Prevalence of Behavioral Flags in the Electronic Health Record Among Black and White Patients Visiting the Emergency Department.

Importance: Behavioral flags in the electronic health record (EHR) are designed to alert clinicians of potentially unsafe or aggressive patients. These flags may introduce bias, and understanding how they are used is important to ensure equitable care. Objective: To investigate the incidence of behavioral flags and assess whether there were differences between Black and White patients and whether the flags were associated with differences in emergency department (ED) clinical care. Design, Setting, and Participants: This was a retrospective cohort study of EHR data of adult patients (aged ≥18 years) from 3 Philadelphia, Pennsylvania, EDs within a single health system between January 1, 2017, and December 31, 2019. Secondary analyses excluded patients with sickle cell disease and high ED care utilization. Data were analyzed from February 1 to April 4, 2022. Main Outcomes and Measures: The primary outcome of interest was the presence of an EHR behavioral flag. Secondary measures included variation of flags across sex, race, age, insurance status, triage status, ED clinical care metrics (eg, laboratory, medication, and radiology orders), ED disposition (discharge, admission, or observation), and length of key intervals during ED care. Results: Participating EDs had 195 601 eligible patients (110 890 [56.7%] female patients; 113 638 Black patients [58.1%]; 81 963 White patients [41.9%]; median [IQR] age, 42 [28-60] years), with 426 858 ED visits. Among these, 683 patients (0.3%) had a behavioral flag notification in the EHR (3.5 flags per 1000 patients), and it was present for 6851 ED visits (16 flagged visits per 1000 visits). Patient differences between those with a flag and those without included male sex (56.1% vs 43.3%), Black race (71.2% vs 56.7%), and insurance status, particularly Medicaid insurance (74.5% vs 36.3%). Flag use varied across sites. Black patients received flags at a rate of 4.0 per 1000 patients, and White patients received flags at a rate of 2.4 per 1000 patients (P < .001). Among patients with a flag, Black patients, compared with White patients, had longer waiting times to be placed in a room (median [IQR] time, 28.0 [10.5-89.4] minutes vs 18.2 [7.2-75.1] minutes; P < .001), longer waiting times to see a clinician (median [IQR] time, 42.1 [18.8-105.5] minutes vs 33.3 [15.3-84.5] minutes; P < .001), and shorter lengths of stay (median [IQR] time, 274 [135-471] minutes vs 305 [154-491] minutes; P = .01). Black patients with a flag underwent fewer laboratory (eg, 2449 Black patients with 0 orders [43.4%] vs 441 White patients with 0 orders [36.7%]; P < .001) and imaging (eg, 3541 Black patients with no imaging [62.7%] vs 675 White patients with no imaging [56.2%]; P < .001) tests compared with White patients with a flag. Conclusions and Relevance: This cohort study found significant differences in ED clinical care metrics, including that flagged patients had longer wait times and were less likely to undergo laboratory testing and imaging, which was amplified in Black patients.

Randomized Trial of Hepatic Artery Embolization for Hepatocellular Carcinoma Using Doxorubicin-Eluting Microspheres Compared With Embolization With Microspheres Alone.

PURPOSE: Transarterial chemoembolization is accepted therapy for hepatocellular carcinoma (HCC). No randomized trial has demonstrated superiority of chemoembolization compared with embolization, and the role of chemotherapy remains unclear. This randomized trial compares the outcome of embolization using microspheres alone with chemoembolization using doxorubicin-eluting microspheres. MATERIALS AND METHODS: At a single tertiary referral center, patients with HCC were randomly assigned to embolization with microspheres alone (Bead Block [BB]) or loaded with doxorubicin 150 mg (LC Bead [LCB]). Random assignment was stratified by number of embolizations to complete treatment, and assignments were generated by permuted blocks in the institutional database. The primary end point was response according to RECIST 1.0 (Response Evaluation Criteria in Solid Tumors) using multiphase computed tomography 2 to 3 weeks post-treatment and then at quarterly intervals, with the reviewer blinded to treatment allocation. Secondary objectives included safety and tolerability, time to progression, progression-free survival, and overall survival. This trial is currently closed to accrual. RESULTS: Between December 2007 and April 2012, 101 patients were randomly assigned: 51 to BB and 50 to LCB. Demographics were comparable: median age, 67 years; 77% male; and 22% Barcelona Clinic Liver Cancer stage A and 78% stage B or C. Adverse events occurred with similar frequency in both groups: BB, 19 of 51 patients (38%); LCB, 20 of 50 patients (40%; P = .48), with no difference in RECIST response: BB, 5.9% versus LCB, 6.0% (difference, -0.1%; 95% CI, -9% to 9%). Median PFS was 6.2 versus 2.8 months (hazard ratio, 1.36; 95% CI, 0.91 to 2.05; P = .11), and overall survival, 19.6 versus 20.8 months (hazard ratio, 1.11; 95% CI, 0.71 to 1.76; P = .64) for BB and LCB, respectively. CONCLUSION: There was no apparent difference between the treatment arms. These results challenge the use of doxorubicin-eluting beads for chemoembolization of HCC.

