Automated identification of eviction status from electronic health record notes.

OBJECTIVE: Evictions are important social and behavioral determinants of health. Evictions are associated with a cascade of negative events that can lead to unemployment, housing insecurity/homelessness, long-term poverty, and mental health problems. In this study, we developed a natural language processing system to automatically detect eviction status from electronic health record (EHR) notes. MATERIALS AND METHODS: We first defined eviction status (eviction presence and eviction period) and then annotated eviction status in 5000 EHR notes from the Veterans Health Administration (VHA). We developed a novel model, KIRESH, that has shown to substantially outperform other state-of-the-art models such as fine-tuning pretrained language models like BioBERT and Bio_ClinicalBERT. Moreover, we designed a novel prompt to further improve the model performance by using the intrinsic connection between the 2 subtasks of eviction presence and period prediction. Finally, we used the Temperature Scaling-based Calibration on our KIRESH-Prompt method to avoid overconfidence issues arising from the imbalance dataset. RESULTS: KIRESH-Prompt substantially outperformed strong baseline models including fine-tuning the Bio_ClinicalBERT model to achieve 0.74672 MCC, 0.71153 Macro-F1, and 0.83396 Micro-F1 in predicting eviction period and 0.66827 MCC, 0.62734 Macro-F1, and 0.7863 Micro-F1 in predicting eviction presence. We also conducted additional experiments on a benchmark social determinants of health (SBDH) dataset to demonstrate the generalizability of our methods. CONCLUSION AND FUTURE WORK: KIRESH-Prompt has substantially improved eviction status classification. We plan to deploy KIRESH-Prompt to the VHA EHRs as an eviction surveillance system to help address the US Veterans' housing insecurity.

MedJEx: A Medical Jargon Extraction Model with Wiki's Hyperlink Span and Contextualized Masked Language Model Score.

This paper proposes a new natural language processing (NLP) application for identifying medical jargon terms potentially difficult for patients to comprehend from electronic health record (EHR) notes. We first present a novel and publicly available dataset with expert-annotated medical jargon terms from 18K+ EHR note sentences (MedJ). Then, we introduce a novel medical jargon extraction (MedJEx) model which has been shown to outperform existing state-of-the-art NLP models. First, MedJEx improved the overall performance when it was trained on an auxiliary Wikipedia hyperlink span dataset, where hyperlink spans provide additional Wikipedia articles to explain the spans (or terms), and then fine-tuned on the annotated MedJ data. Secondly, we found that a contextualized masked language model score was beneficial for detecting domain-specific unfamiliar jargon terms. Moreover, our results show that training on the auxiliary Wikipedia hyperlink span datasets improved six out of eight biomedical named entity recognition benchmark datasets. Both MedJ and MedJEx are publicly available.

Correlative Analysis of Vitamin D and Omega-3 Fatty Acid Intake in Men on Active Surveillance for Prostate Cancer.

OBJECTIVE: To investigate the influence of targeted serum vitamin-D level and omega-6:3 fatty-acid ratio on prostate-specific antigen (PSA) level in men with prostate cancer managed with active surveillance by providing a nutritional intervention and vitamin supplementation. METHODS: Sixty-eight patients with biopsy-proven National Comprehensive Cancer Network very-low or low-risk prostate cancer were enrolled in the prostate cancer nutrition and genetics clinic at the Cleveland Clinic from July 2013-December 2019. Patients adhered to a specific dietary regimen devoid of animal-based products and foods containing omega-6 polyunsaturated fatty acids (PUFAs). The supplement regimen consisted of: Omega-3 PUFAs 720mg (3/day); curcumin 2000 mg/day; vitamin D3 dose titrated to achieve serum level of 60 ng/ml; and vitamin B-complex 1000 mg (4 times weekly). Patients underwent periodic monitoring of PSA, serum vitamin D, and PUFA levels and had frequent follow-up with the nutritionist which included a food frequency questionnaire. Interval prostate biopsy was performed as clinically indicated and/or at 9 months. RESULTS: The mean and 95% confidence interval of PSA slope and Vitamin D serum levels slope were 0.11 (0-0.25) ng/mL/month and 4.65 (3.09-5.98) ng/mL/month, respectively. Patients with higher initial vitamin D levels were twice as likely to have a downward PSA trend (OR = 2.04, 95% confidence interval 1.04-4.01, P = .04). Fifty-five patients underwent follow-up biopsy, all showing no progression of disease. Three patients had loose bowel movements that required omega-3 and or curcumin dose adjustments. CONCLUSION: Intensive nutritional intervention with Vitamin D and Omega-3 PUFA supplementation may benefit men on active surveillance for prostate cancer and further studies are warranted.

