Background Herpes zoster (HZ)-associated pain causes a significant burden on patients and healthcare resources. Treatment options for post-herpetic neuralgia (PHN) is limited, and treatment course could be refractory. The consensus is that preventing the progression of acute zoster pain to PHN is preferable to treating PHN itself. In clinical practice, anticonvulsants such as gabapentin and pregabalin have been reported to reduce the severity and duration of acute pain from HZ and lowered the risk of PHN. Tricyclic antidepressants, including amitriptyline, nortriptyline, desipramine, and imipramine, have also demonstrated efficacy in treating PHN symptoms. Initiating amitriptyline treatment shortly after the HZ onset in those at a higher risk of PHN has been suggested. However, the clinical application of these medications in preventing PHN is limited due to insufficient data. Aims and Objectives To evaluate the association between early initiation of anticonvulsants and/or antidepressants/anti-anxiety medications and the development of PHN in HZ patients 50 years and older Methods We conducted a cohort study at Kaiser Permanente Southern California. The cohort included incident HZ patients, identified by diagnostic codes plus use of antiviral medications, aged 50 years and older who were diagnosed between 4/1/2018 and 12/31/2020 with no history of using anticonvulsants, antidepressants, and anti-anxiety medications within 180 days prior to HZ diagnosis. The exposure was defined as having initiated use of anticonvulsants or antidepressants/anti-anxiety medications, or both categories within one month after HZ diagnosis. The outcome, PHN, was defined as HZ-related pain persisting >3 months after HZ diagnosis. Targeted chart review was conducted to identify PHN from encounter records 90-180 days after the initial HZ diagnosis. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) associated with each exposure category comparing to the reference category, controlling for age, sex, race/ethnicity, zoster vaccination history, immunosuppression conditions, comorbidities, healthcare utilization history, and continuous use of anticonvulsants, antidepressants, and anti-anxiety medication within 31-90 days after HZ diagnosis. Results There were 7865 incident HZ patients identified. Among them, 2829 were excluded due to the use of anticonvulsants, antidepressants, or anti-anxiety medications within 180 days prior to HZ diagnosis. Of the remaining 5036 HZ patients, 300 (5.96%) developed PHN. The odds ratio associated with initiating anticonvulsants, antidepressants/anti-anxiety medications, or both categories within one month after HZ diagnosis, was 0.95 (95% CI: 0.62 - 1.43), 1.22 (95% CI: 0.55 - 2.69), and 2.41 (95% CI: 1.25 - 4.62), respectively. Discussion & Conclusion We find no evidence supporting a lower risk of PHN associated with early initiation of anticonvulsant or antidepressant/anti-anxiety medications in adults 50 years and older. The lack of protective effect may partly be due to the possibility that HZ patients who had severe acute zoster pain or were suspected to be at a higher risk of PHN would initiate these medications earlier. A detailed measure of baseline severity and physician prescribing behavior would be helpful to control the potential confounding by indication. References 1.Johnson, Robert W., and Andrew SC Rice. "Postherpetic neuralgia." New England Journal of Medicine 371.16 (2014): 1526-1533. 2.Saguil, Aaron, et al. "Herpes zoster and postherpetic neuralgia: prevention and management." American family physician 96.10 (2017): 656-663. 3.Finnerup, Nanna B., et al. "Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis." The Lancet Neurology 14.2 (2015): 162-173. 4.Bulilete, Oana, et al. "Efficacy of gabapentin for the prevention of postherpetic neuralgia in patients with acute herpes zoster: A double blind, randomized controlled trial." PLoS One 14.6 (2019): e0217335. 5.John Schutzer-Weissmann &Paul Farquhar-Smith (2017) Post-herpetic neuralgia – a review of current management and future directions, Expert Opinion on Pharmacotherapy, 18:16, 1739-1750

