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BACKGROUND: The survey of Copeia captured early 2022 patient-reported outcomes (PRO) in Germany under cannabis medicinal product (CAM) therapy, with particular attention to symptoms, symptom changes, indications, side effects, dosages, and cost bearers. GOAL: This study investigated the question of whether associations emerge from the results that could play a role in the indication and treatment monitoring of CAM in chronically ill patients. MATERIALS AND METHODS: A standardized questionnaire was administered online nationwide in dialogue form over a 15-week period to collect itemized symptoms and PRO. Recruitment was supported by pharmacies, prescribing physicians, and patient associations. Inclusion criteria included physician-prescribed CAM therapy. RESULTS AND DISCUSSION: Of 1582 participants, 1030 data sets (65%) could be completely analyzed. There was a heterogeneous patient population, whose common feature was disease chronicity. The frequency distribution of symptoms showed a homogeneous pattern for the respective indications, in which the most frequent six (pain 71%, sleep disturbance 64%, stress/tension 52%, inner restlessness 52%, depressive mood 44% and muscle tension 43%) seem to have a special significance. According to subjective assessment, quality of life improved significantly in 84% of all participating patients. CONCLUSION: A symptom matrix (SMX) composed of different symptoms seems to play a special role in CAM therapy to improve the quality of life of chronically ill patients, regardless of the underlying disease. The SMX could contribute to the identification of an indication and to targeted treatment monitoring.
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Maconha Medicinal , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença Crônica , Alemanha , Maconha Medicinal/uso terapêutico , Maconha Medicinal/efeitos adversos , Qualidade de Vida/psicologia , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Pediatric status epilepticus is one of the most frequent pediatric emergencies, with high mortality and morbidity. Utilizing electronic health records (EHRs) permits analysis of care approaches and disease outcomes at a lower cost than prospective research. However, reviewing EHR manually is time intensive. We aimed to compare refractory status epilepticus (rSE) cases identified by human EHR review with a natural language processing (NLP)-assisted rSE screen followed by a manual review. METHODS: We used the NLP screening tool Document Review Tool (DrT) to generate regular expressions, trained a bag-of-words NLP classifier on EHRs from 2017 to 2019, and then tested our algorithm on data from February to December 2012. We compared results from manual review to NLP-assisted search followed by manual review. RESULTS: Our algorithm identified 1528 notes in the test set. After removing notes pertaining to the same event by DrT, the user reviewed a total number of 400 notes to find patients with rSE. Within these 400 notes, we identified 31 rSE cases, including 12 new cases not found in manual review, and 19 of the 20 previously identified cases. The NLP-assisted model found 31 of 32 cases, with a sensitivity of 96.88% (95% CI = 82%-99.84%), whereas manual review identified 20 of 32 cases, with a sensitivity of 62.5% (95% CI = 43.75%-78.34%). SIGNIFICANCE: DrT provided a highly sensitive model compared to human review and an increase in patient identification through EHRs. The use of DrT is a suitable application of NLP for identifying patients with a history of recent rSE, which ultimately contributes to the implementation of monitoring techniques and treatments in near real time.
