United States

Objective: This study aims to compare the risk of intracranial hemorrhage (ICH) progression in traumatic brain injury (TBI) patients treated with unfractionated heparin (UFH) versus low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis.

Methods: A retrospective review was conducted on TBI patients with ICH who were treated at a level one trauma center between January 2018 and July 2020. Patients included had two or more CT head scans and received either UFH or LMWH within 24 hours after stable imaging. The primary outcome was ICH progression on follow-up CT. Secondary outcomes included hospital and intensive care unit (ICU) length of stay (LOS).

Results: Among 335 patients (28% female, 72% male), 160 received UFH, and 175 received LMWH. ICH progression was higher in the UFH group (44% vs. 27%, p=0.002). Hospital LOS and ICU LOS were longer in the UFH group (21.3 vs. 14.9 days, p=0.027; 11.1 vs. 6.5 days, p&lt;0.001, respectively), and remained longer after adjusting for risk level and injury mechanism. Multivariate analysis showed that LMWH was associated with a lower risk of ICH progression (OR: 0.46, 95%CI: 0.27-0.77). Patients with multifocal lesions and those undergoing neurosurgical intervention had higher odds of ICH progression.

Conclusion: UFH administration was associated with a higher risk of intracranial hemorrhage progression, increased hospital LOS, and ICU LOS when compared to LMWH. These results suggest that VTE prophylaxis with LMWH may result in a decreased risk of ICH progression compared to UFH in TBI patients with the added benefit of decreasing LOS.


AMA Research Challenge 2024 

Progression of Intracranial Hemorrhage in TBI: Comparing Chemoprophylaxis with UFH Versus LMWH

Objective: This study aims to compare the risk of intracranial hemorrhage (ICH) progression in traumatic brain injury (TBI) patients treated with unfractionated heparin (UFH) versus low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis.

Methods: A retrospective review was conducted on TBI patients with ICH who were treated at a level one trauma center between January 2018 and July 2020. Patients included had two or more CT head scans and received either UFH or LMWH within 24 hours after stable imaging. The primary outcome was ICH progression on follow-up CT. Secondary outcomes included hospital and intensive care unit (ICU) length of stay (LOS).

Results: Among 335 patients (28% female, 72% male), 160 received UFH, and 175 received LMWH. ICH progression was higher in the UFH group (44% vs. 27%, p=0.002). Hospital LOS and ICU LOS were longer in the UFH group (21.3 vs. 14.9 days, p=0.027; 11.1 vs. 6.5 days, p<0.001, respectively), and remained longer after adjusting for risk level and injury mechanism. Multivariate analysis showed that LMWH was associated with a lower risk of ICH progression (OR: 0.46, 95%CI: 0.27-0.77). Patients with multifocal lesions and those undergoing neurosurgical intervention had higher odds of ICH progression.

Conclusion: UFH administration was associated with a higher risk of intracranial hemorrhage progression, increased hospital LOS, and ICU LOS when compared to LMWH. These results suggest that VTE prophylaxis with LMWH may result in a decreased risk of ICH progression compared to UFH in TBI patients with the added benefit of decreasing LOS.

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Background
Meropenem (a carbapenem antibiotic) has broad indications for use, including complicated skin and soft tissue infections, complicated abdominal infections, and bacterial meningitis.1,2,4,5 
This study is a retrospective chart review of inpatient cases where this medication was prescribed. The main purpose was to determine the clinical reasoning (therapeutic/prophylactic) for which the medication was prescribed and to determine if treatment was generally successful and the incidence of significant side effects. 

Specific Aims:
1) Determine whether the medication was used mainly for therapy vs preventative uses
2) For those patients for whom it was used to treat a specific microbial agent, to determine the outcome of its use 
(Efficacious = released from hospital (with clinical improvement
and/or lab data demonstrating decreased infectivity ) vs 
Non-efficacious = side effect requiring discontinuation).

Methods
Data was collected via a retrospective chart review of patients prescribed Meropenem between August and October of 2023. Data was analyzed for indications of medication prescription and outcomes were determined based on whether patient was discharged with clinical improvement or the medication was discontinued due to adverse side effects. 
Data collected included the condition for which the patient presented to the hospital, length of stay, treatment type (Meropenem) and dates, patient response, reason for discontinuing medication if applicable, any adverse effects of treatment, and microbiology findings.

