No Increased Risk of Major Adverse Cardiovascular Events following Nicotinamide Exposure.

Importance: Nicotinamide metabolites have recently been implicated in increased risk of major cardiovascular events (MACE). Supportive data about clinical risk of MACE for nicotinamide users is lacking.

Objective: To determine whether nicotinamide use results in an increase of MACE.

Toward personalized skin cancer care: multiple skin cancer development in five cohorts.

Importance: Many patients will develop more than one skin cancer, however most research to date has examined only case status.

Objective: Describe the frequency and timing of the treatment of multiple skin cancers in individual patients over time.

Design: Longitudinal claims and electronic health record-based cohort study.

Voriconazole Metabolism is Associated with the Number of Skin Cancers Per Patient.

Voriconazole exposure is associated with skin cancer, but it is unknown how the full spectrum of its metabolizer phenotypes impacts this association. We conducted a retrospective cohort study to determine how variation in metabolism of voriconazole as measured by metabolizer status of CYP2C19 is associated with the total number of skin cancers a patient develops and the rate of development of the first skin cancer after treatment. There were 1,739 organ transplant recipients with data on CYP2C19 phenotype.

A report on the safety of acitretin use in patients with renal failure on haemodialysis.

Acitretin, commonly used for severe psoriasis and keratinocyte carcinoma chemoprevention in high-risk patients, is contraindicated in patients with end-stage renal disease (ESRD) on haemodialysis (HD). However, these patients often lack medication choices and in certain clinical scenarios the benefits of acitretin may outweigh the potential risks. We identified 24 patients with ESRD on HD undergoing acitretin treatment from the Duke and Vanderbilt University Medical Centers.

Sustainable deployment of clinical prediction tools-a 360° approach to model maintenance.

Background: As the enthusiasm for integrating artificial intelligence (AI) into clinical care grows, so has our understanding of the challenges associated with deploying impactful and sustainable clinical AI models. Complex dataset shifts resulting from evolving clinical environments strain the longevity of AI models as predictive accuracy and associated utility deteriorate over time.

Objective: Responsible practice thus necessitates the lifecycle of AI models be extended to include ongoing monitoring and maintenance strategies within health system algorithmovigilance programs.

A framework for understanding label leakage in machine learning for health care.

Introduction: The pitfalls of label leakage, contamination of model input features with outcome information, are well established. Unfortunately, avoiding label leakage in clinical prediction models requires more nuance than the common advice of applying "no time machine rule."

Framework: We provide a framework for contemplating whether and when model features pose leakage concerns by considering the cadence, perspective, and applicability of predictions.

Recent Advances in Melanoma Diagnosis and Prognosis Using Machine Learning Methods.

Purpose Of Review: The purpose was to summarize the current role and state of artificial intelligence and machine learning in the diagnosis and management of melanoma.

Recent Findings: Deep learning algorithms can identify melanoma from clinical, dermoscopic, and whole slide pathology images with increasing accuracy. Efforts to provide more granular annotation to datasets and to identify new predictors are ongoing.

Open questions and research gaps for monitoring and updating AI-enabled tools in clinical settings.

As the implementation of artificial intelligence (AI)-enabled tools is realized across diverse clinical environments, there is a growing understanding of the need for ongoing monitoring and updating of prediction models. Dataset shift-temporal changes in clinical practice, patient populations, and information systems-is now well-documented as a source of deteriorating model accuracy and a challenge to the sustainability of AI-enabled tools in clinical care. While best practices are well-established for training and validating new models, there has been limited work developing best practices for prospective validation and model maintenance.

Does Vitamin D Provide Added Benefit to Antihypertensive Therapy in Reducing Left Ventricular Hypertrophy Determined by Cardiac Magnetic Resonance?

Background: Left ventricular hypertrophy (LVH) and vitamin D deficiency have been linked to hypertension (HTN) and cardiovascular disease, particularly in African Americans (AAs). Our objective was to determine if the addition of vitamin D to antihypertensive therapy would lead to greater regression of LV mass index (LVMI) as determined by cardiac magnetic resonance (CMR) after 1 year in vitamin D deficient AA patients with uncontrolled HTN and LVH.

Methods: This study was a randomized, double-blind, placebo-controlled, single-center study.

Maintaining a National Acute Kidney Injury Risk Prediction Model to Support Local Quality Benchmarking.