The evaluation and management of acute vertigo presentations is challenging for both patients and physicians. Benign paroxysmal positional vertigo (BPPV), acute unilateral vestibulopathy (e.g., vestibular neuritis), and stroke are priority diagnostic considerations in this circumstance. Existing evidence can be used to guide the diagnosis and treatment, however high value care opportunities—such as the Dix-Hallpike test (DHT), canalith repositioning maneuver (CRM), and gaze stabilization exercises (GSE)—are often underused, while neuroimaging studies are often overused. This trial contains a health system focused stepped wedge intervention and an embedded individually patient randomized clinical trial. The study will start with a 6-month pre-intervention period. This will be followed by staggered intervention at the engaged EDs in 11 waves and then an approximately 6-month post-intervention period. Concurrently, patients will be recruited before and after the physician level intervention is implemented at each ED. Enrolled participants will complete baseline survey and then be randomized individually, stratified by sex, age, and medical center, to the intervention or control arm patient materials using central computerized randomization. The intervention arm will be sent intervention materials and the control arm will be sent the hospital’s standard post-discharge materials. The primary outcome of the physician-based part of the trial is use of evidence-based care practices during the index ED visit. The primary outcome of the patient focused part of the trial is the dizziness handicap index over 4 weeks. The DIZZTINCT-2 trial addresses key areas of uncertainty in how to improve the care of emergency department patients with acute vertigo. In addition, follow up data on how much and how fast patients improved was needed. DIZZTINCT-2 will address these key knowledge gaps efficiently. Clinicaltrials.gov NCT05634902. Registered on November 2022.

BACKGROUND:Herpes zoster (HZ) and HZ ophthalmicus (HZO) are associated with an increased risk of cardiovascular complications, such as acute myocardial infarction (AMI) and stroke. We evaluated the association between recombinant zoster vaccine (RZV) and risk of HZO, hospitalized AMI, and hospitalized stroke in adults ≥50 years of age (YoA) at Kaiser Permanente Southern California. METHODS:We conducted a matched cohort analysis of adults ≥50 YoA who received 2 doses of RZV 4 weeks-6 months apart during 01 April 2018-31 December 2020 and were matched 1:4 to RZV-unvaccinated individuals on age, sex, race/ethnicity, and index date (date of second dose among vaccinated; unvaccinated match assigned same date). Follow-up started at index date and ended at receipt of zoster vaccine, termination of membership, death, or 31 December 2022, whichever came first. HZO was identified by natural language processing of clinical notes; hospitalized AMI and stroke were identified by ICD-10 codes. Stratified Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). RESULTS:Among 102 766 2-dose RZV-vaccinated and 411 064 unvaccinated adults, 59.0% were female, 57.1% non-Hispanic White, and median age was 68 years (range: 50-108). The aHRs (95% CI) of HZO, hospitalized AMI, and hospitalized stroke comparing RZV-vaccinated and unvaccinated individuals were 0.271 (95% CI: 0.222, 0.330), 0.720 (0.588-0.881), and 0.575 (0.533-0.619), respectively. The adjusted RZV effectiveness against HZO was 72.9% (67.0%-77.8%). CONCLUSIONS:Among adults ≥50 YoA, 2 RZV doses were associated with a lower risk of HZO, AMI, and stroke.

STUDY OBJECTIVE:The evaluation for suspected acute coronary syndrome is a common and high-risk presentation in emergency departments (EDs). After exclusion of acute myocardial infarction (MI), patients often undergo early (within 72 hours) noninvasive cardiac testing. We evaluated the association between early noninvasive testing and death/acute MI in ED patients suspected of acute coronary syndrome. METHODS:We used a retrospective cohort study design within the adult ED patient population (from October 2015 to December 2020) in whom MI was ruled out, belonging to a large integrated health care delivery system. Using data on history (H), electrocardiogram (E), age (A), risk factors (R), and troponin (T), we computed the HEART risk score. We stratified the cohort into low (score 0 to 3), intermediate (score 4 to 6), and high (score ≥7) risk and followed them up to 1-year after ED discharge. The association between noninvasive testing within 3 days of the ED visit and composite risk of death/acute MI within 1-year of discharge was evaluated by propensity score analysis. RESULTS:The cohort included 174,917 patients (61% low risk [age 53; women 58%; noninvasive testing 5%], 36% intermediate risk [age 71; women 52%; noninvasive testing 18%], and 3% high risk [age 74, women 45%; noninvasive testing 23%]). The risk reduction in death/acute MI associated with early noninvasive testing was -1.54% (-1.95% to -1.12%) number needed to treat (NNT)=65; -4.93% (-5.66% to -4.20%) NNT=20, and -8.98% (95% confidence interval -11.32% to -6.64%) NNT=11; and, in the low, intermediate, and high-risk respectively. CONCLUSION:Early noninvasive testing was associated with reduced risk of 1-year death or acute MI across all risk groups.