Results
87 patients were prescribed meropenem during the period of the study. In 10.5% of patients (n=9), it was prescribed for prophylaxis for to urologic/gastrointestinal surgery and in one patient for empiric treatment of aspiration pneumonia. The remaining 89.5% of patients (n=78) received therapeutic treatment; the majority of these patients (71 patients) had urine, wound and/or blood cultures and labs completed to confirm the appropriate antibiotic usage.
Over 60% of patients (n=48) indicated efficacious treatment (course completed, clinical and/or lab improvement and continued course without side effects); 34.6% of patients (n=27) had meropenem discontinued due to narrowing of therapy and only 5% (n=4) experienced severe side effects, requiring premature cessation of Meropenem.

Conclusion
Overall, Meropenem was well tolerated and generally was prescribed for culture confirmed infections requiring broad antibiotic coverage. Only 5% of the patients experienced disruptive side effects. Several patients had their antibiotic regimen narrowed, indicating good antibiotic stewardship. Patients who required Meropenem for complex infections were able to tolerate the full course and most cleared their infections without complication while under inpatient stay, or continued with treatment at discharge. Meropenem was generally used within acceptable guidelines of usage from an individual patient safety perspective and from a more universal perspective of antibiotic stewardship.

1. Pryka RD, Haig GM: Meropenem: a new carbapenem antimicrobial. Ann Pharmacother. 1994 Sep;28(9):1045-54. 
2. Meropenem: Drug Information. In: UpToDate, Wolters Kluver (Accessed on May 12, 2024)
3. Brown KA, Khanafer N, Daneman N, Fisman DN. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother. 2013 May;57(5):2326-32. doi: 10.1128/AAC.02176-12. Epub 2013 Mar 11. PMID: 23478961; PMCID: PMC3632900.
4. Baldwin CM, Lyseng-Williamson KA, Keam SJ. Meropenem: a review of its use in the treatment of serious bacterial infections. Drugs. 2008;68(6):803-38. doi: 10.2165/00003495-200868060-00006. PMID: 18416587.
5. Matthew E. Levison, Larry M. Bush, in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases (Eighth Edition), 2015

Evaluation of Clinical Indications and Appropriate Usage of Meropenem in an Inpatient Setting

Abstract Title: Prototypical Machine Learning Model for Predicting Postoperative Blood Transfusion

Background 
Postoperative bleeding is a serious surgical complication that can result in re-exploration, transfusion, and mortality. Currently, there is no standardized, quantitative method to screen patients undergoing major surgery to identify patients who are at increased risk of postoperative bleeding. While it has been shown that certain independent risk factors such as age, smoking, medication use, and bleeding disorders play a large role in perioperative bleeding, no prior literature has explored the application of machine learning (ML) models to assess an individual’s risk quantitatively based on co-morbidities and medications. We aim to create an ML model to screen patients undergoing major procedures and assess their risk for significant postoperative bleeding requiring blood transfusion within 30 days. 

Methods
Using the MIMIC-IV dataset available through PhysioNet, we identified 199,277 records of major procedures as defined by the Agency for Healthcare Research and Quality (AHRQ). For each record, patient medical history, demographics, and procedure information were recorded, along with the outcome of blood product administration within 30 days of surgery. A comprehensive list of features can be found in Table 1 to the right. 80% of the records were used to train a Gradient Boosting Machine model, and 20% were used for validation. Based on the receiver operating characteristic (ROC), an optimal threshold of ~0.15 was calculated to differentiate between negative and positive predictions. Performance metrics were reported from the model’s predictions of validation set outcomes.

Results
The final model predicted blood product administration with a sensitivity of 80.82% and specificity of 86.26%. The positive predictive value is 45.26%, and the negative predictive value is 96.97%. The area under the receiver operating characteristic (AUROC) was 0.91. The top five most predictive features, in order, were surgical procedure type, BMI, age, comorbid coagulative disease, and comorbid kidney or ureter disease. 

