The detect consensus report on Attention Deficit/Hyperactivity Disorder and its management among Turkish children and adolescents (Detect: consensus report on ADHD among Turkish youth)

Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most common and heritable neurodevelopmental disorders which may last through the life-span. A consensus report on diagnosis and management of ADHD among Turkish youth was prepared previously. However, the participants as well as the management options were rather limited and developments in the past decade necessitated a revision and update of the consensus. Therefore, this review aims to summarize the consensus among Child and Adolescent Psychiatrists from Türkiye on the nature and management of pediatric ADHD. For those aims, the etiology of ADHD, diagnostic and evaluation process, epidemiology, developmental presentations, differential diagnoses and comorbidities, course/outcome and pharmacological as well as non-pharmacological management options were reviewed and suggestions for clinical practice are presented. Since ADHD is a chronic disorder with wide-ranging effects on functionality that is frequently accompanied by other mental disorders, a multidimensional therapeutic approach is recommended. However, since the disorder has neurobiological basis, pharmacotherapy represents the mainstay of treatment. Additional therapies may include psychosocial therapy, behavioral therapy, school-based therapeutic approaches, and family education. This review provides recommendations for ADHD at the national and global levels. It contains information about ADHD that will contribute to and facilitate clinicians' decision-making processes. It is advisable to consider this guideline in clinical practice.

Topline/Final Diagnostic Inclusion of Relevant Histologic Findings in Surgical Pathology Reporting of Carcinoma in Prostate Biopsies

INTRODUCTION

As the list of histologic parameters to include in surgical pathology reports of prostate cancer biopsies grows, some pathologists include this information in the microscopic description or summary sections of the report, whereas others include it in the "topline" or final diagnosis section. This prompted us to develop a multi-institutional survey to assess reporting trends among genitourinary (GU) pathologists.

METHODS

A survey instrument was shared among 110 GU pathologists via surveymonkey.com. Anonymized respondent data was analyzed.

RESULTS

Eighty-four (76%) participants completed the survey across four continents. Most participants report tumor volume quantitation (88%), number of cores involved (89%), and both Gleason grade and Grade group (93%) in their topline; 71% include percent of pattern 4, with another 16% including it depending on cancer grade; 58% include the presence of cribriform growth pattern 4, with another 11% including it depending on cancer grade. When present, most include extraprostatic extension (90%), prostatic intraductal carcinoma (77%), and perineural invasion (77%). Inclusion of atypical intraductal proliferation (AIP) in the topline diagnosis was cancer grade-dependent, with 74% including AIP in Grade group 1, 61% in Grade group 2, 45% in Grade group 3, 30% in Grade group 4, and 26% in Grade group 5 cancers.

CONCLUSION

Certain histologic features such as Gleason grade and tumor volume/cores involved are frequently included in the topline diagnosis, whereas the incorporation of other findings are more variably included. Prostate biopsy reporting remains a dynamic process with stylistic similarities and differences existing among GU pathologists.

Laboratory approaches to determining blood culture contamination rates: an ASM Laboratory Practices Subcommittee report

Blood culture contamination (BCC) is the presence of specific commensal and environmental organisms cultivated from a single blood culture set out of a blood culture series and that do not represent true bacteremia. BCC can impact quality of care and lead to negative outcomes, unnecessary antibiotic exposure, prolonged hospital stays, and substantial costs. As part of the laboratory's quality management plan, microbiology laboratory personnel are tasked with monitoring BCC rates, preparing BCC rate reports, and providing feedback to the appropriate committees within their healthcare system. The BCC rate is calculated by the laboratory using pre-set criteria. However, pre-set criteria are not universally defined and depend on the individual institution's patient population and practices. This mini-review provides practical recommendations on elaborating BCC rate reports, the parameters to define for the pre-set criteria, how to collect and interpret the data, and additional analysis to include in a BCC report.

A Machine Learning Approach with Human-AI Collaboration for Automated Classification of Patient Safety Event Reports: Algorithm Development and Validation Study

BACKGROUND

Adverse events refer to incidents with potential or actual harm to patients in hospitals. These events are typically documented through patient safety event (PSE) reports, which consist of detailed narratives providing contextual information on the occurrences. Accurate classification of PSE reports is crucial for patient safety monitoring. However, this process faces challenges due to inconsistencies in classifications and the sheer volume of reports. Recent advancements in text representation, particularly contextual text representation derived from transformer-based language models, offer a promising solution for more precise PSE report classification. Integrating the machine learning (ML) classifier necessitates a balance between human expertise and artificial intelligence (AI). Central to this integration is the concept of explainability, which is crucial for building trust and ensuring effective human-AI collaboration.

OBJECTIVE

This study aims to investigate the efficacy of ML classifiers trained using contextual text representation in automatically classifying PSE reports. Furthermore, the study presents an interface that integrates the ML classifier with the explainability technique to facilitate human-AI collaboration for PSE report classification.

METHODS

This study used a data set of 861 PSE reports from a large academic hospital's maternity units in the Southeastern United States. Various ML classifiers were trained with both static and contextual text representations of PSE reports. The trained ML classifiers were evaluated with multiclass classification metrics and the confusion matrix. The local interpretable model-agnostic explanations (LIME) technique was used to provide the rationale for the ML classifier's predictions. An interface that integrates the ML classifier with the LIME technique was designed for incident reporting systems.

RESULTS

The top-performing classifier using contextual representation was able to obtain an accuracy of 75.4% (95/126) compared to an accuracy of 66.7% (84/126) by the top-performing classifier trained using static text representation. A PSE reporting interface has been designed to facilitate human-AI collaboration in PSE report classification. In this design, the ML classifier recommends the top 2 most probable event types, along with the explanations for the prediction, enabling PSE reporters and patient safety analysts to choose the most suitable one. The LIME technique showed that the classifier occasionally relies on arbitrary words for classification, emphasizing the necessity of human oversight.

CONCLUSIONS

This study demonstrates that training ML classifiers with contextual text representations can significantly enhance the accuracy of PSE report classification. The interface designed in this study lays the foundation for human-AI collaboration in the classification of PSE reports. The insights gained from this research enhance the decision-making process in PSE report classification, enabling hospitals to more efficiently identify potential risks and hazards and enabling patient safety analysts to take timely actions to prevent patient harm.