BACKGROUND:The impact of covert cerebrovascular disease on falls in the general population is not well-known. Here, we determine the time to a first fall following incidentally detected covert cerebrovascular disease during a clinical neuroimaging episode. METHODS:This longitudinal cohort study assessed computed tomography (CT) and magnetic resonance imaging from 2009 to 2019 of patients aged >50 years registered with Kaiser Permanente Southern California which is a healthcare organization combining health plan coverage with coordinated medical services, excluding those with before stroke/dementia. We extracted evidence of incidental covert brain infarcts (CBI) and white matter hyperintensities/hypoattenuation (WMH) from imaging reports using natural language processing. We examined associations of CBI and WMH with falls requiring medical attention, using Cox proportional hazards regression models with adjustment for 12 variables including age, sex, ethnicity multimorbidity, polypharmacy, and incontinence. RESULTS:We assessed 241 050 patients, mean age 64.9 (SD, 10.42) years, 61.3% female, detecting covert cerebrovascular disease in 31.1% over a mean follow-up duration of 3.04 years. A recorded fall occurred in 21.2% (51 239/241 050) during follow-up. On CT, single fall incidence rate/1000 person-years (p-y) was highest in individuals with both CBI and WMH on CT (129.3 falls/1000 p-y [95% CI, 123.4-135.5]), followed by WMH (109.9 falls/1000 p-y [108.0-111.9]). On magnetic resonance imaging, the incidence rate was the highest with both CBI and WMH (76.3 falls/1000 p-y [95% CI, 69.7-83.2]), followed by CBI (71.4 falls/1000 p-y [95% CI, 65.9-77.2]). The adjusted hazard ratio for single index fall in individuals with CBI on CT was 1.13 (95% CI, 1.09-1.17); versus magnetic resonance imaging 1.17 (95% CI, 1.08-1.27). On CT, the risk for single index fall incrementally increased for mild (1.37 [95% CI, 1.32-1.43]), moderate (1.57 [95% CI, 1.48-1.67]), or severe WMH (1.57 [95% CI, 1.45-1.70]). On magnetic resonance imaging, index fall risk similarly increased with increasing WMH severity: mild (1.11 [95% CI, 1.07-1.17]), moderate (1.21 [95% CI, 1.13-1.28]), and severe WMH (1.34 [95% CI, 1.22-1.46]). CONCLUSIONS:In a large population with neuroimaging, CBI and WMH are independently associated with greater risks of an index fall. Increasing severities of WMH are associated incrementally with fall risk across imaging modalities.

Abstract Background Herpes zoster (HZ)-associated pain causes a significant burden on patients and healthcare resources. Treatment options for post-herpetic neuralgia (PHN) is limited, and treatment course could be refractory. The consensus is that preventing the progression of acute zoster pain to PHN is preferable to treating PHN itself. In clinical practice, anticonvulsants such as gabapentin and pregabalin have been reported to reduce the severity and duration of acute pain from HZ and lowered the risk of PHN. Tricyclic antidepressants, including amitriptyline, nortriptyline, desipramine, and imipramine, have also demonstrated efficacy in treating PHN symptoms. Initiating amitriptyline treatment shortly after the HZ onset in those at a higher risk of PHN has been suggested. However, the clinical application of these medications in preventing PHN is limited due to insufficient data. Aims and Objectives To evaluate the association between early initiation of anticonvulsants and/or antidepressants/anti-anxiety medications and the development of PHN in HZ patients 50 years and older Methods We conducted a cohort study at Kaiser Permanente Southern California. The cohort included incident HZ patients, identified by diagnostic codes plus use of antiviral medications, aged 50 years and older who were diagnosed between 4/1/2018 and 12/31/2020 with no history of using anticonvulsants, antidepressants, and anti-anxiety medications within 180 days prior to HZ diagnosis. The exposure was defined as having initiated use of anticonvulsants or antidepressants/anti-anxiety medications, or both categories within one month after HZ diagnosis. The outcome, PHN, was defined as HZ-related pain persisting >3 months after HZ diagnosis. Targeted chart review was conducted to identify PHN from encounter records 90-180 days after the initial HZ diagnosis. Logistic regression was used to estimate the odds ratio (OR) and 95% confidence interval (CI) associated with each exposure category comparing to the reference category, controlling for age, sex, race/ethnicity, zoster vaccination history, immunosuppression conditions, comorbidities, healthcare utilization history, and continuous use of anticonvulsants, antidepressants, and anti-anxiety medication within 31-90 days after HZ diagnosis. Results There were 7865 incident HZ patients identified. Among them, 2829 were excluded due to the use of anticonvulsants, antidepressants, or anti-anxiety medications within 180 days prior to HZ diagnosis. Of the remaining 5036 HZ patients, 300 (5.96%) developed PHN. The odds ratio associated with initiating anticonvulsants, antidepressants/anti-anxiety medications, or both categories within one month after HZ diagnosis, was 0.95 (95% CI: 0.62 - 1.43), 1.22 (95% CI: 0.55 - 2.69), and 2.41 (95% CI: 1.25 - 4.62), respectively. Discussion & Conclusion We find no evidence supporting a lower risk of PHN associated with early initiation of anticonvulsant or antidepressant/anti-anxiety medications in adults 50 years and older. The lack of protective effect may partly be due to the possibility that HZ patients who had severe acute zoster pain or were suspected to be at a higher risk of PHN would initiate these medications earlier. A detailed measure of baseline severity and physician prescribing behavior would be helpful to control the potential confounding by indication. References 1.Johnson, Robert W., and Andrew SC Rice. "Postherpetic neuralgia." New England Journal of Medicine 371.16 (2014): 1526-1533. 2.Saguil, Aaron, et al. "Herpes zoster and postherpetic neuralgia: prevention and management." American family physician 96.10 (2017): 656-663. 3.Finnerup, Nanna B., et al. "Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis." The Lancet Neurology 14.2 (2015): 162-173. 4.Bulilete, Oana, et al. "Efficacy of gabapentin for the prevention of postherpetic neuralgia in patients with acute herpes zoster: A double blind, randomized controlled trial." PLoS One 14.6 (2019): e0217335. 5.John Schutzer-Weissmann &Paul Farquhar-Smith (2017) Post-herpetic neuralgia – a review of current management and future directions, Expert Opinion on Pharmacotherapy, 18:16, 1739-1750

