Advanced Medical Support Research Articles

Integrating Structured and Unstructured EHR Data for Predicting Mortality by Machine Learning and Latent Dirichlet Allocation Method.

An ICU is a critical care unit that provides advanced medical support and continuous monitoring for patients with severe illnesses or injuries. Predicting the mortality rate of ICU patients can not only improve patient outcomes, but also optimize resource allocation. Many studies have attempted to create scoring systems and models that predict the mortality of ICU patients using large amounts of structured clinical data. However, unstructured clinical data recorded during patient admission, such as notes made by physicians, is often overlooked. This study used the MIMIC-III database to predict mortality in ICU patients. In the first part of the study, only eight structured variables were used, including the six basic vital signs, the GCS, and the patient's age at admission. In the second part, unstructured predictor variables were extracted from the initial diagnosis made by physicians when the patients were admitted to the hospital and analyzed using Latent Dirichlet Allocation techniques. The structured and unstructured data were combined using machine learning methods to create a mortality risk prediction model for ICU patients. The results showed that combining structured and unstructured data improved the accuracy of the prediction of clinical outcomes in ICU patients over time. The model achieved an AUROC of 0.88, indicating accurate prediction of patient vital status. Additionally, the model was able to predict patient clinical outcomes over time, successfully identifying important variables. This study demonstrated that a small number of easily collectible structured variables, combined with unstructured data and analyzed using LDA topic modeling, can significantly improve the predictive performance of a mortality risk prediction model for ICU patients. These results suggest that initial clinical observations and diagnoses of ICU patients contain valuable information that can aid ICU medical and nursing staff in making important clinical decisions.

Association of influenza outbreaks with advanced pediatric medical support.

Retrospective data evaluated increases in advanced medical support for children with medically attended acute respiratory illness (MAARI) during influenza outbreak periods (IOP). Advanced support included hospitalisation, intensive care unit admission, or mechanical ventilation, for children aged 0-17 years hospitalised in Maryland's 50 acute-care hospitals over 12 influenza seasons. Weekly numbers of positive influenza tests in the Maryland area defined IOP for each season as the fewest consecutive weeks, including the peak week containing at least 85% of positive tests with a 2-week buffer on either side of the IOP. Peak IOP (PIOP) was defined as four consecutive weeks containing the peak week with the most number of positive influenza tests. Off-PIOP was defined as the 'shoulder' weeks during each IOP. Non-influenza season (NIS) was the remaining weeks of that study season. Rate ratios of mean daily MAARI-related admissions resulting in advanced medical support outcomes during PIOP or Off-PIOP were compared with the NIS and were significantly elevated for all 12 study seasons combined. The results suggest that influenza outbreaks are associated with increased advanced medical support utilisation by children with MAARI. We feel that this data may help preparedness for severe influenza epidemics or pandemic.

Surges of advanced medical support associated with influenza outbreaks.

We utilized de-identified data to evaluate increases in four outcomes during influenza outbreak periods (IOPs) including: hospitalization, intensive care unit admission, mechanical ventilation or death for adults aged 18 years or older with medically attended acute respiratory illnesses (MAARI) admitted to any of Maryland's 50 acute-care hospitals over 12 years. Weekly numbers of positive influenza tests in the Maryland area were obtained from the US Center for Disease Control and Prevention interactive website. The fewest consecutive weeks around the peak week containing at least 85% of the positive tests defined the IOP. Weekly counts of individual study outcomes were positively correlated with regional weekly counts of positive influenza tests during all the IOPs over 12 years. Also, rate ratios comparing daily occurrences of each study outcome between the IOP and non-IOP were significantly elevated. These results confirm conclusions of previous studies that influenza outbreaks are clearly associated with deaths and increased use of advanced medical resources by patients with MAARI. These data analyses suggest that increased efforts to develop more effective influenza vaccines and therapeutics should be a priority.

Division of overall duration of stay into operative stay and postoperative stay improves the overall estimate as a measure of quality of outcome in burn care.

Total duration of stay adjusted for percentage of the total body surface area burned (TBSA%) is a commonly used outcome measure in burn care. However, it has been criticised as it is affected by many factors, some of which are not strictly part of burn care. A division into operative stay and postoperative stay may improve this measure. The aim was to evaluate if operative stay can serve as a more standardised measure by: comparing the variation in operative stay/TBSA% with the variation in total stay/TBSA%, and to study different factors associated with operative stay and postoperative stay.Patients and methodsSurgically managed burn patients admitted between 2010–14 were included. Operative stay was defined as the time from admission until the last operation, postoperative stay as the time from the last operation until discharge. The difference in variation was analysed with F-test. A retrospective review of medical records was done to explore reasons for extended postoperative stay. Multivariable regression was used to assess factors associated with operative stay and postoperative stay.ResultsOperative stay/TBSA% showed less variation than total duration/TBSA% (F test = 2.38, p<0.01). The size of the burn, and the number of operations, were the independent factors that influenced operative stay (R2 0.65). Except for the size of the burn other factors were associated with duration of postoperative stay: wound related, psychological and other medical causes, advanced medical support, and accommodation arrangements before discharge, of which the two last were the most important with an increase of (mean) 12 and 17 days (p<0.001, R2 0.51).ConclusionAdjusted operative stay showed less variation than total hospital stay and thus can be considered a more accurate outcome measure for surgically managed burns. The size of burn and number of operations are the factors affecting this outcome measure.

