Venous thromboembolism (VTE) is the leading cause of preventable death in hospitalized patients. Artificial intelligence (AI) and machine learning (ML) can support guidelines recommending an ...individualized approach to risk assessment and prophylaxis. We conducted electronic surveys asking clinician and healthcare informaticians about their perspectives on AI/ML for VTE prevention and management. Of 101 respondents to the informatician survey, most were 40 years or older, male, clinicians and data scientists, and had performed research on AI/ML. Of the 607 US-based respondents to the clinician survey, most were 40 years or younger, female, physicians, and had never used AI to inform clinical practice. Most informaticians agreed that AI/ML can be used to manage VTE (56.0%). Over one-third were concerned that clinicians would not use the technology (38.9%), but the majority of clinicians believed that AI/ML probably or definitely can help with VTE prevention (70.1%). The most common concern in both groups was a perceived lack of transparency (informaticians 54.4%; clinicians 25.4%). These two surveys revealed that key stakeholders are interested in AI/ML for VTE prevention and management, and identified potential barriers to address prior to implementation.
Objective To explore racial differences in newborn telomere length (TL) and the effect moderation of the sex of the infant while establishing the methodology for the use of newborn blood spots for TL ...analyses. Study design Pregnant mothers were recruited from the Greater New Orleans area. TL was determined via monochrome multiplex quantitative real-time polymerase chain reaction on DNA extracted from infant blood spots. Demographic data and other covariates were obtained via maternal report before the infant's birth. Birth outcome data were obtained from medical records and maternal report. Results Black infants weighed significantly less than white infants at birth and had significantly longer TL than white infants ( P = .0134), with the strongest effect observed in black female infants. No significant differences in gestational age were present. Conclusions Significant racial differences in TL were present at birth in this sample, even after we controlled for a range of birth outcomes and demographic factors. Because longer initial TL is predictive of more rapid TL attrition across the life course, these findings provide evidence that, even at birth, biological vulnerability to early life stress may differ by race and sex.
Three months after the first reported cases, COVID-19 had spread to nearly 90% of World Health Organization (WHO) member states and only 24 countries had not reported cases as of 30 March 2020. This ...analysis aimed to 1) assess characteristics, capability to detect and monitor COVID-19, and disease control measures in these 24 countries, 2) understand potential factors for the reported delayed COVID-19 introduction, and 3) identify gaps and opportunities for outbreak preparedness, particularly in low and middle-income countries (LMICs). We collected and analyzed publicly available information on country characteristics, COVID-19 testing, influenza surveillance, border measures, and preparedness activities in these countries. We also assessed the association between the temporal spread of COVID-19 in all countries with reported cases with globalization indicator and geographic location.
Temporal spreading of COVID-19 was strongly associated with countries' globalization indicator and geographic location. Most of the 24 countries with delayed COVID-19 introduction were LMICs; 88% were small island or landlocked developing countries. As of 30 March 2020, only 38% of these countries reported in-country COVID-19 testing capability, and 71% reported conducting influenza surveillance during the past year. All had implemented two or more border measures, (e.g., travel restrictions and border closures) and multiple preparedness activities (e.g., national preparedness plans and school closing).
Limited testing capacity suggests that most of the 24 delayed countries may have lacked the capability to detect and identify cases early through sentinel and case-based surveillance. Low global connectedness, geographic isolation, and border measures were common among these countries and may have contributed to the delayed introduction of COVID-19 into these countries. This paper contributes to identifying opportunities for pandemic preparedness, such as increasing disease detection, surveillance, and international collaborations. As the global situation continues to evolve, it is essential for countries to improve and prioritize their capacities to rapidly prevent, detect, and respond, not only for COVID-19, but also for future outbreaks.
Population‐based data about cerebral venous sinus thrombosis (CVST) are limited.
To investigate the epidemiology of CVST in the United States.
Three administrative data systems were analyzed: the ...2018 Healthcare Cost and Utilization Project National Inpatient Sample (NIS) the 2019 IBM MarketScan Commercial and Medicare Supplemental Claims Database, and the 2019 IBM MarketScan Multi‐state Medicaid Database. CVST, thrombocytopenia, and numerous comorbidities were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. Incidence rates of CVST and CVST with thrombocytopenia were estimated (per 100,000 total US population NIS and per 100,000 population aged 0 to 64 years covered by relevant contributing health plans MarketScan samples). Comorbidity prevalence was estimated among CVST cases versus total inpatients in the NIS sample. Recent pregnancy prevalence was estimated for the Commercial sample.