Conclusion
Our results suggest that an ML model can be utilized to screen patients undergoing major procedures to determine if they are at risk of postoperative bleeding requiring blood transfusion. The model’s predictions can be used to guide postoperative management and follow-up of high-risk patients. Further iterations will modify model inputs and parameters to improve performance and validate the model using another dataset from other institutions. 


Prototypical Machine Learning Model for Predicting Postoperative Blood Transfusion

Objective:
Resistance training, and other exercise regimens, is an overlooked and understudied effective therapy for patients with Parkinson’s disease. We provide cumulative evidence from multiple studies that support the effect of training on Parkinsonian symptoms, as quantified by the UPDRS III rating scale. We present a supplemental non-invasive and non-pharmacologic treatment that can tremendously improve the quality of life and provide a biochemical explanation as to why muscle building offsets the degenerative symptoms of Parkinson’s to delay the loss of fine motor control and prevent comorbidities associated with a sedentary lifestyle.

Background:
Parkinson’s disease (PD) is a progressive neurological movement disorder, with idiopathic onset, that impairs activities of daily living with nearly 10 million individuals diagnosed worldwide according to the Parkinson’s Foundation. Underlying pathology manifests due to the loss of dopaminergic neurons within the substantia nigra pars compacta with a pathological hallmark of α-synuclein Lewy body inclusions. Classical parkinsonian motor features consist of resting tremors, cogwheel rigidity, bradykinesia/akinesia, and gait instability. Pathological advancement gradually debilitates fine-motor activities such as speech and eating. It is vital to continue developing therapies for neurodegenerative disorders such as PD to improve the quality of life in Parkinson’s patients. Typical treatment methodology encompasses levodopa with carbidopa drug courses, as well as deep brain stimulation (DBS) of the subthalamic nucleus (STN) and globus pallidus internus (GPi). 

However, emerging clinical evidence has demonstrated exercise regimens, specifically resistance training, as an efficacious treatment method in improving motor coordination and mental acuity in Parkinson’s. Muscles working against a force activates muscle fiber hypertrophy, contributing to enlarged contractile myofibrils in skeletal muscle tissue which induces acute effects on functional mobility and thus improved motor outcomes. Increased muscle mass ultimately reduces PD symptoms and contributes to finer motor control. A biochemical perspective provides input onto how exercise leads to endorphins which, in turn, drives dopamine release to offset the dopaminergic deficit found in Parkinson’s patients.

Methods & Data Analysis:
PubMed, Google Scholar, Web of Science, and Cochrane Library databases were utilized to collect manuscripts evaluating resistance training regimens. Relevant information extracted pertained to resistance training, exercise training variables (total sessions, duration, repetitions), therapy length, UPDRS type, and UPDRS III pre-mean and post-mean outcomes. Ten out of 17 potential papers met our search criteria. The seven papers excluded from this review did not specify a UPDRS
III score before or after completing a resistance training regimen. We provide a retrospective systematic review to identify 10 prior research studies that reported UPDRS III scores before and after resistance training in Parkinson disease patients. Then, statistical analysis via a paired t-test was conducted to assess for differences in the mean UPDRS III score before and after resistance training for the 10 articles chosen.

Results:
Upon reviewing 10 randomized control studies investigating the therapeutic effects of various resistance training routines on Parkinsonian symptoms, we found a significant decrease in UPDRS III (Unified Parkinson’s Disease Rating Scale) motor scores following adherence to a longitudinal resistance training program. Parkinson’s patients within each study were subjected to approximately seven to 12 weeks of resistance exercises, primarily targeted to postural and appendicular muscle groups. The mean UPDRS III score across all the trials examined was 31.1 with a standard deviation (SD) of 8.3. The mean post-therapy score was 25.7 with an SD of 8.6. Post-analysis paired t-test showed a statistically significant p-value of 0.00528. The T-score was –3.654, beyond the 95% region of significance of –2.2622 to 2.2622. These results reflect only the 10 papers included in this study and could present analytical bias due to low power.