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Processamento de Linguagem Natural , Estado Epiléptico , Humanos , Criança , Estudos Prospectivos , Registros Eletrônicos de Saúde , Algoritmos , Estado Epiléptico/diagnósticoRESUMO
OBJECTIVES: Little is known regarding the differences in microbiology associated with cellulitis or abscess with or without lymphangitic streaking. The objective of our study is to assess whether there are differences in the pathogens identified from wound cultures of patients with paronychia with and without associated lymphangitis. METHODS: Retrospective cross-sectional study at a tertiary pediatric emergency department over 25 years. We opted to assess patients with paronychia of the finger, assuming that these cases will have a greater variety of causative pathogens compared to other cases of cellulitis and soft tissue abscess that are associated with nail biting. Case identification was conducted using a computerized text-screening search that was refined by manual chart review. We included patients from 1 month to 20 years of age who underwent an incision and drainage (I&D) of a paronychia and had a culture obtained. The presence or absence of lymphangitis was determined from the clinical narrative in the medical record. We excluded patients treated with antibiotics prior to I&D as well as immune-compromised patients. We used descriptive statistics for prevalence and χ2 tests for categorical variables. RESULTS: Two hundred sixty-six patients met inclusion criteria. The median age was 9.7 years [IQR 4.7, 15.4] and 45.1% were female. Twenty-two patients (8.3%) had lymphangitic streaking associated with their paronychia. Patients with lymphangitis streaking were similar to those without lymphangitis in terms of age and sex (p = 0.52 and p = 0.82, respectively). Overall, the predominant bacteria was MSSA (40%) followed by MRSA (26%). No significant differences were found between the pathogens in the 22 patients with associated lymphangitis compared to the 244 patients without. CONCLUSION: Staphylococcus aureus represent the majority of pathogens in paronychia, although streptococcal species and gram-negative bacteria were also common. Among patients with paronychia of the finger, there seems to be no association between pathogen type and presence of lymphangitic streaking.
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Linfangite/microbiologia , Criança , Estudos Transversais , Registros Eletrônicos de Saúde , Feminino , Infecções por Bactérias Gram-Negativas/microbiologia , Humanos , Linfangite/etiologia , Masculino , Staphylococcus aureus Resistente à Meticilina , Processamento de Linguagem Natural , Paroniquia/complicações , Paroniquia/microbiologia , Estudos Retrospectivos , Infecções Estafilocócicas/microbiologiaRESUMO
BACKGROUND: Children with hemophilia frequently require long-term central venous access devices (CVADs) for regular infusion of factor products. Hemophilia patients are not immunocompromised, but the presence and use of CVADs are associated with infections including bacteremia. Currently, the utility of blood cultures in evaluation of the febrile hemophilia patient with an indwelling CVAD is unknown, nor is optimal empiric antibiotic use. METHODS: We performed a retrospective cross-sectional study of febrile immunocompetent hemophilia patients with CVADs presenting to a large academic urban pediatric emergency department from 1995 to 2017. We used a natural language processing electronic search, followed by manual chart review to construct the cohort. We analyzed rate of pathogen recovery from cultures of blood in subgroups of hemophilia patients, the pathogen profile, and the reported pathogen susceptibilities to ceftriaxone. RESULTS: Natural language processing electronic search identified 181 visits for fever among hemophilia patients with indwelling CVADs of which 147 cases from 44 unique patients met study criteria. Cultures of blood were positive in 56 (38%) of 147 patients (95% confidence interval, 30%-47%). Seventeen different organisms were isolated (10 pathogens and 7 possible pathogens) with Staphylococcus aureus and coagulase-negative Staphylococcus species as the most common. Thirty-four percent of isolates were reported as susceptible to ceftriaxone. Positive blood cultures were more common in cases involving patients with inhibitors (n = 71) versus those without (n = 76), odds ratio, 7.4 (95% confidence interval, 3.5-15.9). This was observed irrespective of hemophilia type. CONCLUSIONS: Febrile immunocompetent hemophilia patients with indwelling CVADs have high rates of bacteremia. Empiric antimicrobial therapy should be targeted to anticipated pathogens and take into consideration local susceptibility patterns for Staphylococcus aureus.
