Publications by authors named "Hardeep Singh"

345 Publications

Intramolecular H-bond stabilization of a primary hydroxylamine in salen-type metal complexes.

Chem Commun (Camb) 2021 Sep 21. Epub 2021 Sep 21.

Department of Chemistry and Biochemistry, Concordia University, Montreal, QC, Canada.

Primary hydroxylamines, RNHOH, decompose readily in the presence of transition metal ions. We show that this reactivity can be arrested by ligand design an intramolecular hydrogen bond. Six metal complexes with an intact NHOH group were synthesized and crystallographically characterized. The Cu-hydroxylamine complexes can catalyze the aerobic oxidation of benzylic alcohols.
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http://dx.doi.org/10.1039/d1cc03077aDOI Listing
September 2021

Diagnosis Documentation of Critically Ill Children at Admission to a PICU.

Pediatr Crit Care Med 2021 Aug 23. Epub 2021 Aug 23.

University of Iowa Carver College of Medicine, Iowa City, IA. Department of Pediatrics, BronxCare Health System, New York, NY. Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA. Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA. Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX. Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA. Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA.

Objectives: Multidisciplinary PICU teams must effectively share information while caring for critically ill children. Clinical documentation helps clinicians develop a shared understanding of the patient's diagnosis, which informs decision-making. However, diagnosis-related documentation in the PICU is understudied, thus limiting insights into how pediatric intensivists convey their diagnostic reasoning. Our objective was to describe how pediatric critical care clinicians document patients' diagnoses at PICU admission.

Design: Retrospective mixed methods study describing diagnosis documentation in electronic health records.

Setting: Academic tertiary referral PICU.

Patients: Children 0-17 years old admitted nonelectively to a single PICU over 1 year.

Interventions: None.

Measurements And Main Results: One hundred PICU admission notes for 96 unique patients were reviewed. In 87% of notes, both attending physicians and residents or advanced practice providers documented a primary diagnosis; in 13%, primary diagnoses were documented by residents or advanced practice providers alone. Most diagnoses (72%) were written as narrative free text, 11% were documented as problem lists/billing codes, and 17% used both formats. At least one rationale was documented to justify the primary diagnosis in 91% of notes. Diagnostic uncertainty was present in 52% of notes, most commonly suggested by clinicians' use of words indicating uncertainty (65%) and documentation of differential diagnoses (60%). Clinicians' integration and interpretation of information varied in terms of: 1) organization of diagnosis narratives, 2) use of contextual details to clarify the diagnosis, and 3) expression of diagnostic uncertainty.

Conclusions: In this descriptive study, most PICU admission notes documented a rationale for the primary diagnosis and expressed diagnostic uncertainty. Clinicians varied widely in how they organized diagnostic information, used contextual details to clarify the diagnosis, and expressed uncertainty. Future work is needed to determine how diagnosis narratives affect clinical decision-making, patient care, and outcomes.
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http://dx.doi.org/10.1097/PCC.0000000000002812DOI Listing
August 2021

Policies to Promote Shared Responsibility for Safer Electronic Health Records.

JAMA 2021 Sep 10. Epub 2021 Sep 10.

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, and Baylor College of Medicine, Houston, Texas.

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http://dx.doi.org/10.1001/jama.2021.13945DOI Listing
September 2021

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.

BMJ Qual Saf 2021 Aug 20. Epub 2021 Aug 20.

Medicine, University of Minnesota Medical School, Minneapolis, MN, USA

Background: Errors in reasoning are a common cause of diagnostic error. However, it is difficult to improve performance partly because providers receive little feedback on diagnostic performance. Examining means of providing consistent feedback and enabling continuous improvement may provide novel insights for diagnostic performance.

Methods: We developed a model for improving diagnostic performance through feedback using a six-step qualitative research process, including a review of existing models from within and outside of medicine, a survey, semistructured interviews with individuals working in and outside of medicine, the development of the new model, an interdisciplinary consensus meeting, and a refinement of the model.

Results: We applied theory and knowledge from other fields to help us conceptualise learning and comparison and translate that knowledge into an applied diagnostic context. This helped us develop a model, the Diagnosis Learning Cycle, which illustrates the need for clinicians to be given feedback about both their confidence and reasoning in a diagnosis and to be able to seamlessly compare diagnostic hypotheses and outcomes. This information would be stored in a repository to allow accessibility. Such a process would standardise diagnostic feedback and help providers learn from their practice and improve diagnostic performance. This model adds to existing models in diagnosis by including a detailed picture of diagnostic reasoning and the elements required to improve outcomes and calibration.

Conclusion: A consistent, standard programme of feedback that includes representations of clinicians' confidence and reasoning is a common element in non-medical fields that could be applied to medicine. Adapting this approach to diagnosis in healthcare is a promising next step. This information must be stored reliably and accessed consistently. The next steps include testing the Diagnosis Learning Cycle in clinical settings.
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http://dx.doi.org/10.1136/bmjqs-2020-012456DOI Listing
August 2021

Prevalence of coronary calcium deposits in Sheehan's syndrome patients on long term replacement treatment.

Pituitary 2021 Jul 30. Epub 2021 Jul 30.

Department of Internal Medicine and Endocrinology, Government Medical College, Srinagar, Jammu and Kashmir, India.

Purpose: Sheehan's Syndrome (SS) is one of the most important causes of hypopituitarism in developing countries with patients having varying degrees and severity of anterior pituitary hormone deficiency including growth hormone deficiency (GHD). SS is characterized by increased clustering of metabolic and proinflammatory risk factors predisposing them to increased cardiovascular morbidity and mortality. Coronary calcium deposits (CCD), a marker for significant coronary atherosclerosis, is used for evaluation in asymptomatic individuals of global cardiac risk to develop events related to coronary heart disease (CHD). This study therefore aimed to evaluate the prevalence of coronary artery disease in patients with SS appropriately replaced for pituitary hormone deficiencies but untreated for GHD.

Methods: Thirty patients previously diagnosed with SS and stable on a conventional replacement treatment for at least 6 months before the study and thirty age and Body Mass Index (BMI) matched controls were enrolled in this observational study. The subjects underwent detailed clinical, biochemical, and hormone analysis. Coronary multidetector computed tomography was performed in 19 SS patients and 19 healthy participants by a 16-row multislice scanner. Non contrast acquisitions were performed to detect coronary calcifications. Calcium was quantified by the Agatston score (AS) in all subjects. AS > 10 indicates increased CHD risk.