Discussion: 
We found a significant decrease in UPDRS III scores after a longitudinal resistance training plan. These results suggest that resistance training may be a therapeutic, non-invasive, and non-pharmacological option for the treatment for Parkinson's disease. Repeated resistance training leads to the hypertrophy of muscle fibers, significantly improving muscle motor control Resistance training in the form of exercises such as bench press, rowing, leg curls, leg extensions, and deadlifts significantly decreases motor deficits that lead to tremors, rigidity, and stooped posture.

Conclusion:
UPDRS III results suggest resistance interventions via bench press, leg curls, rowing, leg extensions, and deadlifts significantly reduce motor deficits that lead to Parkinsonian rigidity, postural instability, and resting tremors. Furthermore, we plan to explore if other forms of physical activity including aerobics, Tai Chi, and balance training yield similar or improved symptom relief. Resistance training may be an optimistic, non-invasive and non-pharmacological therapy for Parkinson’s neuropathology as it shows promising measures for the independence and livelihood of PD patients. Future studies should analyze the therapeutic effects of other physical therapies (aerobics, aquatic training etc.) in treating Parkinson disease.

Effect of Resistance Training on Parkinson’s Disease Motor Symptoms:A Systematic Review & Analysis

Title: Obesity and Clear Cell Renal Cell Carcinoma: Unraveling the Connection
Objectives: Obesity has been identified as an established risk factor in the development of clear cell renal cell carcinoma (ccRCC). Obesity can lead to chronic cellular insults which may lead to DNA injury and whether these mechanisms are critical to cancer initiation in the kidney is unclear. Understanding how free fatty acids initiate cancer is critical to understanding the role of obesity in cancer initiation and development. We hypothesize that chronic injury and repair due to excess FFA exposure could lead to ccRCC carcinogenesis and aim to define the metabolic phenotype of obesity associated ccRCC. 
Methods: Using publicly available data from The KIRC Cancer Genome Atlas Program (TCGA) and clinicopathologic data, we compared the RNAseq profiles of obese (BMI >= 30) to normal weight (BMI =< 25) sample origins. Of the 337, a total of 333 had BMI available for analysis. We evaluated differences in Hallmark and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. Using DESeq, we adjusted for age and sex. We clustered the mRNA, miRNA, and DNA methylation data using the iClusterBayes package. In vitro, HK PCT cells were cultured in DMEM+FBS and treated with bovine serum albumin (BSA)-palmitic acid complex and we measured cell viability at 24 and 48 hours using Alamar Blue. We extracted protein and performed western blots to identify DNA damage (pATM, H2AX) and endoplasmic reticulum stress (ATF4, eFI2alpha). 
Results: We identified several metabolic pathways to be unregulated in the obese group, including adipogenesis, heme metabolism, fatty acid metabolism, and bile acid metabolism. Analysis of methylation levels showed that obese patients appear to present a higher number of hypermethylated genes than normal weight patients. We identified decreased viability of renal proximal tubule and embryonal cells with excess free fatty acid supplementation. We also saw decreased cell viability with supplementation of BSA alone and are exploring the possible implication of BSA in endoplasmic reticulum stress to the cells. To further evaluate fatty acid associated parthenogenesis, we are repeating studies on in vitro HK PCT and treating cells with various concentrations of ceramide extracts. 
Conclusions: Through the investigation of these questions, we hope to improve understanding of obesity associated ccRCC and impact oncological outcomes for patients with this cancer. Understanding changes in lipid metabolism around ccRCC initiation will help identify novel pathways for pharmacologic intervention at earlier stages of the disease.

Obesity and Clear Cell Renal Cell Carcinoma: Unraveling the Connection

Background
The prevalence of obstructive sleep apnea (OSA) in children with Down syndrome is as high as 80% with limited treatment options. While adenotonsillectomy is the first line treatment, less than 33% of children with Down syndrome have resolution of OSA after adenotonsillectomy alone, and subsequent positive airway pressure (PAP) support is often poorly tolerated. Upper airway stimulation, which stimulates the hypoglossal nerve to protrude the tongue and open the airway during sleep, has shown efficacy for adults with OSA, but had not been evaluated in pediatric populations. Our objective was to describe the efficacy of upper airway stimulation for adolescent patients with Down syndrome and severe OSA.

