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* Context.--Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) is a rare and lethal tumor, characterized by hypercalcemia and early onset and associated with germline and somatic SMARCA4 variants. Objective.--To identify all known cases of SCCOHT in the Slovenian population from 1991 to 2021 and present genetic testing results, histopathologic findings, and clinical data for these patients. We also estimate the incidence of SCCOHT. Design.--We conducted a retrospective analysis of hospital medical records and data from the Slovenian Cancer Registry in order to identify cases of SCCOHT and obtain relevant clinical data. Histopathologic review of tumor samples with assessment of immunohistochemical staining for SMARCA4/BRG1 was undertaken to confirm the diagnosis of SCCOHT. Germline and somatic genetic analyses were performed using targeted next-generation sequencing. Results.--Between 1991 and 2021, we identified 7 cases of SCCOHT in a population of 2 million. Genetic causes were determined in all cases. Two novel germline loss-of-function variants in SMARCA4 LRG_878t1:c.1423_1429delTACCTCA p.(Tyr475Ilefs*24) and LRG_878t1: c.3216-1G>T were identified. At diagnosis, patients were ages 21 to 41 and had International Federation of Gynecology and Obstetrics, or FIGO, stage IA-III disease. Outcomes were poor, with 6 of 7 patients dying of disease-related complications within 27 months from diagnosis. One patient had stable disease for 12 months while receiving immunotherapy. Conclusions.--We present genetic, histopathologic, and clinical characteristics for all cases of SCCOHT identified in the Slovenian population during a 30-year period. We report 2 novel germline SMARCA4 variants, possibly associated with high penetrance. We estimate the minimal incidence of SCCOHT to be 0.12 per 1 million per year., Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT) is a very rare and devastatingly lethal tumor, first defined by Scully (1) in 1979 and described in more detail by [...]

Purpose Remimazolam, a newly synthesized ultrashort-acting benzodiazepine, has not been previously compared with sevoflurane with regard to postoperative nausea and vomiting (PONV). The aim of this study is to investigate the incidence of PONV between remimazolam and sevoflurane among patients undergoing artificial joint replacement surgery. Methods We conducted a retrospective analysis of the electronic medical records of patients who underwent artificial joint replacement surgery at Kobe City Medical Center General Hospital from 2020 to 2022, with a focus on comparing the incidence of PONV among those who received sevoflurane versus remimazolam anesthesia. To control for confounding factors, we employed a propensity score-matching technique to pair patients who received sevoflurane anesthesia with those who received remimazolam anesthesia. Results The records of 292 patients receiving general anesthesia for artificial joint replacement surgery were collected and categorized into group sevoflurane (n = 241) or group remimazolam (n = 51). Before propensity score matching, age and ASA-PS exhibited significant differences between two groups. There was no significant difference in the incidence of PONV between them (p = 0.461). After matching, there were 51 patients in each group. However, there is no significant difference in the incidence of PONV between the two matched cohorts (p = 0.243). Conclusions This study demonstrated that there was no difference in the prevalence of PONV between remimazolam and sevoflurane anesthesia in patients undergoing artificial joint replacement surgery., Author(s): Kazuma Yunoki [sup.1], Hiroyuki Mima [sup.1] Author Affiliations: (1) https://ror.org/04j4nak57, grid.410843.a, 0000 0004 0466 8016, The Department of Anesthesiology and Critical Care, Kobe City Medical Center General Hospital, , [...]