Background Diagnosis codes and prescription data are used in algorithms to identify postherpetic neuralgia (PHN), a debilitating complication of herpes zoster (HZ). Because of the questionable accuracy of codes and prescription data, manual chart review is sometimes used to identify PHN in electronic health records (EHRs), which can be costly and time-consuming. Objective This study aims to develop and validate a natural language processing (NLP) algorithm for automatically identifying PHN from unstructured EHR data and to compare its performance with that of code-based methods. Methods This retrospective study used EHR data from Kaiser Permanente Southern California, a large integrated health care system that serves over 4.8 million members. The source population included members aged ≥50 years who received an incident HZ diagnosis and accompanying antiviral prescription between 2018 and 2020 and had ≥1 encounter within 90‐180 days of the incident HZ diagnosis. The study team manually reviewed the EHR and identified PHN cases. For NLP development and validation, 500 and 800 random samples from the source population were selected, respectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), F-score, and Matthews correlation coefficient (MCC) of NLP and the code-based methods were evaluated using chart-reviewed results as the reference standard. Results The NLP algorithm identified PHN cases with a 90.9% sensitivity, 98.5% specificity, 82% PPV, and 99.3% NPV. The composite scores of the NLP algorithm were 0.89 (F-score) and 0.85 (MCC). The prevalences of PHN in the validation data were 6.9% (reference standard), 7.6% (NLP), and 5.4%‐13.1% (code-based). The code-based methods achieved a 52.7%‐61.8% sensitivity, 89.8%‐98.4% specificity, 27.6%‐72.1% PPV, and 96.3%‐97.1% NPV. The F-scores and MCCs ranged between 0.45 and 0.59 and between 0.32 and 0.61, respectively. Conclusions The automated NLP-based approach identified PHN cases from the EHR with good accuracy. This method could be useful in population-based PHN research.

