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BackgroundDiagnostic 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. ObjectiveThis study aims to identify variables associated with diagnostic errors in emergency departments using large-scale EHR data and machine learning techniques. MethodsThis 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. ResultsThis 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. ConclusionsThe 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

BackgroundMore 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. ObjectiveThis 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. MethodsWe 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. ResultsWe 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. ConclusionsAI 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.

Abstract: Long bean (Vigna unguiculata subsp. sesquipedalis, asparagus bean, Asian yardlong bean), the vegetable type of cowpea [Vigna unguiculata (L.) Walp], is a climate‐resilient and nutritious food legume grown by Southeast Asian farmers in the Central Valley of California and marketed to Asian immigrant communities across the United States. Insect pests are major threats, reducing yield and quality of all current lines. Modern plant breeding protocols and extension activities were implemented to develop resistant lines using sources of natural resistance found in African cowpea germplasm. Three aphid‐resistant long bean lines, Dark Green 1994 (Reg no. GP‐320, PI 702995), Light Green 2055 (Reg. no. GP‐321, PI 702996), and Purple 2056 (Reg. no. GP‐322, PI 702997), were developed by introgression of two known quantitative trait loci (QTL) for aphid resistance into three local elite lines through marker‐assisted backcrossing (MABC). One bush‐type long bean line, Bush 2074 (Reg. no. GP‐319, PI 702994), carrying two known QTL for root‐knot nematode resistance, was also developed to enable scaling up production and to improve nematode management in large‐scale commercial farming. These improved lines were evaluated in controlled experiments which also served in outreach activities to enable adoption. Each of these advanced lines, when forming a near‐isogenic pair with its recurrent parent, can provide useful genetic materials for resistance gene discovery.

Persons living with dementia (PLWD) have high emergency department (ED) utilization. Little is known about using telemedicine with PLWD and caregivers as an alternative to ED visits for minor acute health problems. This qualitative interview-based study elicited caregivers perspectives about the acceptability of telemedicine for acute complaints. We performed telephone interviews with 28 caregivers of PLWD from two academic EDs, one in the Northeast and another in the South. Using a combined deductive-inductive approach, we coded interview transcripts and elucidated common themes by consensus. All caregivers reported they would need to participate in the telemedicine visit to help overcome communication and digital literacy challenges. People from racial/ethnic minority groups reported lower comfort with the virtual format. In both sites, participants expressed uncertainty about illness severity that could preclude using telemedicine for acute complaints. Overall, respondents deemed acute care telemedicine acceptable, but caregivers describe specific roles as crucial intermediaries to facilitate virtual care.