A Case Report Describing Hemophilus parainfluenza Recovered From Pleural Effusion

Hemophilus parainfluenza, a less common pathogen typically found in the oropharyngeal flora, has been associated with various clinical conditions. However, its role in pleural effusions remains scarcely documented. We present a unique case of a 42-year-old female with a history of asthma, hypertension, and obesity who presented with epigastric pain and a moderate right-sided pleural effusion. Hemophilus parainfluenza was isolated from the pleural fluid despite an atypical, asymptomatic presentation without pneumonia. Antibiotic treatment led to a positive response, highlighting the importance of recognizing Hemophilus parainfluenza as a potential causative agent in pleural effusion cases.

Slimmer's Palsy Following Weight Loss Associated With Metastatic Breast Cancer: A Case Report

Common peroneal neuropathy (CPN), also known as Slimmer's Palsy, is an isolated peripheral neuropathy typically associated with rapid weight loss resulting in loss of adipose tissue and subsequent nerve compression at the fibular head and is up to three times more common in individuals with malignancy. In this case report, we describe the diagnosis of CPN in a 54-year-old female with a 2.5-month history of atraumatic left foot drop and left ankle paresthesias, preceded by a 35-40 pound weight loss over the prior 3.5 month period in the setting of metastatic breast cancer.

Guide to the preparation of speech reports for implanted children: opinion of specialists

PURPOSE

To develop a guide for the preparation of speech-language reports of implanted children to be shared among speech-language pathologists of cochlear implant (CI) services and rehabilitation professionals.

METHODS

The Delphi method was used to select the relevant and fundamental items that should be included in the two versions proposed for the guide: Guide 1 - Speech-language reports provided by the CI services to rehabilitators, and Guide 2 - Speech-language reports provided by the rehabilitators to CI services. Twenty-one speech therapists specialized and with experience in cochlear implants and auditory rehabilitation participated in the discussion and judgment of the items during the selection rounds. Consensus was considered when the item reached agreement equal to or greater than 80% among participants, being selected to compose the two guides.

RESULTS

After the two rounds, 21 items from Guide 1 reached consensus among therapists, that is, more than 80% of them agreed that these items should be present in the report sent by the CI service. For Guide 2, 22 items analyzed by speech therapists working in CI services in the postoperative sector were selected in the second round.

CONCLUSION

Based on the analysis of the two rounds, the "Guide for the preparation of speech-language pathology reports: intersection between CI service and rehabilitators" was developed. This material can be applied in the follow-up of implanted children, standardizing the information shared about the electronic device, evaluation results, monitoring of results and therapeutic process of this population.

Extracting Clinical Information From Japanese Radiology Reports Using a 2-Stage Deep Learning Approach: Algorithm Development and Validation

Background

Radiology reports are usually written in a free-text format, which makes it challenging to reuse the reports.

Objective

For secondary use, we developed a 2-stage deep learning system for extracting clinical information and converting it into a structured format.

Methods

Our system mainly consists of 2 deep learning modules: entity extraction and relation extraction. For each module, state-of-the-art deep learning models were applied. We trained and evaluated the models using 1040 in-house Japanese computed tomography (CT) reports annotated by medical experts. We also evaluated the performance of the entire pipeline of our system. In addition, the ratio of annotated entities in the reports was measured to validate the coverage of the clinical information with our information model.

Results

The microaveraged F1-scores of our best-performing model for entity extraction and relation extraction were 96.1% and 97.4%, respectively. The microaveraged F1-score of the 2-stage system, which is a measure of the performance of the entire pipeline of our system, was 91.9%. Our system showed encouraging results for the conversion of free-text radiology reports into a structured format. The coverage of clinical information in the reports was 96.2% (6595/6853).

Conclusions

Our 2-stage deep system can extract clinical information from chest and abdomen CT reports accurately and comprehensively.

Systematic Violence Monitoring to Reduce Underreporting and to Better Inform Workplace Violence Prevention Among Health Care Workers: Before-and-After Prospective Study

BACKGROUND

Monitoring workplace violence (WPV) against health care workers (HCWs) through incident reporting is crucial to drive prevention, but the actual implementation is spotty and experiences underreporting.

OBJECTIVE

This study aims to introduce a systematic WPV surveillance in 2 public referral hospitals in Italy and assess underreporting, WPV annual rates, and attributes "before" (2016-2020) and "after" its implementation (November 2021 to 2022).

METHODS

During 2016-2020, incident reporting was based on procedures and data collection forms that were neither standardized between hospitals nor specific for aggressions. We planned and implemented a standardized WPV surveillance based on (1) an incident report form for immediate and systematic event notification, adopting international standards for violence definitions; (2) second-level root cause analysis with a dedicated psychologist, assessing violence determinants and impacts and offering psychological counseling; (3) a web-based platform for centralized data collection; and (4) periodic training for workforce coordinators and newly hired workers. We used data from incident reports to estimate underreporting, defined as an observed-to-expected (from literature and the "before" period) WPV ratio less than 1, and the 12-month WPV rates (per 100 HCWs) in the "before" and "after" periods. During the latter period, we separately estimated WPV rates for first and recurrent events.

RESULTS

In the "before" period, the yearly observed-to-expected ratios were consistently below 1 and as low as 0.27, suggesting substantial violence underreporting of up to 73%. WPV annual rates declined in 1 hospital (from 1.92 in 2016 to 0.57 in 2020) and rose in the other (from 0.52 to 1.0), with the divergence being attributable to trends in underreporting. Available data were poorly informative to identify at-risk HCW subgroups. In the "after" period, the observed-to-expected ratio rose to 1.14 compared to literature and 1.91 compared to the "before" period, consistently in both hospitals. The 12-month WPV rate was 2.08 (95% CI 1.79-2.42; 1.52 and 2.35 in the 2 hospitals); one-fifth (0.41/2.08, 19.7%) was due to recurrences. Among HCWs, the youngest group (3.79; P<.001), nurses (3.19; P<.001), and male HCWs (2.62; P=.008) reported the highest rates. Emergency departments and psychiatric wards were the 2 areas at increased risk. Physical assaults were more likely in male than female HWCs (45/67, 67.2% vs 62/130, 47.7%; P=.01), but the latter experienced more mental health consequences (46/130, 35.4% vs 13/67, 19.4%; P=.02). Overall, 40.8% (53/130) of female HWCs recognized sociocultural (eg, linguistic or cultural) barriers as contributing factors for the aggression, and 30.8% (40/130) of WPV against female HCWs involved visitors as perpetrators.

