Warthin-like papillary carcinoma thyroid.

Solitary thyroid nodule should raise a suspicion of malignancy, which is very common in middle-aged females. Papillary carcinoma thyroid is the most common thyroid malignancy. Warthin-like papillary carcinoma is one of its rare variants. It has a frequent association with Hashimoto's thyroiditis. Here, we report a case of 43-year-old female who presented with swelling in the anterior aspect of neck for 1 month. Fine-needle aspiration cytology features were suggestive of papillary carcinoma thyroid and biopsy confirmed the diagnosis of Warthin-like papillary carcinoma thyroid. This variant is of great clinical and prognostic significance as it carries an excellent prognosis.

A Study on Efficacy of UGI Scopy in Cholelithiasis Patients before Laparoscopic Cholecystectomy.

OBJECTIVES: Upper abdominal symptoms are common in both gallstone disease and inflammatory disorders of gastroduodenum. To differentiate the causes of upper gastrointestinal symptoms due to gallstone and gastroduodenal disorders, upper gastrointestinal (UGI) scopy is a useful diagnostic tool. Our aim of study is to determine the efficacy of the preoperative UGI scopy and concurrent treatment of associated esophageal and gastric pathologies with symptomatic cholelithiasis in view of postoperative symptom reduction. MATERIALS AND METHODS: This is a prospective study comprising 400 symptomatic cholelithiasis patients admitted in our institution. All patients underwent upper GI endoscopy (1-4 days) prior to cholecystectomy, and the findings were noted. Then, based on findings in UGI scopy, patients were grouped as group A (endoscopy normal) and group B (endoscopy with some findings). Group B patients were treated with medication, and both groups were operated with laparoscopic cholecystectomy. Pain and other symptoms in the preoperative period and postoperative period were measured and compared in both groups. RESULTS: After excluding 7 patients with significant endoscopy findings, we have included 400 patients who underwent laparoscopy cholecystectomy. In a total of 400 patients, median age of presentation was 47.3 and female to male ratio was 2.2 : 1. Endoscopy showed some pathological findings in 75.5% patients, and the commonest endoscopy finding was gastritis. On comparison of pain score in preoperative patients, pain score was high in group B patients (p < 0.05). Pain reduction was significant in postoperative 1st, 4th, and 6th weeks in both groups (p < 0.0005). In the same way, other symptoms other than pain were compared which shows postoperative symptom reduction is highly significant in group B patients. CONCLUSION: Clinical presentation of cholelithiasis and other upper GI diseases resemble each other. It is difficult to discriminate between upper GI symptoms due to cholelithiasis or any other upper GI conditions. Although UGI scopy is not recommended for all patients with cholelithiasis, it may be beneficial to do UGI scopy in certain cholelithiasis patients with atypical presentation to prevent atypical symptoms after surgery.

A Web-Based, Mobile-Responsive Application to Screen Health Care Workers for COVID-19 Symptoms: Rapid Design, Deployment, and Usage.

BACKGROUND: As of July 17, 2020, the COVID-19 pandemic has affected over 14 million people worldwide, with over 3.68 million cases in the United States. As the number of COVID-19 cases increased in Massachusetts, the Massachusetts Department of Public Health mandated that all health care workers be screened for symptoms daily prior to entering any hospital or health care facility. We rapidly created a digital COVID-19 symptom screening tool to enable this screening for a large, academic, integrated health care delivery system, Partners HealthCare, in Boston, Massachusetts. OBJECTIVE: The aim of this study is to describe the design and development of the COVID Pass COVID-19 symptom screening application and report aggregate usage data from the first three months of its use across the organization. METHODS: Using agile principles, we designed, tested, and implemented a solution over the span of one week using progressively customized development approaches as the requirements and use case become more solidified. We developed the minimum viable product (MVP) of a mobile-responsive, web-based, self-service application using research electronic data capture (REDCap). For employees without access to a computer or mobile device to use the self-service application, we established a manual process where in-person, socially distanced screeners asked employees entering the site if they have symptoms and then manually recorded the responses in an Office 365 Form. A custom .NET Framework application solution was developed as COVID Pass was scaled. We collected log data from the .NET application, REDCap, and Microsoft Office 365 from the first three months of enterprise deployment (March 30 to June 30, 2020). Aggregate descriptive statistics, including overall employee attestations by day and site, employee attestations by application method (COVID Pass automatic screening vs manual screening), employee attestations by time of day, and percentage of employees reporting COVID-19 symptoms, were obtained. RESULTS: We rapidly created the MVP and gradually deployed it across the hospitals in our organization. By the end of the first week, the screening application was being used by over 25,000 employees each weekday. After three months, 2,169,406 attestations were recorded with COVID Pass. Over this period, 1865/160,159 employees (1.2%) reported positive symptoms. 1,976,379 of the 2,169,406 attestations (91.1%) were generated from the self-service screening application. The remainder were generated either from manual attestation processes (174,865/2,169,406, 8.1%) or COVID Pass kiosks (25,133/2,169,406, 1.2%). Hospital staff continued to work 24 hours per day, with staff attestations peaking around shift changes between 7 and 8 AM, 2 and 3 PM, 4 and 6 PM, and 11 PM and midnight. CONCLUSIONS: Using rapid, agile development, we quickly created and deployed a dedicated employee attestation application that gained widespread adoption and use within our health system. Further, we identified 1865 symptomatic employees who otherwise may have come to work, potentially putting others at risk. We share the story of our implementation, lessons learned, and source code (via GitHub) for other institutions who may want to implement similar solutions.