Definition of biochemical success following primary whole gland prostate cryoablation.

PURPOSE: We identified an evidence-based definition of biochemical success following primary whole gland prostate cryoablation. MATERIALS AND METHODS: The COLD Registry was queried for a risk stratified cohort of otherwise treatment naïve patients who underwent primary whole gland prostate cryoablation, of whom none had received any type of adjuvant therapy. Minimum followup in all study patients was 5 years. Variables included patient age, prostate specific antigen at diagnosis, Gleason score, D'Amico risk category and followup prostate specific antigen. Biochemical progression-free survival was studied based on Kaplan-Meier results using the Phoenix definition. HRs were calculated using proc PHReg. RESULTS: Of 1,111 patients 891 achieved nadir prostate specific antigen less than 0.4 ng/ml, which correlated with a 5-year biochemical progression-free survival rate of 90.4% in those at low risk, 81.1% in those at intermediate risk and 73.6% in those at high risk. Nadir prostate specific antigen 0.4 ng/ml or greater was associated with 24-month biochemical failure of 29.2% in those at low risk, 46.4% in those at intermediate risk and 48.9% in those at high risk. Statistical analysis failed to reveal a superior prostate specific antigen end point compared to 0.4 ng/ml. HR findings supported the relevance of the end point of less than 0.4 ng/ml (p <0.0001). CONCLUSIONS: To our knowledge this study represents the first evidence-based definition of biochemical success after primary whole gland prostate cryoablation. Nadir prostate specific antigen less than 0.4 ng/ml was the best objective indicator of biochemical success. Nadir prostate specific antigen 0.4 ng/ml or greater was associated with less favorable biochemical progression, precluding the use of a higher nadir prostate specific antigen end point (HR 5.649, 95% CI 4.33-7.38, p <0.0001).

Hydroureteronephrosis secondary to juxta-uretrovesical junction bladder diverticula.

Bladder diverticulum is rarely associated to hydroureteronephrosis. We present clinical images of an adult patient with a bladder diverticulum near the ureterovesical junction (UVJ) with secondary obstruction. An 84-year-old man presented with left hydroureteronephrosis and a presumed 25-mm left ureteral stone at UVJ on computed tomography. Cystoscopy revealed a stone located in a bladder diverticulum just cephalad and medial to left ureteral orifice; the patient successfully underwent endoscopic laser cystolithotripsy with resolution of his hydronephrosis. Juxta-UVJ bladder diverticula may cause obstruction of the ipsilateral upper urinary tract.

Predictors of biochemical failure in patients undergoing prostate whole-gland salvage cryotherapy: a novel risk stratification model.