Results: The mean (± SD) age was 38.30 ± 10.73 years and the diagnostic delay was 11.35 ± 4.74 years. Patients with SS had significantly higher mean triglyceride, total cholesterol, and low density lipoprotein (LDL) cholesterol and lower HDL cholesterol concentrations on conventional replacement therapy. The prevalence of CCD was significantly higher in patients of SS compared to controls (42.1% vs. 5.3%; P = 0.023). The presence of CCD and AS > 10 were detected in 42.1% and 31.6% of patients respectively. The presence of significant calcification (Agatston score > 10) was documented in 75% of patients (6/8) of the SS patients with CCD compared to none in the control group (P = 0.019). (Left anteriordescending, 1; left circumflex, 2; right coronary artery, 2 and posterior descending, 1) CONCLUSION: Since coronary artery calcium is an independent predictor of CHD events, the presence of significant prevalence of CCD in patients with SS compared to healthy matched controls, undermines the importance of early risk stratification of SS individuals with plethora of conventional cardiovascular risk factors that are at relatively high risk to avoid the adverse vascular consequences.
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http://dx.doi.org/10.1007/s11102-021-01174-zDOI Listing
July 2021

Patient and clinician experiences of uncertainty in the diagnostic process: Current understanding and future directions.

Patient Educ Couns 2021 Jul 15. Epub 2021 Jul 15.

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA. Electronic address:

Objective: Uncertainty occurs throughout the diagnostic process and must be managed to facilitate accurate and timely diagnoses and treatments. Better characterization of uncertainty can inform strategies to manage it more effectively in clinical practice. We provide a comprehensive overview of current literature on diagnosis-related uncertainty describing (1) where patients and clinicians experience uncertainty within the diagnostic process, (2) how uncertainty affects the diagnostic process, (3) roots of uncertainty related to probability/risk, ambiguity, or complexity, and (4) strategies to manage uncertainty.

Discussion: Each diagnostic process step involves uncertainty, including patient engagement with the healthcare system; information gathering, interpretation, and integration; formulating working diagnoses; and communicating diagnoses to patients. General management strategies include acknowledging uncertainty, obtaining more contextual information from patients (e.g., gathering occupations and family histories), creating diagnostic safety nets (e.g., informing patients what red flags to look for), engaging in worst case/best case scenario planning, and communicating diagnostic uncertainty to patients, families, and colleagues. Potential strategies tailored to various aspects of diagnostic uncertainty are also outlined.

Conclusion: Scientific knowledge on diagnostic uncertainty, while previously elusive, is now becoming more clearly defined. Next steps include research to evaluate relationships between management and communication of diagnostic uncertainty and improved patient outcomes.
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http://dx.doi.org/10.1016/j.pec.2021.07.028DOI Listing
July 2021

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.

J Am Med Inform Assoc 2021 Sep;28(10):2202-2211

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA.

Objective: Diagnostic errors are major contributors to preventable patient harm. We validated the use of an electronic health record (EHR)-based trigger (e-trigger) to measure missed opportunities in stroke diagnosis in emergency departments (EDs).

Methods: Using two frameworks, the Safer Dx Trigger Tools Framework and the Symptom-disease Pair Analysis of Diagnostic Error Framework, we applied a symptom-disease pair-based e-trigger to identify patients hospitalized for stroke who, in the preceding 30 days, were discharged from the ED with benign headache or dizziness diagnoses. The algorithm was applied to Veteran Affairs National Corporate Data Warehouse on patients seen between 1/1/2016 and 12/31/2017. Trained reviewers evaluated medical records for presence/absence of missed opportunities in stroke diagnosis and stroke-related red-flags, risk factors, neurological examination, and clinical interventions. Reviewers also estimated quality of clinical documentation at the index ED visit.

Results: We applied the e-trigger to 7,752,326 unique patients and identified 46,931 stroke-related admissions, of which 398 records were flagged as trigger-positive and reviewed. Of these, 124 had missed opportunities (positive predictive value for "missed" = 31.2%), 93 (23.4%) had no missed opportunity (non-missed), 162 (40.7%) were miscoded, and 19 (4.7%) were inconclusive. Reviewer agreement was high (87.3%, Cohen's kappa = 0.81). Compared to the non-missed group, the missed group had more stroke risk factors (mean 3.2 vs 2.6), red flags (mean 0.5 vs 0.2), and a higher rate of inadequate documentation (66.9% vs 28.0%).

Conclusion: In a large national EHR repository, a symptom-disease pair-based e-trigger identified missed diagnoses of stroke with a modest positive predictive value, underscoring the need for chart review validation procedures to identify diagnostic errors in large data sets.
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http://dx.doi.org/10.1093/jamia/ocab121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8449630PMC
September 2021

Synthesising evidence regarding hospital to home transitions supported by volunteers of third sector organisations: a scoping review protocol.

BMJ Open 2021 07 5;11(7):e050479. Epub 2021 Jul 5.

Global Health Institute, Duke University, Durham, North Carolina, USA.

Introduction: Given the risks inherent in care transitions, it is imperative that patients discharged from hospital to home receive the integrated care services necessary to ensure a successful transition. Despite efforts by the healthcare sector to develop health system solutions to improve transitions, problems persist. Research on transitional support has predominantly focused on services delivered by healthcare professionals; the evidence for services provided by lay navigators or volunteers in this context has not been synthesised. This scoping review will map the available literature on the engagement of volunteers within third sector organisations supporting adults in the transition from hospital to home.

Methods And Analysis: Using the well-established scoping review methodology outlined by the Joanna Briggs Institute, a five-stage review is outlined: (1) determining the research question, (2) search strategy, (3) inclusion criteria, (4) data extraction and (5) analysis and presentation of the results. The search strategy will be applied to 10 databases reflecting empirical and grey literature. A two-stage screening process will be used to determine eligibility of articles. To be included in the review, articles must describe a community-based programme delivered by a third sector organisation that engages volunteers in the provisions of services that support adults transitioning from hospital to home. All articles will be independently assessed for eligibility, and data from eligible articles will be extracted and charted using a standardised form. Extracted data will be analysed using narrative and descriptive analyses.