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Bacteriemia , Hemofilia A , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Bacteriemia/epidemiologia , Hemocultura , Criança , Estudos Transversais , Hemofilia A/complicações , Hemofilia A/tratamento farmacológico , Humanos , Estudos RetrospectivosRESUMO
OBJECTIVE: To compare the clinical presentation of intussusception among children younger and older than 24 months of age. DESIGN/METHODS: We performed a retrospective cross-sectional cohort study of children treated in the emergency department, aged 1 month to 6 years, who had an abdominal ultrasound to evaluate for intussusception over a 5-year period. After stratifying by an age cut-point of 24 months, univariate and multivariate analyses were performed. RESULTS: One thousand two hundred fifty-eight cases of suspected intussusception were studied; median age was 1.7 years (interquartile range, 0.8, 2.9 years), and 37% were female. Intussusception was identified in 176 children (14%); 153 (87%) were ileocolic, and 23 were ileoileal. Abdominal pain (odds ratio, 4.0; 95% confidence interval [CI], 1.5-10.5), emesis (OR, 3.5; 95% CI, 1.8-6.7), bilious emesis (OR, 2.9; 95% CI, 1.5-5.7), lethargy (OR, 2.3; 95% CI, 1.3-5.7), rectal bleeding (OR, 2.8; 95% CI, 1.4-5.7), and irritability (OR, 0.4; 95% CI, 0.2-0.8) were found to be predictors in those younger than 24 months. In children older than 24 months, male sex was the only predictor identified (OR, 2.0; 95% CI, 1.1-3.7). In cases where abdominal radiographs were obtained (n = 1212), any abnormality on abdominal radiograph was found to be predictive in both age groups (OR, 7.8; 95% CI, 3.8-25.7; and OR, 3.1; 95% CI, 1.8-5.2, respectively). CONCLUSIONS: Intussusception presents differently in children younger than 24 months compared with older children. "Traditional" clinical predictors of intussusception should be interpreted with caution when assessing children older than 2 years.
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Intussuscepção/diagnóstico por imagem , Ultrassonografia/métodos , Dor Abdominal/diagnóstico , Fatores Etários , Criança , Pré-Escolar , Estudos Transversais , Serviço Hospitalar de Emergência , Feminino , Hemorragia Gastrointestinal/diagnóstico , Humanos , Lactente , Humor Irritável , Letargia , Masculino , Estudos Retrospectivos , Vômito/diagnósticoRESUMO
OBJECTIVES: We sought to identify predictors for a drainable suppurative adenitis [DSA] among patients presenting with acute cervical lymphadenitis. METHODS: A retrospective cross sectional study of all patients admitted to an urban pediatric tertiary care emergency department over a 15â¯year period. Otherwise healthy patients who underwent imaging for an evaluation of cervical lymphadenitis were included. Cases were identified using a text-search module followed by manual review. We excluded immunocompromised patients and those with lymphadenopathy felt to be not directly infected (i.e. reactive) or that was not acute (symptom duration >28â¯days). Data collected included: age, gender, duration of symptoms, highest recorded temperature, physical exam findings, laboratory and imaging results, and surgical findings. A DSA was defined as >1.5â¯cm in diameter on imaging. We performed binary logistic regression to determine independent clinical predictors of a DSA. RESULTS: Three hundred sixty-one patients met inclusion criteria. Three hundred six patients (85%) had a CT scan, 55 (15%) had an ultrasound and 33 (9%) had both. DSA was identified in 71 (20%) patients. Clinical features independently associated with a DSA included absence of clinical pharyngitis, WBC >15,000/mm3, age ≤3â¯years, anterior cervical chain location, largest palpable diameter on exam >3â¯cm and prior antibiotic treatment of >24â¯h. The presence of fever, skin erythema, or fluctuance on examination, was not found to be predictive of DSA. CONCLUSIONS: We identified independent predictors of DSA among children presenting with cervical adenitis. Risk can be stratified into risk groups based on these clinical features.
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Drenagem/métodos , Serviços Médicos de Emergência , Linfadenite/diagnóstico , Faringite/diagnóstico , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Linfadenite/terapia , Masculino , Faringite/terapia , Estudos Retrospectivos , Supuração , Tomografia Computadorizada por Raios X , Resultado do Tratamento , UltrassonografiaRESUMO
BACKGROUND: Clinicians utilize inflammatory markers, including C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), to identify febrile children who may have an occult serious illness or infection. OBJECTIVES: Our objective was to determine the relationship between invasive bacterial infections (IBIs) and CRP and ESR in febrile children. METHODS: We performed a retrospective cross-sectional study of 1460 febrile children <21â¯years of age, who presented to a single Emergency Department (ED) between 2012 and 2014 for evaluation of fever of <14â¯days' duration, who had both CRP and ESR obtained. Our primary outcome was IBI, defined as growth of pathogenic bacteria from a culture of cerebrospinal fluid or blood. We reviewed all ED encounters that occurred within three days of the index visits for development of IBI. We examined the negative predictive value (NPV) of CRP and ESR for IBI. RESULTS: Of the 1460 eligible ED encounters, the median patient age was 5.3â¯years [interquartile range (IQR) 2.4-10.0â¯years] and 762 (50.4%) were hospitalized. The median duration of fever was 4â¯days (IQR 1-7â¯days). Overall, 20 had an IBI (20/1460; 1.4%, 95% confidence interval (CI) 0.9-2.1%). None of those with a normal CRP (NPV 273/273; 100%, 95% CI 98.6-100%) or a normal ESR (NPV 486/486; 100%, 95% CI 99.2-100%) had an IBI. CONCLUSIONS: In our cross-sectional study of febrile children, IBI was unlikely with either a normal CRP or ESR. Inflammatory markers could be used to assist clinical decision-making while awaiting results of bacterial cultures.
