In one example, a clinical service in a large pediatric hospital, faced with a question of whether to prescribe anticoagulation in a patient with a complex constellation of findings, was able to ...identify 98 patients in their institution's data warehouse with similar findings and to estimate the occurrence of thrombosis in that group (2). Because the risk of thrombosis was much higher than expected, the clinical team felt justified in using anticoagulation in their patient, despite the lack of published studies addressing that particular patient phenotype. ...the use of data warehouses for quality-improvement efforts and clinical decision-making must be distinguished from clinical research, which requires additional approval from an institutional review board (IRB). In general, if the answer to any ofthese 3 questions is yes, the study should be considered research and subject to IRB review (10, 11). Because data warehouse searches are typically focused on generating institution-specific knowledge with data from patients receiving standard care, they usually fall outside the strict definition of research, but referral to an IRB may still be helpful, particularly if there are questions about risk to patients. ...the medication exposures collected for the study were documented in different sections of the patient chart (e.g., prescription orders, administration records), preventing a systematic assessment of whether patients were truly exposed to the reported medications (1). Because of this limitation, the study validated new-found cross-reactivities experimentally with supplemented samples, supporting the robustness of the data mining method.
To evaluate the association between early (within 10 d) pRBC transfusion and the development of severe ROP.
This was a single-center retrospective study. Inclusion criteria were preterm infants born ...≤32 weeks gestation or weighing ≤1500 g. Severe ROP was defined as infants requiring retinal laser ablation or bevacizumab injection. Logistic regression was used to identify the association between transfusions and severe ROP.
A total of 1635 infants were included in the final analysis. The severe ROP incidence was 8% (126/1635). Ninety-one percent (115/126) of infants who developed severe ROP received a pRBC transfusion in the first 10 d. Early transfusion was associated with severe ROP; adjusted odds ratio of 3.8 (95% CI: 1.8-8.1).
pRBC transfusions in the first 10 days of life are associated with an almost four-fold increased risk of severe ROP, independent of gestational age at birth or bronchopulmonary dysplasia (BPD) status.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
In this issue of Clinical Chemistry, Moyer et al. describe the implementation and findings of a CPOE alert designed to reduce unnecessary repeat ordering of 3 tests-ionized calcium (iCa), serum ...magnesium (Mg), and N-terminal pro-brain natriuretic peptide (NTproBNP)- in 5 intensive care units at a single institution (1 ). The ordering of unnecessary tests on such a massive scale may impact not only direct healthcare costs, but also patient safety, and may lead to unnecessary follow-up investigation and iatrogenic blood loss due to excess phlebotomy (3 ).
Abstract
Background
Intravenous (IV) fluid contamination is a common cause of preanalytical error that can delay or misguide treatment decisions, leading to patient harm. Current approaches for ...detecting contamination rely on delta checks, which require a prior result, or manual technologist intervention, which is inefficient and vulnerable to human error. Supervised machine learning may provide a means to detect contamination, but its implementation is hindered by its reliance on expert-labeled training data. An automated approach that is accurate, reproducible, and practical is needed.
Methods
A total of 25 747 291 basic metabolic panel (BMP) results from 312 721 patients were obtained from the laboratory information system (LIS). A Uniform Manifold Approximation and Projection (UMAP) model was trained and tested using a combination of real patient data and simulated IV fluid contamination. To provide an objective metric for classification, an “enrichment score” was derived and its performance assessed. Our current workflow was compared to UMAP predictions using expert chart review.
Results
UMAP embeddings from real patient results demonstrated outliers suspicious for IV fluid contamination when compared with the simulated contamination's embeddings. At a flag rate of 3 per 1000 results, the positive predictive value (PPV) was adjudicated to be 0.78 from 100 consecutive positive predictions. Of these, 58 were previously undetected by our current clinical workflows, with 49 BMPs displaying a total of 56 critical results.
Conclusions
Accurate and automatable detection of IV fluid contamination in BMP results is achievable without curating expertly labeled training data.
Clinical decision support alerts for laboratory testing have poor compliance. Once-per-visit alerts, triggered by reorder of a test within the same admission, are highly specific for unnecessary ...orders and provide a means to study alert compliance.
Once-per-visit alerts for 18 laboratory orderables were analyzed over a 60-month period from September 2012 to October 2016 at a 1200-bed academic medical center. To determine correlates of alert compliance, we compared alerts by test and provider characteristics.
Overall alert compliance was 54.5%. In multivariate regression, compliance correlated with length of stay at time of alert, provider type, previous alerts in a patient visit, test ordered, total alerts experienced by ordering provider, and previous order status.
A diverse set of provider and test characteristics influences compliance with once-per-visit laboratory alerts. Future alerts should incorporate these characteristics into alert design to minimize alert overrides.
Background
Transfusion of ABO‐incompatible platelets (PLTs) is associated with reduced PLT recovery and a risk of transfusion reactions. However, a policy of transfusing only ABO‐identical PLTs may ...increase wastage due to product outdating. A prospective study attempting to compare the effects of different ABO compatibility strategies could be costly and disruptive to a blood bank's operations.
Study Design and Methods
We designed a “virtual blood bank,” a stochastic computer program that models the stocking and release of products to meet demand for PLT transfusion in a simulated hospital population. ABO‐nonidentical transfusions (ABOni), outdates, and inventory shortages were recorded and compared under two different transfusion strategies: ABO‐First, a strategy that prioritizes transfusion of ABO‐identical PLTs, and Age‐First, a strategy that minimizes outdating by transfusing products closest to expiration.
Results
The ABO‐First strategy resulted in fewer ABOni but more outdates than the Age‐First strategy. Under conditions that mimic a large hospital blood bank, the ABO‐First strategy was more cost‐effective overall than the Age‐First strategy if avoiding an ABOni is valued at more than $19 to $26. For a small blood bank, the ABO‐First strategy was more cost‐effective if avoiding an ABOni is valued at more than $104 to $123.
Conclusion
Based on a virtual blood bank computer simulation, the cost of avoiding an ABOni using the ABO‐First strategy varies greatly by size of institution. Individual blood banks must carefully consider these management strategies to determine the most cost‐effective solution.
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Although the structures of many β-barrel membrane proteins are available, our knowledge of the principles that govern their energetics and oligomerization states is incomplete. Here we describe a ...computational method to study the transmembrane (TM) domains of β-barrel membrane proteins. Our method is based on a physical interaction model, a simplified conformational space for efficient enumeration, and an empirical potential function from a detailed combinatorial analysis. Using this method, we can identify weakly stable regions in the TM domain, which are found to be important structural determinants for β-barrel membrane proteins. By calculating the melting temperatures of the TM strands, our method can also assess the stability of β-barrel membrane proteins. Predictions on membrane enzyme PagP are consistent with recent experimental NMR and mutant studies. We have also discovered that out-clamps, in-plugs, and oligomerization are 3 general mechanisms for stabilizing weakly stable TM regions. In addition, we have found that extended and contiguous weakly stable regions often signal the existence of an oligomer and that strands located in the interfaces of protein-protein interactions are considerably less stable. Based on these observations, we can predict oligomerization states and can identify the interfaces of protein-protein interactions for β-barrel membrane proteins by using either structure or sequence information. In a set of 25 nonhomologous proteins with known structures, our method successfully predicted whether a protein forms a monomer or an oligomer with 91% accuracy; in addition, our method identified with 82% accuracy the protein-protein interaction interfaces by using sequence information only when correct strands are given.
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