Ethics And Dissemination: Ethics approval is not required for this scoping review. Members of an international special interest group focused on the voluntary sector will be consulted to provide insight and feedback on study findings, help with dissemination of the results and engage in the development of future research proposals. Dissemination activities will include peer-reviewed publications and academic presentations.
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http://dx.doi.org/10.1136/bmjopen-2021-050479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258550PMC
July 2021

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices.

BMJ Qual Saf 2021 Jun 14. Epub 2021 Jun 14.

NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK

Background: Diagnostic error is a global patient safety priority.

Objectives: To estimate the incidence, origins and avoidable harm of diagnostic errors in English general practice. Diagnostic errors were defined as missed opportunities to make a correct or timely diagnosis based on the evidence available (missed diagnostic opportunities, MDOs).

Method: Retrospective medical record reviews identified MDOs in 21 general practices. In each practice, two trained general practitioner reviewers independently conducted case note reviews on 100 randomly selected adult consultations performed during 2013-2014. Consultations where either reviewer identified an MDO were jointly reviewed.

Results: Across 2057 unique consultations, reviewers agreed that an MDO was possible, likely or certain in 89 cases or 4.3% (95% CI 3.6% to 5.2%) of reviewed consultations. Inter-reviewer agreement was higher than most comparable studies (Fleiss' kappa=0.63). Sixty-four MDOs (72%) had two or more contributing process breakdowns. Breakdowns involved problems in the patient-practitioner encounter such as history taking, examination or ordering tests (main or secondary factor in 61 (68%) cases), performance and interpretation of diagnostic tests (31; 35%) and follow-up and tracking of diagnostic information (43; 48%). 37% of MDOs were rated as resulting in moderate to severe avoidable patient harm.

Conclusions: Although MDOs occurred in fewer than 5% of the investigated consultations, the high numbers of primary care contacts nationally suggest that several million patients are potentially at risk of avoidable harm from MDOs each year. Causes of MDOs were frequently multifactorial, suggesting the need for development and evaluation of multipronged interventions, along with policy changes to support them.
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http://dx.doi.org/10.1136/bmjqs-2020-012594DOI Listing
June 2021

Monitoring Diagnostic Safety Risks in Emergency Departments: Protocol for a Machine Learning Study.

JMIR Res Protoc 2021 Jun 14;10(6):e24642. Epub 2021 Jun 14.

Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States.

Background: Diagnostic decision making, especially in emergency departments, is a highly complex cognitive process that involves uncertainty and susceptibility to errors. A combination of factors, including patient factors (eg, history, behaviors, complexity, and comorbidity), provider-care team factors (eg, cognitive load and information gathering and synthesis), and system factors (eg, health information technology, crowding, shift-based work, and interruptions) may contribute to diagnostic errors. Using electronic triggers to identify records of patients with certain patterns of care, such as escalation of care, has been useful to screen for diagnostic errors. Once errors are identified, sophisticated data analytics and machine learning techniques can be applied to existing electronic health record (EHR) data sets to shed light on potential risk factors influencing diagnostic decision making.

Objective: This study aims to identify variables associated with diagnostic errors in emergency departments using large-scale EHR data and machine learning techniques.

Methods: This study plans to use trigger algorithms within EHR data repositories to generate a large data set of records that are labeled trigger-positive or trigger-negative, depending on whether they meet certain criteria. Samples from both data sets will be validated using medical record reviews, upon which we expect to find a higher number of diagnostic safety events in the trigger-positive subset. Machine learning will be used to evaluate relationships between certain patient factors, provider-care team factors, and system-level risk factors and diagnostic safety signals in the statistically matched groups of trigger-positive and trigger-negative charts.

Results: This federally funded study was approved by the institutional review board of 2 academic medical centers with affiliated community hospitals. Trigger queries are being developed at both organizations, and sample cohorts will be labeled using the triggers. Machine learning techniques such as association rule mining, chi-square automated interaction detection, and classification and regression trees will be used to discover important variables that could be incorporated within future clinical decision support systems to help identify and reduce risks that contribute to diagnostic errors.

Conclusions: The use of large EHR data sets and machine learning to investigate risk factors (related to the patient, provider-care team, and system-level) in the diagnostic process may help create future mechanisms for monitoring diagnostic safety.

International Registered Report Identifier (irrid): DERR1-10.2196/24642.
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http://dx.doi.org/10.2196/24642DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240801PMC
June 2021

Electronic Health Records' Support for Primary Care Physicians' Situation Awareness: A Metanarrative Review.

Hum Factors 2021 May 25:187208211014300. Epub 2021 May 25.

20116 Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.

Objective: Situation awareness (SA) refers to people's perception and understanding of their dynamic environment. In primary care, reduced SA among physicians increases errors in clinical decision-making and, correspondingly, patients' risk of experiencing adverse outcomes. Our objective was to understand the extent to which electronic health records (EHRs) support primary care physicians (PCPs)' SA during clinical decision-making.

Method: We conducted a metanarrative review of papers in selected academic databases, including CINAHL and MEDLINE. Eligible studies included original peer-reviewed research published between January 2012 and August 2020 on PCP-EHR interactions. We iteratively queried, screened, and summarized literature focused on EHRs supporting PCPs' clinical decision-making and care management for adults. Then, we mapped findings to an established SA framework to classify external factors (individual, task, and system) affecting PCPs' levels of SA (1-Perception, 2-Comprehension, and 3-Projection) and identified SA barriers.

Results: From 1504 articles identified, we included and synthesized 19 studies. Study designs were largely noninterventional. Studies described EHR workflow misalignments, usability issues, and communication challenges. EHR information, including lab results and care plans, was characterized as incomplete, untimely, or irrelevant. Unmet information needs made it difficult for PCPs to obtain even basic SA, Level 1 SA. Prevalent barriers to PCPs developing SA with EHRs were errant mental models, attentional tunneling, and data overload.

Conclusion: Based on our review, EHRs do not support the development of higher levels of SA among PCPs. Review findings suggest SA-oriented design processes for health information technology could improve PCPs' SA, satisfaction, and decision-making.
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http://dx.doi.org/10.1177/00187208211014300DOI Listing
May 2021

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

BMJ Qual Saf 2021 Jul 6;30(7):591-597. Epub 2021 May 6.

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA.