Background Postoperative nausea and vomiting (PONV) is a common and unpleasant complication of general anesthesia. There are well-known risk factors that predispose a patient to develop PONV. While studies exist that explore PONV incidence in gravid and non-gravid women separately, limited studies exist to compare the two cohorts to identify if pregnancy is associated with increased risk for PONV or differences in PONV prophylaxis and treatment. Methods This is a retrospective case-control cohort study, with 1:2 matching based on age, year of surgery, and surgical procedure. Electronic medical records were abstracted for demographic information, predisposing risk factors, prophylactic antiemetics, PONV documentation, rescue antiemetics, PACU stay, and length of hospitalization. Analyses of risk factors for PONV were performed using logistic and multinomial logistic regression analyses. Results 237 gravid women who underwent non-obstetric procedures with general anesthesia were identified and matched with 474 non-gravid women. PONV complicated the course of 51 (21.5%) gravid and 72 (15.2%) non-gravid women. The number of prophylactic antiemetics was fewer among gravid (median 2 [1, 2]) than non-gravid (3 [2, 3]) women (P < 0.001). No association was found between gravid status and risk for PONV (adjusted odds ratio 1.35 [95%CI 0.84, 2.17], P = 0.222). Gravid women had longer hospital lengths of stay (P < 0.001), despite having shorter surgical duration (P = 0.015). Conclusions The risk for PONV is similar between gravid and similarly aged women. However, anesthesiologists administer fewer prophylactic antiemetics to gravid women during non-obstetric surgery., Author(s): A. Deljou [sup.1], A. Kanaparthi [sup.1], J. Soleimani [sup.1], J. Sprung [sup.1], D. R. Schroeder [sup.2], T. N. Weingarten [sup.1], A. N. Chalupka [sup.1] Author Affiliations: (1) https://ror.org/02qp3tb03, grid.66875.3a, [...]

Clinical workflows that prioritize repetitive patient intake screening to meet performance metrics may have unintended consequences. This retrospective analysis of electronic health record data from 24 Federally Qualified Health Centers assessed effectiveness and accuracy of the 2-item Patient Health Questionnaire (PHQ-2) for depression screening and Generalized Anxiety Disorder 2 (GAD-2) for anxiety screening from 2019 to 2021. Scores of over 91% of PHQ-2 and GAD-2 tests indicated low likelihood of depression or anxiety, which diverged markedly from published literature on screening outcomes. Visit-based screenings linked to performance metrics may not be delivering the intended value in a real-world setting and risk distracting clinical effort from other high value activities. Key words: performance measures; health care quality; administrative burden; practice-based research; PHQ-9; quality improvement; physician burnout, INTRODUCTION Primary care visits often start with a myriad of standardized intake screening questions that are tied to performance metrics and incorporated into electronic health records (EHRs). Prioritizing repetition of [...]

* Context.--Machine learning (ML) allows for the analysis of massive quantities of high-dimensional clinical laboratory data, thereby revealing complex patterns and trends. Thus, ML can potentially improve the efficiency of clinical data interpretation and the practice of laboratory medicine. However, the risks of generating biased or unrepresentative models, which can lead to misleading clinical conclusions or overestimation of the model performance, should be recognized. Objectives.--To discuss the major components for creating ML models, including data collection, data preprocessing, model development, and model evaluation. We also highlight many of the challenges and pitfalls in developing ML models, which could result in misleading clinical impressions or inaccurate model performance, and provide suggestions and guidance on how to circumvent these challenges. Data Sources.--The references for this review were identified through searches of the PubMed database, US Food and Drug Administration white papers and guidelines, conference abstracts, and online preprints. Conclusions.--With the growing interest in developing and implementing ML models in clinical practice, laboratorians and clinicians need to be educated in order to collect sufficiently large and high-quality data, properly report the data set characteristics, and combine data from multiple institutions with proper normalization. They will also need to assess the reasons for missing values, determine the inclusion or exclusion of outliers, and evaluate the completeness of a data set. In addition, they require the necessary knowledge to select a suitable ML model for a specific clinical question and accurately evaluate the performance of the ML model, based on objective criteria. Domain-specific knowledge is critical in the entire workflow of developing ML models. (Arch Pathol Lab Med. 2023;147:826-836; doi: 10.5858/ arpa.2021-0635-RA), Machine learning (ML) (1) has emerged as a powerful tool for analyzing and interpreting laboratory test results as well as integrating clinical findings with laboratory data. (2) In recent years, [...]

