BackgroundDeploying accurate computable phenotypes in pragmatic trials requires a trade-off between precise and clinically sensical variable selection. In particular, evaluating the medical encounter to assess a pattern leading to clinically significant impairment or distress indicative of disease is a difficult modeling challenge for the emergency department.ObjectiveThis study aimed to derive and validate an electronic health record–based computable phenotype to identify emergency department patients with opioid use disorder using physician chart review as a reference standard.MethodsA two-algorithm computable phenotype was developed and evaluated using structured clinical data across 13 emergency departments in two large health care systems. Algorithm 1 combined clinician and billing codes. Algorithm 2 used chief complaint structured data suggestive of opioid use disorder. To evaluate the algorithms in both internal and external validation phases, two emergency medicine physicians, with a third acting as adjudicator, reviewed a pragmatic sample of 231 charts: 125 internal validation (75 positive and 50 negative), 106 external validation (56 positive and 50 negative).ResultsCohen kappa, measuring agreement between reviewers, for the internal and external validation cohorts was 0.95 and 0.93, respectively. In the internal validation phase, Algorithm 1 had a positive predictive value (PPV) of 0.96 (95% CI 0.863-0.995) and a negative predictive value (NPV) of 0.98 (95% CI 0.893-0.999), and Algorithm 2 had a PPV of 0.8 (95% CI 0.593-0.932) and an NPV of 1.0 (one-sided 97.5% CI 0.863-1). In the external validation phase, the phenotype had a PPV of 0.95 (95% CI 0.851-0.989) and an NPV of 0.92 (95% CI 0.807-0.978).ConclusionsThis phenotype detected emergency department patients with opioid use disorder with high predictive values and reliability. Its algorithms were transportable across health care systems and have potential value for both clinical and research purposes.

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Introduction: Tranexamic acid (TXA) is an antifibrinolytic agent currently approved and utilized in the treatment of dysfunctional uterine bleeding, traumatic extracranial hemorrhage, anterior epistaxis, and dental procedures on patients with hemophilia. There is a paucity of literature evaluating the use of TXA for hemostasis in patients on direct oral anticoagulants (DOACs). Case Report: Our patient, a 72 year-old male on rivaroxaban, presented with persistent bleeding following a punch biopsy of the buccal mucosa. Given the site of bleeding, inability to effectively tamponade, patient’s anticoagulated state, and risk of impending airway compromise, a dressing was soaked with 500 milligram (mg) of TXA and was held in place with pressure using a makeshift clamp until a thrombus formed. Hemostasis was achieved preventing the need for acute ENTotolaryngologic intervention and/or intubation. The patient was observed in the medical setting overnight and discharged home without any recurrence of bleeding or adverse events. Discussion: This case report describes our experience achieving hemostasis for an otherwise uncontrollable oral bleed in an anticoagulated patient on a DOAC who could not be reversed. Intervention is simple to perform, cost-effective, and requires few resources which are readily available in most emergency departments. Conclusion: We report a novel application of TXA to control an oral mucosal bleed in an anticoagulated patient which was on a DOAC refractory to traditional measures.

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