BACKGROUND:Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is widely used to identify ischemia. There is limited research to evaluate if there is a risk threshold below which SPECT-MPI may not add significant prognostic value. METHODS:Between January 1, 2012, and December 31, 2018, individuals who underwent SPECT-MPI were stratified into 4 risk groups. The primary outcome was acute myocardial infarction (MI) or death. Multivariable Cox proportional hazards regression analysis was used to calculated hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS:Among 48,845 patients (52.3% male, median age 67 years), 8.5% were low risk, 4.8% borderline risk, 18.1% intermediate risk, and 68.6% high risk based on the American College of Cardiology pooled cohort equation. Ischemia was more commonly detected in the high-risk cohort (19.4% in high-risk vs 6.5% in low-risk). SPECT-MPI testing was associated with a significantly increased use of preventive medications such as statin therapy, regardless of stress test results. At a median follow-up of 4.2 years, there was no significant association between ischemia and death or MI in the low-risk cohort (adjusted HR, 1.91; 95% CI, 0.94-3.92) or the borderline-risk cohort (adjusted HR, 1.58; 95% CI, 0.79-3.15). Ischemia was associated with a higher risk of death or MI in the intermediate-risk (adjusted HR, 1.57; 95% CI, 1.24-1.99) and high-risk groups (adjusted HR, 1.54; 95% CI, 1.44-1.64). CONCLUSIONS:SPECT-MPI was less useful for risk stratification among low-risk patients because of their low event rates regardless of test results.

Aims This study aimed to develop and apply natural language processing (NLP) algorithms to identify recurrent atrial fibrillation (AF) episodes following rhythm control therapy initiation using electronic health records (EHRs). Methods and results We included adults with new-onset AF who initiated rhythm control therapies (ablation, cardioversion, or antiarrhythmic medication) within two US integrated healthcare delivery systems. A code-based algorithm identified potential AF recurrence using diagnosis and procedure codes. An automated NLP algorithm was developed and validated to capture AF recurrence from electrocardiograms, cardiac monitor reports, and clinical notes. Compared with the reference standard cases confirmed by physicians’ adjudication, the F-scores, sensitivity, and specificity were all above 0.90 for the NLP algorithms at both sites. We applied the NLP and code-based algorithms to patients with incident AF (n = 22 970) during the 12 months after initiating rhythm control therapy. Applying the NLP algorithms, the percentages of patients with AF recurrence for sites 1 and 2 were 60.7% and 69.9% (ablation), 64.5% and 73.7% (cardioversion), and 49.6% and 55.5% (antiarrhythmic medication), respectively. In comparison, the percentages of patients with code-identified AF recurrence for sites 1 and 2 were 20.2% and 23.7% for ablation, 25.6% and 28.4% for cardioversion, and 20.0% and 27.5% for antiarrhythmic medication, respectively. Conclusion When compared with a code-based approach alone, this study's high-performing automated NLP method identified significantly more patients with recurrent AF. The NLP algorithms could enable efficient evaluation of treatment effectiveness of AF therapies in large populations and help develop tailored interventions.

BACKGROUND:Prior studies characterizing worsening heart failure events (WHFE) have been limited in using structured healthcare data from hospitalizations, and with little exploration of sociodemographic variation. The current study examined the impact of incorporating unstructured data to identify WHFE, describing age-, sex-, race and ethnicity-, and left ventricular ejection fraction (LVEF)-specific rates. METHODS:Adult members of Kaiser Permanente Southern California (KPSC) with a HF diagnosis between 2014 and 2018 were followed through 2019 to identify hospitalized WHFE. The main outcome was hospitalizations with a principal or secondary HF discharge diagnosis meeting rule-based Natural Language Processing (NLP) criteria for WHFE. In comparison, we examined hospitalizations with a principal discharge diagnosis of HF. Age-, sex-, and race and ethnicity-adjusted rates per 100 person-years (PY) were calculated among age, sex, race and ethnicity (non-Hispanic (NH) Asian/Pacific Islander [API], Hispanic, NH Black, NH White) and LVEF subgroups. RESULTS:Among 44,863 adults with HF, 10,560 (23.5%) had an NLP-defined, hospitalized WHFE. Adjusted rates (per 100 PY) of WHFE using NLP were higher compared to rates based only on HF principal discharge diagnosis codes (12.7 and 9.3, respectively), and this followed similar patterns among subgroups, with the highest rates among adults ≥75 years (16.3 and 11.2), men (13.2 and 9.7), and NH Black (16.9 and 14.3) and Hispanic adults (15.3 and 11.4), and adults with reduced LVEF (16.2 and 14.0). Using NLP disproportionately increased the perceived burden of WHFE among API and adults with mid-range and preserved LVEF. CONCLUSION:Rule-based NLP improved the capture of hospitalized WHFE above principal discharge diagnosis codes alone. Applying standardized consensus definitions to EHR data may improve understanding of the burden of WHFE and promote optimal care overall and in specific sociodemographic groups.