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Infecções Bacterianas/diagnóstico , Proteína C-Reativa/metabolismo , Febre/microbiologia , Infecções Bacterianas/sangue , Biomarcadores/metabolismo , Sedimentação Sanguínea , Criança , Pré-Escolar , Estudos Transversais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: Currant jelly stool is a late manifestation of intussusception and is rarely seen in clinical practice. Other forms of GI bleeding have not been thoroughly studied and little is known about their respective diagnostic values. OBJECTIVE: To assess the predictive value of GI bleeding (positive guaiac test, bloody stool and rectal bleeding in evaluation of intussusception. METHODS: We performed a retrospective cross-sectional study cohort of all children, ages 1month-6years of age, who had an abdominal ultrasound obtained evaluating for intussusception over 5year period. We identified intussusception if diagnosed by ultrasound, air-contrast enema or surgery. Univariate and a multivariate logistic regression analysis were performed. RESULTS: During the study period 1258 cases met the study criteria; median age was 1.7years (IQR 0.8, 2.9) and 37% were females. Overall 176 children had intussusception; 153 (87%) were ileo-colic and 23 were ileo-ileal. Univariate risk ratio and adjusted Odds ratio were 1.3 (95% CI, 0.8, 2.0) and 1.3 (0.7, 2.4) for positive guaiac test, 1.1 (0.6, 2.1) and 0.9 (0.3, 3.0) for bloody stool, and 1.7 (1.02, 2.8) and 1.3 (0.5, 3.1) for rectal bleeding . CONCLUSION: Blood in stool, whether visible or tested by guaiac test has poor diagnostic performance in the evaluation of intussusception and is not independently predictive of intussusception. If the sole purpose of a rectal exam in these patients is for guaiac testing it should be reconsidered.
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Hemorragia Gastrointestinal/diagnóstico , Guaiaco/análise , Intussuscepção/diagnóstico , Criança , Pré-Escolar , Estudos Transversais , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Sangue Oculto , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Tempo , UltrassonografiaAssuntos
Acidentes Domésticos/estatística & dados numéricos , Equipamentos Esportivos/efeitos adversos , Ferimentos e Lesões/epidemiologia , Acidentes Domésticos/prevenção & controle , Adolescente , Amputação Cirúrgica , Criança , Pré-Escolar , Avulsões Cutâneas/epidemiologia , Equimose/epidemiologia , Registros Eletrônicos de Saúde , Feminino , Fixação de Fratura , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/terapia , Humanos , Lactente , Recém-Nascido , Lacerações/epidemiologia , Lacerações/terapia , Masculino , Processamento de Linguagem Natural , Radiografia , Técnicas de Sutura , Ferimentos e Lesões/diagnóstico por imagem , Ferimentos e Lesões/etiologia , Ferimentos e Lesões/terapia , Adulto JovemRESUMO
Electronically stored clinical documents may contain both structured data and unstructured data. The use of structured clinical data varies by facility, but clinicians are familiar with coded data such as International Classification of Diseases, Ninth Revision, Systematized Nomenclature of Medicine-Clinical Terms codes, and commonly other data including patient chief complaints or laboratory results. Most electronic health records have much more clinical information stored as unstructured data, for example, clinical narrative such as history of present illness, procedure notes, and clinical decision making are stored as unstructured data. Despite the importance of this information, electronic capture or retrieval of unstructured clinical data has been challenging. The field of natural language processing (NLP) is undergoing rapid development, and existing tools can be successfully used for quality improvement, research, healthcare coding, and even billing compliance. In this brief review, we provide examples of successful uses of NLP using emergency medicine physician visit notes for various projects and the challenges of retrieving specific data and finally present practical methods that can run on a standard personal computer as well as high-end state-of-the-art funded processes run by leading NLP informatics researchers.
