@peopl-health/nexus 5.71.12 → 5.71.13

package/lib/clinical/helpers/chemoContextHelper.js

@@ -25,6 +25,7 @@ function normalize(raw) {
   const dated = (value, keys) => (isPlainObject(value) && isDay(value.fecha) && keys.every((k) => k in value) ? value : null);
   return {
     ultimaAplicacion: last,
+    ultimaCitotoxica: dayOr(raw.ultimaCitotoxica),
     esquema: list(raw.esquema).filter(isPlainObject).filter((e) => text(e.farmaco)),
     vigilancia: texts(raw.vigilancia),
     nadirDias: nadir,
@@ -50,6 +51,10 @@ function parseChemoContext(raw) {
   return isPlainObject(parsed) && parsed.version === 1 ? normalize(parsed) : null;
 }
 
+function daysSinceLastCytotoxic(context, today = mexicoDay(new Date())) {
+  return context?.ultimaCitotoxica ? daysBetween(context.ultimaCitotoxica, today) : null;
+}
+
 function chemoStatus(context, today) {
   const last = context.ultimaAplicacion?.fecha;
   if (!last) return { active: false, days: null };
@@ -162,4 +167,4 @@ function withChemoContext(clinical, context, today = mexicoDay(new Date())) {
   }
 }
 
-module.exports = { parseChemoContext, renderChemoContext, withChemoContext };
+module.exports = { daysSinceLastCytotoxic, parseChemoContext, renderChemoContext, withChemoContext };

package/lib/clinical/helpers/clinicalProfileHelper.js

@@ -1,5 +1,6 @@
 const { resolveProfileIdentity } = require('../services/patientProfileService');
 const { safeParse } = require('../../utils/jsonUtils');
+const { parseChemoContext } = require('./chemoContextHelper');
 
 const CONTEXT_FIELD = 'clinical-context-json';
 
@@ -32,15 +33,28 @@ function richestProfile(records) {
   return parsed[0].profile;
 }
 
-async function readClinicalProfile(code) {
+// null: no profile; undefined: unreadable
+async function readResolvedRecord(code) {
   try {
     const identity = await resolveProfileIdentity(code);
     if (identity.kind === 'missing') return null;
-    if (identity.kind !== 'resolved') return undefined;
-    return richestProfile([identity.record]);
+    return identity.kind === 'resolved' ? identity.record : undefined;
   } catch {
     return undefined;
   }
 }
 
-module.exports = { readClinicalProfile, richestProfile };
+async function readClinicalProfile(code) {
+  const record = await readResolvedRecord(code);
+  return record ? richestProfile([record]) : record;
+}
+
+// null: no chemo record; undefined: unreadable or unparseable
+async function readRecordedChemo(code) {
+  const record = await readResolvedRecord(code);
+  if (!record) return record;
+  if (!record.quimio_context) return null;
+  return parseChemoContext(record.quimio_context) ?? undefined;
+}
+
+module.exports = { readClinicalProfile, readRecordedChemo, richestProfile };

package/lib/clinical/tools/reportMedicalEscalationTool.js

@@ -17,6 +17,10 @@ const { URGENCY_RANK } = require('../../models/escalationReviewModel');
 const { objectArg, safeParse, isPlainObject } = require('../../utils/jsonUtils');
 const { logger } = require('../../utils/logger');
 
+const FEVER_RUBRIC_STAT = 'neutropenia febril CON inestabilidad, fiebre ≥38.0 °C en la ventana de quimioterapia descrita en la regla de fiebre,';
+
+const FEVER_RUBRIC_ASAP = 'riesgo de infección sin fiebre ≥38.0 °C en esa ventana (p. ej. 37.5–37.9 °C con el paciente bien),';
+
 const FEVER_RULE = 'Fever that is `stat`: ≥38.0 °C within 8 weeks of cytotoxic chemotherapy (or a hematologic cancer, transplant, known neutropenia), any fever within 4 weeks of CAR-T or during bispecific step-up dosing, or sepsis signs with or without fever — say it calmly: "ve a urgencias ahora y di que estás en tratamiento oncológico" (CAR-T / bispecific: call the treating center first). If you don\'t know the treatment or the last dose date, ask in the same message; unknown date on chemo counts as within the window. Fever 37.5–37.9 °C in that window with the patient well is `asap`: remeasure in 30–60 min. ';
 