Prenatal imaging and immunohistochemical analysis of congenital peribronchial myofibroblastic tumor

A 32-year-old pregnant woman, gravida 4 para 1, was referred to us at 27 weeks' gestation because of fetal hydrops. Ultrasound examination revealed a male fetus with a large homogeneous mass occupying the whole mediastinum with encasement of the great vessels and bronchus (Figure 1 and Videoclip S1). The tumor had a spiculated margin and infiltrated deep into adjacent tissues, suggestive of a sarcoma or other malignancy (Videoclip S2). Subsequent karyotyping following amniocentesis provided a normal result. Maternal blood tests were negative for active infection of adenovirus, toxoplasma and cytomegalovirus. Fetal magnetic resonance imaging revealed a large mediastinal tumor of 6 cm in longitudinal diameter with encasement of adjacent mediastinal structures (Figure 2). At 29 weeks' gestation, the neonate was delivered by elective Cesarean section and intubated by ex-utero intrapartum treatment owing to fetal distress. Apgar scores were 0, 1 and 4 at 1, 5 and 10 min, respectively. The newborn was put on immediate ventilator support for severe hypoxemia, and bilateral chest tubes were inserted to drain the pleural effusions. Transthoracic sonography showed a large extracardiac mediastinal mass with compression of the left atrium. Despite the advanced medical support, the newborn developed refractory hypotension and died 2 days later. Autopsy revealed multiple cystic changes in the periventricular area of the brain (Figure S1). The mediastinal tumor was brown and soft and weighed 26.2 g with dimensions of 69 × 37 mm (Figure 3). It was found to encompass the esophagus, trachea, pulmonary trunk, aortic arch and other great vessels. Microscopic examination of the mass revealed interlacing fascicles of uniform spindle cells, with focal nuclear atypia (Figure S2). These tumor cells were diffusely positive for vimentin, focally positive for smooth muscle actin and CD68, but negative for CD31, CD34, S-100 and desmin. Tumor complementary DNA of the fusion gene transcript ETV6-NTRK3 was amplified specifically and no specific fusion gene transcripts were detected. Fluorescence in-situ hybridization revealed a wild-type EWSR1, encoding the Ewing sarcoma fusion protein, with no splitting of the alleles. The diagnosis of congenital peribronchial myofibroblastic tumor (CPMT) was made based on the myofibroblastic immunophenotype and genetic investigations (Table 1 and Table S1)123. CPMT was first defined in 1993 by McGinnis et al.4 to describe a neoplasm that develops from the embryonic pluripotent mesenchyme found surrounding large bronchi. In the past it was recognized as a malignancy or low-grade sarcoma, but it has now been categorized as a benign mesenchymal tumor with different extents of nuclear atypia. Fewer than 30 cases have been reported in the English medical literature12345. CPMT presents typically as a solid lung mass in the perinatal period, but has not been seen previously as a mediastinal tumor. Heart failure is considered the result of increased mediastinal pressure caused by encasement of the great vessels and direct cardiac compression. The clinical behaviors of CPMT are diverse, and survival rate is only 36% after excluding cases of elective termination123 5. However, patients with CPMT may have a good outcome if they can survive long enough for surgical resection5. In conclusion, when non-immune hydrops fetalis is encountered, the mediastinum should be examined carefully when other etiologies are unlikely to be the cause. Subsequent counseling and management pose more challenges than the detection of the fetal neoplasm itself. Despite its benign histopathology, CPMT in the mediastinum can have a devastating effect on the fetus because of its location and rapid growth. Y.-A. Tu†, W.-C. Lin‡, H.-J. Chen‡ and J.-C. Shih*† †Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, 15F, No. 8, Chung-Shan South Road, 10002, Taipei, Taiwan; ‡Department of Pathology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan *Correspondence. (e-mail: jcshih@ntu.edu.tw) Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

HELLP Syndrome Complicated by Subcapsular Hematoma of Liver: A Case Report and Review of the Literature.