UNLABELLED: What's known on the subject? and what does the study add?: Previous studies have identified the most important prognostic factors of the likely outcomes of salvage prostate whole-gland ablation, including initial clinical stage, biopsy Gleason score, and PSA (total and doubling time). There is potential for further optimization of candidate selection for salvage cryoablation with curative intent and nadir PSA achieved after whole-gland cryotherapy may provide additional prognostic value. The study shows that the most important prognostic factors of biochemical progression-free survival for patients who have undergone whole-gland salvage prostate cryotherapy are nadir PSA achieved after therapy and pre-therapy biopsy Gleason score. Based on these two prognostic variables, we have identified risk stratification groups (low, intermediate and high) which help predict the expected outcomes of salvage whole-gland prostate cryotherapy in a given patient. This risk stratification constitutes a useful clinical tool in defining which patients maybe best suited for this local salvage treatment method. OBJECTIVE: To assess the prognostic variables predicting the risk of biochemical progression-free survival (bPFS) after salvage prostate whole-gland cryotherapy using the Phoenix definition of bPFS. PATIENTS AND METHODS: A total of 132 patients underwent prostate whole-gland salvage cryotherapy with curative intent. No patient underwent neoadjuvant/adjuvant hormonal ablative therapy, and all had extended post-salvage prostate-specific antigen (PSA) follow-up data. Cox univariate and multivariate logistic regression analyses of potential predictors of bPFS were conducted. Kaplan-Meier analyses of bPFS was also performed. RESULTS: At a mean (range) follow-up of 4.3 (0.9-12.7) years, the median (range) post-cryotherapy nadir PSA achieved was 0.17 (0-33.9) ng/mL. On multivariate analysis, predictors of bPFS were nadir PSA post-cryotherapy and pre-salvage biopsy Gleason score (P < 0.001 and 0.009, respectively). Risk stratification groups (low, intermediate and high) were developed based on the presence of zero, one or two adverse risk factors, the risk factors being either a nadir PSA >2.5 ng/mL or biopsy Gleason score ≥ 7, with the Kaplan-Meier bPFS curves of these risk groups being significantly different (P = 0.02 and <0.001, respectively). CONCLUSIONS: Post-salvage nadir PSA and pre-salvage biopsy Gleason score are important predictors of outcome in this patient cohort. Low-, intermediate- and high-risk groups can be determined based on these variables and can define patients best suited for prostate cryotherapy.

Policy and paradox: grounded theory at the moment of DADT repeal.

Through a mixed-methods approach of oral history and grounded theory, we report on a study investigating the effects of the U.S. military's Don't Ask, Don't Tell policy on active-duty service members at the moment of transition to open service. A stratified, snowball sample of lesbian, gay, bisexual, and queer (LGBQ) service members (n = 17) from across all branches of the armed services were interviewed within two weeks of repeal (September 20, 2011). We find evidence that DADT was implicated in the structuring of military culture in terms of five irreconcilable contradictions: values, heroism, wartime, control, and silence. Military culture had moved in the direction of acceptance of LGBQ service members long before repeal, without the recognition of many leaders who had entered military service decades earlier.

Outcomes of salvage prostate cryotherapy stratified by pre-treatment PSA: update from the COLD registry.

OBJECTIVES: In this study, we evaluate the outcomes of salvage cryotherapy for locally recurrent prostate cancer within the COLD (cryo online data) Registry. Furthermore, we assess the results of salvage cryotherapy (with intermediate follow-up) stratified by pre-treatment prostate-specific antigen (PSA) levels to determine which patients may best be suited for treatment. METHODS: The COLD registry was developed as a prospective, centrally collected database among patients undergoing salvage cryoablation for locally recurrent prostate cancer following primary prostate radiotherapy with curative intent. Of the patients undergoing salvage cryotherapy (without neoadjuvant hormonal ablative therapy), complete medical records were available in 156 patients, with their mean follow-up being 3.8 years (0.9-12.7 years). The treatment outcomes of salvage cryotherapy were assessed using the Phoenix definition (nadir PSA + 2 ng/ml) of biochemical failure. RESULTS: Of our entire study population, the biochemical disease-free survival (bDFS) rates at 1, 2, and 3 years were 89.0, 73.7, and 66.7%, respectively. Stratification of our patients into two subgroups is based on their pre-treatment total serum PSA values <5 and ≥5 ng/ml, and bDFS rates at 3 years for these two subgroups were 78.3 and 52.9%, respectively. A Kaplan-Meier analysis of bDFS stratified by these same pre-treatment PSA values revealed that the subset of patients with a PSA ≥ 5 ng/ml had statistically significant poorer bDFS rates (P = 0.01). CONCLUSIONS: Salvage prostate cryotherapy is a potentially curative local salvage therapy. The importance of early referral when patients have a pre-treatment PSA < 5 ng/ml is essential to optimize treatment outcomes.