Methods
We conducted a Phase 1, single-arm, multi-center trial of the safety and efficacy of hypoglossal stimulation in adolescent patients with Down syndrome and persistent severe OSA. Patients with Down syndrome were included if they were between 10-21 years old, had persistent severe OSA (AHI >10 after adenotonsillectomy and inability to tolerate CPAP), and had a drug-induced sleep endoscopy that did not show circumferential palatal collapse. Polysomnographic and quality of life outcomes were assessed at 1, 2, 6, and 12 months postoperatively. The prespecified primary outcomes were safety and the change in apnea-hypopnea index (AHI) from baseline to 12 months postoperatively.

Results
Among the 42 patients, 28 patients (66.7%) were male with a mean (SD) age of 15.1 (3.0). The mean decrease in AHI was 12.9 events/h (95% CI, –17.0 to –8.7 events/h). The 12-month response rate was 65.9%, and 73.2% of patients had a 12-month AHI <10 events/h. The most common complication was temporary oral discomfort, which occurred in 5 patients (11.9%). The reoperation rate was 4.8%. The mean improvement for the OSA-18 total score was 34.8 (95% CI, –42.1 to –27.5) and for the Epworth Sleepiness Scale score was 5.1 (95% CI, –7.4 to –2.8). The mean (SD) duration of nightly therapy was 9.0 (1.8) hours, with 40 patients (95.2%) using the device >4 hours nightly.

Conclusion
Upper airway stimulation was safely performed for adolescents who had Down syndrome and persistent severe OSA after adenotonsillectomy with PAP intolerance. Patients had significant improvements in polysomnographic and quality of life outcomes 1 year after surgery. These results describe a novel therapy option for treatment resistant OSA in children with Down syndrome, which led to FDA approval for this indication.

Upper Airway Stimulation for Adolescents with Down Syndrome and Obstructive Sleep Apnea

Objective: Practice patterns for using cervical collars vary widely following cervical spine surgery. We surveyed spine surgeons regarding their postoperative usage of cervical collars, postulating that their use would be controversial and both surgeon and patient-pathology dependent.

Methods: An online survey was created and distributed to neurosurgical and orthopedic residents, spine fellows, and attending surgeons. Demographic characteristics of the respondents were obtained. The anonymous survey consisted of 19 questions addressing indications for use of a cervical collar, its rationale, and duration of use. Responses were evaluated with percent agreement and inter-rater reliability as measured by Gwet's AC1. For individual questions, the proportion of positive answers was compared to the proportion expected by chance alone.

Results: Three hundred forty participants from 39 states in the U.S. and 41 countries responded to the survey. The percent agreement across all questions was greater than the 50% expected by chance alone (58% [56.5%, 58.5%]) and there was modest inter-rater reliability (Gwet's AC=0.23, p<0.001). Providers' decisions to use a collar varied significantly by pathology (p<0.0001), procedure performed (p<0.0001), duration of use (p<0.0001), and rationale for use (p<0.0001). The presentation for which there was most agreement to use collars was trauma (81%), the greatest agreement not to use collars was infection (19%), and the lowest rate of agreement was neoplasm (48% [42.3%, 53.0%]). Collars were utilized most often following multilevel corpectomy (2+ levels, 74% [69.1%, 78.5%]), least often following disc arthroplasty (13% [9.6%, 16.9%]), and the lowest rate of agreement was seen for 1-2 level posterior cervical fusion (44% [38.5%, 49.1%]). Providers were more likely to use a collar for posterior approach surgery (OR=3.94 [2.48, 6.26], p<0.0001). The most common rationales for using a collar were to limit the patient's activity (56%), support arthrodesis (47%), and reduce pain (41%). A total of 88% of providers have observed complications from cervical collar use in their practice.

Conclusions: The use of cervical collars is controversial, and providers' practices vary significantly in terms of pathologies, procedures, rationales, and duration. These findings underscore the need for evidence-based recommendations to guide clinical practice.