Incidence rates of CVST in NIS, Commercial, and Medicaid samples were 2.85, 2.45, and 3.16, respectively. Incidence rates of CVST with thrombocytopenia were 0.21, 0.22, and 0.16, respectively. In all samples, CVST incidence increased with age; however, peak incidence was reached at younger ages in females than males. Compared with the general inpatient population, persons with CVST had higher prevalences of hemorrhagic stroke, ischemic stroke, other venous thromboembolism (VTE), central nervous system infection, head or neck infection, prior VTE, thrombophilia, malignancy, head injury, hemorrhagic disorder, and connective tissue disorders. Women aged 18 to 49 years with CVST had a higher pregnancy prevalence than the same‐aged general population.
Our findings provide recent and comprehensive data on the epidemiology of CVST and CVST with thrombocytopenia.
Background Hospital-associated venous thromboembolism (HA-VTE) is a significant, deadly, costly, and growing public health problem. While as many as 70% of cases of HA-VTE in patients could be ...prevented, proven VTE prevention strategies are not applied systematically across U.S. hospitals systems. There is a need to assess and better understand the landscape around VTE prevention practices in U.S. hospitals. Methods The Joint Commission and the Centers for Disease Control and Prevention (CDC) collaborated in the development of a probability-based hospital survey collected in accordance with the American Association for Public Opinion Research guidelines. The population comprised all U.S. and territorial general medical, general surgical, and critical-access hospitals in the 2019 American Hospital Association database. Hospitals were stratified by bed size (small ≤100 beds; medium 100-399 beds; and large ≥400 beds), then randomly sampled an equal number of hospitals in each group. The intended respondent was the chief medical officer, director of quality or safety, or person of a similar title. The questionnaire comprised 44 items, including topics on hospital policies and protocols, barriers to implementation of VTE prevention practice, quality monitoring and improvement efforts, and risk assessment activities. The χ2 test was used to examine differences in response rates by hospital characteristics. This project was deemed non-research in accordance with federal regulation for the protection of human subjects in research. Results There were 4605 eligible hospitals, of which 1290 were randomly selected for the sample, and 1212 had available contact information and were presumed reached. Of these, 311 submitted sufficient data for inclusion, a response rate of 25.7%. Response rates did not differ significantly by location (urban vs rural) or bed size, however major teaching hospitals were more likely to respond than minor or non-teaching hospitals (p<.001). (Table 1) More than half of hospitals reported having a VTE prevention policy (58.0%) (Table 2). Most had a hospital-wide VTE prevention protocol (81.5%) and/or unit-specific protocols (59.9%). Less than half had a VTE prevention team, committee, or workgroup and only 21.8% had a designated VTE prevention team and 19.2% reported VTE prevention activities were addressed by another committee. Large hospitals were more likely to have a designated team (p<.001). When a team or committee exists, there is representation from at least 2 departments (96.7%). Almost 80% reported they have clinical decision support (CDS) tools to help guide the selection of appropriate VTE prophylaxis for medical and surgical patients. The availability of CDS was greater in large and medium hospitals for both medical and surgical units (p<.002). Approximately 60% reported that their admission order sets addressed VTE prophylaxis and completion is mandatory. Reminders or alerts are provided for patients by about 60% of hospitals. Missed anticoagulant doses are routinely documented at 80.1% of hospitals. Around 50% of hospitals reported they conduct audits and provide feedback related to VTE prophylaxis for patients. Over 70% of hospitals educate patients about VTE prevention, including the importance of VTE prophylaxis, during the hospitalization; a little more than a third of hospitals provide annual VTE prevention education to clinicians. About half reported they have an ambulation protocol for patients. There were no variations by hospital bed size for education or ambulation protocols. Data on the number of newly diagnosed HA-VTE is collected in 75.6% of hospitals. This was lower in small hospitals (p=.004). Whereas just 44.7% track the number of patients with bleeding events and/or complications related to anticoagulant prophylaxis. Only 43.7% collect data on the patients receiving appropriate VTE prophylaxis and even fewer collect data on of patients receiving risk assessment (29.3%). Conclusion This survey of hospital VTE prevention practices identified numerous areas for improvement in the establishment and implementation of HA-VTE prevention policies and procedures. Overall, there were limited differences in prevention practices based on hospital bed size. Improving the awareness and application of evidence-based guidelines and interventions may reduce the incidence of HA-VTE.