CONCLUSIONS

A systematic WPV surveillance reduced underreporting. The identification of high-risk workers and characterization of violence patterns and attributes can better inform priorities and contents of preventive policies. Our evaluation provides useful information for the large-scale implementation of standardized WPV-monitoring programs.

Digital Patient Reported Outcome Measures Platform for Post-COVID-19 Condition and Other Long-Term Conditions: User-Centered Development and Technical Description

BACKGROUND

Post-COVID-19 condition (PCC), colloquially known as long COVID, is a multisystem condition characterized by persistent symptoms beyond 4 weeks after the SARS-CoV-2 infection. More than 60 million people with PCC worldwide need prompt assessment, diagnosis, and monitoring, with many requiring specialist help from a multidisciplinary team of health care professionals (HCPs). Consequently, a scalable digital system is required for both people with PCC and HCPs to capture the breadth of symptoms and their impact on health, using patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs).

OBJECTIVE

We aim to develop and implement a novel PCC digital PROM (DPROM) platform for (1) securely collecting PROM and PREM data from people with PCC, (2) enabling users to monitor symptoms longitudinally and assess response to treatment, (3) generating reports for the electronic health records (EHRs), (4) providing summary reports on PCC services based on national requirements, and (5) facilitating the sharing of relevant data with authorized research teams to accelerate our understanding of this new condition and evaluate new strategies to manage PCC.

METHODS

We (1) undertook requirement analysis with people with PCC, HCPs, and researchers to identify the needs of the DPROM platform and determine its required functionalities; (2) designed and developed a clinically useful web portal for staff and a mobile app for patients, with a web-based alternative app to improve patient and staff choice, limit the risk of digital exclusion, and account for variability across services; (3) determined the PROMs and PREMs that PCC services would prefer to use on the platform; and (4) designed the summary report function that can be generated for each user for the EHR and for reporting to national health authorities.

RESULTS

A DPROM platform to record PCC symptom profile, condition severity, functional disability, and quality of life, based on the C19-YRS (Yorkshire Rehabilitation Scale) and other PROMs and PREMs, was developed. Individual-level medical information and details on the COVID-19 illness can be captured systematically. The platform generates easy-to-understand scores, radar plots and line graphs for people with PCC to self-monitor their condition and for HCPs to assess the natural course of the condition and the response to interventions. Clinics can configure a suite of PROMs and PREMs based on their local and national service and commissioning requirements and support research studies which require large-scale data collection on PROMs. The DPROM platform enables automatic aggregate data analysis for services to undertake service evaluation and cost-effectiveness analysis. The DPROM platform generated summary report can be uploaded to the EHRs of people with PCC.

CONCLUSIONS

A multifunctional DPROM platform to assess, grade, and monitor PCC has been developed. Future research will analyze the system's usability in specialist PCC clinical services and other long-term conditions.

Does report modality modulate psychophysical sensitivity? The jury remains out

Scientific studies of perception use motoric reports as the principal means of communicating subjective experience. In such experiments, a widely held and implicit assumption is that the motor action conveys but does not tamper with perceptual experience. We tested nine observers on a luminance detection task in a cross-over repeated measures design. In separate conditions, observers reported their detection via movements of either their hands or eyes. We found only anecdotal evidence for any modality-dependent effect on psychophysical sensitivity. We also reanalyzed an existing dataset from which deployed a similar detection paradigm involving hand and eye reports. In the four paradigm variants tested, we again only found anecdotal evidence for the effect of report modality on psychophysical sensitivity. Both studies reported here provide only anecdotal evidence; thus, whether we can replicate report-dependent perceptual effects still needs to be resolved. We argue why this remains an important question for consciousness research and why it deserves more rigorous and high-powered replication attempts.

Pleomorphic Adenoma of a Minor Salivary Gland of the Hard Palate: A Case Report

Pleomorphic adenoma affects mostly the parotid gland (85%), submandibular glands (5%), and the minor salivary glands (5%). They are usually referred to as benign mixed tumors because they are composed of both epithelial cells, which are cells from the body's surface, and myoepithelial cells, present inside glands to aid in secretion. An 88-year-old male who had an ulcer for 10 days and a three to four-month-old swelling on his palate arrived in the OPD. On examination, at the intersection of the hard and soft palates, there is a single, well-delineated, nodular exophytic development of small salivary glands left to the median half (most of the pleomorphic adenomas are unilateral). For further and confirmatory diagnosis, fine needle aspiration cytology, immunohistochemistry tests, and radiodiagnosis, i.e., X-rays, were performed which revealed periapical abscess and swelling on palate unassociated with pus discharge. Surgical removal of the swelling and extraction of the root stump was done. The patient was asked to stop smoking strictly. Post-operatively, the patient was given suitable medications.

Evidence-based suggestions to improve the methodological issues in reporting of prevalence studies on gingival recession

Gingival recession (GR) is considered a public health problem which is highly prevalent across different populations. Accuracy of psychometric properties of prevalence estimates of GR reported in epidemiological studies is important to facilitate setting public health goals, planning of public health programs, implementation of best practices and thereby developing public health policy. However, the reported prevalence estimates are influenced by the methodological variations among different studies, as observed in our recently published systematic review and meta-analysis on the global prevalence of GR. It substantially limits the comparability between studies and inferences about the true global variation in the prevalence of GR are difficult to establish. To address these issues, this commentary suggests to follow the standardized principles related to study design, clinical examination protocol, and characteristics of study subjects in future epidemiological studies on prevalence estimates of GR. Furthermore, the inclusion of additional domains in the reporting data is suggested for a deeper insight into the patterns of GR in different populations. Our suggestions are derived from a pragmatic approach and their consistent implementation would improve the reporting quality and achieve uniformity in future studies, thus benefitting the research in this area.

A Video-Based Study of Emergency Medical Services Handoffs to a Pediatric Emergency Department

BACKGROUND

Emergency medical services (EMS) to emergency department (ED) handoffs are important moments in patient care, but patient information is communicated inconsistently.

OBJECTIVE

The aim of this study was to describe the duration, completeness, and communication patterns of patient handoffs from EMS to pediatric ED clinicians.

METHODS

We conducted a video-based, prospective study in the resuscitation suite of an academic pediatric ED. All patients 25 years and younger transported via ground EMS from the scene were eligible. We completed a structured video review to assess frequency of transmission of handoff elements, handoff duration, and communication patterns. We compared outcomes between medical and trauma activations.