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http://dx.doi.org/10.1136/bmjqs-2020-012464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237185PMC
July 2021

Why Test Results Are Still Getting "Lost" to Follow-up: a Qualitative Study of Implementation Gaps.

J Gen Intern Med 2021 Apr 27. Epub 2021 Apr 27.

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, 2002 Holcombe Boulevard 152, Houston, TX, 77030, USA.

Background: Lack of timely follow-up of abnormal test results is common and has been implicated in missed or delayed diagnosis, resulting in potential for patient harm.

Objective: As part of a larger project to implement change strategies to improve follow-up of diagnostic test results, this study sought to identify specifically where implementation gaps exist, as well as possible solutions identified by front-line staff.

Design: We used a semi-structured interview guide to collect qualitative data from Veterans Affairs (VA) facility staff who had experience with test results management and patient safety.

Setting: Twelve VA facilities across the USA.

Participants: Facility staff members (n = 27), including clinicians, lab and imaging professionals, nursing staff, patient safety professionals, and leadership.

Approach: We conducted a content analysis of interview transcripts to identify perceived barriers and high-risk areas for effective test result management, as well as recommendations for improvement.

Results: We identified seven themes to guide further development of interventions to improve test result follow-up. Themes related to trainees, incidental findings, tracking systems for electronic health record notifications, outdated contact information, referrals, backup or covering providers, and responsibility for test results pending at discharge. Participants provided recommendations for improvement within each theme.

Conclusions: Perceived barriers and recommendations for improving test result follow-up often reflected previously known problems and their corresponding solutions, which have not been consistently implemented in practice. Better policy solutions and improvement methods, such as quality improvement collaboratives, may bridge the implementation gaps between knowledge and practice.
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http://dx.doi.org/10.1007/s11606-021-06772-yDOI Listing
April 2021

Diagnostic Errors in Pediatric Critical Care: A Systematic Review.

Pediatr Crit Care Med 2021 08;22(8):701-712

Division of Pediatric Anesthesia and Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD.

Objectives: To summarize the literature on prevalence, impact, and contributing factors related to diagnostic error in the PICU.

Data Sources: Search of PubMed, EMBASE, and the Cochrane Library up to December 2019.

Study Selection: Studies on diagnostic error and the diagnostic process in pediatric critical care were included. Non-English studies with no translation, case reports/series, studies providing no information on diagnostic error, studies focused on non-PICU populations, and studies focused on a single condition/disease or a single diagnostic test/tool were excluded.

Data Extraction: Data on research design, objectives, study sample, and results pertaining to the prevalence, impact, and factors associated with diagnostic error were abstracted from each study.

Data Synthesis: Using independent tiered review, 396 abstracts were screened, and 17 studies (14 full-text, 3 abstracts) were ultimately included. Fifteen of 17 studies (88%) had an observational research design. Autopsy studies (autopsy rates were 20-47%) showed a 10-23% rate of missed major diagnoses; 5-16% of autopsy-discovered diagnostic errors had a potential adverse impact on survival and would have changed management. Retrospective record reviews reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions and 21-25% of patients discussed at PICU morbidity and mortality conferences. Cardiovascular, infectious, congenital, and neurologic conditions were most commonly misdiagnosed. Systems factors (40-67%), cognitive factors (20-3%), and both systems and cognitive factors (40%) were associated with diagnostic error. Limited information was available on the impact of misdiagnosis.

Conclusions: Knowledge of diagnostic errors in the PICU is limited. Future work to understand diagnostic errors should involve a balanced focus between studying the diagnosis of individual diseases and uncovering common system- and process-related determinants of diagnostic error.
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http://dx.doi.org/10.1097/PCC.0000000000002735DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373621PMC
August 2021

Therapists' perspectives on fall prevention in spinal cord injury rehabilitation: a qualitative study.

Disabil Rehabil 2021 Mar 31:1-10. Epub 2021 Mar 31.

KITE, Toronto Rehab-University Health Network, Toronto, Canada.

Purpose: Therapists play a key role in delivering fall prevention/management education to individuals with spinal cord injury/disease, yet their perspectives on this topic remain understudied. Here, we described the perspectives of physical and occupational therapists who routinely provided rehabilitation to patients with spinal cord injury/disease on: (1) how fall risk was assessed, (2) what fall prevention education, interventions or strategies were provided, and (3) opportunities to improve fall risk assessment and the delivery of fall prevention education, strategies and interventions.

Materials And Methods: Twenty-one therapists completed an individual interview or focus group that was analyzed using an inductive thematic analysis.

Results: Four main themes were identified: (1) policy and procedures impact practice (i.e., policy and procedures positively and negatively impact practice), (2) assessing and managing fall risk/falls in patients with spinal cord injury/disease (i.e., discipline-specific roles in fall risk assessments and fall management processes in rehabilitation), (3) fall prevention and management education (i.e., helicopter therapists and challenges with fall prevention and management education), (4) building insight into fall risk and management (e.g., building insight into fall risk for patients and therapists).

Conclusions: This study revealed opportunities to improve the delivery of fall prevention education and training to individuals with spinal cord injury/disease.IMPLICATIONS FOR REHABILITATIONFall prevention education should be initiated in spinal cord injury rehabilitation and then reinforced in community rehabilitation.Barriers and challenges faced by therapists when delivering fall prevention and management education/training in spinal cord injury rehabilitation include their perceptions of a patient's readiness to receive fall prevention education, short length of stay in rehabilitation, organization's expectations of zero falls and a lack of spinal cord injury-specific fall prevention resources.Therapists who work in spinal cord injury rehabilitation may benefit from information about fall risk factors encountered by individuals with spinal cord injury/disease in the community.
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http://dx.doi.org/10.1080/09638288.2021.1904013DOI Listing
March 2021

Artificial Intelligence Techniques That May Be Applied to Primary Care Data to Facilitate Earlier Diagnosis of Cancer: Systematic Review.

J Med Internet Res 2021 03 3;23(3):e23483. Epub 2021 Mar 3.

Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, United Kingdom.

Background: More than 17 million people worldwide, including 360,000 people in the United Kingdom, were diagnosed with cancer in 2018. Cancer prognosis and disease burden are highly dependent on the disease stage at diagnosis. Most people diagnosed with cancer first present in primary care settings, where improved assessment of the (often vague) presenting symptoms of cancer could lead to earlier detection and improved outcomes for patients. There is accumulating evidence that artificial intelligence (AI) can assist clinicians in making better clinical decisions in some areas of health care.