 const definition = {
@@ -34,7 +38,7 @@ const definition = {
           'urgent',
           'routine'
         ],
-        'description': 'Tier of medical escalation — the FHIR request-priority code (RequestPriority), a RELATIVE urgency ordered routine < urgent < asap < stat. It encodes priority / speed-of-action, NOT a fixed time window — the per-case clock is safety_gate.max_action_time_hours. 1:1 with the gate route. In urgency_justification say why this level and not the one above or below.\n- `stat` (inmediato, gate emergencia) — acción inmediata, prioridad máxima, flujo de emergencia. Inestabilidad o amenaza vital: neutropenia febril CON inestabilidad, fiebre ≥38.0 °C en la ventana de quimioterapia descrita en la regla de fiebre, disnea severa, alteración del estado mental, sangrado mayor, compresión medular con déficit agudo.\n- `asap` (lo antes posible, gate urgencias) — máxima prioridad NO inmediata; objetivo interno de valoración en horas (no se le promete al paciente), porque la demora puede crear riesgo; el paciente no va a urgencias salvo que aparezca una señal de la red de seguridad. Complicación seria sospechada pero aún no claramente inestable: dolor que empeora rápido, riesgo de infección sin fiebre ≥38.0 °C en esa ventana (p. ej. 37.5–37.9 °C con el paciente bien), síntoma neurológico nuevo sin déficit agudo.\n- `urgent` (urgente, gate equipo_tratante_hoy) — objetivo interno de revisión en 24 h (no se le promete al paciente), por encima de rutina porque la demora podría importar clínicamente; el paciente puede seguir en casa con una red de seguridad: síntoma nuevo moderado, anormalidad de laboratorio preocupante pero estable, toxicidad de tratamiento que necesita input oportuno.\n- `routine` (rutina, sin gate o verdict suavizado) — prioridad normal, vía de atención habitual. Sin riesgo por demora: seguimiento, aclaración de medicación, síntoma >72h sin empeorar, contexto clínico desactualizado.'
+        'description': 'Tier of medical escalation — the FHIR request-priority code (RequestPriority), a RELATIVE urgency ordered routine < urgent < asap < stat. It encodes priority / speed-of-action, NOT a fixed time window — the per-case clock is safety_gate.max_action_time_hours. 1:1 with the gate route. In urgency_justification say why this level and not the one above or below.\n- `stat` (inmediato, gate emergencia) — acción inmediata, prioridad máxima, flujo de emergencia. Inestabilidad o amenaza vital: ' + FEVER_RUBRIC_STAT + ' disnea severa, alteración del estado mental, sangrado mayor, compresión medular con déficit agudo.\n- `asap` (lo antes posible, gate urgencias) — máxima prioridad NO inmediata; objetivo interno de valoración en horas (no se le promete al paciente), porque la demora puede crear riesgo; el paciente no va a urgencias salvo que aparezca una señal de la red de seguridad. Complicación seria sospechada pero aún no claramente inestable: dolor que empeora rápido, ' + FEVER_RUBRIC_ASAP + ' síntoma neurológico nuevo sin déficit agudo.\n- `urgent` (urgente, gate equipo_tratante_hoy) — objetivo interno de revisión en 24 h (no se le promete al paciente), por encima de rutina porque la demora podría importar clínicamente; el paciente puede seguir en casa con una red de seguridad: síntoma nuevo moderado, anormalidad de laboratorio preocupante pero estable, toxicidad de tratamiento que necesita input oportuno.\n- `routine` (rutina, sin gate o verdict suavizado) — prioridad normal, vía de atención habitual. Sin riesgo por demora: seguimiento, aclaración de medicación, síntoma >72h sin empeorar, contexto clínico desactualizado.'
       },
       'patient_check_in': {
         'anyOf': [
@@ -157,16 +161,9 @@ const MODE_DESCRIPTION = '\n\n**mode:** `new` abre un aviso; `update` actualiza
 
 const FEVER_RULE_TIMER = 'Fever within 6 weeks (42 days) of cytotoxic chemotherapy (or with a hematologic cancer, transplant, known neutropenia) — ≥38.0 °C, ≤36.0 °C, feeling feverish or chills with no thermometer, or malaise while on an antipyretic or steroid — is `asap` with `category: febrile_neutropenia`. It is `stat` only with a clear, confirmed red flag (clear shortness of breath, clear confusion, strong rigors, mottled skin, bleeding), or any fever within 4 weeks of CAR-T or during bispecific step-up dosing — say it calmly: "ve a urgencias ahora y di que estás en tratamiento oncológico" (CAR-T / bispecific: call the treating center first). If you don\'t know the treatment or the last dose date, ask in the same message. 37.5–37.9 °C in that window is `urgent`: remeasure in 30–60 min. ';
 