Background: The utility of quality dashboards to inform decision-making and improve clinical outcomes is tightly linked to the accuracy of the information they provide and, in turn, accuracy of underlying prediction models. Despite recognition of the need to update prediction models to maintain accuracy over time, there is limited guidance on updating strategies. We compare predefined and surveillance-based updating strategies applied to a model supporting quality evaluations among US veterans.

Feasibility and Short-Term Effects of a Multi-Component Emergency Department Blood Pressure Intervention: A Pilot Randomized Trial.

Background Emergency department (ED) visits can be opportunities to address uncontrolled hypertension. We sought to compare short-term blood pressure measures between the Vanderbilt Emergency Room Bundle (VERB) intervention and usual care plus education. Methods and Results We conducted a randomized trial of 206 adult patients with hypertension and elevated systolic blood pressure (SBP) presenting to 2 urban emergency departments in Tennessee, USA.

Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic.

Background: Since the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them.

Methods: This study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic.

Estimating the impact of engagement with digital health interventions on patient outcomes in randomized trials.

Objective: Guidance is needed on studying engagement and treatment effects in digital health interventions, including levels required for benefit. We evaluated multiple analytic approaches for understanding the association between engagement and clinical outcomes.

Materials And Methods: We defined engagement as intervention participants' response rate to interactive text messages, and considered moderation, standard regression, mediation, and a modified instrumental variable (IV) analysis to investigate the relationship between engagement and clinical outcomes.

Diurnal Variation in SARS-CoV-2 PCR Test Results: Test Accuracy May Vary by Time of Day.

False negative tests for SARS-CoV-2 are common and have important public health and medical implications. We tested the hypothesis of diurnal variation in viral shedding by assessing the proportion of positive versus negative SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) tests and cycle time (Ct) values among positive samples by the time of day. Among 86,342 clinical tests performed among symptomatic and asymptomatic patients in a regional health care network in the southeastern United States from March to August 2020, we found evidence for diurnal variation in the proportion of positive SARS-CoV-2 tests, with a peak around 1400 h and 1.

User preferences for and engagement with text messages to support antihypertensive medication adherence: Findings from a pilot study evaluating an emergency department-based behavioral intervention.

Objective: We examined users' preferences for and engagement with text messages delivered as part of an emergency department (ED)-based intervention to improve antihypertensive medication adherence.

Methods: We recruited ED patients with elevated blood pressure for a pilot randomized trial evaluating a medication adherence intervention with text messages. Intervention participants chose text content and frequency, received texts for 45 days, and completed a feedback survey.

A novel wellness intervention: A virtual hangout from coast to coast using video conferencing platforms to increase physician wellness during the COVID-19 pandemic.

Within the context of the evolving SARS-CoV-2 pandemic, we sought to design a project to increase social connectivity among emergency medicine physicians with ties to Vanderbilt University Medical Center. Our project aimed to promote physician wellness through fostering and maintaining community at one large academic institution.

Transfer boarding delays care more in low-volume rural emergency departments: A cohort study.

Purpose: Emergency department (ED) crowding is increasing and is associated with adverse patient outcomes. The objective of this study was to measure the relative impact of ED boarding on timeliness of early ED care for new patient arrivals, with a focus on the differential impact in low-volume rural hospitals.

Methods: A retrospective cohort of all patients presenting to a Veterans Health Administration (VHA) ED between 2011 and 2014.

Institutional Challenges and Solutions to Evidence-Based, Patient-Centered Practice: Implementing ICU Diaries.

Background: Although diaries are an evidence-based practice that improves the quality of life of patients in an intensive care unit and their loved ones, centers in the United States are struggling to successfully implement diary programs in intensive care units. Currently, few published recommendations address how to facilitate implementation of a diary program, and how to effectively sustain it, in an intensive care unit.

Objectives: To discuss challenges with implementing diary programs in intensive care units at 2 institutions in the United States, and to identify solutions that were operationalized to overcome these perceived difficulties.

Understanding the Information Needs and Context of Trauma Handoffs to Design Automated Sensing Clinical Documentation Technologies: Qualitative Mixed-Method Study of Military and Civilian Cases.

Background: Current methods of communication between the point of injury and receiving medical facilities rely on verbal communication, supported by brief notes and the memory of the field medic. This communication can be made more complete and reliable with technologies that automatically document the actions of field medics. However, designing state-of-the-art technology for military field personnel and civilian first responders is challenging due to the barriers researchers face in accessing the environment and understanding situated actions and cognitive models employed in the field.