RESULTS

We included 156 of 164 eligible patient encounters from January to June 2022. Mean (SD) handoff duration was 76 (39) seconds. Chief symptom and mechanism of injury were included in 96% of handoffs. Most EMS clinicians communicated prehospital interventions (73%) and physical examination findings (85%). However, vital signs were reported for fewer than one-third of patients. EMS clinicians were more likely to communicate prehospital interventions and vital signs for medical compared with trauma activations (p < 0.05). Communication challenges between EMS clinicians and the ED were common; ED clinicians interrupted EMS or requested information already communicated by EMS in nearly one-half of handoffs.

CONCLUSIONS

EMS to pediatric ED handoffs take longer than recommended and frequently lack important patient information. ED clinicians engage in communication patterns that may hinder organized, efficient, and complete handoff. This study highlights the need for standardizing EMS handoff and ED clinician education regarding communication strategies to ensure active listening during EMS handoff.

European Union Legislation for the Welfare of Animals Used for Scientific Purposes: Areas Identified for Further Discussion

The Directive 2010/63/EU of the European Parliament and of the Council has been in force for more than a decade and has brought about significant improvements and novel requirements for the welfare of animals used for scientific purposes, while safeguarding research integrity. The Directive sets clear provisions for its scope, the authorization procedures, animal welfare bodies, national committees, cost/benefit analysis, severity classification, retrospective assessment, and statistical reporting, among many others. From this perspective, indicative areas in the existing legislative texts and guidance documents, which may influence animal welfare and scientific integrity, have been identified by the authors after years of working in this field. Suggested solutions to address these areas by potential future revisions in the legislation or other actions to benefit animal welfare are discussed, with the aim to clarify and simplify them for all stakeholders involved.

Sexual harassment and abuse; disclosure and awareness of report- and support resources in Norwegian sport- and non-sport high schools: a prospective exploratory study

Purpose

To examine high school students' disclosure of sexual harassment and abuse (SHA), and awareness of reporting systems and support mechanisms in school among students, leaders, and coaches.

Method

Norwegian 17-year-old high school elite athletes (n = 630), recreational athletes (n = 307), and reference students (n = 263) responded to an online questionnaire at two measurement points, 1 year apart (T1 and T2). Leaders and coaches (n = 249) at the participating high schools responded to an adapted version of the questionnaire at T1. Data were analyzed using ANOVA or Welch test, Pearson Chi-Square test, and McNemar test.

Results

In total, 11.4 and 34.0% of the adolescents were aware of reporting systems and support mechanisms, respectively, in their schools. Nearly all the leaders, and half of the coaches were aware of these resources. Among the adolescents with lifetime experience of SHA, 20.1% had disclosed their experiences to someone. Girls disclosed more frequently than boys. The elite- and recreational athletes disclosed less often compared with the reference students. A negative change from T1 to T2 was found in disclosure of SHA and awareness of support mechanisms. At T2, 6.5% of the adolescents reported that their school had implemented measures against SHA during the last 12 months.

Conclusion

The results emphasize a need for institutional effort to improve information about available report- and support resources and increase the relevance of use of such systems for adolescents.

Management of Littre Hernia-Case Report and Systematic Review of Case Reports

Littre hernia is a rare type of hernia in which a Meckel diverticulum is found in the hernia sac. Given the rare nature of this disease, little data on demographics and surgical management exists. In this article, we provide a case report of a strangulated inguinal Littre hernia and perform a systematic review of the literature. The PubMed database was searched on 5 March 2022, and all cases of Littre hernia in adults that had English abstracts or full-text were analyzed. Our primary objective was to evaluate the surgical management and outcomes of this particular type of hernia, and our secondary objectives were to assess demographic characteristics, presentation particularities, and recurrence rates. We identified 89 articles with 98 cases, including our own. Results show a high prevalence of complications described intraoperatively, with strangulation being present in up to 38.46% of patients. The laparoscopic approach was utilized in patients with femoral, inguinal, and umbilical hernias. The most commonly performed type of resection was MD resection, followed by bowel resection, while a minority of cases (5.48%) remained unresected. Mesh repair was more frequently performed in patients with MD resection. A mortality rate of 8.7% in patients who underwent bowel resection was found. A relatively high number of reports of ectopic tissue (21.21%), ulceration (12.12%), and tumors (9.09%) were found. The average follow-up was 19.5 ± 10.29 months, with no hernia recurrence. In conclusion, most cases are admitted in an emergency setting, and intestinal obstruction is frequently associated. A minimally invasive approach can be an option even for complicated hernias. MD resection or bowel resection is usually employed, depending on the extent of ischemic lesions. Patients undergoing bowel resection may be prone to worse outcomes.

Combining Isotretinoin and Topical Cholesterol/Atorvastatin in the Treatment of Linear Porokeratosis: A Case Report

Linear porokeratosis (LP) is an epidermal keratinization disorder manifesting in the form of annular plaques with an atrophic center and hyperkeratotic margins. Although rare, LP carries a significant risk of skin cancer. Histological examination usually reveals the cornoid lamella, a parakeratosis column visualized in the outer layer of the epidermis. First-line treatment of LP is retinoids. However, the effects of combination therapy of isotretinoin and topical statins on LP are not well-understood. Herein, we attempted treatment with both isotretinoin and 2% cholesterol/atorvastatin ointment, with considerable improvement observed using the former but not the latter. These findings suggest that 2% topical cholesterol/atorvastatin treatment may not carry any additional benefits, even if used alongside retinoids. Further studies are needed to assess the potential effects of statins on LP.

Thoracic UltrasONOgraphy Reporting: The TUONO Consensus

The widespread use of the lung ultrasound (LUS) has not been followed by the development of a comprehensive standardized tool for its reporting in the intensive care unit (ICU) which could be useful to promote consistency and reproducibility during clinical examination. This work aims to define the essential features to be included in a standardized reporting tool and provides a structured model form to fully express the diagnostic potential of LUS and facilitate intensivists in the use of a LUS in everyday clinical ICU examination. We conducted a modified Delphi process to build consensus on the items to be integrated in a standardized report form and on its structure. A committee of 19 critical care physicians from 19 participating ICUs in Italy was formed, including intensivists experienced in ultrasound from both teaching hospitals and referral hospitals, and internationally renowned experts on the LUS. The consensus for 31 statements out of 33 was reached at the third Delphi round. A structured model form was developed based on the approved statements. The development of a standardized model as a backbone to report a LUS may facilitate the guidelines' application in clinical practice and increase inter-operator agreement. Further studies are needed to evaluate the effects of standardized reports in critically ill patients.

