Perceived Barriers to the De-implementation of Routine Preoperative History & Physicals Preceding Low-Risk Ambulatory Procedures: A Qualitative Study of Surgeon Perspectives.

BACKGROUND: For patients undergoing surgery at an Ambulatory Surgical Center, recent changes to Centers for Medicare and Medicaid Services policy allow for the omission of a 30-day preoperative History and Physical (H&P). Preoperative H&Ps for low-risk surgery may contribute to health care waste and lead to unnecessary preoperative testing and treatment cascades. METHODS: In this qualitative study, we conducted 30 semi-structured interviews with surgeons who frequently perform low-risk surgeries. We aimed to evaluate surgeon perspectives on the continued use of the 30-day preoperative H&P and specifically the potential risks and benefits associated with the elimination of a preoperative H&P requirement from institutional practice. We used an interpretive description approach to generate a thematic description. RESULTS: Most participants felt that the 30-day preoperative H&P was low value and frequently described it as "unnecessary," "redundant," or "just checking a box." Many viewed the 30-day requirement as arbitrary and felt that new H&P findings were rare and unlikely to influence surgical care. The participants who favored the preoperative H&P felt it was a safeguard to ensure "nothing was missed" and were less likely to be burdened by the requirement than participants who felt it was low value. CONCLUSIONS: Surgeons performing low-risk procedures question the utility and value of conducting a preoperative H&P within 30 days of surgery. De-implementation of the 30-day preoperative H&P for low-risk patients may increase convenience for patients and providers. Furthermore, it may improve value in surgery by increasing access to services for patients with greater need for preoperative assessment.

Generalizing biomedical relation classification with neural adversarial domain adaptation.

Motivation: Creating large datasets for biomedical relation classification can be prohibitively expensive. While some datasets have been curated to extract protein-protein and drug-drug interactions (PPIs and DDIs) from text, we are also interested in other interactions including gene-disease and chemical-protein connections. Also, many biomedical researchers have begun to explore ternary relationships. Even when annotated data are available, many datasets used for relation classification are inherently biased. For example, issues such as sample selection bias typically prevent models from generalizing in the wild. To address the problem of cross-corpora generalization, we present a novel adversarial learning algorithm for unsupervised domain adaptation tasks where no labeled data are available in the target domain. Instead, our method takes advantage of unlabeled data to improve biased classifiers through learning domain-invariant features via an adversarial process. Finally, our method is built upon recent advances in neural network (NN) methods. Results: We experiment by extracting PPIs and DDIs from text. In our experiments, we show domain invariant features can be learned in NNs such that classifiers trained for one interaction type (protein-protein) can be re-purposed to others (drug-drug). We also show that our method can adapt to different source and target pairs of PPI datasets. Compared to prior convolutional and recurrent NN-based relation classification methods without domain adaptation, we achieve improvements as high as 30% in F1-score. Likewise, we show improvements over state-of-the-art adversarial methods. Availability and implementation: Experimental code is available at https://github.com/bionlproc/adversarial-relation-classification. Supplementary information: Supplementary data are available at Bioinformatics online.

Cross-registry neural domain adaptation to extract mutational test results from pathology reports.

OBJECTIVE: We study the performance of machine learning (ML) methods, including neural networks (NNs), to extract mutational test results from pathology reports collected by cancer registries. Given the lack of hand-labeled datasets for mutational test result extraction, we focus on the particular use-case of extracting Epidermal Growth Factor Receptor mutation results in non-small cell lung cancers. We explore the generalization of NNs across different registries where our goals are twofold: (1) to assess how well models trained on a registry's data port to test data from a different registry and (2) to assess whether and to what extent such models can be improved using state-of-the-art neural domain adaptation techniques under different assumptions about what is available (labeled vs unlabeled data) at the target registry site. MATERIALS AND METHODS: We collected data from two registries: the Kentucky Cancer Registry (KCR) and the Fred Hutchinson Cancer Research Center (FH) Cancer Surveillance System. We combine NNs with adversarial domain adaptation to improve cross-registry performance. We compare to other classifiers in the standard supervised classification, unsupervised domain adaptation, and supervised domain adaptation scenarios. RESULTS: The performance of ML methods varied between registries. To extract positive results, the basic convolutional neural network (CNN) had an F1 of 71.5% on the KCR dataset and 95.7% on the FH dataset. For the KCR dataset, the CNN F1 results were low when trained on FH data (Positive F1: 23%). Using our proposed adversarial CNN, without any labeled data, we match the F1 of the models trained directly on each target registry's data. The adversarial CNN F1 improved when trained on FH and applied to KCR dataset (Positive F1: 70.8%). We found similar performance improvements when we trained on KCR and tested on FH reports (Positive F1: 45% to 96%). CONCLUSION: Adversarial domain adaptation improves the performance of NNs applied to pathology reports. In the unsupervised domain adaptation setting, we match the performance of models that are trained directly on target registry's data by using source registry's labeled data and unlabeled examples from the target registry.

Case Report: An Innovative Endovascular Technique for Repair of Descending Thoracic Aortic Aneurysm following an Open Coarctation Repair.

