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OBJECTIVE:This study aimed to evaluate the location-specific and time-sensitive trajectories of pressure injuries (PrIs) stages using real-world electronic health record (EHR) datasets. APPROACH:Using a dataset of 29,475 patients with records of PrIs documented from 2015 to 2023, we developed four PrI patient sub-cohorts with common PrI locations, including coccyx, buttocks, sacrum and heel. We estimated transition intensities between three PrI states: stage 1, stage 2, and a severe stage in each group. Stages and transition paths were derived from domain knowledge provided by clinical experts and The National PrI Advisory Panel (NPIAP) guidelines. RESULTS:The trajectory analysis suggested that stage 2 serves as a "gateway state" in all four locations, meaning that once a PrI reaches stage 2, the likelihood of transiting to severe stages increases significantly. The commonly used Braden Scale and its sub-components are more likely to be associated with transitions from stage 2 to severe stages, suggesting that manual risk assessment tools are suboptimal for predicting early-stage PrI transitions. Further, we observed race-dependent variations across injury location groups. INNOVATION:To our knowledge, this is the first study to introduce multi-state trajectory analysis in PrI research. Our model can investigate PrI status in a dynamic manner, which fills an important gap in the field. CONCLUSION:Our findings underscore the lack of time-sensitive information in existing PrI risk assessment tools, revealing a critical gap in their ability to capture the dynamic nature of PrI progression. Clinical decision support using time sensitive data is needed for delivering personalized, timely, and effective PrI prevention.
Goals: To identify clinical features associated with geographic residency in patients with eosinophilic esophagitis (EoE). Background: Prior studies on the geographic distribution of eosinophilic esophagitis (EoE) have focused on disease prevalence. Geographic and environmental factors may impact the clinical characteristics and phenotypes of EoE, although data remain limited. Study: This was a cross-sectional study of consecutive patients residing in Massachusetts with newly diagnosed EoE (≥15 eosinophils/hpf). Patients’ residency settings were classified as urban or nonurban based on the 2020 US Census and residential zip codes. Clinical, endoscopic, and histologic variables were recorded. EoE patients in urban versus nonurban settings were compared using the student t test or the Fisher exact test for univariate analyses. Multivariable logistic regression was performed to identify the independent association between urban residency and comorbid atopic conditions, the inflammatory endotype, and the fibrostenotic endotype. Results: Six hundred eighty-three EoE patients were included, with 136 (20.0%) urban and 547 (80%) nonurban residents. Urban patients had higher rates of atopy (63.2% vs. 51.8%, P =0.02), severe food/environmental allergies (17.7% vs. 8.3%, P =0.002), and inflammatory findings endoscopic (43.4% vs. 27.8%, P =0.0006). On multivariable analysis, atopy (OR=1.57, CI: 1.02-2.40, P =0.04), severe food/environmental allergies (OR=1.99, CI: 1.09-3.63, P =0.02), and inflammatory findings (OR=1.90, CI: 1.22-2.94, P =0.004) remained independently associated with urban residency. Conclusions: Urban residency is independently associated with severe food/environmental allergies and inflammatory endoscopic findings at EoE diagnosis, suggesting increased allergic phenotype and active inflammation at presentation. Allergen exposure, particularly indoors, and social determinants may be contributory factors. Environmental considerations, such as geographic residency, may impact EoE disease presentation, activity, and outcome.
Background:Left atrial flutter (LAF) most commonly arises in patients with previous left atrial ablation or surgery. Rarely, it can present as a de novo arrhythmia without previous interventions. Objective:We aimed to compare patient characteristics, pathophysiological mechanisms, and ablation outcomes of patients with de novo LAF with those of patients with postablation LAF. Methods:Patients undergoing LAF ablation between January 2021 and June 2023 were included. Baseline data, arrhythmia mechanisms, and ablation targets were collected. Patients were followed with 7-day Holter electrocardiograms at 3, 6, and 12 months. The primary endpoint was arrhythmia recurrence after a 90-day blanking period. Results:A total of 147 patients with LAF were analyzed (median age 71 years; 65% men). Of those, 32 (22%) presented with de novo LAF, and 115 (78%) presented with postablation LAF. Patients in the de novo group were older (74 years vs 70 years; P = .037), were more often women (50% vs 30%; P = .058), and had a lower body mass index (26.0 vs 27.1; P = .025). In 28% of patients in the de novo group, atrial fibrillation had not been diagnosed before the procedure. The dominant arrhythmia mechanisms in the de novo group were anteroseptal localized reentry (44%), followed by perimitral flutter (31%) and roof-dependent flutter (16%). Freedom from any atrial arrhythmia at 12 months was 46% (95% confidence interval 30-69) in the de novo and 50% (95% confidence interval 41-62) in the postablation group (P = .39). Conclusion:Patients with de novo LAF are older and leaner than patients with postablation LAF, and the predominant arrhythmia mechanism is anteroseptal localized reentry. Arrhythmia-free survival is similar in both groups.
INTRODUCTION:Teleneurology has been increasingly implemented where in-person consultations are not feasible. However, the neurology education of internal medicine residents using teleneurology has not been studied. Our study assessed internal medicine residents' experience and comfort with teleneurology and the effect of a simulation-based curriculum on their neurology skills and confidence. METHODS:Our 2023-2024 curricular intervention included a workshop with neurologic exam teaching and simulated patient sessions as well as case discussions and lectures. Participants completed validated questionnaires evaluating perceptions on neurology, neurology education and teleneurology, and participated in a focus group. Teleneurology utilisation data was obtained. RESULTS:Nineteen residents (90%) completed questionnaires before and after the workshop and 8 (42%) completed questionnaires at the end of the intervention. All felt neurology is important; 94% considered it difficult and 31.6% reported being afraid of neurology. The workshop led to an increase in their confidence performing a neurological exam and recognising, diagnosing and working up acute stroke and seizure. Their comfort practicing without in-house neurologists increased, and their perception that neurology is difficult decreased. Residents identified barriers, including a lack of systematic examination and infrequent exposure to neurologic diagnoses, valued an in-person neurology rotation and recommended structured in-person and asynchronous neurology learning. DISCUSSION:We identified an educational gap among residents training in centres that use teleneurology. An in-person session with exam teaching and simulated patient sessions on acute stroke and seizure recognition and management may improve residents' confidence in their neurologic skills.