Background: Diagnostic errors lead to patient harm; however, most research has been conducted in nonsurgical disciplines. We sought to characterize diagnostic error in the pre-, intra-, and postoperative surgical phases, describe their contributing factors, and quantify their impact related to patient harm. Methods: We performed a retrospective analysis of closed medico-legal cases and complaints using a database representing more than 95% of all Canadian physicians. We included cases if they involved a legal action or complaint that closed between 2014 and 2018 and involved a diagnostic error assigned by peer expert review to a surgeon. Results: We identified 387 surgical cases that involved a diagnostic error. The surgical specialties most often associated with diagnostic error were general surgery (n = 151, 39.0%), gynecology (n = 71, 18.3%), and orthopedic surgery (n = 48, 12.4%), but most surgical specialties were represented. Errors occurred more often in the postoperative phase (n = 171, 44.2%) than in the pre- (n = 127, 32.8%) or intra-operative (n = 120, 31.0%) phases of surgical care. More than 80% of the contributing factors for diagnostic errors were related to providers, with clinical decision-making being the principal contributing factor. Half of the contributing factors were related to the health care team (n = 194, 50.1%), the most common of which was communication breakdown. More than half of patients involved in a surgical diagnostic error experienced at least moderate harm, with 1 in 7 cases resulting in death. Conclusion: In our cohort, diagnostic errors occurred in most surgical disciplines and across all surgical phases of care; contributing factors were commonly attributed to provider clinical decision-making and communication breakdown. Surgical patient safety efforts should include diagnostic errors with a focus on understanding and reducing errors in surgical clinical decision-making and improving communication. Contexte : Les erreurs de diagnostic causent des préjudices à la patientèle; par contre, la majeure partie de la recherche a porté sur d'autres disciplines que la chirurgie. Nous avons voulu caractériser les erreurs de diagnostic susceptibles de survenir lors des périodes pré-, per-, et postopératoires, en décrire les facteurs contributifs, et mesurer leur impact sur le plan des préjudices causés à la patientèle. Méthodes : À partir d'une base de données représentant plus de 95% de tous les médecins canadiens, nous avons procédé à une analyse rétrospective des dossiers et des plaintes de nature médico-légale réglés. Nous avons inclus tous les dossiers ayant donné lieu à une poursuite judiciaire ou à une plainte officielle qui ont été réglés entre 2014 et 2018 et qui, après expertise, mettaient en cause une erreur de diagnostic imputée à un chirurgien ou une chirurgienne. Résultats : Nous avons recensé 387 cas chirurgicaux associés à une erreur de diagnostic. Les spécialités chirurgicales les plus souvent impliquées dans une erreur diagnostique étaient la chirurgie générale (n = 151, 39,0%), la gynécologie (n = 71, 18,3%), et la chirurgie orthopédique (n = 48, 12,4%), mais la plupart des spécialités chirurgicales étaient représentées. Les erreurs se sont produites plus fréquemment durant la période postopératoire (n = 171, 44,2%) que durant les périodes pré- (n = 127, 32,8%) ou peropératoires (n = 120, 31,0%). Plus de 80% des facteurs contributifs impliquaient le personnel soignant, la prise de décision clinique en étant le principal. La moitié des facteurs contributifs avaient à voir avec l'équipe soignante (n = 194, 50,1%), et le plus fréquent concernait un quelconque bris de communication. Plus de la moitié des cas ayant fait l'objet d'une erreur de diagnostic ont subi des préjudices au moins modérés, et 1 fois sur 7, l'issue en a été fatale. Conclusion : Dans notre cohorte, les erreurs de diagnostic ont touché la plupart des disciplines chirurgicales et toutes les périodes opératoires; les facteurs contributifs ont souvent été liés à la prise de décision clinique et à un bris de communication. Les efforts déployés pour assurer la sécurité de la patientèle devraient aussi tenir compte des erreurs de diagnostic et mettre l'accent sur l'analyse et la prévention des erreurs associées à la prise de décision clinique et sur l'amélioration de la communication., The diagnostic process is a foundational element of every medical specialty, both surgical and nonsurgical. In any clinical practice, the diagnostic process involves information gathering (via history taking, physical examination, [...]

BackgroundPatients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital’s electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians’ opinions. ObjectiveThe aim was to explore emergency physicians’ current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results. MethodsA cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification. ResultsThe response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61). ConclusionsAlthough patients’ direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians’ concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