Objective: This study aimed to systematically review AI techniques that may facilitate earlier diagnosis of cancer and could be applied to primary care electronic health record (EHR) data. The quality of the evidence, the phase of development the AI techniques have reached, the gaps that exist in the evidence, and the potential for use in primary care were evaluated.

Methods: We searched MEDLINE, Embase, SCOPUS, and Web of Science databases from January 01, 2000, to June 11, 2019, and included all studies providing evidence for the accuracy or effectiveness of applying AI techniques for the early detection of cancer, which may be applicable to primary care EHRs. We included all study designs in all settings and languages. These searches were extended through a scoping review of AI-based commercial technologies. The main outcomes assessed were measures of diagnostic accuracy for cancer.

Results: We identified 10,456 studies; 16 studies met the inclusion criteria, representing the data of 3,862,910 patients. A total of 13 studies described the initial development and testing of AI algorithms, and 3 studies described the validation of an AI algorithm in independent data sets. One study was based on prospectively collected data; only 3 studies were based on primary care data. We found no data on implementation barriers or cost-effectiveness. Risk of bias assessment highlighted a wide range of study quality. The additional scoping review of commercial AI technologies identified 21 technologies, only 1 meeting our inclusion criteria. Meta-analysis was not undertaken because of the heterogeneity of AI modalities, data set characteristics, and outcome measures.

Conclusions: AI techniques have been applied to EHR-type data to facilitate early diagnosis of cancer, but their use in primary care settings is still at an early stage of maturity. Further evidence is needed on their performance using primary care data, implementation barriers, and cost-effectiveness before widespread adoption into routine primary care clinical practice can be recommended.
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http://dx.doi.org/10.2196/23483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970165PMC
March 2021

How digital health solutions align with the roles and functions that support hospital to home transitions for older adults: a rapid review study protocol.

BMJ Open 2021 02 25;11(2):e045596. Epub 2021 Feb 25.

Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada

Introduction: Older adults may experience challenges during the hospital to home transitions that could be mitigated by digital health solutions. However, to promote adoption in practice and realise benefits, there is a need to specify how digital health solutions contribute to hospital to home transitions, particularly pertinent in this era of social distancing. This rapid review will: (1) elucidate the various roles and functions that have been developed to support hospital to home transitions of care, (2) identify existing digital health solutions that support hospital to home transitions of care, (3) identify gaps and new opportunities where digital health solutions can support these roles and functions and (4) create recommendations that will inform the design and structure of future digital health interventions that support hospital to home transitions for older adults (eg, the pre-trial results of the Digital Bridge intervention; ClinicalTrials.gov Identifier: NCT04287192).

Methods And Analysis: A two-phase rapid review will be conducted to meet identified aims. In phase 1, a selective literature review will be used to generate a conceptual map of the roles and functions of individuals that support hospital to home transitions for older adults. In phase 2, a search on MEDLINE, EMBASE and CINAHL will identify literature on digital health solutions that support hospital to home transitions. The ways in which digital health solutions can support the roles and functions that facilitate these transitions will then be mapped in the analysis and generation of findings.

Ethics And Dissemination: This protocol is a review of the literature and does not involve human subjects, and therefore, does not require ethics approval. This review will permit the identification of gaps and new opportunities for digital processes and platforms that enable care transitions and can help inform the design and implementation of future digital health interventions. Review findings will be disseminated through publications and presentations to key stakeholders.
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http://dx.doi.org/10.1136/bmjopen-2020-045596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908914PMC
February 2021

Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.

BMJ Qual Saf 2021 Feb 17. Epub 2021 Feb 17.

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.

Background: Patient complaints are associated with adverse events and malpractice claims but underused in patient safety improvement.

Objective: To systematically evaluate the use of patient complaint data to identify safety concerns related to diagnosis as an initial step to using this information to facilitate learning and improvement.

Methods: We reviewed patient complaints submitted to Geisinger, a large healthcare organisation in the USA, from August to December 2017 (cohort 1) and January to June 2018 (cohort 2). We selected complaints more likely to be associated with diagnostic concerns in Geisinger's existing complaint taxonomy. Investigators reviewed all complaint summaries and identified cases as 'concerning' for diagnostic error using the National Academy of Medicine's definition of diagnostic error. For all 'concerning' cases, a clinician-reviewer evaluated the associated investigation report and the patient's medical record to identify any missed opportunities in making a correct or timely diagnosis. In cohort 2, we selected a 10% sample of 'concerning' cases to test this smaller pragmatic sample as a proof of concept for future organisational monitoring.

Results: In cohort 1, we reviewed 1865 complaint summaries and identified 177 (9.5%) concerning reports. Review and analysis identified 39 diagnostic errors. Most were categorised as 'Clinical Care issues' (27, 69.2%), defined as concerns/questions related to the care that is provided by clinicians in any setting. In cohort 2, we reviewed 2423 patient complaint summaries and identified 310 (12.8%) concerning reports. The 10% sample (n=31 cases) contained five diagnostic errors. Qualitative analysis of cohort 1 cases identified concerns about return visits for persistent and/or worsening symptoms, interpersonal issues and diagnostic testing.

Conclusions: Analysis of patient complaint data and corresponding medical record review identifies patterns of failures in the diagnostic process reported by patients and families. Health systems could systematically analyse available data on patient complaints to monitor diagnostic safety concerns and identify opportunities for learning and improvement.
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http://dx.doi.org/10.1136/bmjqs-2020-011593DOI Listing
February 2021

Advancing Diagnostic Safety Research: Results of a Systematic Research Priority Setting Exercise.

J Gen Intern Med 2021 Feb 9. Epub 2021 Feb 9.

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA.

Background: Diagnostic errors are a major source of preventable harm but the science of reducing them remains underdeveloped.

Objective: To identify and prioritize research questions to advance the field of diagnostic safety in the next 5 years.

Participants: Ninety-seven researchers and 42 stakeholders were involved in the identification of the research priorities.