Covert cerebrovascular disease (CCD) is frequently reported on neuroimaging and associates with increased dementia and stroke risk. We aimed to determine how incidentally-discovered CCD during clinical neuroimaging in a large population associates with mortality. We screened CT and MRI reports of adults aged ≥50 in the Kaiser Permanente Southern California health system who underwent neuroimaging for a non-stroke clinical indication from 2009-2019. Natural language processing identified incidental covert brain infarcts (CBI) and/or white matter hyperintensities (WMH), grading WMH as mild/moderate/severe. Models adjusted for age, sex, ethnicity, multimorbidity, vascular risks, depression, exercise, and imaging modality. Of n=241,028, the mean age was 64.9 (SD=10.4); mean follow-up 4.46 years; 178,554 (74.1%) had CT; 62,474 (25.9%) had MRI; 11,328 (4.7%) had CBI; and 69,927 (29.0%) had WMH. The mortality rate per 1,000 person-years with CBI was 59.0 (95%CI 57.0-61.1); with WMH=46.5 (45.7-47.2); with neither=17.4 (17.1-17.7). In adjusted models, mortality risk associated with CBI was modified by age, e.g. HR 1.34 [1.21-1.48] at age 56.1 years vs HR 1.22 [1.17-1.28] at age 72 years. Mortality associated with WMH was modified by both age and imaging modality e.g., WMH on MRI at age 56.1 HR = 1.26 [1.18-1.35]; WMH on MRI at age 72 HR 1.15 [1.09-1.21]; WMH on CT at age 56.1 HR 1.41 [1.33-1.50]; WMH on CT at age 72 HR 1.28 [1.24-1.32], vs. patients without CBI or without WMH, respectively. Increasing WMH severity associated with higher mortality, e.g. mild WMH on MRI had adjusted HR=1.13 [1.06-1.20] while severe WMH on CT had HR=1.45 [1.33-1.59]. Incidentally-detected CBI and WMH on population-based clinical neuroimaging can predict higher mortality rates. We need treatments and healthcare planning for individuals with CCD.

This observational retrospective matched cohort study evaluated the safety of a prenatal tetanus, diphtheria, acellular pertussis (Tdap) vaccination, Boostrix. We previously reported on the risk of maternal and neonatal outcomes; here we report on the risk of congenital anomalies in infants at birth through 6 months of age. The study included pregnant Kaiser Permanente Southern California members. Women who received the Tdap vaccine on or after the 27th week of pregnancy between January 2018 and January 2019 were matched to women who were pregnant between January 2012 and December 2014 and were not vaccinated with Tdap during pregnancy. Unadjusted and adjusted relative risks (aRRs) with 95

Importance Patients presenting to the emergency department with chest pain are routinely risk stratified for major adverse cardiac events using the HEART (History, Electrocardiogram, Age, Risk factors, and Troponin) score pathway, which incorporates clinical features, risk factors, electrocardiography findings, and initial serum troponin testing. A new HEART pathway incorporating high-sensitivity troponin level may improve risk stratification among patients with possible acute myocardial infarction (AMI).Objective To compare health outcomes and resource use among emergency department patients undergoing cardiac risk stratification with a HEART pathway using conventional vs high-sensitivity serum troponin.Design, Setting, and Participants This multicenter pre-post cohort study was conducted between January 1 and September 6, 2021, at 16 Kaiser Permanente Southern California hospitals during uptake of a high-sensitivity serum troponin assay and included 17 384 adult patients who presented to an emergency department with chest pain and were risk stratified with a HEART pathway based on conventional troponin or high-sensitivity troponin.Exposures A HEART pathway incorporating either conventional or high-sensitivity serum troponin was used to stratify study groups for risk of major adverse cardiac events within 30 days.Main Outcomes and Measures The primary outcome was detection of AMI in the emergency department and within 30 days.Results Of the 17 384 patients (median age, 58 years [IQR, 45-69 years]; 9767 women [56.2%]), 12 440 (71.6%) were risk stratified with a HEART pathway based on conventional troponin, and 4944 (28.4%) were risk stratified with a HEART pathway based on high-sensitivity troponin. Detection of AMI within 30 days was higher for the high-sensitivity troponin group than the conventional troponin group (288 [5.8%] vs 545 [4.4%]; P < .001), while the 30-day all-cause mortality rate was unchanged (16 [0.3%] vs 50 [0.4%]; P = .50). In the emergency department, 228 of 4944 patients (4.6%) in the high-sensitivity troponin group received a diagnosis of AMI compared with 251 of 12 440 patients (2.0%) in the conventional troponin group (P < .001). Among those who did not receive a diagnosis of AMI in the emergency department, an additional 60 patients (1.2%) in the high-sensitivity troponin group and 294 (2.4%) in the conventional troponin group (P < .001) received a diagnosis within 30 days. Patients in the high-sensitivity troponin group had lower rates of health care use compared with the conventional troponin group, including admission (605 [12.2%] vs 1862 [15.0%]; P < .001), stress testing within 7 days (506 [10.2%] vs 1591 [12.8%]; P < .001), and coronary revascularization within 30 days (51 [1.0%] vs 244 [2.0%]; P < .001).Conclusions and Relevance This multicenter pre-post cohort study suggests that a new HEART pathway incorporating high-sensitivity troponin may improve detection of AMI and decrease resource use among emergency department patients with chest pain.