It was once postulated that open surgical repair of coarctation of the aorta during childhood patients was cured. However, long-term follow-up has been significant for late problems such as an aneurysm. The incidence of such aneurysm after open surgical coarctation repair is 11-24%. If such an aneurysm is left untreated, patients are at a high risk of morbidity and mortality. Prior to the endovascular era, patients would require a redo open repair which in itself is a highly morbid operation. Currently, thoracic endovascular aortic repair (TEVAR) has been reported as a feasible and safe alternative to open surgical reprocedures in this context. However, TEVAR might be challenging due to the proximity of the pathology to supraaortic vessels and the ongoing presence of the coarctation. We are reporting a unique case of a 48-year-old male undergoing TEVAR due to aortic aneurysm after previous surgical coarctation treatment and successful closure of the coarctation with a vascular plug device.

Ordinal convolutional neural networks for predicting RDoC positive valence psychiatric symptom severity scores.

BACKGROUND: The CEGS N-GRID 2016 Shared Task in Clinical Natural Language Processing (NLP) provided a set of 1000 neuropsychiatric notes to participants as part of a competition to predict psychiatric symptom severity scores. This paper summarizes our methods, results, and experiences based on our participation in the second track of the shared task. OBJECTIVE: Classical methods of text classification usually fall into one of three problem types: binary, multi-class, and multi-label classification. In this effort, we study ordinal regression problems with text data where misclassifications are penalized differently based on how far apart the ground truth and model predictions are on the ordinal scale. Specifically, we present our entries (methods and results) in the N-GRID shared task in predicting research domain criteria (RDoC) positive valence ordinal symptom severity scores (absent, mild, moderate, and severe) from psychiatric notes. METHODS: We propose a novel convolutional neural network (CNN) model designed to handle ordinal regression tasks on psychiatric notes. Broadly speaking, our model combines an ordinal loss function, a CNN, and conventional feature engineering (wide features) into a single model which is learned end-to-end. Given interpretability is an important concern with nonlinear models, we apply a recent approach called locally interpretable model-agnostic explanation (LIME) to identify important words that lead to instance specific predictions. RESULTS: Our best model entered into the shared task placed third among 24 teams and scored a macro mean absolute error (MMAE) based normalized score (100·(1-MMAE)) of 83.86. Since the competition, we improved our score (using basic ensembling) to 85.55, comparable with the winning shared task entry. Applying LIME to model predictions, we demonstrate the feasibility of instance specific prediction interpretation by identifying words that led to a particular decision. CONCLUSION: In this paper, we present a method that successfully uses wide features and an ordinal loss function applied to convolutional neural networks for ordinal text classification specifically in predicting psychiatric symptom severity scores. Our approach leads to excellent performance on the N-GRID shared task and is also amenable to interpretability using existing model-agnostic approaches.

A marker-based neural network system for extracting social determinants of health.

OBJECTIVE: The impact of social determinants of health (SDoH) on patients' healthcare quality and the disparity is well known. Many SDoH items are not coded in structured forms in electronic health records. These items are often captured in free-text clinical notes, but there are limited methods for automatically extracting them. We explore a multi-stage pipeline involving named entity recognition (NER), relation classification (RC), and text classification methods to automatically extract SDoH information from clinical notes. MATERIALS AND METHODS: The study uses the N2C2 Shared Task data, which were collected from 2 sources of clinical notes: MIMIC-III and University of Washington Harborview Medical Centers. It contains 4480 social history sections with full annotation for 12 SDoHs. In order to handle the issue of overlapping entities, we developed a novel marker-based NER model. We used it in a multi-stage pipeline to extract SDoH information from clinical notes. RESULTS: Our marker-based system outperformed the state-of-the-art span-based models at handling overlapping entities based on the overall Micro-F1 score performance. It also achieved state-of-the-art performance compared with the shared task methods. Our approach achieved an F1 of 0.9101, 0.8053, and 0.9025 for Subtasks A, B, and C, respectively. CONCLUSIONS: The major finding of this study is that the multi-stage pipeline effectively extracts SDoH information from clinical notes. This approach can improve the understanding and tracking of SDoHs in clinical settings. However, error propagation may be an issue and further research is needed to improve the extraction of entities with complex semantic meanings and low-frequency entities. We have made the source code available at https://github.com/Zephyr1022/SDOH-N2C2-UTSA.

Towards Understanding the Generalization of Medical Text-to-SQL Models and Datasets.

Electronic medical records (EMRs) are stored in relational databases. It can be challenging to access the required information if the user is unfamiliar with the database schema or general database fundamentals. Hence, researchers have explored text-to-SQL generation methods that provide healthcare professionals direct access to EMR data without needing a database expert. However, currently available datasets have been essentially "solved" with state-of-the-art models achieving accuracy greater than or near 90%. In this paper, we show that there is still a long way to go before solving text-to-SQL generation in the medical domain. To show this, we create new splits of the existing medical text-to- SQL dataset MIMICSQL that better measure the generalizability of the resulting models. We evaluate state-of-the-art language models on our new split showing substantial drops in performance with accuracy dropping from up to 92% to 28%, thus showing substantial room for improvement. Moreover, we introduce a novel data augmentation approach to improve the generalizability of the language models. Overall, this paper is the first step towards developing more robust text-to-SQL models in the medical domain.