Recurrent Plunging Ranula - A Rare Case Report

BACKGROUND

Plunging ranula is a variant of ranula, which present as a painless subcutaneous anterolateral neck mass and is located beyond the mylohyoid muscle. These swelling presentations with no intraoral component are extremely rare and rarely provide a diagnostic challenge.

CASE REPORT

An elderly male presented with painless neck mass in the cervical region for three months. The mass was excised, and the patient was doing well on follow-up. We report a case of recurrent plunging ranula without any intraoral component.

CONCLUSION

Whenever the intraoral component is missing in ranula, chances of misdiagnosis and mismanagement are high. Awareness of this entity and high index of suspicion is needed for accurate diagnosis and effective management.

Estimating the Under-ascertainment of COVID-19 cases in Toronto, Ontario, March to May 2020

Background

Public health surveillance data do not always capture all cases, due in part to test availability and health care seeking behaviour. Our study aimed to estimate under-ascertainment multipliers for each step in the reporting chain for COVID-19 in Toronto, Canada.

Design and methods

We applied stochastic modeling to estimate these proportions for the period from March 2020 (the beginning of the pandemic) through to May 23, 2020, and for three distinct windows with different laboratory testing criteria within this period.

Results

For each laboratory-confirmed symptomatic case reported to Toronto Public Health during the entire period, the estimated number of COVID-19 infections in the community was 18 (5th and 95th percentile: 12, 29). The factor most associated with under-reporting was the proportion of those who sought care that received a test.

Conclusions

Public health officials should use improved estimates to better understand the burden of COVID-19 and other similar infections.

Moving toward standardization: physician reporting of sleep studies

Detailed primary data collected from sleep studies should lead to specific and clear reports with evidence-based clinical recommendations that, when introduced by sleep medicine specialists, create a window of opportunity to support our non-sleep medicine referring teams and to engage patients and caregivers in their care as recipients of the reports. This is how sleep study reporting differs from other test reports; currently, there is wide variation in how the data collected are presented and summarized. The goal of this document is to offer recommendations for structured reporting of sleep studies. We offer a practical, complete, and relevant document and a structure that can be implemented across sleep centers nationwide and does not burden the interpreter. We anticipate some readers will opine that some of the content is beyond the scope of what the interpreter physician needs to include, while others will propose missing data that they feel should have been included. We feel that the flexibility of the proposal accommodates for this and allows for a "first step" toward standardization of physician reporting of sleep studies. High-quality structured reporting of sleep studies is becoming ever more important for patient care, benefiting patients, caregivers, clinicians, durable medical equipment companies, and payers.

CITATION

Lastra AC, Ingram D, Park J, et al. Moving toward standardization: physician reporting of sleep studies. J Clin Sleep Med. 2023;19(3):595-603.

A Change in the Trend of Quality Reporting in Leprosy Trials: A Systematic Review

BACKGROUND

Leprosy is a communicable disease caused by bacteria Mycobacterium Leprae. Despite all attempts, it has not been eradicated in several underdeveloped nations since the start of the antibiotic age. It's a social issue as well as a stigmatised disease. Due to these restrictions, randomised controlled trials in leprosy confront numerous obstacles, which are reflected in the quality of study reporting.

OBJECTIVES

The objective of this study is to use the Consolidated Standard for Reporting Trials (CONSORT) 2010 checklist to assess the quality of leprosy trial reporting.

METHODS

We assess the quality of reporting of randomised control trials on leprosy conducted after 2010 in the PubMed database, using the CONSORT checklist 2010. Second, we compare the quality of RCT reporting before and after the release of the CONSORT guidelines in 2010.

RESULTS

A total of 19 full-text eligible articles were examined and included in the final list of articles, which were then evaluated further. 4 out of 19 trials had a compliance percentage of more than 75%. 6 out of 19 trials had compliance percentage of 50% to 75%. 9 trials had a compliance percentage of below 50%. Highest compliance was 86.48% and the lowest compliance was 32.43%. When compared with trials before 2010, we could see an improvement in some criteria showing a statistically significant rise in comparison with trials conducted before 2010.

CONCLUSION

Leprosy is still a concern in developing countries, which have failed to eradicate the disease despite their best efforts and resources. The compliance of leprosy related RCTs has improved since the introduction of the CONSORT guidelines, but the quality of reporting still remains on the lower side.

After-hours radiology reporting in an Australian tertiary hospital: Factors influencing the rate of discrepancy for computed tomography reporting

INTRODUCTION

Demand for after-hours radiology services across Australia has been rapidly increasing for many years. Public hospital radiology departments are generally staffed by trainees after hours, often 1-2 doctors. This study reviewed 1 year of after-hours data at a tertiary hospital in Sydney, to determine overall discrepancy rates and factors which influenced the rate of discrepancy after hours. Overall radiology and after-hours case volumes are increasing, and the goal was to ensure that our department practices are within safe limits at current staffing levels.

METHODS

After-hours computed tomography scan reports issued by registrars were reviewed over 1 year between 01 January 2019 and 01 January 2020. Data recorded included overall case numbers on each shift, discrepancy rates and rates of clinically significant discrepancy. Caseload was measured by equivalent ascribed reporting time as described by Pitman et al. (2018).

RESULTS

There were 10,886 cases reported after hours during the study period and 1,412 discrepancies (13% cases). Of these, 300 (3.7%) were clinically significant. Factors that increased the rate of significant discrepancy included shifts with caseloads greater than 3 h of equivalent consultant reporting time per 8-h shift and the radiology trainee's level of training. The frequency of discrepancy for trauma cases was similar to non-trauma after adjusting for study type; however, the frequency of significant discrepancy was higher.

CONCLUSION

In all instances, the rates of discrepancy and clinically significant discrepancy remained well within ranges previously described.