Current trends in the use of cervical collar immobilization after spine surgery: a global survey

Background: Although ulnar collateral ligament reconstruction (UCLR) is commonly performed in Major League Baseball (MLB) pitchers, few studies have evaluated advanced analytical data in the context of return to play (RTP) after injury. Traditional postoperative outcomes have not reliably predicted players return to their preoperative performance level. Pitch movements and release extension, defined as the raw horizontal and/or vertical movement of a pitch, and distance off the pitcher’s mound a pitcher releases the pitch are all key elements professional pitchers rely upon for effectiveness. Existing literature has demonstrated a varying degree of impact of some objective advanced measurements, such as spin rate and pitch movements, using a pitching tracking system that has been recently implemented and used for analytical data collection in professional baseball. The present study is one of the first to explore the impact of UCL reconstruction on horizontal and vertical pitch movement as well as pitch release extension. The study is also the first comparison of those advanced measurements between MLB pitchers who returned with sustained performance and those who were unable to return to preinjury performance levels for sustained time.
Methods: 113 MLB pitchers who underwent UCLR between 2016 and 2022 were identified via public record. The identified cohort was separated into those who returned with sustained levels of play, defined as throwing >500 pitches per season for multiple seasons following UCLR, and those who did not. The Statcast system was utilized to collect horizontal movement, vertical movement, and release extension for 4FB, 2FB, CU, and SL in the preinjury year as well as in each of the 2 years after following UCLR.
Results: 70 pitchers (62%) returned to the MLB level after UCLR. There was significant change in vertical movement for 4FB preoperatively compared to 1-year postoperatively (p<0.05). Pitchers who returned to the MLB with sustained level of performance demonstrated a statistical increase (p<0.05) in release extension for all pitch types in the first postoperative season when compared to those who returned without longevity, but the observed changes in release extension was only maintained in 4FB in the second postoperative season.
Conclusion: MLB pitchers who underwent UCLR and returned to the MLB level demonstrated a significant change in pitch release extension with all pitch types two years after surgery. The MLB pitchers who returned to the MLB level after UCLR and achieved longevity averaged a greater release extension postoperatively than those who did not.

Major League Baseball Pitchers with Greater Release Extensions After Ulnar Collateral Ligament Reconstruction Have Better Career Longevity.

Abstract Title
Education, Language, and Cultural Concordance Influence Patient-Physician Communication in Orthopaedics

Background

Disparities in healthcare outcomes are pronounced among racial and ethnic minorities in the United States, particularly in orthopaedics where only 4.7% of faculty are from underrepresented minority (URiM) groups. Previous research highlights that cultural competency and humility in healthcare can reduce these disparities and improve patient satisfaction. However, there is limited data on the impact of patient-physician cultural and language concordance in orthopaedic care.

Methods

A convenience sample of patients and orthopaedic surgeons from an urban tertiary medical center was surveyed between August 2021 and May 2023. A self-administered questionnaire, available in English and Spanish, assessed demographic information, language proficiency, treatment satisfaction, and the importance of cultural and language understanding by clinicians. The cohort included 394 patients, with data analyzed using descriptive statistics, ANOVA, Pearson’s correlation, chi-square tests, and logistic regression.

Results

A total of 394 patients completed the questionnaire, with 35% male and 65% female, and an average age of 54 years. Hispanic patients reported lower English proficiency compared to Caucasian and African-American subjects (p<0.001), and educational attainment significantly influenced patients' ability to communicate with their orthopaedic surgeon (p<0.001). Hispanic and African-American patients placed higher importance on cultural understanding by their orthopaedic surgeons compared to Caucasian patients (p<0.001). Among Hispanic patients, those treated by culturally and linguistically concordant surgeons reported better communication and higher satisfaction levels. Logistic regression showed that Hispanic patients who saw culture and language concordant surgeons valued Spanish-speaking surgeons more (66% vs 45%, p=0.04). 

Conclusion

This study highlights the critical role of educational attainment and patient-physician cultural and language concordance in effective communication within orthopaedic care. The novel finding that Hispanic patients show significantly improved communication and satisfaction when treated by culturally and linguistically concordant surgeons underscores the need for increasing the number of culturally and linguistically proficient orthopaedic surgeons. Addressing these factors can enhance patient outcomes and satisfaction, particularly among Hispanic and African-American populations. Efforts should focus on improving health literacy and cultural humility training for orthopaedic surgeons to bridge the communication gap and reduce disparities in orthopaedic care.