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Codificação Clínica , Registros Eletrônicos de Saúde , Armazenamento e Recuperação da Informação , Processamento de Linguagem Natural , HumanosRESUMO
BACKGROUND: PRISMA-based literature reviews require meticulous scrutiny of extensive textual data by multiple reviewers, which is associated with considerable human effort. OBJECTIVE: To evaluate feasibility and reliability of using GPT-4 API as a complementary reviewer in systematic literature reviews based on the PRISMA framework. METHODOLOGY: A systematic literature review on the role of natural language processing and Large Language Models (LLMs) in automatic patient-trial matching was conducted using human reviewers and an AI-based reviewer (GPT-4 API). A RAG methodology with LangChain integration was used to process full-text articles. Agreement levels between two human reviewers and GPT-4 API for abstract screening and between a single reviewer and GPT-4 API for full-text parameter extraction were evaluated. RESULTS: An almost perfect GPT-human reviewer agreement in the abstract screening process (Cohen's kappa > 0.9) and a lower agreement in the full-text parameter extraction were observed. CONCLUSION: As GPT-4 has performed on a par with human reviewers in abstract screening, we conclude that GPT-4 has an exciting potential of being used as a main screening tool for systematic literature reviews, replacing at least one of the human reviewers.
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Processamento de Linguagem Natural , Humanos , Reprodutibilidade dos Testes , Revisões Sistemáticas como Assunto , Inteligência ArtificialRESUMO
OBJECTIVE: This study assessed the feasibility of nursing handoff notes to identify underreported hospital-acquired pressure injury (HAPI) events. METHODS: We have established a natural language processing-assisted manual review process and workflow for data extraction from a corpus of nursing notes across all medical inpatient and intensive care units in a tertiary care pediatric center. This system is trained by 2 domain experts. Our workflow started with keywords around HAPI and treatments, then regular expressions, distributive semantics, and finally a document classifier. We generated 3 models: a tri-gram classifier, binary logistic regression model using the regular expressions as predictors, and a random forest model using both models together. Our final output presented to the event screener was generated using a random forest model validated using derivation and validation sets. RESULTS: Our initial corpus involved 70,981 notes during a 1-year period from 5484 unique admissions for 4220 patients. Our interrater human reviewer agreement on identifying HAPI was high ( κ = 0.67; 95% confidence interval [CI], 0.58-0.75). Our random forest model had 95% sensitivity (95% CI, 90.6%-99.3%), 71.2% specificity (95% CI, 65.1%-77.2%), and 78.7% accuracy (95% CI, 74.1%-83.2%). A total of 264 notes from 148 unique admissions (2.7% of all admissions) were identified describing likely HAPI. Sixty-one described new injuries, and 64 describe known yet possibly evolving injuries. Relative to the total patient population during our study period, HAPI incidence was 11.9 per 1000 discharges, and incidence rate was 1.2 per 1000 bed-days. CONCLUSIONS: Natural language processing-based surveillance is proven to be feasible and high yield using nursing handoff notes.