Impact of prostate gland volume on cryoablation prostate-specific antigen outcomes.

OBJECTIVES: To assess the impact of prostate volume on prostate-specific antigen (PSA) outcomes after primary whole-gland cryoablation. METHODS: The prognostic value of prostate volume, PSA at diagnosis, Gleason score, risk category, and clinical stage for favorable initial postcryoablation PSA (<0.6 ng/mL) was assessed in a risk-stratified cohort from the Cryo On Line Data (COLD) Registry. The cohort was substratified by prostate volume, <50 cm(3) (n = 2316) and ≥50 cm(3) (n = 369). The incidence of incontinence, rectal fistula, and potency is reported. RESULTS: Prostate volume was not a statistically significant predictor of favorable PSA outcome (P = .153, univariate, 0.101, multivariate). Favorable PSA (<0.6 ng/mL) occurred in 80% (<50 cm(3)) and 83% (≥50 cm(3)) of patients, respectively. PSA at diagnosis (P = .02) and Gleason score (P < .0001) by univariate analysis, and clinical stage (P < .0001) and risk category (P < .0001) by multivariate analysis predicted for favorable PSA outcomes. Initial postcryoablation PSA ≥0.6 ng/mL was associated with significantly worse 24-month biochemical progression. No statistical difference in incidence of incontinence (3.3% vs 2.1%) retention (1.1% vs 2.6%), potency (30.3% vs 32.2%) or fistula (0.6% vs 0.2%) based on prostate volume was identified. CONCLUSIONS: Prostate volume does not predict for favorable PSA after cryoablation. PSA at diagnosis (P = .02) and Gleason score (P < .0001) (univariate) and risk category (P < .0001) and clinical stage (P < 0.0001) (multivariate) are prognostic for favorable PSA outcomes. Morbidity was similar between groups.

Management of rising prostate-specific antigen after a negative biopsy.

Prostate biopsy remains one of the most commonly performed urologic office procedures. A significant percentage of men with a negative result may have unrecognized disease. Inadequate biopsy strategies or findings of high-grade prostatic intraepithelial neoplasia or atypia increase this likelihood. The term "negative biopsy" may be misleading. Traditional sextant biopsy is inaccurate and extended- or saturation-biopsy protocols miss small cancers. A rising prostate-specific antigen (PSA) after a negative prostate biopsy may indicate undiagnosed cancer. Magnetic resonance imaging (MRI) and template-guided biopsy have been proposed as diagnostic adjuncts in this setting. Medical manipulation has met with limited acceptance in this setting. In the presence of a rising PSA after a negative biopsy a low threshold for repeat biopsy should be entertained. Saturation biopsy increases cancer detection, especially in patients with more than two prior biopsies. Adjuncts to improve cancer detection, such as administration of 5-α-reductase inhibitors and MRI, are promising.

Disease burden predicts for favorable post salvage cryoablation PSA.