On the effect of muscular cocontraction on the 3-D human arm impedance.

Humans have the inherent ability to perform highly dexterous tasks with their arms, involving maintenance of posture, movement, and interaction with the environment. The latter requires the human to control the dynamic characteristics of the upper limb musculoskeletal system. These characteristics are quantitatively represented by inertia, damping, and stiffness, which are measures of mechanical impedance. Many previous studies have shown that arm posture is a dominant factor in determining the end point impedance on a horizontal plane. This paper presents the characterization of the end point impedance of the human arm in 3-D space. Moreover, it models the regulation of the arm impedance with muscle cocontraction. The characterization is made by route of experimental trials where human subjects maintained arm posture while their arms were perturbed by a robot arm. Furthermore, the subjects were asked to control the level of their arm muscles' cocontraction, using visual feedback, in order to investigate the effect of muscle cocontraction on the arm impedance. The results of this study show an anisotropic increase of arm stiffness due to muscle cocontraction. These results could improve our understanding of the human arm biomechanics, as well as provide implications for human motor control-specifically the control of arm impedance through muscle cocontraction.

An intrinsically safe mechanism for physically coupling humans with robots.

Robots are increasingly used in tasks that include physical interaction with humans. Examples can be found in the area of rehabilitation robotics, power augmentation robots, as well as assistive and orthotic devices. However, current methods of physically coupling humans with robots fail to provide intrinsic safety, adaptation and efficiency, which limit the application of wearable robotics only to laboratory and controlled environments. In this paper we present the design and verification of a novel mechanism for physically coupling humans and robots. The device is intrinsically safe, since it is based on passive, non-electric features that are not prone to malfunctions. The device is capable of transmitting forces and torques in all directions between the human user and the robot. Moreover, its re-configurable nature allows for easy and consistent adjustment of the decoupling force. The latter makes the mechanism applicable to a wide range of human-robot coupling applications, ranging from low-force rehabilitation-therapy scenarios to high-force augmentation cases.

Activation of transglutaminase in mu-calpain null erythrocytes.

Intracellular transglutaminases (protein-glutamine: amine gamma-glutamyltransferase, EC 2.3.2.13) are calcium-dependent thiol enzymes that catalyze the covalent cross-linking of proteins, including those in the erythrocyte membrane. Several studies suggest that the activation of some transglutaminases is positively regulated by the calcium-dependent cysteine protease, mu-calpain. Using mu-calpain null (Capn1(-/-)) mouse erythrocytes, we demonstrate that the activation of soluble as well as membrane-bound forms of transglutaminase (TG2) in mouse erythrocytes was independent of mu-calpain. Also, the absence of mu-calpain or any detectable cysteine protease did not affect the transglutaminase activity in the erythrocyte lysate. Our studies also identify physiological substrates of mu-calpain in the erythrocyte membrane and show that their cleavage has no discernible effect on the transglutaminase mediated cross-linking of membrane proteins. Taken together, these data suggest the existence of a calpain-independent mechanism for the activation of transglutaminase 2 by calcium ions in the mouse erythrocytes and presumably also in non-erythroid cells.

Labor shortages spark innovation. An interview with Gerald F. O'Neill.

Labor shortages in both clinical and nonclinical areas are plaguing hospitals and health systems around the country. In Methuen, Massachusetts, Holy Family Hospital and Medical Center is pioneering new ways to fill nursing and other staff vacancies with permanent, experienced personnel who already are loyal to the hospital. Holy Family's senior vice president and CFO, Gerald F. O'Neill, discusses his organization's creative efforts to battle the healthcare labor shortage and other challenges facing healthcare organizations.