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Processamento de Linguagem Natural , Úlcera por Pressão , Humanos , Criança , Úlcera por Pressão/diagnóstico , Úlcera por Pressão/epidemiologia , Pacientes Internados , Hospitalização , Unidades de Terapia IntensivaRESUMO
Building clinical registries is an important step in clinical research and improvement of patient care quality. Natural Language Processing (NLP) methods have shown promising results in extracting valuable information from unstructured clinical notes. However, the structure and nature of clinical notes are very different from regular text that state-of-the-art NLP models are trained and tested on, and they have their own set of challenges. In this study, we propose Sentence Extractor with Keywords (SE-K), an efficient and interpretable classification approach for extracting information from clinical notes and show that it outperforms more computationally expensive methods in text classification. Following the Institutional Review Board (IRB) approval, we used SE-K and two embedding based NLP approaches (Sentence Extractor with Embeddings (SE-E) and Bidirectional Encoder Representations from Transformers (BERT)) to develop comprehensive registry of anterior cruciate ligament surgeries from 20 years of unstructured clinical data at a multi-site tertiary-care regional children's hospital. The low-resource approach (SE-K) had better performance (average AUROC of 0.94 ± 0.04) than the embedding-based approaches (SE-E: 0.93 ± 0.04 and BERT: 0.87 ± 0.09) for out of sample validation, in addition to minimum performance drop between test and out-of-sample validation. Moreover, the SE-K approach was at least six times faster (on CPU) than SE-E (on CPU) and BERT (on GPU) and provides interpretability. Our proposed approach, SE-K, can be effectively used to extract relevant variables from clinic notes to build large-scale registries, with consistently better performance compared to the more resource-intensive approaches (e.g., BERT). Such approaches can facilitate information extraction from unstructured notes for registry building, quality improvement and adverse event monitoring.
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Processamento de Linguagem Natural , Sistema de Registros , Humanos , Registros Eletrônicos de Saúde , Mineração de Dados/métodosRESUMO
BACKGROUND AND OBJECTIVES: Patient and family violent outbursts toward staff, caregivers, or through self-harm, have increased during the ongoing behavioral health crisis. These health care-associated violence (HAV) episodes are likely under-reported. We sought to assess the feasibility of using nursing notes to identify under-reported HAV episodes. METHODS: We extracted nursing notes across inpatient units at 2 hospitals for 2019: a pediatric tertiary care center and a community-based hospital. We used a workflow for narrative data processing using a natural language processing (NLP) assisted manual review process performed by domain experts (a nurse and a physician). We trained the NLP models on the tertiary care center data and validated it on the community hospital data. Finally, we applied these surveillance methods to real-time data for 2022 to assess reporting completeness of new cases. RESULTS: We used 70 981 notes from the tertiary care center for model building and internal validation and 19 332 notes from the community hospital for external validation. The final community hospital model sensitivity was 96.8% (95% CI 90.6% to 100%) and a specificity of 47.1% (39.6% to 54.6%) compared with manual review. We identified 31 HAV episodes in July to December 2022, of which 26 were reportable in accordance with the hospital internal criteria. Only 7 of 26 cases were reported by employees using the self-reporting system, all of which were identified by our surveillance process. CONCLUSIONS: NLP-assisted review is a feasible method for surveillance of under-reported HAV episodes, with implementation and usability that can be achieved even at a low information technology-resourced hospital setting.
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Processamento de Linguagem Natural , Humanos , Estudos de Viabilidade , Hospitais Comunitários , Centros de Atenção Terciária , Violência no Trabalho/estatística & dados numéricos , Hospitais Pediátricos , Masculino , Feminino , Criança , Vigilância da População/métodosRESUMO
BACKGROUND AND OBJECTIVES: Blood cultures (BCxs) are often obtained in the initial evaluation of children with fever and acute lower extremity pain; however, their yield in this population is unknown. We aim to describe the prevalence of bacteremia among children presenting to the emergency department (ED) with fever and acute lower extremity pain and identify predictors of bacteremia. METHODS: Cross-sectional review of children aged 1 to 18 years presenting to the ED with fever and acute lower extremity pain between 2010 and 2020. We excluded patients with trauma within the previous 24 hours, orthopedic comorbidity, immunocompromised status, or antibiotic pretreatment. We identified our cohort using a Natural Language Processing-assisted model with manual review and abstracted clinical data. Our primary outcome was a BCx positive for a pathogen. RESULTS: We screened 478 979 ED notes and identified 689 patients who met inclusion criteria. Median age was 5.3 years (interquartile range 2.7-8.8); 39.5% were female. BCxs were obtained from 75.9% (523/689) of patients, of which 510 were available for review. BCxs were positive in 70/510 (13.7%; 95% CI, confidence interval [CI], 10.9-17.0) of children and in 70/689 (10.2%; 95% CI, 8.0-12.7%) of the entire cohort. The most common pathogens were methicillin-susceptible Staphylococcus aureus (71.6%) and methicillin-resistant Staphylococcus aureus (15.7%). Predictors of bacteremia include C-reactive protein ≥3 mg/dL (odds ratio, 4.5; 95% CI, 2.1-9.6) and localizing examination findings (odds ratio, 3.3; 95% CI, 1.4-7.9). CONCLUSIONS: The prevalence of bacteremia among children presenting to the ED with fever and acute lower extremity pain is high. Routine BCx should be considered in the initial evaluation of this population.