Background: Venous thromboembolism (VTE) is a significant cause of preventable death among hospitalized patients. Artificial intelligence (AI) and its sub-branch machine learning (ML) may be useful ...in standardizing and improving VTE management in hospitalized patients. To learn attitudes towards using AI for VTE, we previously conducted a national survey of 100 clinical informaticians recruited through professional organizations and a publicly available database listing recipients of National Institutes of Health informatics grant awardees (Lam et al, RPTH, 2023). For the current study, we interviewed a subset of these informaticians to explore their perspectives in depth on using AI in clinical decision making and VTE management. Methods: Survey participants interested in participating in interviews were asked to submit their email addresses. We then recruited these participants and asked them to recommend other informaticians who may be interested. We conducted 30-60 minute interviews via videoconference which were recorded and transcribed. Two coders separately reviewed the interviews using thematic analyses to develop a codebook. Codes were identified inductively and agreed upon by consensus. Once a codebook was agreed upon, it was used to code all interviews in duplicate. Results: Of 32 informaticians who were contacted, 11 agreed to be interviewed. The final participant group included 4 clinicians, 6 data scientists, and 1 biomedical/computational biologist. The major themes that emerged were that AI is a powerful tool to reduce clinician burden and AI is well suited to preventing and managing VTE, but bias in the creation of AI tools must be minimized. Since machine learning models increase accuracy and efficiency in clinical practice, they can serve as decision support and management tools and help to improve communication thereby reducing clinician burden. (Table 1) Other than the ethical concerns regarding bias, subpar quality of training data and model inaccuracy were identified as potential challenges. ML tools need to be validated as safe and effective for their specific role. In addition, one theme highlighted that clinicians fear being replaced by AI, while another noted that most patients would prefer interacting with humans about their medical care over AI. There were multiple suggestions for implementation of AI. Participants noted that AI could be integrated into the EMR and that ML tools should be further investigated with input from domain experts (data scientists, computational biologists and clinicians). Finally, interviewees recognized that VTE management was an area of medicine in which AI could be used successfully given that it is a clearly defined problem that lends itself to an algorithmic solution which can incorporate the current guidelines into a tool within the EMR system. Conclusion: Informaticians see AI as a promising tool to support clinical decision making about VTE prophylaxis because not only does it increase accuracy and efficiency, but it is also a clearly defined area of clinical management where guidelines can be effectively incorporated into the EMR system via machine learning. Challenges identified to implementing AI/ML will have to be addressed in order to create an ethical and accurate model which reduces the burden on healthcare providers in the clinical setting.
Infections and stress, immune responses, and hormones are interconnected, ensuring immune competence to deal with immediate threat of overwhelming infection and metabolic collapse. Emergence of ...cytokines as key signal mediators and appreciation of autocrine-paracrine influences of hormones have helped explain how signals are transmitted and responses evoked. This has led to possibilities of creating therapies that might be used to enhance protective signals and dampen signals emanating from host and invading organism interaction that might otherwise be detrimental. Correcting certain metabolic abnormalities, such as hyperglycemia and metabolic acidosis, benefits the host by decreasing morbidity and mortality.
We studied in vitro production of interferon-gamma and expression of interferon-gamma receptors (R1 and R2) by the peripheral blood mononuclear cells of 24 HIV-1-infected patients and 12 healthy ...volunteers. Interferon-gamma production was lower in HIV-1-infected patients compared with healthy volunteers (p < 0.05), and it further declined in patients with lower CD4+ T-cell counts. In contrast, expression of interferon-gamma R1 by CD4+ T lymphocytes was higher in HIV-infected patients than healthy volunteers (25% versus 10%, p < 0.05). In the HIV-infected group, interferon-gamma R1 expression increased with a decline in CD4+ T-cell count (r = -0.64, p < 0.001). Interferon-gamma R2 expression directly correlated with interferon-gamma R1 expression (p < 0.001). When stimulated with heat-killed Mycobacterium avium complex (MAC) and phorbol myristic acetate (PMA), the mononuclear cells of patients with advanced HIV-1 infection had lowered ability to produce additional interferon-gamma (either MAC or PMA) and interferon-gamma receptors (MAC). In conclusion, with progression of HIV-1 infection, interferon-gamma production declines whereas expression of interferon-gamma receptors (R1 and R2) increases. Persistent upregulation of both interferon-gamma R1 and R2 receptors probably favors development of type 2 T-helper cells environment and promotes viral replication. This dysfunction in the interferon-gamma pathway contributes to a further impairment in cellular immune function in patients with advanced HIV-1 infection, which may further increase susceptibility to opportunistic infections.
The returning traveler with fever presents a diagnostic challenge for the health care provider. When evaluating such a patient, the highest priority should be given to diseases that are potentially ...fatal or may represent public health threats. A good history is paramount and needs to include destination, time and duration of travel, type of activity, onset of fever in relation to travel, associated comorbidities, and any associated symptoms. Pretravel immunizations and chemoprophylaxis may alter the natural course of disease and should be inquired about specifically. The fever pattern, presence of a rash or eschar, organomegaly, or neurologic findings are helpful physical findings. Laboratory abnormalities are nonspecific but when corroborated with clinical and epidemiologic data may offer a clue to diagnosis.
PDF
