OBJECTIVE To identify risk factors predictive of pulmonary embolus (PE) timing after a traumatic injury. METHODS One hundred eight traumatic injury patients with a confirmed diagnosis of PE were classified as early PE (≤4 days, n = 54) or late PE (>4 days, n = 54). Independent predictors of early versus late PE were identified using multivariate logistic regression. RESULTS Half the PEs were diagnosed ≤4 days of injury. Only long bone fractures independently predicted early PE (odds ratio 2.8; 95% confidence interval, 1.1–7.1). Severe head injuries were associated with late PE (odds ratio 11.1; 95% confidence interval, 3.9–31). Established risk factors such as age did not affect timing. CONCLUSIONS Half the PEs were diagnosed ≤4 days after injury. The risk of early PE appeared highest in patients with long bone fractures, and the benefits of immediate prophylaxis may outweigh risks. Patients with severe head injuries appear to have later PE events. Prospective interventional trials in these injury populations are needed.

During the last two decades, primary aldosteronism has emerged as the most common cause of secondary hypertension, and advances in the diagnosis and treatment of this condition have improved patient care substantially. A major stumbling block in the evaluation and management of these patients, which ultimately guides treatment and prognosis, is answering the question, "Which adrenal gland(s) produce aldosterone?" Adrenal vein sampling has emerged as the only reliable method to determine the answer to this question; however, the methodology and criteria for lateralization have been determined empirically with little prospective data. The major remaining controversies surrounding adrenal vein sampling include: who should perform and who should undergo the procedure; what criteria should be used to define a successful study and lateralization of aldosterone production; whether cosyntropin should be infused during the procedure and how; and what to do when results are ambiguous? This article reviews some of the advances in the execution of this procedure, the variations in procedure, the data that fuel the controversies, and the issues that need to be resolved in the future.

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The COVID-19 pandemic has challenged the United States’ existing national public health informatics infrastructure. This report details the factors that have contributed to COVID-19 data inaccuracies and reporting delays and their effect on the modeling and monitoring of the COVID-19 pandemic.

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Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

ObjectiveWe sought to demonstrate applicability of user stories, progressively elaborated by testable acceptance criteria, as lightweight requirements for agile development of clinical decision support (CDS).Materials and MethodsUser stories employed the template: As a [type of user], I want [some goal] so that [some reason]. From the “so that” section, CDS benefit measures were derived. Detailed acceptance criteria were elaborated through ensuing conversations. We estimated user story size with “story points,” and depicted multiple user stories with a use case diagram or feature breakdown structure. Large user stories were split to fit into 2-week iterations.ResultsOne example user story was: As a rheumatologist, I want to be advised if my patient with rheumatoid arthritis is not on a disease-modifying anti-rheumatic drug (DMARD), so that they receive optimal therapy and can experience symptom improvement. This yielded a process measure (DMARD use), and an outcome measure (Clinical Disease Activity Index). Following implementation, the DMARD nonuse rate decreased from 3.7% to 1.4%. Patients with a high Clinical Disease Activity Index improved from 13.7% to 7%. For a thromboembolism prevention CDS project, diagrams organized multiple user stories.DiscussionUser stories written in the clinician’s voice aid CDS governance and lead naturally to measures of CDS effectiveness. Estimation of relative story size helps plan CDS delivery dates. User stories prove to be practical even on larger projects.ConclusionsUser stories concisely communicate the who, what, and why of a CDS request, and serve as lightweight requirements for agile development to meet the demand for increasingly diverse CDS.

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