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Bacteriemia , Staphylococcus aureus Resistente à Meticilina , Infecções Estafilocócicas , Humanos , Criança , Feminino , Pré-Escolar , Masculino , Estudos Transversais , Bacteriemia/diagnóstico , Bacteriemia/epidemiologia , Bacteriemia/tratamento farmacológico , Febre/epidemiologia , Dor , Extremidade Inferior , Estudos Retrospectivos , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/tratamento farmacológicoRESUMO
OBJECTIVE: We describe our approach to surveillance of reportable safety events captured in hospital data including free-text clinical notes. We hypothesize that a) some patient safety events are documented only in the clinical notes and not in any other accessible source; and b) large-scale abstraction of event data from clinical notes is feasible. MATERIALS AND METHODS: We use regular expressions to generate a training data set for a machine learning model and apply this model to the full set of clinical notes and conduct further review to identify safety events of interest. We demonstrate this approach on peripheral intravenous (PIV) infiltrations and extravasations (PIVIEs). RESULTS: During Phase 1, we collected 21,362 clinical notes, of which 2342 were reviewed. We identified 125 PIV events, of which 44 cases (35%) were not captured by other patient safety systems. During Phase 2, we collected 60,735 clinical notes and identified 440 infiltrate events. Our classifier demonstrated accuracy above 90%. CONCLUSION: Our method to identify safety events from the free text of clinical documentation offers a feasible and scalable approach to enhance existing patient safety systems. Expert reviewers, using a machine learning model, can conduct routine surveillance of patient safety events.
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Processamento de Linguagem Natural , Segurança do Paciente , Humanos , Registros Eletrônicos de Saúde , Aprendizado de Máquina , EletrônicaRESUMO
OBJECTIVES: We assessed the clinical characteristics of primary intracranial hypertension (PIH) in children using a newly recommended threshold for cerebrospinal fluid opening pressure (280 mm H2O). METHOD: Cross-sectional study of patients age ≤21 years who had a lumbar puncture done for evaluation of PIH. Patients were excluded if lumbar puncture was done for a suspected infection, seizure, mental status changes, multiple sclerosis, or Guillain-Barre syndrome. Cases were identified using a text-search module followed by manual review. We performed χ2 analysis for categorical data and Mann-Whitney U test for continuous data, followed by a binary logistic regression. RESULTS: We identified 374 patients of whom 67% were female, median age was 13 years interquartile range (11 to 16 years), and admission rate was 24%. Using an opening pressure cutoff of 250 mm H2O, 127 patients (34%) were identified as having PIH, whereas using the new cutoff 105 patients (28%) met PIH criteria. Predictors for PIH included optic disc edema or sixth nerve palsy using both old, odds ratio (OR) 7.6 (4.3, 13.5), and new cutoffs, OR 9.7 (95% confidence interval 5.1, 18.5). Headache duration ≤61 days is predictive of PIH using the new cutoff OR 4.1 (95% confidence interval 1.3, 12.8). A model is presented which stratifies patients into groups with low (7%), medium (18%), and high (greater than 42%) risk of PIH. CONCLUSIONS: A higher cerebrospinal fluid opening pressure threshold in the criteria of PIH is associated with PIH patients with a different symptom profile. Children with optic disc edema, bulging fontanel or sixth nerve palsy, are at increased risk for PIH.