Purpose Postoperative delirium (POD) occurs commonly in older adults, resulting in unfavorable outcomes. Several recent clinical studies have suggested that 5-hydroxytryptamine 3 (5-HT.sub.3) receptor antagonists can treat and prevent POD. In this retrospective study, the association between 5-HT.sub.3 receptor antagonists and POD was investigated in older adults who underwent hip fracture surgery. Methods The electronic medical records of older adults aged [greater than or equal to] 65 years who underwent hip fracture surgery between January 2011 and June 2018 were reviewed retrospectively. Multivariable logistic regression analysis was used to investigate the association between 5-HT.sub.3 receptor antagonists and the occurrence of POD. In addition to the incidence of POD, anesthesia-, surgery-, and patient-related factors related to POD were evaluated. Results Of the 1025 patients included, 813 (79.3%) were administered 5-HT.sub.3 receptor antagonists intraoperatively; 471 (45.9%) were administered ramosetron, and 342 (33.4%) were administered palonosetron. POD was identified in 242 patients (23.6%). Ramosetron and palonosetron reduced the POD incidence by 53% (odds ratio [OR] 0.47; 95% confidence interval [CI] 0.32â0.71; P < 0.001) and 41% (OR 0.59; 95% CI 0.39â0.89; P = 0.011), respectively. Additionally, age, American Society of Anesthesiologists physical status class 4, and male were confirmed as risk factors for POD. Conclusion Intraoperative 5-HT.sub.3 receptor antagonists may be associated with a reduced risk of POD and can be considered one of the preventive strategies for POD in older adults undergoing hip fracture surgery., Author(s): Hyun-Jung Shin [sup.1] [sup.2], Ji In Park [sup.1], Sohyun Lee [sup.1], Jung-Won Hwang [sup.1] [sup.2], Hyo-Seok Na [sup.1] [sup.2] Author Affiliations: (1) grid.412480.b, 0000 0004 0647 3378, Department of [...]

Purpose A high daily census may hinder the ability of physicians to deliver quality care in the intensive care unit (ICU). We sought to determine the relationship between intensivist-to-patient ratios and mortality among ICU patients. Methods We performed a retrospective cohort study of intensivist-to-patient ratios in 29 ICUs in 10 hospitals in the United States from 2018 to 2020. We used meta-data from progress notes in the electronic health record to determine an intensivist-specific caseload for each ICU day. We then fit a multivariable proportional hazards model with time-varying covariates to estimate the relationship between the daily intensivist-to-patient ratio and ICU mortality at 28 days. Results The final analysis included 51,656 patients, 210,698 patient days, and 248 intensivist physicians. The average caseload per day was 11.8 (standard deviation: 5.7). There was no association between the intensivist-to-patient ratio and mortality (hazard ratio for each additional patient: 0.987, 95% confidence interval: 0.968-1.007, p = 0.2). This relationship persisted when we defined the ratio as caseload over the sample-wide average (hazard ratio: 0.907, 95% confidence interval: 0.763-1.077, p = 0.26) and cumulative days with a caseload over the sample-wide average (hazard ratio: 0.991, 95% confidence interval: 0.966-1.018, p = 0.52). The relationship was not modified by the presence of physicians-in-training, nurse practitioners, and physician assistants (p value for interaction term: 0.14). Conclusions Mortality for ICU patients appears resistant to high intensivist caseloads. These results may not generalize to ICUs organized differently than those in this sample, such as ICUs outside the United States., Author(s): Jeremy M. Kahn [sup.1] [sup.2], Jonathan G. Yabes [sup.3] [sup.4], Leigh A. Bukowski [sup.1], Billie S. Davis [sup.1] Author Affiliations: (1) grid.21925.3d, 0000 0004 1936 9000, CRISMA Center, Department [...]