Design: We used systematic prioritization methods based on the Child Health and Nutrition Research Initiative (CHNRI) methodology. We first invited a large international group of expert researchers in various disciplines to submit research questions while considering five prioritization criteria: (1) usefulness, (2) answerability, (3) effectiveness, (4) potential for translation, and (5) maximal potential for effect on diagnostic safety. After consolidation, these questions were prioritized at an in-person expert meeting in April 2019. Top-ranked questions were subsequently reprioritized through scoring on the five prioritization criteria using an online questionnaire. We also invited non-research stakeholders to assign weights to the five criteria and then used these weights to adjust the final prioritization score for each question.

Key Results: Of the 207 invited researchers, 97 researchers responded and 78 submitted 333 research questions which were then consolidated. Expert meeting participants (n = 21) discussed questions in different breakout sessions and prioritized 50, which were subsequently reduced to the top 20 using the online questionnaire. The top 20 questions addressed mostly system factors (e.g., implementation and evaluation of information technologies), teamwork factors (e.g., role of nurses and other health professionals in the diagnostic process), and strategies to engage patients in the diagnostic process.

Conclusions: Top research priorities for advancing diagnostic safety in the short-term include strengthening systems and teams and engaging patients to support diagnosis. High-priority areas identified using these systematic methods can inform an actionable research agenda for reducing preventable diagnostic harm.
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http://dx.doi.org/10.1007/s11606-020-06428-3DOI Listing
February 2021

Patient and Physician Perspectives of Deprescribing Potentially Inappropriate Medications in Older Adults with a History of Falls: a Qualitative Study.

J Gen Intern Med 2021 Jan 19. Epub 2021 Jan 19.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA.

Background: High-risk medications pose serious safety risks to older adults, including increasing the risk of falls. Deprescribing potentially inappropriate medications (PIMs) in older adults who have experienced a fall is a key element of fall reduction strategies. However, continued use of PIMs in older adults is common, and clinicians may face substantial deprescribing barriers.

Objective: Explore patient and clinician experiences with and perceptions of deprescribing PIMs in patients with a history of falls.

Design: We led guided patient feedback sessions to explore deprescribing scenarios with patient stakeholders and conducted semi-structured interviews with primary care physicians (PCPs) to explore knowledge and awareness of fall risk guidelines, deprescribing experiences, and barriers and facilitators to deprescribing.

Participants: PCPs from Kaiser Permanente Southern California (KPSC) and patient members of the KPSC Regional Patient Advisory Committee.

Approach: We used maximum variation sampling to identify PCPs with patients who had a fall, then categorized the resulting PIM dispense distribution for those patients into high and low frequency. We analyzed the data using a hybrid deductive-inductive approach. Coders applied initial deductively derived codes to the data, simultaneously using an open-code inductive approach to capture emergent themes.

Key Results: Physicians perceived deprescribing discussions as potentially contentious, even among patients with falls. Physicians reported varying comfort levels with deprescribing strategies: some felt that the conversations might be better suited to others (e.g., pharmacists), while others had well-planned negotiation strategies. Patients reported lack of clarity as to the reasons and goals of deprescribing and poor understanding of the seriousness of falls.

Conclusions: Our study suggests that key barriers to deprescribing include PCP trepidation about raising a contentious topic and insufficient patient awareness of the potential seriousness of falls. Findings suggest the need for multifaceted, multilevel deprescribing approaches with clinician training strategies, patient educational resources, and a focus on building trusting patient-clinician relationships.
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http://dx.doi.org/10.1007/s11606-020-06493-8DOI Listing
January 2021

Prolonged Diagnostic Intervals as Marker of Missed Diagnostic Opportunities in Bladder and Kidney Cancer Patients with Alarm Features: A Longitudinal Linked Data Study.

Cancers (Basel) 2021 Jan 5;13(1). Epub 2021 Jan 5.

Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, London WC1E 6BT, UK.

Background: In England, patients who meet National Institute for Health and Care Excellence (NICE) guideline criteria for suspected cancer should receive a specialist assessment within 14 days. We examined how quickly bladder and kidney cancer patients who met fast-track referral criteria were actually diagnosed.

Methods: We used linked primary care and cancer registration data on bladder and kidney cancer patients who met fast-track referral criteria and examined the time from their first presentation with alarm features to diagnosis. Using logistic regression we examined factors most likely to be associated with non-timely diagnosis (defined as intervals exceeding 90 days), adjusting for age, sex and cancer type, positing that such occurrences represent missed opportunity for timely referral, possibly due to sub-optimal guideline adherence.

Results: 28%, 42% and 31% of all urological cancer patients reported no, one or two or more relevant symptoms respectively in the year before diagnosis. Of the 2105 patients with alarm features warranting fast-track assessment, 1373 (65%) presented with unexplained haematuria, 382 (18%) with recurrent urinary tract infections (UTIs), 303 (14%) with visible haematuria, and 45 (2%) with an abdominal mass. 27% overall, and 24%, 45%, 18% and 27% of each group respectively, had a non-timely diagnosis. Presentation with recurrent UTI was associated with longest median diagnostic interval (median 83 days, IQR 43-151) and visible haematuria with the shortest (median 50 days, IQR 30-79). After adjustment, presentation with recurrent UTIs, being in the youngest or oldest age group, female sex, and diagnosis of kidney and upper tract urothelial cancer, were associated with greater odds of non-timely diagnosis.

Conclusion: More than a quarter of patients presenting with fast-track referral features did not achieve a timely diagnosis, suggesting inadequate guideline adherence for some patients. The findings highlight a substantial number of opportunities for expediting the diagnosis of patients with bladder or kidney cancers.
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http://dx.doi.org/10.3390/cancers13010156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796444PMC
January 2021

Reciprocal Induction of MDM2 and MYCN in Neural and Neuroendocrine Cancers.

Front Oncol 2020 23;10:563156. Epub 2020 Dec 23.

The Vision Center, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA, United States.