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Doenças do Nervo Abducente/diagnóstico , Pressão do Líquido Cefalorraquidiano/fisiologia , Fontanelas Cranianas , Hipertensão Intracraniana/diagnóstico , Papiledema/diagnóstico , Doenças do Nervo Abducente/fisiopatologia , Adolescente , Criança , Fontanelas Cranianas/fisiopatologia , Estudos Transversais , Feminino , Humanos , Hipertensão Intracraniana/fisiopatologia , Masculino , Papiledema/fisiopatologia , Prognóstico , Pseudotumor Cerebral/diagnóstico , Pseudotumor Cerebral/fisiopatologia , Estudos RetrospectivosRESUMO
BACKGROUND AND OBJECTIVES: In 2012, Massachusetts changed its emergency shelter eligibility policy for homeless families. One new criterion to document homelessness was staying in a location "not meant for human habitation," and the emergency department (ED) fulfilled this requirement. Our aim for this study is to analyze the frequency and costs of pediatric ED visits for homelessness before and after this policy. METHODS: This is a retrospective study of ED visits for homelessness at a children's hospital from March 2010 to February 2016. A natural language processing tool was used to identify cases, which were manually reviewed for inclusion. We compared demographic and homelessness circumstance characteristics and conducted an interrupted time series analysis to compare ED visits by homeless children before and after the policy. We compared the change in ED visits for homelessness to the number of homeless children in Massachusetts. We analyzed payment data for each visit. RESULTS: There were 312 ED visits for homelessness; 95% (n = 297) of visits were after the policy. These visits increased 4.5 times after the policy (95% confidence interval: 1.33 to 15.23). Children seen after the policy were more likely to have no medical complaint (rate ratio: 3.27; 95% confidence interval: 1.18 to 9.01). Although the number of homeless children in Massachusetts increased 1.4 times over the study period, ED visits for homelessness increased 13-fold. Payments (average: $557 per visit) were >4 times what a night in a shelter would cost; 89% of payments were made through state-based insurance plans. CONCLUSIONS: A policy change to Massachusetts' shelter eligibility was associated with increased pediatric ED visits for homelessness along with substantial health care costs.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Abrigo de Emergência/legislação & jurisprudência , Custos de Cuidados de Saúde/estatística & dados numéricos , Pessoas Mal Alojadas/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/economia , Feminino , Pessoas Mal Alojadas/legislação & jurisprudência , Humanos , Lactente , Recém-Nascido , Masculino , Massachusetts , Estudos RetrospectivosRESUMO
BACKGROUND: Diagnostic error can lead to increased morbidity, mortality, healthcare utilization and cost. The 2015 National Academy of Medicine report "Improving Diagnosis in Healthcare" called for improving diagnostic accuracy by developing innovative electronic approaches to reduce medical errors, including missed or delayed diagnosis. The objective of this article was to develop a process to detect potential diagnostic discrepancy between pediatric emergency and inpatient discharge diagnosis using a computer-based tool facilitating expert review. METHODS: Using a literature search and expert opinion, we identified 10 pediatric diagnoses with potential for serious consequences if missed or delayed. We then developed and applied a computerized tool to identify linked emergency department (ED) encounters and hospitalizations with these discharge diagnoses. The tool identified discordance between ED and hospital discharge diagnoses. Cases identified as discordant were manually reviewed by pediatric emergency medicine experts to confirm discordance. RESULTS: Our computerized tool identified 55,233 ED encounters for hospitalized children over a 5-year period, of which 2161 (3.9%) had one of the 10 selected high-risk diagnoses. After expert record review, we identified 67 (3.1%) cases with discordance between ED and hospital discharge diagnoses. The most common discordant diagnoses were Kawasaki disease and pancreatitis. CONCLUSIONS: We successfully developed and applied a semi-automated process to screen a large volume of hospital encounters to identify discordant diagnoses for selected pediatric medical conditions. This process may be valuable for informing and improving ED diagnostic accuracy.