Intermountain St. George Regional Hospital

BackgroundPatients receiving angiogenesis inhibitor treatment require attention regarding proteinuria. Monitoring proteinuria using the urine protein-to-creatinine ratio (UPCR) is critical. However, the utility of the UPCR for administering angiogenesis inhibitors to elderly patients remains unclear.ObjectivesWe retrospectively examined whether UPCR measurements are associated with improved efficacy and safety of angiogenesis inhibitors in elderly patients.MethodsThis study included patients who experienced grade 2 or higher proteinuria at least once after the administration of angiogenesis inhibitors. The UPCR values at which bevacizumab and ramucirumab could be administered were defined to be less than 3.5 and 2.0, respectively. The actual total dose/planned total dose was used as an efficacy indicator. A proteinuria rate of grade 2 or higher was used as a safety indicator.ResultsThere were 14 patients in both the UPCR and qualitative test groups. The medians of the actual total dose/planned total dose (%) for the angiogenesis inhibitors in the UPCR and qualitative test groups were 96.8 (48.5–103.9) and 77.7 (9.1–93.1), respectively, with that in the UPCR group being significantly higher (p < 0.001). However, one patient in the UPCR group developed nephrotic syndrome.ConclusionsMonitoring UPCR in elderly patients with grade 2 or higher proteinuria increases the total dosage of angiogenesis inhibitors, which may enhance their therapeutic effects. However, nephrotic syndrome was not fully confirmed in this small-scale study. Although further safety verifications are needed, our findings highlight the importance of monitoring UPCR to improve the efficacy and safety of angiogenesis inhibitors in elderly patients.

BackgroundSkin cancers are the most common malignancies diagnosed worldwide. While the early detection and treatment of pre-cancerous and cancerous skin lesions can dramatically improve outcomes, factors such as a global shortage of pathologists, increased workloads, and high rates of diagnostic discordance underscore the need for techniques that improve pathology workflows. Although AI models are now being used to classify lesions from whole slide images (WSIs), diagnostic performance rarely surpasses that of expert pathologists. ObjectivesThe objective of the present study was to create an AI model to detect and classify skin lesions with a higher degree of sensitivity than previously demonstrated, with potential to match and eventually surpass expert pathologists to improve clinical workflows. MethodsWe combined supervised learning (SL) with semi-supervised learning (SSL) to produce an end-to-end multi-level skin detection system that not only detects 5 main types of skin lesions with high sensitivity and specificity, but also subtypes, localizes, and provides margin status to evaluate the proximity of the lesion to non-epidermal margins. The Supervised Training Subset consisted of 2188 random WSIs collected by the PathologyWatch (PW) laboratory between 2013 and 2018, while the Weakly Supervised Subset consisted of 5161 WSIs from daily case specimens. The Validation Set consisted of 250 curated daily case WSIs obtained from the PW tissue archives and included 50 “mimickers”. The Testing Set (3821 WSIs) was composed of non-curated daily case specimens collected from July 20, 2021 to August 20, 2021 from PW laboratories. ResultsThe performance characteristics of our AI model (i.e., Mihm) were assessed retrospectively by running the Testing Set through the Mihm Evaluation Pipeline. Our results show that the sensitivity of Mihm in classifying melanocytic lesions, basal cell carcinoma, and atypical squamous lesions, verruca vulgaris, and seborrheic keratosis was 98.91% (95% CI: 98.27%, 99.55%), 97.24% (95% CI: 96.15%, 98.33%), 95.26% (95% CI: 93.79%, 96.73%), 93.50% (95% CI: 89.14%, 97.86%), and 86.91% (95% CI: 82.13%, 91.69%), respectively. Additionally, our multi-level (i.e., patch-level, ROI-level, and WSI-level) detection algorithm includes a qualitative feature that subtypes lesions, an AI overlay in the front-end digital display that localizes diagnostic ROIs, and reports on margin status by detecting overlap between lesions and non-epidermal tissue margins. ConclusionsOur AI model, developed in collaboration with dermatopathologists, detects 5 skin lesion types with higher sensitivity than previously published AI models, and provides end users with information such as subtyping, localization, and margin status in a front-end digital display. Our end-to-end system has the potential to improve pathology workflows by increasing diagnostic accuracy, expediting the course of patient care, and ultimately improving patient outcomes.