OBJECTIVE: We wanted to identify prognostic factors for favorable biochemical outcome (prostate specific antigen [PSA] < 0.6 ng/mL) after salvage prostate cryoablation. METHODS: The charts from 58 salvage cryoablation patients treated at Cleveland Clinic from 2004 through July 2009 were reviewed. Patient age, race, PSA at diagnosis, Gleason score, risk category, prostate volume, clinical T stage, number of cores positive, percent of cores involved with disease, ratios of number of cores positive to total cores biopsied and number of cores positive to prostate gland volume, and initial PSA results were studied. Initial PSA levels measured at 6-12 weeks post treatment of < 0.6 ng/mL were used as the criterion for a favorable outcome based on previously published data. RESULTS: Thirty-one percent of patients had unfavorable postoperative PSA levels. The number of positive biopsy cores (P = .012), ratio of positive cores to prostate volume (mL) (P = .004), and, marginally, the percentage of cores positive divided by total number of cores biopsied (P = .060) were prognostic for favorable PSA outcomes. A higher ratio of number of cores positive to prostate volume (third quartile) had a lower (35%) chance of a favorable PSA than a lower ratio (first quartile) (OR = 0.35, 95% CI: .14-.84, P = .019). CONCLUSION: Prostate gland disease burden as reflected by the number of cores positive and ratio of positive cores to gland volume (mL) is prognostic for favorable biochemical outcome after salvage whole-gland prostate cryoablation. Further study is warranted to better delineate this relationship.

Prognostic value of initial prostate-specific antigen levels after salvage cryoablation for prostate cancer.

OBJECTIVE: To assess the prognostic value of initial prostate-specific antigen (PSA) levels after salvage cryoablation (SCA) for the long-term biochemical progression-free survival (bPFS) in patients with prostate cancer. PATIENTS AND METHODS: In all, 455 hormone-naïve patients from the Cryo On Line Data Registry, and treated with whole-gland SCA were assessed for PSA-based bPFS using the Phoenix criteria. The initial PSA level measured after SCA was considered the nadir. Kaplan-Meier plots of bPFS for initial PSA level of <0.6, ≥0.6-≤5.0 and >5.0 ng/mL were constructed and plotted to 60 months. RESULTS: In all, 280 patients had an initial PSA level of <0.6 ng/mL after SCA. At 12, 24 and 36 months 80%, 73.6%, and 67% of patients, respectively, were progression-free. For 118 patients with an initial PSA level after SCA of ≥0.6-≤5 ng/mL, 28% and 50% of these patients at 6 and 12 months, respectively, had PSA progression. Of 57 patients with an initial PSA level of ≥5 ng/mL, 64% progressed at 6 months. The PSA level before SCA and Gleason score correlated with bPFS by Spearman correlation (P < 0.001 and 0.002), respectively. CONCLUSION: Curative therapy in prostate cancer not responding to radiotherapy is extremely challenging. There is no definition of success for cryosurgical treatment. The available data indicate that an initial PSA level of <0.6 ng/mL after SCA portends a favourable (67% at 36 months) bPFS. Individuals with initial PSA levels of ≥0.6 ng/mL after SCA are at risk of short-term biochemical progression (50% at 12 months).

Correlation of thermocouple data with voiding function after prostate cryoablation.

OBJECTIVES: To identify possible correlations of thermocouple recorded data with altered postoperative voiding function after prostate cryosurgery. METHODS: A retrospective analysis of the records of 58 patients treated with prostate cryoablation from October 2005 through April 2009 was conducted. Multivariate analysis of patient age, presenting prostate-specific antigen level, Gleason score, clinical T stage, prostate volume, maximum low temperature thermocouple recordings, history of radiation and or hormonal therapy, were studied as possible correlative factors for altered postoperative voiding function. RESULTS: Of 58 patients, 22 (37.9%) manifested postcryoablation urgency and frequency (n = 13) requiring medical therapy or retention (n = 9). On multivariate analysis, age (P = .037) and an external sphincter temperature < or = 23 degrees C (P = .012) were associated with voiding frequency, urgency, or retention (odds ratio = 6.26, 95% CI: 1.62-24.16), whereas anterior rectal wall temperature (Denon) was weakly associated (P = .079). CONCLUSIONS: Thermocouple data provide an objective means of assessing cryosurgical outcomes. This is the first report of a correlation of such data to post-treatment voiding function. A total of 37.9% of patients experienced urgency and/or frequency or urinary retention after cryoablation of the prostate for localized disease. Older age and external sphincter temperature < or = 23 degrees C were statistically significant predictors of these events. The data suggest that limiting the degree of freezing at the external sphincter may decrease procedure related morbidity. Further study is warranted to better delineate temperature-related data on treatment outcomes.