Objective The objectives of this project were to (1) describe maternal-centric measures and survey data which are publicly available to evaluate the incidence, frequency, and distribution of maternal morbidity in the postpartum period, and (2) to identify postpartum care quality improvement targets and outline the types of measurement and data required to support them. Methods We conducted a scoping review of two types of data sources: maternal health quality measures used by providers and payers and nationally-representative survey data sets administered by federal agencies. Each source was searched for keywords associated with pregnancy and the postpartum period. We included quality measures and survey questions that are maternal-centric and addressed the postpartum period. We excluded infant-centric measures and data. Quality measures were organized according to the Donabedian quality model. Results Our analysis demonstrates that existing maternal-centric quality measures and survey data offer limited insight into diagnosis and patient care delivery experiences associated with maternal morbidities during the postpartum period. Conclusion There is inadequate maternal-centric data on the incidence, frequency, and distribution of postpartum maternal morbidities and associated care use. This gap reduces the ability of research to estimate the incidence of illness and injury among postpartum women and create targeted quality improvement efforts. Our findings highlight the need for quality measure stewards and data sponsors to enhance data collection and methods to become more inclusive of maternal-centric outcomes during the postpartum period., Author(s): Jessica Holzer [sup.1] [sup.2] , Gabrielle Fiedler [sup.1] , Shilpa Londhe [sup.2] [sup.3] Author Affiliations: (1) grid.266831.8, 0000 0001 2168 8754, School of Health Sciences, Department of Population Health [...]

The SPARK cohort was established to facilitate recruitment in studies of large numbers of participants with autism spectrum disorder (ASD). Online registration requires participants to have received a lifetime professional diagnosis by health or school providers although diagnoses are not independently verified. This study was set to examine the validity of self- and caregiver-reported autism diagnoses. Electronic medical records (EMR) of 254 SPARK participants (77.6% male, age 10.7 years) were abstracted. Using two different methods, confirmation of ASD diagnosis in EMRs was obtained in 98.8% of cases. Core clinical features recorded in EMRs were typical of autism samples and showed very good agreement with SPARK cohort data, providing further evidence of the validity of clinical information in the SPARK database., Author(s): Eric Fombonne [sup.1] [sup.2] , Leigh Coppola [sup.1] , Sarah Mastel [sup.1] , Brian J. O'Roak [sup.3] Author Affiliations: (1) grid.5288.7, 0000 0000 9758 5690, Department of Psychiatry, Oregon [...]

Introduction: Integrating behavioral health (BH) and primary care is an important strategy to improve health behaviors, mental health, and substance misuse, particularly at community health centers (CHCs) where disease burden is high and access to mental health services is low. Components of different integrated BH models are often combined in practice. It is unknown which components distinguish developing versus established integrated BH programs. Method: A survey was mailed to 128 CHCs in 10 Midwestern states in 2016. Generalized estimating equation models were used to assess associations between program characteristics and stage of integration implementation (precontemplation, contemplation, preparation, action, or maintenance). Content analysis of open-ended responses identified integration barriers. Results: Response rate was 60% (N = 77). Most CHCs had colocated BH and primary care services, warm hand-offs from primary care to BH clinicians, shared scheduling and electronic health record (EHR) systems, and depression and substance use disorder screening. Thirty-two CHCs (42%) indicated they had completed integration and were focused on quality improvement (maintenance). Being in the maintenance stage was associated with having a psychologist on staff (odds ratio [OR] = 7.16, 95% confidence interval [CI] [2.76, 18.55]), a system for tracking referrals (OR = 3.42, 95% CI [1.03, 11.36]), a registry (OR = 2.71, 95% CI [1.86, 3.94]), PCMH designation (OR = 2.82, 95% CI [1.48, 5.37]), and a lower proportion of Black/African American patients (OR = .82, 95% CI [.75, .89]). The most common barriers to integration were difficulty recruiting and retaining BH clinicians and inadequate reimbursement. Discussion: CHCs have implemented many foundational components of integrated BH. Future work should address barriers to integration and racial disparities in access to integrated BH. Keywords: behavioral health, primary care, integration, health centers, Nearly one in five adults in the United States experiences a mental health or substance use disorder each year (National Institute of Mental Health, 2019). An important strategy to address [...]