Messages from the Seventh International Conference on Clinical Metagenomics (ICCMg7)

Clinical metagenomics (CMg), referring to the application of metagenomic sequencing of clinical samples to obtain clinically relevant information for the diagnosis and management of infectious diseases, has been rapidly evolving these last years. Following this trend, we held the seventh International Conference on Clinical Metagenomics (ICCMg7) in Geneva in October 2022. During the two-day conference, cutting-edge advances and new discoveries using CMg were presented which we summarize in the present paper. During this ICCMg7, we kept on following the progresses achieved worldwide that cover reproducibility in CMg, the advent of new technologies applied to the field of infectious diseases, innovative research in the field of the gut microbiota, and finally the expansion of CMg in the fields of clinical epidemiology with surveillance studies on emerging and known pathogens, but also on antibiotic resistance genes, in the environment and in the animal reservoirs.

Subclavian steal syndrome associated with right aortic arch: A case report

The right aortic arch (RAA) is a rare congenital vascular variant disease. We reported a case of subclavian steal syndrome associated with RAA. The primary clinical symptoms were vertigo and ischemic symptoms of the left upper extremity. We diagnosed the condition using aortic computed tomography angiography and digital subtraction angiography. The patient underwent carotid-subclavian bypass surgery.

A Literature Review on How We Can Address Medical Laboratory Scientist Staffing Shortages

OBJECTIVE

Laboratories are facing a critical shortage of medical laboratory scientists (MLS) and medical laboratory technicians (MLT) to address an increasing demand for laboratory testing. Training program closures, fewer student applicants, and financial decisions have contributed to staffing shortages. Lack of visibility, low wages, and perceived lack of opportunities for upward career mobility contribute to challenges in recruiting and retaining qualified individuals and students who are unaware of laboratory medicine careers. Our goal was to review the literature to determine the current state and consequences of staffing shortages, and potential solutions to address these shortages.

METHODS

Medline/PubMed, PubMed Central, MeSH, Google Scholar, and Marshall Digital Scholar were used as resources.

DISCUSSION/CONCLUSIONS

A collaboration of stakeholders is needed to identify staffing challenges, barriers, and solutions and to increase visibility of laboratory professionals. Early recruitment is best started in the middle and high school educational process.

Conference Report: European Society for Medical Oncology Congress 2022

The European Society of Medical Oncology took place in Paris Convention Centre, Paris, France on 9th -13th September 2022 and was attended by more than 28,000 delegates, 23,000 of which were in person and 5000 online. This was the first on-site ESMO congress after the COVID-19 pandemic. This report focuses on a selection of talks delivered at the conference. There was a vast collection of interesting talks, nevertheless, I attended talks that focused on rare cancers.

Giant Malignant Phyllode Tumor: A Case Report

Phyllodes are an uncommon type of fibroepithelial neoplasm of the breast, which account for only 0.3 to 0.5% of all breast neoplasms. Management requires complete surgical excision with negative margins. Giant phyllode tumors portray a surgical challenge because complete surgical excision with negative margins is vital to reduce local recurrence and metastatic spread. Here, we report a case of giant malignant phyllode tumor, approached with wide local excision and negative margins were successfully achieved. The purpose behind this paper is to report the patient's clinical history, presentation, intra-operative and histopathological findings, accompanied by a literature review to determine the significance of this finding and the approach in management.

What parents want in an autism diagnostic report: An interview-based study of parents accessing a neurodevelopmental assessment service

Diagnostic reports are a key outcome of autism assessment services. However, there is limited evidence regarding what key stakeholders, including families, want to see in reports. In this project, 30 parents whose young person had recently received a diagnosis of autism from a Neurodevelopmental Assessment Service in the North East of England took part in a telephone-based interview to explore what they want from a report. Interviews were analysed using thematic analysis. Ten key recommendations for reports were identified. Parents indicated that they want a detailed, balanced, sensitively written report. They highlighted that reports needed to be accessible and clearly structured. In this respect, it might be helpful to include a parent-driven summary of key points at the top, clear signposting of the structure of the report, and a description of what happened in the assessment process. Parents also valued practical, personalised recommendations based on the young person's strengths and difficulties. Future research might explore perspectives on reports in families accessing other services, in other client groups (e.g., families of pre-schoolers diagnosed with autism), and with different stakeholders, including schools, referrers and autistic people.

Operationalization and Reporting Practices in Manuscripts Addressing Gender Differences in Biomedical Research: A Cross-Sectional Bibliographical Study

Historically, authors in the biomedical field have often conflated the terms sex and gender in their research significantly limiting the reproducibility of the reported results. In the present study, we investigated current reporting practices around gender in biomedical publications that claim the identification of "gender differences". Our systematic research identified 1117 articles for the year 2019. After random selection of 400 publications and application of inclusion criteria, 302 articles were included for analysis. Using a systematic evaluation grid, we assessed the provided methodological detail in the operationalization of gender and the provision of gender-related information throughout the manuscript. Of the 302 articles, 69 (23%) solely addressed biological sex. The remaining articles investigated gender, yet only 15 (6.5%) offered reproducible information about the operationalization of the gender dimension studied. Followingly, these manuscripts also provided more detailed gender-specific background, analyses and discussions compared to the ones not detailing the operationalization of gender. Overall, our study demonstrated persistent inadequacies in the conceptual understanding and methodological operationalization of gender in the biomedical field. Methodological rigor correlated with more nuanced and informative reporting, highlighting the need for appropriate training to increase output quality and reproducibility in the field.

Pleuropulmonary Ultrasound in Pediatrics: Proposal of a Reporting Model From the Academy of Thoracic Ultrasound

With the emergence of the Covid-19 pandemic, pleuropulmonary ultrasound has become a very common tool in clinical practice, even in the pediatric field. Therefore, the clinicians' need to speak a common ultrasound language becomes increasingly necessary. The Italian scientific society AdET (Academy of Thoracic Ultrasound) has been carrying out the study and dissemination of pulmonary ultrasound in medical practice in Italy for years. With this article, the pediatric AdET group wants to propose a report model of pediatric pulmonary ultrasound as a useful tool in daily clinical practice to interpret the images and reach a diagnostic conclusion, aiming to share a standardized approach that may also support the sharing of research findings.