Impact of disease burden on cryoablation prostate-specific antigen outcomes.

OBJECTIVES: To identify prognostic factors for favorable biochemical outcome (prostate-specific antigen [PSA] <0.6 ng/mL) after primary whole gland prostate cryoablation. METHODS: The charts from 122 cryoablation patients treated at Cleveland Clinic from 2004 through May 2009 were reviewed. Patient age, race, PSA at diagnosis, Gleason score, risk category, prostate gland volume, clinical T stage, number of cores positive, percent of core involved with disease, ratios of number of cores positive to total cores biopsied and number of cores positive to prostate gland volume, and initial PSA results were studied. An initial post-cryoablation PSA of <0.6 was used as the criterion for favorable outcome based on previously published data. RESULTS: A total of 16.4% of patients had unfavorable postoperative PSA levels. On univariate analysis, number of cores positive (P = .031) and maximum percent core positive (P = .024) were prognostic of PSA outcome. On multivariate analysis, number of cores positive (P = .010), maximum percent core positive (P = .034), and ratio of number of positive cores to prostate gland volume (cm(3)) (P = .023) were prognostic for favorable PSA outcomes based on an initial PSA <.6 ng/mL. CONCLUSIONS: Favorable PSA outcomes after primary prostate cryoablation appear to be correlated with disease burden. The relative disease burden as defined by the number of and percent core positive, and the ratio of number of cores positive to prostate gland volume (cm(3)) are highly prognostic for initial post-cryoablation PSA <0.6 ng/mL, which is associated with favorable long-term biochemical disease-free survival regardless of risk stratification.

Primary cryoablation nadir prostate specific antigen and biochemical failure.

PURPOSE: We correlated nadir post-cryoablation prostate specific antigen with long-term biochemical disease-free survival in a risk stratified cohort of patients with prostate cancer treated with cryoablation. MATERIALS AND METHODS: The records of 2,427 patients treated with cryoablation from the Cryo On-Line Data Registry were studied for biochemical disease-free survival based on nadir + 2 criteria using prostate specific antigen determinations out to 60 months after cryoablation. RESULTS: For nadir prostate specific antigen less than 0.1 ng/ml, the 36, 48 and 60-month biochemical disease-free survival was 93%, 91.8% and 91.8%, respectively, for low risk disease; 88%, 81% and 76%, respectively, for intermediate risk; and 82%, 76% and 71%, respectively, for high risk disease. For prostate specific antigen 0.1 to 0.5 ng/ml the 36, 48 and 60-month biochemical disease-free survival rates were 92%, 91.5% and 86%, respectively, for low risk; 78%, 72% and 67%, respectively, for intermediate risk; and 64%, 61% and 51%, respectively, for high risk disease. For a prostate specific antigen of 0.6 to 1.0 ng/ml the 24-month biochemical disease-free survival was 70.5% for low risk, 56.1% for intermediate risk and 46.7% for high risk disease. A prostate specific antigen of 1.1 to 2.5 ng/ml was associated with a 12-month failure rate of 29.6%, 38% and 74.8% for low, intermediate and high risk groups, respectively. CONCLUSIONS: Nadir prostate specific antigen after prostate cryoablation is prognostic for biochemical disease-free survival. However, by itself it cannot be used as a definition of disease-free survival since it has not been correlated with disease specific or metastasis-free survival. A prostate specific antigen of 0.6 ng/ml or greater correlated with a 29.5% biochemical failure rate at 24 months regardless of risk stratification and, therefore, these cases require close followup.