MYC family oncoproteins MYC, MYCN, and MYCL are deregulated in diverse cancers and via diverse mechanisms. Recent studies established a novel form of MYCN regulation in MYCN-overexpressing retinoblastoma and neuroblastoma cells in which the MDM2 oncoprotein promotes MYCN translation and MYCN-dependent proliferation via a p53-independent mechanism. However, it is unclear if MDM2 also promotes expression of other MYC family members and has similar effects in other cancers. Conversely, MYCN has been shown to induce MDM2 expression in neuroblastoma cells, yet it is unclear if MYC shares this ability, if MYC family proteins upregulate MDM2 in other malignancies, and if this regulation occurs during tumorigenesis as well as in cancer cell lines. Here, we report that intrinsically high MDM2 expression is required for high-level expression of MYCN, but not for expression of MYC, in retinoblastoma, neuroblastoma, small cell lung cancer, and medulloblastoma cells. Conversely, ectopic overexpression of MYC as well as MYCN induced high-level MDM2 expression and gave rise to rapidly proliferating and MDM2-dependent cone-precursor-derived masses in a cultured retinoblastoma genesis model. These findings reveal a highly specific collaboration between the MDM2 and MYCN oncoproteins and demonstrate the origin of their oncogenic positive feedback circuit within a normal neuronal tissue.
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http://dx.doi.org/10.3389/fonc.2020.563156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793692PMC
December 2020

A Roadmap to Advance Patient Safety in Ambulatory Care.

JAMA 2020 12;324(24):2481-2482

Department of Industrial and Systems Engineering, Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison.

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http://dx.doi.org/10.1001/jama.2020.18551DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8016440PMC
December 2020

Building the evidence-base to reduce electronic health record-related clinician burden.

J Am Med Inform Assoc 2021 04;28(5):1057-1061

Division of Digital Healthcare Research, Agency for Healthcare Research and Quality, Rockville, Maryland, USA.

Clinicians face competing pressures of being clinically productive while using imperfect electronic health record (EHR) systems and maximizing face-to-face time with patients. EHR use is increasingly associated with clinician burnout and underscores the need for interventions to improve clinicians' experiences. With an aim of addressing this need, we share evidence-based informatics approaches, pragmatic next steps, and future research directions to improve 3 of the highest contributors to EHR burden: (1) documentation, (2) chart review, and (3) inbox tasks. These approaches leverage speech recognition technologies, natural language processing, artificial intelligence, and redesign of EHR workflow and user interfaces. We also offer a perspective on how EHR vendors, healthcare system leaders, and policymakers all play an integral role while sharing responsibility in helping make evidence-based sociotechnical solutions available and easy to use.
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http://dx.doi.org/10.1093/jamia/ocaa238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068419PMC
April 2021

Exploring the perspectives of outpatient rehabilitation clinicians on the challenges with monitoring patient health, function and activity in the community.

Disabil Rehabil 2020 Nov 30:1-10. Epub 2020 Nov 30.

KITE - Toronto Rehabilitation Institute - University Health Network, Toronto, Canada.

Purpose: Rehabilitation clinicians need information about patient activities in the home/community to inform care. Despite active efforts to develop technologies that can meet this need, clinicians' perspectives regarding how information is collected and used in outpatient rehabilitation have not been comprehensively described. Therefore, we aimed to describe: (1) what data pertaining to a patient's health, function and activity in their home/community are currently collected in outpatient rehabilitation, (2) how these data can impact clinical decisions, and (3) what challenges clinicians encounter when they manage the care of outpatients based on this information.

Materials And Methods: Eight clinicians working in outpatient rehabilitation programs completed qualitative interviews that were analyzed using an inductive thematic analysis.

Results: Four themes were identified: "Nature of data about a patient's health, function and activity in the home/community and how it is collected by clinicians," "Value of data from the home/community," "Perceived drawbacks of current data collection methods," and "Improving data collection to understand patient trajectory."

Conclusions: Clinicians described the importance of understanding patient activities in the home/community, but perspectives varied regarding the suitability of current methods. These perceptions may inform the design of solutions to bridge the gap between the clinic and the community in outpatient rehabilitation.Implications for rehabilitationClinical decision-making in outpatient rehabilitation is guided by verbal and written reports about a patient's health and function in the community and adherence to treatment plans.Differing perceptions on the suitability of current data collection methods indicate that the development of new solutions, such as rehabilitation technologies, needs to carefully consider clinician workflows and what data are perceived as meaningful.Potentially impactful directions for new solutions include providing well validated data on adherence, movement quality, or longitudinal progression, presented in formats that match clinical decision criteria.
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http://dx.doi.org/10.1080/09638288.2020.1849422DOI Listing
November 2020

Identifying trigger concepts to screen emergency department visits for diagnostic errors.

Diagnosis (Berl) 2021 08 13;8(3):340-346. Epub 2020 Nov 13.

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA.

Objectives: The diagnostic process is a vital component of safe and effective emergency department (ED) care. There are no standardized methods for identifying or reliably monitoring diagnostic errors in the ED, impeding efforts to enhance diagnostic safety. We sought to identify trigger concepts to screen ED records for diagnostic errors and describe how they can be used as a measurement strategy to identify and reduce preventable diagnostic harm.

Methods: We conducted a literature review and surveyed ED directors to compile a list of potential electronic health record (EHR) trigger (e-triggers) and non-EHR based concepts. We convened a multidisciplinary expert panel to build consensus on trigger concepts to identify and reduce preventable diagnostic harm in the ED.

Results: Six e-trigger and five non-EHR based concepts were selected by the expert panel. E-trigger concepts included: unscheduled ED return to ED resulting in hospital admission, death following ED visit, care escalation, high-risk conditions based on symptom-disease dyads, return visits with new diagnostic/therapeutic interventions, and change of treating service after admission. Non-EHR based signals included: cases from mortality/morbidity conferences, risk management/safety office referrals, ED medical director case referrals, patient complaints, and radiology/laboratory misreads and callbacks. The panel suggested further refinements to aid future research in defining diagnostic error epidemiology in ED settings.

Conclusions: We identified a set of e-trigger concepts and non-EHR based signals that could be developed further to screen ED visits for diagnostic safety events. With additional evaluation, trigger-based methods can be used as tools to monitor and improve ED diagnostic performance.
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http://dx.doi.org/10.1515/dx-2020-0122DOI Listing
August 2021

"Hybrid Reconstruction" for Zygomaticomaxillary Complex Defect Using CAD/CAM: A Case Report.

Plast Reconstr Surg Glob Open 2020 Sep 21;8(9):e3140. Epub 2020 Sep 21.

Department of Plastic, Aesthetic & Reconstructive Surgery, Medanta, The Medicity, Gurgaon, Haryana, India.