Why Do School Staff Sometimes Fail to Report Potential Victimization Cases? A Mixed-methods Study

Schools are in a position to connect children and adolescents suspected of being victims of violence with an external source of support by making referrals to external agencies. However, several studies have identified obstacles that hinder early reporting among school staff members. Very few studies have applied a mixed-method approach to try to understand this sensitive issue. The current study used this approach to analyze to what extent the students suspected of being victimized match the ones reported by active school staff members in Spain (n = 453, 83.5% females, age: M = 42.23, SD = 9.46). We classified the reasons given for not reporting the potential victimization cases encountered and made comparisons to determine whether there were differences in the level of knowledge, or in the sociodemographic characteristics, of respondents who gave different reasons for not reporting. Although 73.5% of school staff members had detected at least one potential case, 40.8% of them referred it to an external agency. The most common reasons for lack of reporting included deciding not to do so once concerns had been shared within the school and believing that one must be certain or that only serious violence should be reported. The findings of this study may help to further understand the decisions not to report certain suspicions of potential victimization cases to external agencies by school staff. There is an urgent need to raise awareness about the duty to report these concerns to external agencies, even in the absence of agreement from the school management team. Members of school staff need to be strongly encouraged to become familiar with the existing protocols.

Pictorial essay on MRI local staging of rectal carcinoma: An easy approach

Rectal cancer is common and accounts for more than one-third of colorectal tumors. It is associated with significant morbidity and mortality. Previously computed tomography scan is the key imaging modality in preoperative assessment to detect local invasion and distant metastasis. However, the advent of magnetic resonance imaging (MRI) has aided in local staging and prognosticates the outcome of rectal tumor. Here, the author briefly explains why rectal MRI has a comprehensive role and provides a simple and easy way in reporting an MRI rectal carcinoma, even for a non-radiologist.

Case Report: Hematologic Recovery Following Stereotactic Ablative Radiotherapy in a Patient With Early-Stage Non-Small Cell Lung Cancer and Paraneoplastic Myelofibrosis

Herein, we report the first case presentation of paraneoplastic myelofibrosis associated with cancer. Paraneoplastic syndromes occur in some patients with thoracic malignancies; however, myelofibrosis is not commonly seen in non-small cell lung cancer (NSCLC). We report a case of myelofibrosis in a patient with a new diagnosis of NSCLC that resolved after stereotactic ablative radiotherapy (SABR). In conclusion, NSCLC may evoke unexpected systemic effects that resolve with treatment.

[The research activity of students in "The public health and health care, health care economics" discipline]

The article considers research work of students in "The Public health and health care, health economics" discipline in 2001-2020, organized in course of public health and health care of the Medical Institute of Petrozavodsk State University. The article reveals such concepts as student scientific activity, knowledge requirements for discipline to prepare student research work, classification of student research works by degree of collection and analysis of material, levels of student work performance, stages and classes of social hygienic research, requirements for content of presentation, criteria of evaluating report and presentation. During 2001-2021, 250 students of medical institute in the section "Public health and health care" made more than 200 reports, published more than 20 thesis and articles. The annual plan of 30 topics for student research works was developed, including requirements for content of presentation, 3 indices to evaluate quality of work. The text of presentation-report in 90% included information on one discipline "Public health and health care, health economics". At that, topic was disclosed in format of describing research objectives with construction of diagrams and graphs, comparison of indices and only 10% of reports contained statistical analysis of the results.

Mycobacterium fortuitum pacemaker infection: A case report

BACKGROUND

Mycobacterium fortuitum is a rapidly growing mycobacterium, ubiquitous in soil and water, but it is an uncommon cause of infections in immunocompetent hosts. Cardiac device infections and bloodstream infections due to non-tuberculous mycobacteria are rare.

CASE PRESENTATION

We present the case of an 85-year-old patient with infective endocarditis and pacemaker lead infection secondary to M. fortuitum.

Non-radiologist perception of the use of artificial intelligence (AI) in diagnostic medical imaging reports

INTRODUCTION

Incorporating artificial intelligence (AI) in diagnostic medical imaging reports has the potential to improve efficiency. Although perception of radiologists, radiographers, medical students and patients on AI use in image reporting has been explored, there is limited literature on non-radiologist clinicians' opinion on this topic.

METHOD

Single-centre online survey targeting non-radiologist medical staff conducted from May to August 2021 at a tertiary referral hospital in Melbourne, Australia. Survey questions revolved around clinicians' level of comfort acting on AI-generated reports with varying levels of radiologist involvement and scan complexity, opinion on medicolegal responsibility for erroneous AI-issued reports and perception of data privacy and security.

RESULTS

Eighty-eight responses were collected, including 47.9% of consultants. Non-radiologist clinicians across all seniorities and specialties felt significantly less comfortable acting on AI-issued reports compared with radiologist-issued reports (mean comfort radiologist 6.44/7, mean comfort AI 3.35/7, P < 0.001) but felt equally comfortable with an AI-hybrid model of care (mean comfort hybrid 6.38/7, P = 0.676). Non-radiologist clinicians believed that medicolegal responsibility with errors in AI-issued reports mostly lay with hospitals or health service providers (65.9%) and radiologists (54.5%). Regarding data privacy and security, non-radiologist clinicians felt significantly less comfortable with AI issuing image reports instead of radiologists (P < 0.001).

CONCLUSION

A hybrid AI-generated radiologist-confirmed method of image reporting may be the ideal way of integrating AI into clinical practice based on the perception of our referring non-radiologist medical colleagues. Formal guidelines on medicolegal responsibility and data privacy should be established prior to utilising AI in the clinical setting.

Case Report: A Novel Genetic Mutation Causes Idiopathic Infantile Arterial Calcification in Preterm Infants

Idiopathic infantile arterial calcification (IIAC), also known as generalized arterial calcification of infancy (GACI), is a heritable ectopic mineralization disorder that results in diffuse arterial calcifications and or stenosis, which are attributed to mutations in the ENPP1 gene. In this case study, we report the development of IIAC in a 2-month-old male preterm infant. The patient presented with severe hypertension and seizures, which revealed diffused calcifications and c.130C > T and c.1112A > T mutations in the ENPP1 gene. With biphosphonate, antihypertensive, and control epilepsy therapy, his blood pressure was maintained at 110–120/50–60 mmHg. Intellectual motor development retardation was anticipated in this patient. To the best of our knowledge, this is the first case in which a novel c.130C > T mutation in the ENPP1 gene has been identified, and the administration of bisphosphonates to patients with IIAC has been assessed.

Multicentre cohort study of cochlear implantation outcomes in Thailand

OBJECTIVES

To report the status and outcomes of cochlear implantation in Thailand.

DESIGN

Cohort study.

SETTING

Tertiary care and university hospitals.