Abstract Background Postherpetic neuralgia (PHN) is a debilitating complication of herpes zoster (HZ). PHN diagnosis codes tend to be inaccurate or incomplete. The criterion standard for identifying PHN in electronic health records (EHR) is manual chart review, which can be costly and time-consuming. We developed and validated a method to automatically identify PHN from free-text EHR data using natural language processing (NLP). Methods This study utilized EHR data of patients aged ≥50 years who had an incident HZ diagnosis and associated antiviral prescription between 2018-2022 at Kaiser Permanente Southern California. Among patients with ≥1 encounter during the 90-180 days after the incident HZ diagnosis, PHN was defined as pain/discomfort consistent with the HZ episode between 90-180 days after the initial HZ diagnosis; the symptoms were at the location of the initial HZ rash and were not due to other obvious causes. Trained research associates and an infectious disease physician manually reviewed and identified PHN cases from EHR. From these reviewed HZ cases, we randomly selected 500 and 800 cases for NLP development and validation, respectively. We developed and validated an NLP algorithm to identify PHN based on our case definition. Using chart-reviewed results as the criterion standard, the accuracy of NLP-based results was compared with that of diagnosis code-based results (ICD-10 codes B02.22, B02.23, B02.29 from all clinical encounters during the 90-180-day period). Results Compared to the criterion standard, the NLP algorithm achieved 100% sensitivity (code-based 64.8%), 99.9% specificity (code-based 97.0%), 98.6% positive predictive value (code-based 67.7%), and 100% negative predictive value (code-based 96.6%) in identifying PHN cases. In the validation data, the prevalence of PHN was 8.9% based on manual chart review. Although the prevalence of PHN identified by the two methods was similar (NLP-based 9.0%, code-based 8.5%), the code-based method misclassified more than one-third of chart-confirmed PHN cases. Accuracy measurements of NLP and diagnosis codes in identifying PHN, as compared with chart-confirmed validation data. Conclusion We developed and validated an automated method to identify PHN cases using the clinical text from EHR of HZ patients with high accuracy. This method can be a valuable tool to facilitate population-based studies of PHN. Disclosures Bradley Ackerson, MD, Dynavax: Grant/Research Support|Genentech: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support Leticia I. Vega Daily, MSW, GlaxoSmithKline: Grant/Research Support Jeannie Song, MPH, GlaxoSmithKline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support Lina S. Sy, MPH, Dynavax: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Moderna: Grant/Research Support Lei Qian, PhD, Dynavax: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Moderna: Grant/Research Support Yi Luo, PhD, GlaxoSmithKline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support Ana Florea, PhD MPH, Gilead: Grant/Research Support|GlaxoSmithKline: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support Jennifer H. Ku, PhD MPH, GlaxoSmithKline: Grant/Research Support|Moderna: Grant/Research Support Hung Fu Tseng, PhD MPH, GSK: Grant/Research Support|Moderna: Grant/Research Support