BackgroundDiagnostic errors, reframed as missed opportunities for improving diagnosis (MOIDs), are poorly understood in the paediatric emergency department (ED) setting. We investigated the clinical experience, harm and contributing factors related to MOIDs reported by physicians working in paediatric EDs.MethodsWe developed a web-based survey in which physicians participating in the international Paediatric Emergency Research Network representing five out of six WHO regions, described examples of MOIDs involving their own or a colleague's patients. Respondents provided case summaries and answered questions regarding harm and factors contributing to the event.ResultsOf 1594 physicians surveyed, 412 (25.8%) responded (mean age=43 years (SD=9.2), 42.0% female, mean years in practice=12 (SD=9.0)). Patient presentations involving MOIDs had common undifferentiated symptoms at initial presentation, including abdominal pain (21.1%), fever (17.2%) and vomiting (16.5%). Patients were discharged from the ED with commonly reported diagnoses, including acute gastroenteritis (16.7%), viral syndrome (10.2%) and constipation (7.0%). Most reported MOIDs (65%) were detected on ED return visits (46% within 24 hours and 76% within 72 hours). The most common reported MOID was appendicitis (11.4%), followed by brain tumour (4.4%), meningitis (4.4%) and non-accidental trauma (4.1%). More than half (59.1%) of the reported MOIDs involved the patient/parent-provider encounter (eg, misinterpreted/ignored history or an incomplete/inadequate physical examination). Types of MOIDs and contributing factors did not differ significantly between countries. More than half of patients had either moderate (48.7%) or major (10%) harm due to the MOID.ConclusionsAn international cohort of paediatric ED physicians reported several MOIDs, often in children who presented to the ED with common undifferentiated symptoms. Many of these were related to patient/parent-provider interaction factors such as suboptimal history and physical examination. Physicians' personal experiences offer an underexplored source for investigating and mitigating diagnostic errors in the paediatric ED.

Background Recent evidence indicates increased access to and use of Internet and non-healthcare-related email by older patients. Because email adoption could potentially reduce some of the disparities faced by this age group, there is a need to understand factors determining older patients’ enthusiasm to use email to communicate with their physicians. Electronic mail (email) represents a means of communication that, coupled with face-to-face communication, could enhance quality of care for older patients. Objective Test a model to determine factors associated with older patients’ enthusiasm to use email to communicate with their physicians. Methods We conducted a secondary data analysis of survey data collected in 2003 for two large, longitudinal, randomized controlled trials. Logistic-regression models were used to model the dichotomous outcome of patient enthusiasm for using email to communicate with their physicians. Explanatory variables included demographic characteristics, health status, use of email with people other than their physician, characteristics of the physician-patient relationship, and physician enthusiasm to use email with patients. Results Participants included a pooled sample of 4059 patients over 65 years of age and their respective physicians (n = 181) from community-based practices in Southern California. Although only 52 (1.3%) patient respondents reported that they communicated with their physician by email, about half (49.3%) expressed enthusiasm about the possibility of using it. Odds of being enthusiastic decreased with increased age (by 0.97 for each year over 66) but were significantly higher in African Americans (OR = 2.1, CI = 1.42 - 3.06), Hispanics (OR = 1.6, CI = 1.26 - 2.14) and men (OR = 1.3, CI = 1.1 - 1.5). Conclusions Despite perceived barriers such as limited access to the Internet, older patients seem to want to use email to communicate with their physicians.

Organophosphorus compounds (OPs) are phosphoric acid derivatives represented by the formula (R2XP=O/S), R as organic groups; however, they need not contain a direct carbon-phosphorus bond. The organophosphorus compounds can be categorized into three classes, viz., organophosphates, carbamates nerve agents. The OPs having application as insecticides are generally phosphorothioates (i.e., containing P=S bond). These sulfur analogs are first bioactivated (in vivo) and converted to oxygen analogs responsible for exerting toxic action. These organophosphorus compounds are esters, fluorides, anhydrides, and amides of phosphoric, phosphorothioate, and phosphorodithioic acids. The toxicity of OPs is related to their molecular structure, metabolism in the targeted organisms, concentration, mode of decomposition, application, ingestion in organisms, etc. Exposure to OPs leads to the appearance of neurological symptoms followed by acute poisoning by targeting the target primarily, acetylcholine (AChE). However, secondary targets and other harmful effects besides nerve system problems are also reported. Organophosphates poison insects and other animals, including birds, amphibians, and mammals. These chemicals can have neural effects (Neurotoxicity), non-neuronal effects, or acute toxicity, which may also result in fatality. Their uncontrollable widespread became a significant threat to the environment; thus, corrective measures have been essential to save living beings and the environment from further damage.