Education, Language, and Cultural Concordance Influence Patient-Physician Communication in Orthopaedics

Importance: The United States is experiencing a public health crisis due to an exponential rise in syphilis incidence, which can cause multi-systemic manifestations, including ocular syphilis. The standard of care treatment for ocular syphilis, a neuro-syphilis equivalent, has been intravenous (IV) aqueous crystalline penicillin G 18-24 million units per day for 10-14 days, however, this is costly to both the healthcare system and patients. 
Objective: To assess the efficacy of oral doxycycline to treat ocular syphilis when compared to standard of care IV penicillin.
Design: Retrospective cohort study. 
Setting: Los Angeles General Medical Center, a large, urban academic medical center caring for underserved patients.
Participants: 32 patients with ocular syphilis. 
Interventions: Patients received either doxycycline 200mg twice daily for 28 days as an outpatient or IV penicillin for 10-14 days through shared decision making.
Main Outcomes: The main outcome measure was clinical resolution of ocular inflammation. Secondary outcome measures included visual acuity and serologic resolution (four-fold decrease in RPR titers). 
Results: Sixteen patients received oral doxycycline and sixteen patients received IV penicillin. There were no differences in age, sex, race, HIV infection, CD4 count, or treponemal test positivity between the cohorts. There was no difference in the rates of ocular inflammation resolution among patients who were treated with doxycycline or penicillin (p=0.62). Median visual acuity was better among patients receiving oral doxycycline than IV penicillin at presentation and final follow-up. Visual acuity change between presentation and final visit were similar between groups. Among patients with 9 months of follow-up, 4 out of 4 patients receiving doxycycline and 7/7 patients received IV penicillin achieved a four-fold crease in RPR titers. 
Conclusions: Oral doxycycline for the treatment of ocular syphilis may be safe and effective in a carefully selected subset of patients. An outpatient oral regimen has many benefits, most crucially in its avoidance of inpatient admissions, which are costly to the healthcare system and hazardous to the patient. Further prospective studies are required to evaluate the clinical and serologic effects of treating ocular syphilis with oral doxycycline.

Outpatient Oral Doxycycline Therapy for Ocular Syphilis

Background

Electronic health record (EHR) notes are critical to medical decision making but have become unwieldy to manually sift through due to their many aims: communication, compliance, and billing. Consequently, clinicians spend more time navigating EHRs than with patients, leading to burnout. 

Prior analysis focuses on static completed notes, and few have explored granular reading and writing activities. Clinicians describe time-varying purposes of EHR use: rapid sense-making of new patients and re-familiarization with existing patients. We introduce a framework to dynamically retrieve relevant notes at different points during a patient’s visit to streamline discovery of relevant history and satisfy changing information needs.

Methods

We analyze 48,192 note-writing sessions in the high-acuity emergency department (ED). We design a binary classification task of whether to retrieve a past note during the next session given the current writing context. Audit logs, which track reading and writing activity in the EHR, provide labels for machine learning. We encode patient and clinician information, note metadata, and a bag of words representation for note text. We train logistic regression models to predict the top ten most relevant notes for each session. 

For quantitative evaluation, we measure precision@10, recall@10, and AUC. Additionally, two physicians conducted chart review for five random patients. Each clinician was given the patient's age, sex, and chief complaint, and assigned relevance for past notes. We compared their relevance judgments with the predicted relevant notes.

Results

Our learned models’ quantitative performance surpassed that of deterministic baselines and achieved an AUC of 0.963. For the qualitative evaluation, for four out of five visits, the top ranked predicted note surfaced during the first session of the patient’s visit was determined to be directly helpful to the patient’s current presentation by both clinicians. For three of four visits, showing only the top ranked predicted note was sufficient information that both clinicians needed to proceed with patient care.

Conclusion

We present a novel framework that updates retrieval suggestions dynamically as clinical context changes, thus helping clinicians find relevant information more quickly at different points during the patient’s visit. It also surfaces difficult-to-find information and suggests patterns a clinician may not have initially deemed relevant, prompting them to reassess a diagnosis they initially anchored on and evaluate potential biases. Demonstrating that our methods perform well in the demanding ED setting is a promising proof of concept that can translate to other clinical settings and data modalities.

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