Accurate and complete identification of spontaneous abortion (SAB) is critical important for conducting SAB-related studies. We  developed and validated a natural language processing (NLP) algorithm to identify SAB from free-text clinical notes. Potential SAB cases were identified among subjects after influenza vaccinations during influenza season of 2012–2015 or quadrivalent human papillomavirus (4vHPV) vaccinations in 2012–2013 through diagnosis codes. The SAB and the matched non-SAB subjects after influenza vaccinations were used to develop the NLP algorithm. Chart-reviewed and adjudicated SAB cases after 4vHPV vaccinations were used to validate the algorithm performance. The developed algorithm was then applied to documented pregnancy episodes in the electronic medical record (EMR) system in 2011–2014. The NLP results were compared against the cases identified by diagnosis codes. The NLP algorithm successfully identified 289 of the 310 confirmed SAB cases in the validation dataset and achieved a sensitivity of 93.2% (95% confidence interval [CI] 90.4–96.0%), positive predictive value of 96.0% (95% CI 93.8–98.2%)specificity of 58.6% (95% CI 40.7–76.6%) and negative predictive value of 44.7% (95% CI 28.9–60.6%) when it was applied to the potential SAB cases identified by diagnosis codes in the 4vHPV validation dataset. When the NLP process was applied to the 195,395 documented pregnancies between 2011 and 2014, the NLP algorithm identified a total of 20,709 potential SAB cases (10.6% of pregnancies). Of those potential cases, 9856 (47.6%) were not identified by diagnosis codes. These data suggest that the NLP algorithm can be used to identify SAB from EMR effectively. The developed algorithms could be potentially augmented with EMR structured data to improve the accuracy.

Background: Covert cerebrovascular disease (CCD) includes white matter disease (WMD) and covert brain infarction (CBI). Incidentally discovered CCD is associated with increased risk of subsequent symptomatic stroke. However, it is unknown whether the severity of WMD or the location of CBI predicts risk. Objectives: The aim of this study was to examine the association of incidentally discovered WMD severity and CBI location with risk of subsequent symptomatic stroke. Method: This retrospective cohort study includes patients aged ≥50 years old in the Kaiser Permanente Southern California health system who received neuroimaging for a nonstroke indication between 2009 and 2019. Incidental CBI and WMD were identified via natural language processing of the neuroimage report, and WMD severity was classified into grades. Results: A total of 261,960 patients received neuroimaging; 78,555 patients (30.0%) were identified to have incidental WMD and 12,857 patients (4.9%) to have incidental CBI. Increasing WMD severity is associated with an increased incidence rate of future stroke. However, the stroke incidence rate in CT-identified WMD is higher at each level of severity compared to rates in MRI-identified WMD. Patients with mild WMD via CT have a stroke incidence rate of 24.9 per 1,000 person-years, similar to that of patients with severe WMD via MRI. Among incidentally discovered CBI patients with a determined CBI location, 97.9% are subcortical rather than cortical infarcts. CBI confers a similar risk of future stroke, whether cortical or subcortical or whether MRI- or CT-detected. Conclusions: Increasing severity of incidental WMD is associated with an increased risk of future symptomatic stroke, dependent on the imaging modality. Subcortical and cortical CBI conferred similar risks.

Introduction: AHA guidelines recommend non-invasive cardiac testing (NIT) within 72 hours after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS), after acute myocardial infarction (AMI) has been excluded. However, the effectiveness of this strategy to reduce the risk of future AMI or death, in low-risk patients is contested. Hypothesis: We hypothesized that in patients with low risk based on history, electrocardiogram, age, risk factors and troponin (HEART) based scoring, early NIT may not be beneficial compared to higher risk. Methods: We compared the effectiveness of early NIT vs. no early testing, in a retrospective cohort of adult (age ≥18) members of the Kaiser Permanente Southern California health system from 05/2016-12/2020. We included all adults presenting at EDs with suspected ACS and who had data to compute HEART score. We stratified the cohort into low risk (score 0-3); intermediate risk (score 4-6) and high-risk (score ≥7) based on HEART score. Within each group, confounder adjusted instrumental variables models were used to evaluate the marginal effect of early NIT, and the number needed to treat (NNT) was calculated as the inverse of the absolute composite risk reduction in death/AMI within 30 days of ED discharge. Results: The cohort included 174,936 patients [61% Low risk (mean age 53; female 58%; early NIT 5%), 36% intermediate risk (mean age 71; female 72%; early NIT 18%), and 3% high risk (mean age 74, female 45%; early NIT 23%)]. The risk reduction in 30-day death/AMI due to early NIT increased progressively through the intermediate-risk (NNT = 59) and high-risk groups (NNT = 24) (Table 1). Risk reduction in the low-risk group was not statistically significant. Conclusions: HEART score based high risk patients may benefit the most from early NIT. However, the majority of the suspected ACS cohort was classified as low risk and the benefit of early NIT on 30-day death/AMI was uncertain in this low-risk group.