NEDS), 2016. Included patients were 274,227 who were admitted to the same hospital as the ED or died in the ED. This was 77% of 354,616 patients with pulmonary embolism seen in the ED in 2016. Patients were identified based on International Classification of Diseases, 10th Edition, Clinical Modification (ICD-10-CM) Codes. High-risk with no cardiac arrest were 4,317 of 274,227 (1.6%) and high-risk with cardiac arrest were 1,027 of 274,227 (0.4%). Mortality of high-risk patients who did not have cardiac arrest was 1,753 of 4,317 (41%). Mortality of high-risk patients who had cardiac arrest was 754 of 1027 (74%). Mortality increased with age in high-risk patients who did not have cardiac arrest, but mortality was not age-related in high-risk patients with cardiac arrest. In conclusion, high-risk patients with PE are a heterogeneous group and stratification according to whether they had cardiac arrest refines risk assessment.

Adaptive change in simulation education: Comparison of effectiveness of a communication skill curriculum on death notification using in person methods versus a digital communication platform.

Background: Mandates to social distance and "shelter in place" during the COVID-19 pandemic necessitated the exploration of new academic content delivery methods. Digital communication platforms (DCP; e.g., Zoom) were widely used to facilitate content delivery, yet little is known about DCP's capacity or effectiveness, especially for simulation. Objective: The objective was to compare the experience, outcomes, and resources required to implement a simulation-based communication skill curriculum on death notification to a cohort of learners using in-person versus DCP delivery of the same content. Methods: We used the GRIEV_ING mnemonic to train students in death notification techniques either in person or utilizing a DCP. For all learners, three measures were collected: knowledge, confidence, and performance. Individual learners completed knowledge and confidence assessments pre- and postintervention. All performance assessments were completed by standardized patients (SPs) in real time. Wilcoxon rank-sum test was used to identify differences in individual and between-group performances. Results: Thirty-four learners participated (N = 34), 22 in person and 12 via DCP. There was a statistically significant improvement in both groups for all three measures: knowledge, confidence, and performance. Between-group comparisons revealed a difference in pretest confidence but no differences between groups in knowledge or performance. More preparation and prior planning were required to set up the DCP environment than the in-person event. Conclusions: The in-person and DCP delivery of death notification training were comparable in their ability to improve individual knowledge, confidence, and performance. Additional preparation time, training, and practice with DCPs may be required for SPs, faculty, and learners less familiar with this technology.

Tumor-Nipple Distance of ≥ 1 cm Predicts Negative Nipple Pathology After Neoadjuvant Chemotherapy.

BACKGROUND: As neoadjuvant chemotherapy (NAC) for breast cancer has become more widely used, so has nipple-sparing mastectomy. A common criterion for eligibility is a 1 cm tumor-to-nipple distance (TND), but its suitability after NAC is unclear. In this study, we examined factors predictive of negative nipple pathologic status (NS-) in women undergoing total mastectomy after NAC. METHODS: Women with invasive breast cancer treated with NAC and total mastectomy from August 2014 to April 2018 at our institution were retrospectively identified. Following review of pre- and post-NAC magnetic resonance imaging (MRI) and mammograms, the association of clinicopathologic and imaging variables with NS- was examined and the accuracy of 1 cm TND on imaging for predicting NS- was determined. RESULTS: Among 175 women undergoing 179 mastectomies, 74% of tumors were cT1-T2 and 67% were cN+ on pre-NAC staging; 10% (18/179) had invasive or in situ carcinoma in the nipple on final pathology. On multivariable analysis, after adjusting for age, grade, and tumor stage, three factors, namely number of positive nodes, pre-NAC nipple-areolar complex retraction, and decreasing TND, were significant predictors of nipple involvement (p < 0.05). The likelihood of NS- was higher with increasing TND on pre- and post-NAC imaging (p < 0.05). TND ≥ 1 cm predicted NS- in 97% and 95% of breasts on pre- and post-NAC imaging, respectively. CONCLUSIONS: Increasing TND was associated with a higher likelihood of NS-. A TND ≥ 1 cm on pre- or post-NAC imaging is highly predictive of NS- and could be used to determine eligibility for nipple-sparing mastectomy after NAC.

Nineteen-Year Trends in Mortality of Patients Hospitalized in the United States with High-Risk Pulmonary Embolism.

BACKGROUND: Several advanced treatments of high-risk patients with pulmonary embolism have been used in recent decades. We assessed the 19-year national trend in mortality of high-risk patients with pulmonary embolism to determine what impact, if any, advanced therapy might have had on mortality. METHODS: Mortality (case fatality rate) was assessed in patients with a primary (first-listed) diagnosis of high-risk pulmonary embolism who were hospitalized during the period from 1999 to 2014 and in 2016 and 2017. High-risk was defined as patients with pulmonary embolism who were in shock or suffered cardiac arrest. International Classification of Diseases, 9th revision, Clinical Modification codes were used for data on the period from 1999 to 2014, and version 10 codes were used for data on the years 2016 and 2017. Trends in mortality were assessed according to treatment. RESULTS: From 1999 to 2017 (excluding 2015), 58,784 patients were hospitalized in United States with a primary diagnosis of pulmonary embolism that was high risk. Mortality in all high-risk patients decreased from 72.7% in 1999 to 49.8% in 2017 (P < .0001). Most high-risk patients (60.3%) were treated with anticoagulants alone and did not receive an inferior vena cava filter. Mortality in these patients decreased from 79.0% in 1999 to 55.7% in 2017 (P < .0001). Thrombolytic therapy was administered to 16.1% of high-risk patients, open pulmonary embolectomy alone was used in 4.3%, and extracorporeal membrane oxygenation was used in 0.4%. CONCLUSIONS: Mortality of high-risk patients with pulmonary embolism has decreased. This decrease can be attributed to improved treatment of patients with shock and with cardiac arrest, and does not reflect advances in therapy for pulmonary embolism.

Site of Deep Venous Thrombosis and Age in the Selection of Patients in the Emergency Department for Hospitalization Versus Home Treatment.

Despite apparent advantages of home treatment of deep venous thrombosis (DVT) based upon results of randomized controlled trials, physicians maintain a conservative approach, and a large proportion of patients with DVT are hospitalized. In the present investigation we assess whether selection of patients for hospitalization for acute DVT was related to the site of the DVT or to age. This was a retrospective cohort study based on administrative data from the Nationwide Emergency Department Sample, 2016. Patients were identified by International Classification of Diseases-10-Clinical Modification codes. Most, 87,436 of 133,414 (66%), had proximal DVT. A minority of patients with isolated distal DVT were hospitalized, 10,621 of 37,592 (28%). However, hospitalization was selected for 47,459 of 87,436 (54%) with proximal DVT; 4,867 of 7,599 (64%) with pelvic vein DVT; and 611 of 788 (78%) with DVT involving the inferior vena cava. Hospitalization for patients with distal DVT, proximal DVT, and pelvic vein DVT was age-dependent. In conclusion, both the site of acute DVT and age were factors affecting the clinical decision of emergency department physicians to select patients for hospital treatment.