Challenges faced in the management of complicated Boerhaave syndrome: a tertiary care center experience.

Spontaneous esophageal perforation is rare and is associated with high morbidity and mortality. A spectrum of various surgical modalities ranging from primary surgical repair to esophagectomy is available for its management. The optimal management of patients presenting late in a hemodynamically stable condition is not clearly defined in the literature. A retrospective review of all patients with Boerhaave syndrome managed by a single surgical team in a tertiary care center between 2008 and 2019 was performed (n = 16). Eleven patients were initially managed in the medical intensive care unit (MICU) as non-esophageal cause and 5 patients were referred after failed management (conservative/endoscopic). Demographics, clinical presentation, characteristics of perforation, initial diagnosis, and treatment were analyzed. All patients were males with a mean age of 42.2 years. A history of ethanol use was present in 6 patients. The median delay in diagnosis and referral was 16 days (range: 11-40 days). The common presenting symptoms were chest pain (n=11), dyspnoea (n=10), vomiting (n=4) and cough (n=2). The perforation was directed into right, left, and bilateral pleural cavities in 6, 8, and 2 patients respectively. The location of perforation was distal esophagus except for one patient. One patient was successfully treated with conservative management. The remaining patients underwent esophagectomy as a definitive surgical procedure. There was no significant postoperative morbidity and mortality. Esophagectomy can be done as a one-stage definitive procedure for patients with Boerhaave syndrome who present late in a hemodynamically stable condition with acceptable morbidity and good long term outcome.

Lost Denture Found in Esophagus After a Decade: A Rare Case Report.

Dentures are accidentally ingested foreign bodies, especially in the geriatric population. They get frequently lodged in the esophagus because of their larger size, rigidity, and pointed edges. But, it is unusual for a denture to remain asymptomatic in the esophagus for a decade. We report a case of 45-year-old female who presented with the complaints of progressive dysphagia for six months. Endoscopy revealed an impacted denture in the mid-esophagus. The patient recollected that she lost her denture 13 years back and was unaware that she swallowed it. Right thoracotomy and esophagotomy were done to remove the impacted denture. The esophagotomy site was buttressed with vascularised intercostal muscle flap.

A novel strategy for evaluating the effects of an electronic test ordering alert message: Optimizing cardiac marker use.

BACKGROUND: Laboratory ordering functions within computerized provider order entry (CPOE) systems typically support the display of electronic alert messages to improve test utilization or implement new ordering policies. However, alert strategies have been shown to vary considerably in their success and the characteristics contributing to an alert's success are poorly understood. Improved methodologies are needed to evaluate alerts and their mechanisms of action. MATERIALS AND METHODS: Clinicians order inpatient and emergency department laboratory tests using our institutional CPOE system. We analyzed user interaction data captured by our CPOE system to evaluate how clinicians responded to an alert. We evaluated an alert designed to implement an institutional policy restricting the indications for ordering creatine kinase-MB (CKMB). RESULTS: Within 2 months of alert implementation, CKMB-associated searches declined by 79% with a corresponding decline in CKMB orders. Furthermore, while prior to alert implementation, clinicians searching for CKMB ultimately ordered this test 99% of the time, following implementation, only 60% of CKMB searches ultimately led to CKMB test orders. This difference presumably represents clinicians who reconsidered the need for CKMB in response to the alert, demonstrating the alert's just-in-time advisory capability. In addition, as clinicians repeatedly viewed the alert, there was a "dose-dependant" decrease in the fraction of searches without orders. This presumably reflects the alerting strategy's long-term educational component, as clinicians aware of the new policy will not search for CKMB when not indicated. CONCLUSIONS: Our analytic approach provides insight into the mechanism of a CPOE alert and demonstrates that alerts may act through a combination of just-in-time advice and longer term education. Use of this approach when implementing alerts may prove useful to improve the success of a given alerting strategy.

Implementation of computerized add-on testing for hospitalized patients in a large academic medical center.

BACKGROUND: Physician requests for additional testing on an existing laboratory specimen (add-ons) are resource intensive and generally require a phone call to the laboratory. Verbal orders such as these have been noted to be associated with errors in accuracy. The aim of this study was to compare a novel computerized system for add-on requests to the prior verbal system. METHOD: We compare the computerized add-on request system to the verbal system with respect to order completeness and workflow. RESULTS: We demonstrate that the computerized add-on system resulted in the complete in-laboratory documentation of the add-on request 100% of the time, compared to 58% with the verbal add-on system. In addition, we show that documentation of a verbal add-on request in the electronic medical record (EMR) occurred for 4% of requests, while in the computerized system EMR documentation occurred 100% of the time. We further demonstrate that the computerized add-on request process was well accepted by providers and did not significantly change the test mix of the add-on requests. CONCLUSIONS: In computerized physician order entry (CPOE) implementations, add-on order functionality should be considered so these orders are documented in the EMR.

A novel class of laboratory middleware. Promoting information flow and improving computerized provider order entry.

A central duty of the laboratory is to inform clinicians about the availability and usefulness of laboratory testing. In this report, we describe a new class of laboratory middleware that connects the traditional clinical laboratory information system with the rest of the enterprise, facilitating information flow about testing services. We demonstrate the value of this approach in efficiently supporting an inpatient order entry application. We also show that order entry monitoring and iterative middleware updates can enhance ordering efficiency and promote improved ordering practices. Furthermore, we demonstrate the value of algorithmic approaches to improve the accuracy and completeness of laboratory test searches. We conclude with a discussion of design recommendations for middleware applications and discuss the potential role of middleware as a sharable, centralized repository of laboratory test information.