-const CHEMO_WINDOW_PROPERTY = nullable({
-  'type': 'object',
-  'description': 'Quimioterapia citotóxica, del expediente o de lo que el paciente confirmó. Requerida y confirmada para `febrile_neutropenia`; pasa `null` si no está confirmada. No la supongas.',
-  'properties': {
-    'on_cytotoxic_chemo': { 'type': 'boolean' },
-    'days_since_last_cycle': nullable({ 'type': 'integer' }),
-  },
-  'required': ['on_cytotoxic_chemo', 'days_since_last_cycle'],
-  'additionalProperties': false,
-});
+const FEVER_RUBRIC_STAT_TIMER = 'fiebre en la ventana de quimioterapia con una bandera roja confirmada (regla de fiebre),';
+
+const FEVER_RUBRIC_ASAP_TIMER = 'fiebre ≥38.0 °C o ≤36.0 °C en la ventana de quimioterapia sin bandera roja (regla de fiebre),';
 
 const CLINICAL_ASSESSMENT_PROPERTY = nullable({
   'type': 'object',
@@ -224,20 +221,14 @@ function liveDefinition() {
     properties.details.required.push('clinical_assessment');
   }
   if (feverTimer) {
-    live.description = live.description.replace('`recommended_action`).', '`recommended_action`, `chemo_window`).');
     live.description = live.description.replace(FEVER_RULE, FEVER_RULE_TIMER);
-    properties.details.properties.chemo_window = CHEMO_WINDOW_PROPERTY;
-    properties.details.required.push('chemo_window');
+    properties.urgency_level.description = properties.urgency_level.description
+      .replace(FEVER_RUBRIC_STAT, FEVER_RUBRIC_STAT_TIMER)
+      .replace(FEVER_RUBRIC_ASAP, FEVER_RUBRIC_ASAP_TIMER);
   }
   return live;
 }
 
-function chemoWindowOf(raw) {
-  if (!isPlainObject(raw) || typeof raw.on_cytotoxic_chemo !== 'boolean') return null;
-  const days = raw.days_since_last_cycle;
-  return { onCytotoxicChemo: raw.on_cytotoxic_chemo, daysSinceLastCycle: Number.isInteger(days) && days >= 0 ? days : null };
-}
-
 const yesNo = (value) => (value === true ? 'sí' : value === false ? 'no' : null);
 
 function knownExplanationNote(known) {
@@ -334,7 +325,6 @@ async function handler(args, context = {}) {
           indicators: (Array.isArray(details.indicators) ? details.indicators : [])
             .filter((indicator) => typeof indicator === 'string' && indicator.trim()),
           turnId: runtime.turnId || null,
-          chemoWindow: chemoWindowOf(details.chemo_window),
           ...(clinicalAssessment ? { clinicalAssessment } : {}),
         },
       })

package/lib/models/escalationReviewModel.js

@@ -16,11 +16,6 @@ const DOCTOR_DECISIONS = ['approved', 'edited_approved', 'needs_intervention', '
 const DECISION_SOURCES = ['platform', 'registered_by_navigator', 'chat'];
 const RETURN_REASONS = ['llamar', 'falta_dato', 'no_requiere'];
 
-const chemoWindowSchema = new mongoose.Schema({
-  onCytotoxicChemo: { type: Boolean, default: null },
-  daysSinceLastCycle: { type: Number, default: null },
-}, { _id: false });
-
 const alarmSchema = new mongoose.Schema({
   alarmId: { type: String, default: null },
   urgencyLevel: { type: String, enum: URGENCY_LEVELS, required: true },
@@ -35,7 +30,6 @@ const alarmSchema = new mongoose.Schema({
   clinicalAssessment: { type: mongoose.Schema.Types.Mixed, default: null },
   emergencyRecordId: { type: String, default: null },
   appliedLevel: { type: String, default: null },
-  chemoWindow: { type: chemoWindowSchema, default: null },
   raisedAt: { type: Date, required: true },
 }, { _id: false });
 

package/lib/services/escalationReviewService.js

@@ -5,7 +5,7 @@ const { httpError, requiredText } = require('../utils/httpErrorUtils');
 const { inlineOf } = require('../utils/coercionUtils');
 const { logger } = require('../utils/logger');
 const { PATIENT_CODE, redactDirectIdentifiers } = require('../utils/sanitizerUtils');
-const { isoDay } = require('../utils/dateUtils');
+const { isoDay, mexicoDay } = require('../utils/dateUtils');
 const {
   CALL_OUTCOMES,
   CANCELLABLE_AFTER_HANDOFF_STATUSES,
@@ -33,6 +33,9 @@ const { characterizationSeedOf } = require('../clinical/helpers/reviewUpdateHelp
 const { readNoteFacts, assertionOf } = require('../clinical/services/escalationNoteFactsService');
 const { humanReplyFilter } = require('../clinical/config/safetyNetConfig');
 const { feverPatientTimerLive: feverTimerLive } = require('../clinical/flags/escalationFlags');
+const { chemoContextLive } = require('../clinical/flags/clinicalContextFlags');
+const { daysSinceLastCytotoxic } = require('../clinical/helpers/chemoContextHelper');
+const { readRecordedChemo } = require('../clinical/helpers/clinicalProfileHelper');
 const { composePrompt } = require('../clinical/services/promptComposerService');
 const { storeContextFacts, readContextFacts } = require('../fhir/services/clinicalContextService');
 