Rationale: Care of emergency department (ED) patients with pneumonia can be challenging. Clinical decision support may decrease unnecessary variation and improve care. Objectives: To report patient outcomes and processes of care after deployment of electronic pneumonia clinical decision support (ePNa): a comprehensive, open loop, real-time clinical decision support embedded within the electronic health record. Methods: We conducted a pragmatic, stepped-wedge, cluster-controlled trial with deployment at 2-month intervals in 16 community hospitals. ePNa extracts real-time and historical data to guide diagnosis, risk stratification, microbiological studies, site of care, and antibiotic therapy. We included all adult ED patients with pneumonia over the course of 3 years identified by International Classification of Diseases, 10th Revision discharge coding confirmed by chest imaging. Measurements and Main Results: The median age of the 6,848 patients was 67 years (interquartile range, 50-79), and 48% were female; 64.8% were hospital admitted. Unadjusted mortality was 8.6% before and 4.8% after deployment. A mixed effects logistic regression model adjusting for severity of illness with hospital cluster as the random effect showed an adjusted odds ratio of 0.62 (0.49-0.79; P < 0.001) for 30-day all-cause mortality after deployment. Lower mortality was consistent across hospital clusters. ePNa-concordant antibiotic prescribing increased from 83.5% to 90.2% (P < 0.001). The mean time from ED admission to first antibiotic was 159.4 (156.9-161.9) minutes at baseline and 150.9 (144.1-157.8) minutes after deployment (P < 0.001). Outpatient disposition from the ED increased from 29.2% to 46.9%, whereas 7-day secondary hospital admission was unchanged (5.2% vs. 6.1%). ePNa was used by ED clinicians in 67% of eligible patients. Conclusions: ePNa deployment was associated with improved processes of care and lower mortality. Clinical trial registered with www.clinicaltrials.gov (NCT03358342).

Speech-language pathologists (SLPs) that care for patients with dysphagia are uniquely aware of the physiology of swallowing and how important eating is to patients and their family members. We liv...

Neonatal hemolytic jaundice is a risk factor for kernicterus. Pyruvate kinase (PK) deficiency is a rare cause of neonatal hemolytic jaundice, with a prevalence estimated at 1 case per 20,000 births in the United States, but with a higher prevalence among the Amish communities in Pennsylvania and Ohio. We discovered four neonates with PK deficiency born in a small community of polygamists. All four had early, severe, hemolytic jaundice. PK deficiency should be considered in neonates with early hemolytic, Coombs-negative, non-spherocytic jaundice, particularly in communities with considerable consanguinity. Such cases should be recognized early and managed aggressively to prevent kernicterus.

The authors present a case study of a successful collaborative effort to reduce student malingering in a school-based health center and to address the academic and social problems related to overuse of center services. School-based health centers have been identified as important sources of support for teenagers who have emotional and psychological problems, and, in this case, the overuse of a school-based health center is linked to such challenges for a substantial subset of students. It demonstrates that it is possible to identify, based on their status as frequent center users, students with potentially serious academic, family, or personal problems who are at risk for academic failure. The case involves multiple professionals, from a variety of disciplines, who dealt successfully with the problems associated with overuse of center services.

Rapid changes due to healthcare reform have impacted the patient care setting, demanding that care is provided in an efficient manner--a team working in harmony to meet patient care needs. However, inappropriate behavior at the work site continues to rob healthcare providers of valuable time as they stop to regroup from its effects on staff and organizations. A search in the Dixie Regional Medical Center in St. George, Utah, to solve this age-old dilemma led to the formation of a policy to guide staff members in a positive direction when resolving conflict issues. This article addresses these efforts.

Materiel-intensive expenditures account for a significant portion of all hospital costs, second only to salaries and wages, yet materiel managers may often be overlooked as key members of the management team. This is alarming since the potential exists for materiel managers to impact annual savings of hundreds of thousands of dollars by operating efficient departments. Materiel managers have a tremendous opportunity to enhance their image and improve hospital productivity in the coming decade. The challenges of the 1990s will stretch materiel managers' skills toward enhancing their professionalism and achieving the expectations of themselves and top management. If materiel managers will effectively utilize (C3)PO they will increase their educational levels, continue to learn new skills, maintain a customer-oriented management style, exercise creativity, develop and adhere to standards, and be proactive in their responsibilities. The benefits of their success will be felt by patients, hospitals, the industry, and materiel managers everywhere.