Subcapsular liver hematoma (SLH) is a rare complication of severe preeclampsia and HELLP syndrome. These patients must be followed up in intensive care unit for advanced medical support with infused fluid, replacement of blood products, and treatment of underlying disorders. There are a lot of therapeutic options varying from conservative management to surgical treatment including hepatic resection, hepatic artery ligation, and liver transplantation. In this report we aimed to present a 26-year-old woman with SLH secondary to HELLP syndrome.

Impact of Severe Acute Respiratory Syndrome (SARS) Outbreaks on the Use of Emergency Department Medical Resources

BackgroundThe impact of the severe acute respiratory syndrome (SARS) outbreak in 2003 on the emergency department (ED) medical needs of adult patients has not been elucidated. The purpose of this study was to investigate the demographic and clinical characteristics of ED adult patients before, during and after the SARS epidemic in a SARS-dedicated hospital.MethodsA retrospective, ED chart review was conducted, and demographic data were obtained from a computer database, for a total of 17,586 patients. Patient information, including age, gender, mode of arrival, triage category, time of visit, main diagnosis, use of ED services, and status after the ED visit, were collected and compared for pre-, early-, peak-, late-, and post-SARS epidemic stages.ResultsDemographic data demonstrated a significant decrease in patient attendances per day, with a mean reduction of 92.5 ± 8.3 patients (43.7 ± 3.9% reduction in rate; p < 0.01) during peak-versus pre-epidemic stages, but revealed no differences in patient age and gender. The numbers of patients with ambulance transport, inter-hospital referral, and critical illnesses, including DOA, categorized as triage 1, or admitted to a ward or intensive care unit after the ED visit, were not influenced by the SARS epidemic. The number of patients with upper airway infections and suicide attempts from drug overdoses increased, but not statistically significantly. The number of patients with other diagnoses decreased progressively from early- to peak-epidemic stages, but returned to their earlier levels at the post-epidemic stage. Statistically significant decreases (p < 0.05) were noted in mean attendance at peak-versus pre- and early-epidemic stages for patients with cardiovascular disease, inflammatory or functional bowel disease, endocrine disease, dizziness or vertigo, or trauma.ConclusionThe SARS outbreak did not eliminate the need of critically ill patients for advanced medical support. However, besides an overall decrease in patient numbers, the SARS epidemic markedly altered demographic information, clinical characteristics, and the use of medical services by adult patients in the ED of a SARS-dedicated hospital.

Les appels d’urgence au Samu

The French emergency medical system is public and medical. Named Samu, it is almost entirely managed by anesthesiologists specially trained for emergency medical assistance and advanced medical support. The system comprises a reception and dispatching center for emergency calls, directly connected to police and firemen, but assuring patient confidentiality. This fixed center is managing mobile unities which are Medical Intensive Care Ambulances (MICA named Smur in France). The Samu’s mission consists in performing urgent individual medical assistance and also medical services for treatment of mass casualties. It is also to find adequate hospital units for the patients, to perform medical transport and to be a consultant for general practitionners in emergency.

Telemedicine at the top of the world: the 1998 and 1999 Everest extreme expeditions.

The National Aeronautics and Space Administration (NASA) initially established a Commercial Space Center (CSC) in the Department of Surgery at Yale University School of Medicine to further develop and evaluate technologies in information systems, telecommunications applied to medicine, and physiologic sensors. The CSC is known as the Medical Informatics and Technology Applications Consortium (MITAC). The overall purpose for this NASA program is to leverage technology, innovation, and resources from industry and academia through collaborative partnerships. The Yale-NASA CSC/MITAC organized the Everest Extreme Expeditions (E3) for the spring Himalayan climbing seasons in the years 1998 and 1999. The primary mission was to deliver advanced medical support with global telemedicine capabilities to one of the world's most remote and hostile settings--Mount Everest. The purpose was both humanitarian (providing medical support) and scientific (conducting medical and technology research). The Yale team provided medical care for the Everest Base Camp community; conducted validation experiments for several types of advanced medical technologies in this remote, hostile environment; and performed real-time monitoring of selected climbers, while also assessing the basic science of altitude physiology. Additionally, the teams conducted outreach medical care to the citizens of Nepal and provided several educational forums for a variety of medical and nonmedical personnel--including school-age children. As part of the project's mission, the E3 medical teams at both Nepal and New Haven were on a 24-hour emergency call system to deliver medical care in the event of a crisis. Unlike most of the teams at Everest, the mission of E3 was not to climb the 29,028-foot mountain the Nepalese call Sagarmatha ("Sky Head"). The mountain served as an extreme testing ground for telemedicine. The lessons learned from this testbed are reviewed here and further clarify the abilities to provide better health care in remote and extreme environments--which for some may even be their home environment during/after a medical illness.

Advanced Medical Support: Adult Medical Emergencies

Advanced Medical Support: Adult Medical Emergencies