PARTICIPANTS

Patients who underwent cochlear implant surgery in Thailand.

INTERVENTIONS

This project collected data from all government and university hospitals in Thailand where cochlear implant surgery was performed between 2016 and 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

Baseline characteristics, operation data, complications, audiological outcomes and quality of life were reported.

RESULTS

This study included 458 patients, and nearly half of the patients were children and adolescents (46.94%). The mean age of the patients was 2.96±5.83 years. At 1 year postoperatively, the mean pure tone average of the hearing threshold in the implanted ear significantly improved from unaided preoperative baseline (mean difference (MD) 64.23 dB HL; 95% CI 59.81 to 68.65; p<0.001). The mean speech recognition threshold also improved (MD 55.96 dB HL; 95% CI 49.50 to 62.42, p<0.001). The quality-of-life scores of the EQ-5D-5L, PedsQL and HUI3 questionnaires at 1 year showed improved mobility (range, 0-5; MD 0.65; 95% CI 0.05 to 1.25; p=0.037), hearing (range, 0-6; MD 0.96; 95% CI 0.30 to 1.61; p=0.006) and speech (range, 0-5; MD 0.44; 95% CI 0.04 to 0.84; p=0.031). Common complications included electrode dislodgement (2.18%), vertigo (1.23%) and meningitis (1.93%).

CONCLUSIONS

Excellent audiological outcomes and improvement in the quality of life in the mobility, hearing and speech domains were observed in patients who underwent cochlear implantation in Thailand.

Facial Nerve Palsy as a Neurological Manifestation of COVID-19

Facial nerve palsy is the most frequent acute mononeuropathy and it is often of viral etiology, although many other causes have been identified. It has recently been described as a potential manifestation of COVID-19. We report the case of a patient with recent history of diarrhea and malaise that was admitted to the hospital presenting right facial paresis with orbicular muscle involvement. Nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the real-time reverse transcription polymerase chain reaction and magnetic resonance imaging showed no structural changes. During the hospital stay, the patient showed clinical improvement, and no other symptoms were observed. This case presentation suggests a possible association between neuropathies and SARS-CoV-2 infection.

Lessons learned about appendiceal neuroendocrine neoplasms from data analysis of the Belgian Cancer Registry 2010-2015

BACKGROUND AND STUDY AIMS

Appendiceal neuroendocrine neo-plasms (aNENs) are a diverse group of malignant neoplasms of varying biological behavior for which information about manage-ment and outcome is sparse, with the majority of available studies being retrospective, including only a limited number of patients, and therefore not necessarily reflecting the reality in the community. In the present study clinical, epidemiological and pathological data of appendiceal neuroendocrine neoplasms in Belgium is provided and compared with current literature.

METHODS

A population-based study was conducted by linking data of the Belgian Cancer Registry with medical procedures in the Belgian Health Insurance database for patients diagnosed with aNEN between 2010 and 2015.

RESULTS

We found an aNEN incidence of 0.97/100.000 person years in Belgium. Neuroendocrine carcinoma of the appendix are rare. Most appendiceal neuroendocrine tumors (aNETs) are small G1 tumors. Positive lymph nodes are often found in tumors larger than 2cm, especially aNET G2.

CONCLUSION

A rapid uptake of changing classifications was seen in the community. However, systematic reporting of risk factors for small aNEN can still be improved and should be stimulated. In 9% of cases, reclassifications had to be made, pointing out that in a retrospective analysis, original pathological reports should be checked for specific parameters, before reliable conclusions can be drawn.

Implementation of Machine Learning Software on the Radiology Worklist Decreases Scan View Delay for the Detection of Intracranial Hemorrhage on CT

BACKGROUND AND PURPOSE

Prompt identification of acute intracranial hemorrhage on CT is important. The goal of this study was to assess the impact of artificial intelligence software for prioritizing positive cases.

MATERIALS AND METHODS

Cases analyzed by Aidoc (Tel Aviv, Israel) software for triaging acute intracranial hemorrhage cases on non-contrast head CT were retrospectively reviewed. The scan view delay time was calculated as the difference between the time the study was completed on PACS and the time the study was first opened by a radiologist. The scan view delay was stratified by scan location, including emergency, inpatient, and outpatient. The scan view delay times for cases flagged as positive by the software were compared to those that were not flagged.

RESULTS

A total of 8723 scans were assessed by the software, including 6894 cases that were not flagged and 1829 cases that were flagged as positive. Although there was no statistically significant difference in the scan view time for emergency cases, there was a significantly lower scan view time for positive outpatient and inpatient cases flagged by the software versus negative cases, with a reduction of 604 min on average, 90% in the scan view delay (p-value < 0.0001) for outpatients, and a reduction of 38 min on average, and 10% in the scan view delay (p-value <= 0.01) for inpatients.

CONCLUSION

The use of artificial intelligence triage software for acute intracranial hemorrhage on head CT scans is associated with a significantly shorter scan view delay for cases flagged as positive than cases not flagged among outpatients and inpatients at an academic medical center.

Musculoskeletal Soft-Tissue Sarcoma: Quality Assessment of Initial MRI Reports Shows Frequent Deviation from ESSR Guidelines

Soft-tissue sarcomas (STS) are a rare subtype of soft-tissue mass and are frequently misinterpreted as benign lesions. Magnetic resonance imaging (MRI) is the primary recommended type of diagnostics. To assess the quality of primary radiology reports, we investigated whether recommended MRI report elements were included in compliance with European Society of Musculoskeletal Radiology (ESSR) guidelines. A total of 1107 patients were evaluated retrospectively, and 126 radiological reports on patients with malignant STS were assessed for ESSR quality criteria. One or more required sequences or planes were missing in 67% of the reports. In all 126 cases, the report recognized the mass as anomalous (100%). Sixty-eight percent of the reports mentioned signs of malignancy. The majority of reports (n = 109, 87%) articulated a suspected diagnosis, 32 of which showed a mismatch with the final diagnosis (25%). Thirty-two percent of the reports had a misinterpretation of the masses as benign. Benign misinterpretations were more common in masses smaller than 5 cm (65% vs. 27%). Thirty percent of the reports suggested tissue biopsy and 6% recommended referral to a sarcoma center. MRI reports showed frequent deviations from ESSR guidelines, and protocol guidelines were not routinely met. Deviations from standard protocol and reporting guidelines could put patients at risk for inadequate therapy.