In this unique case report, we present a patient of left zygomatico maxillary complex reconstruction with a combination of autogenous tissue (osteocutaneous free fibula flap) and alloplastic implant [patient-specific templated polymethyl methacrylate (PMMA)]. In such large defects, reconstruction using either autogenous tissue or alloplastic implant alone is inadequate and leads to poor functional and aesthetic outcomes. In this case we used osteocutaneous free fibula flap for left alveolus and patient-specific templated PMMA implant for reconstruction of orbital wall and zygoma. Osseointegrated implants were placed secondarily in the fibula for complete dental rehabilitation. With the use of virtual surgical planning and 3D printing we were able to achieve a good result for a complex defect. Since both autogenous tissue and alloplastic implant were used for complete reconstruction, we have named this as "hybrid reconstruction."
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http://dx.doi.org/10.1097/GOX.0000000000003140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7544311PMC
September 2020

Relationship of the Musculocutaneous Nerve and Its Twigs to the Coracoid Process: An Operative Exposure.

Orthop J Sports Med 2020 Oct 13;8(10):2325967120954417. Epub 2020 Oct 13.

Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany.

Background: A musculocutaneous nerve (MCN) injury is a rare complication of the Latarjet procedure. Most of these injuries are neurapraxias and resolve with time; however, permanent injuries can occur. Understanding the anatomy and relationship of the MCN to the coracoid process is essential to prevent injuries.

Purpose: To provide realistic, in situ-referenced measurements for the Latarjet procedure.

Study Design: Descriptive laboratory study.

Methods: A total of 12 matched-pair cadaveric specimens (24 fresh-frozen shoulders) were dissected. Coracoid osteotomy was performed, and the MCN and its respective twigs were identified. Measurements were made from the coracoid process to the entry site of the nerve twigs and trunk into the coracobrachialis muscle.

Results: Overall, 70.8% of specimens had twigs; however, there was a discrepancy in the presence (41.7%) and number (75.0%) of twigs in the paired specimens. The most proximal twigs were, on average, 33.5 ± 8.1 mm (range, 21.9-47.6 mm) from the coracoid process. The main trunk was, on average, 51.1 ± 14.4 mm (range, 16.7-71.9 mm) from the coracoid process. In 33.3% of specimens, the nerve entered the coracobrachialis at a distance shorter than 5 cm below the coracoid process, and this increased to 91.7% when the twigs were accounted for.

Conclusion: The previously described safe zone of 5 cm below the coracoid process may not be reliable to protect the MCN or its twigs. Using 3 cm would decrease the chances of damaging a twig or the main trunk. In 33.3% of the specimens, the nerve entered the coracobrachialis at a distance shorter than 5 cm below the coracoid process, and this increased to 91.7% when twigs were accounted for.

Clinical Relevance: As the Latarjet procedure is an emerging technique, it is essential to be aware of the anatomic structures and the relation between different neural structures to anatomic points of reference. Therefore, the results of this study add significant information for a safe surgical procedure for the majority of patients suffering from shoulder instability.
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http://dx.doi.org/10.1177/2325967120954417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557702PMC
October 2020

Application of Human Factors Methods to Understand Missed Follow-up of Abnormal Test Results.

Appl Clin Inform 2020 10 21;11(5):692-698. Epub 2020 Oct 21.

Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, United States.

Objective: This study demonstrates application of human factors methods for understanding causes for lack of timely follow-up of abnormal test results ("missed results") in outpatient settings.

Methods: We identified 30 cases of missed test results by querying electronic health record data, developed a critical decision method (CDM)-based interview guide to understand decision-making processes, and interviewed physicians who ordered these tests. We analyzed transcribed responses using a contextual inquiry (CI)-based methodology to identify contextual factors contributing to missed results. We then developed a CI-based flow model and conducted a fault tree analysis (FTA) to identify hierarchical relationships between factors that delayed action.

Results: The flow model highlighted barriers in information flow and decision making, and the hierarchical model identified relationships between contributing factors for delayed action. Key findings including underdeveloped methods to track follow-up, as well as mismatches, in communication channels, timeframes, and expectations between patients and physicians.

Conclusion: This case report illustrates how human factors-based approaches can enable analysis of contributing factors that lead to missed results, thus informing development of preventive strategies to address them.
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http://dx.doi.org/10.1055/s-0040-1716537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577780PMC
October 2020

Complications and Failure to Rescue After Inpatient Pediatric Surgery.

Ann Surg 2020 Oct 19. Epub 2020 Oct 19.

Center for Innovations in Quality, Effectiveness, and Safety Michael E DeBakey VA Medical Center.

Objective: To describe the frequency and patterns of postoperative complications and failure to rescue (FTR) after inpatient pediatric surgical procedures and to evaluate the association between number of complications and failure to rescue.

Summary And Background: FTR, or a postoperative death after a complication, is currently a nationally endorsed quality measure for adults. While it is a contributing factor to variation in mortality, relatively little is known about FTR after pediatric surgery.

Methods: Cohort study of 200,554 patients within the National Surgical Quality Improvement Program-Pediatric database (2012-2016) who underwent a high (≥1%) or low (<1%) mortality risk inpatient surgical procedures. Patients were stratified based on number of postoperative complications (0, 1, 2, or ≥3) and further categorized as having undergone either a low- or high-risk procedure. The association between the number of postoperative complications and FTR was evaluated with multivariable logistic regression.

Results: Among patients who underwent a low- (89.4%) or high-risk (10.6%) procedures, 14.0% and 12.5% had at least one postoperative complication, respectively. FTR rates after low- and high-risk procedures demonstrated step-wise increases as the number of complications accrued (e.g.: low-risk-9.2% in patients with ≥3 complications; high-risk-36.9% in patients with ≥3 complications). Relative to patients who had no complications, there was a dose-response relationship between mortality and the number of complications after low-risk (1 complication - Odds Ratio [OR] 3.34 [95% CI 2.62-4.27]; 2 - OR 10.15 [95% CI 7.40-13.92]; ≥3-27.48 [95% CI 19.06-39.62]) and high-risk operations (1 - OR 3.29 [2.61-4.16]; 2-7.24 [5.14-10.19]; ≥3-20.73 [12.62-34.04]).

Conclusions: There is a dose-response relationship between the number of postoperative complications after inpatient surgery and FTR, ever after common, 'minor' surgical procedures. These findings suggest FTR may be a potential quality measure for pediatric surgical care.
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http://dx.doi.org/10.1097/SLA.0000000000004463DOI Listing
October 2020
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