@@ -933,21 +936,14 @@ const appliedLevelOf = (alarm) => alarm.appliedLevel || alarm.urgencyLevel;
 const feverAlarmsOf = (review) => currentAlarms(review)
   .filter((alarm) => appliedLevelOf(alarm) === 'asap' && alarm.category === FEVER_CATEGORY);
 
-// The timer is only for a patient confirmed on cytotoxic chemotherapy with a known last cycle inside the
-// window; anything short of that (unknown, off chemo, no date, too long ago) leaves it unarmed.
-function chemoWindowGap(alarm) {
-  const chemo = alarm?.chemoWindow;
-  if (!chemo) return 'chemo_window_missing';
-  if (chemo.onCytotoxicChemo !== true) return 'not_on_cytotoxic_chemo';
-  const days = chemo.daysSinceLastCycle;
-  if (!Number.isInteger(days)) return 'days_since_last_cycle_missing';
-  return days >= 0 && days <= feverChemoWindowDays() ? null : 'outside_chemo_window';
-}
-
-function feverTimerGap(review) {
-  const fevers = feverAlarmsOf(review);
-  if (fevers.some((alarm) => !chemoWindowGap(alarm))) return null;
-  return chemoWindowGap(fevers.at(-1));
+async function feverTimerGap(patientCode, now) {
+  if (!chemoContextLive()) return 'chemo_context_off';
+  const chemo = await readRecordedChemo(patientCode);
+  if (chemo === undefined) return 'chemo_record_unreadable';
+  if (!chemo?.ultimaCitotoxica) return 'no_recorded_cytotoxic';
+  const days = daysSinceLastCytotoxic(chemo, mexicoDay(now));
+  if (days < 0) return 'last_cycle_in_future';
+  return days > feverChemoWindowDays() ? 'outside_chemo_window' : null;
 }
 
 // The timer runs from the first asap alert of this episode, so a retried alert never restarts it and a
@@ -1001,10 +997,16 @@ async function feverTakenReason(review, since, ownStart = null) {
 
 async function armFeverTimerOnJoin(review, alarm, now) {
   try {
-    if (!feverTimerLive() || appliedLevelOf(alarm) !== 'asap' || alarm.category !== FEVER_CATEGORY || chemoWindowGap(alarm)) return;
+    if (!feverTimerLive() || appliedLevelOf(alarm) !== 'asap' || alarm.category !== FEVER_CATEGORY) return;
     if (alertedRankOf(review) !== URGENCY_RANK.asap) return;
     const since = feverTimerSince(review);
     if (!since || promptedSince(review, since)) return;
+    if (review.doctorAlertDueAt) return;
+    const gap = await feverTimerGap(review.patientCode, now);
+    if (gap) {
+      await audit(review, ALERT_OPERATOR, null, { action: 'patient_prompt_not_armed', reason: gap });
+      return;
+    }
     // The patient gets the full timer from when the case became eligible, not from the earlier alert.
     await getEscalationReview().updateOne(
       { _id: review._id, doctorAlertDueAt: null },
@@ -1186,10 +1188,10 @@ async function sendScheduledDoctorAlert({ id, kind, lease = null, now = new Date
   // while there is time before the prompt and attempts left, then the patient prompt is the safety net.
   // Stat already sends the patient to the ED.
   const latestReview = updated ?? review;
-  const feverCase = urgencyLevel === 'asap' && feverTimerLive() && feverAlarmsOf(latestReview).length > 0;
-  const feverGap = feverCase ? feverTimerGap(latestReview) : null;
   const since = feverTimerSince(latestReview) ?? now;
-  const promptAt = feverCase && !feverGap && !promptedSince(latestReview, since) ? since.getTime() + feverTimerMs() : null;
+  const feverCase = urgencyLevel === 'asap' && feverTimerLive() && feverAlarmsOf(latestReview).length > 0 && !promptedSince(latestReview, since);
+  const feverGap = feverCase ? await feverTimerGap(review.patientCode, now) : null;
+  const promptAt = feverCase && !feverGap ? since.getTime() + feverTimerMs() : null;
   const retriesDoctor = sent.error
     && (promptAt == null || (now.getTime() + ALERT_RETRY_DELAY_MS < promptAt && (review.doctorAlertAttempts ?? 0) < MAX_ALERT_ATTEMPTS));
   if (promptAt != null && !retriesDoctor) {

package/package.json

@@ -1,6 +1,6 @@
 {
   "name": "@peopl-health/nexus",
-  "version": "5.71.12",
+  "version": "5.71.13",
   "description": "Core messaging and assistant library for WhatsApp communication platforms",
   "keywords": [
     "whatsapp",