Consideration of Acute Porphyria in an Emergency Department Patient: A Case Report and Discussion of Common Pitfalls.

INTRODUCTION: Porphyria refers to a group of disorders associated with defects in heme synthesis. They can be associated with severely debilitating features, including abdominal pain, psychiatric symptoms, neurological defects, and cardiovascular irregularities. Although these diseases are rare, patients with attacks often do present to the emergency department (ED) where consideration of porphyria is generally not included in the differential. CASE REPORT: Here, we examine a case of a 16-year-old male who presented to our ED for evaluation of recurring abdominal pain and auditory hallucinations in which porphyria was considered by the emergency physician. DISCUSSION: Not considering acute porphyria in patients with recurring neurovisceral symptoms in the ED can lead to missed opportunities for diagnosing such pathologies.

The risk of racial bias while tracking influenza-related content on social media using machine learning.

OBJECTIVE: Machine learning is used to understand and track influenza-related content on social media. Because these systems are used at scale, they have the potential to adversely impact the people they are built to help. In this study, we explore the biases of different machine learning methods for the specific task of detecting influenza-related content. We compare the performance of each model on tweets written in Standard American English (SAE) vs African American English (AAE). MATERIALS AND METHODS: Two influenza-related datasets are used to train 3 text classification models (support vector machine, convolutional neural network, bidirectional long short-term memory) with different feature sets. The datasets match real-world scenarios in which there is a large imbalance between SAE and AAE examples. The number of AAE examples for each class ranges from 2% to 5% in both datasets. We also evaluate each model's performance using a balanced dataset via undersampling. RESULTS: We find that all of the tested machine learning methods are biased on both datasets. The difference in false positive rates between SAE and AAE examples ranges from 0.01 to 0.35. The difference in the false negative rates ranges from 0.01 to 0.23. We also find that the neural network methods generally has more unfair results than the linear support vector machine on the chosen datasets. CONCLUSIONS: The models that result in the most unfair predictions may vary from dataset to dataset. Practitioners should be aware of the potential harms related to applying machine learning to health-related social media data. At a minimum, we recommend evaluating fairness along with traditional evaluation metrics.

Assigning ICD-O-3 Codes to Pathology Reports using Neural Multi-Task Training with Hierarchical Regularization.

Tracking population-level cancer information is essential for researchers, clinicians, policymakers, and the public. Unfortunately, much of the information is stored as unstructured data in pathology reports. Thus, too process the information, we require either automated extraction techniques or manual curation. Moreover, many of the cancer-related concepts appear infrequently in real-world training datasets. Automated extraction is difficult because of the limited data. This study introduces a novel technique that incorporates structured expert knowledge to improve histology and topography code classification models. Using pathology reports collected from the Kentucky Cancer Registry, we introduce a novel multi-task training approach with hierarchical regularization that incorporates structured information about the International Classification of Diseases for Oncology, 3rd Edition classes to improve predictive performance. Overall, we find that our method improves both micro and macro F1. For macro F1, we achieve up to a 6% absolute improvement for topography codes and up to 4% absolute improvement for histology codes.

Neural transfer learning for assigning diagnosis codes to EMRs.

OBJECTIVE: Electronic medical records (EMRs) are manually annotated by healthcare professionals and specialized medical coders with a standardized set of alphanumeric diagnosis and procedure codes, specifically from the International Classification of Diseases (ICD). Annotating EMRs with ICD codes is important for medical billing and downstream epidemiological studies. However, manually annotating EMRs is both time-consuming and error prone. In this paper, we explore the use of convolutional neural networks (CNNs) for automatic ICD coding. Because many codes occur infrequently, CNN performance is inhibited. Therefore, we propose supplementing EMR data with PubMed indexed biomedical research abstracts through neural transfer learning. MATERIALS AND METHODS: Transfer learning is the process of "transferring" knowledge acquired from one task (the source task) to a different (target) task. For the source task, we train a CNN to predict medical subject headings (MeSH) using 1.6 million PubMed indexed biomedical abstracts. For the target task, we train a CNN on 71,463 real-world EMRs collected from the University of Kentucky (UKY) medical center to predict ICD diagnosis codes. We introduce a simple, yet effective, transfer learning methodology which avoids forgetting knowledge gained from the source task. RESULTS: Compared to our prior work using EMRs from the UKY medical center, we improve both the micro and macro F-scores by more than 8%. Likewise, compared to other transfer learning methods, our approach results in nearly 2% improvement in macro F-score. CONCLUSION: We show that transfer learning can improve CNN performance for EMR coding in the presence of data sparsity issues. Furthermore, we find that our proposed transfer learning approach outperforms other methods with respect to macro F-score. Finally, we analyze how transfer learning impacts codes with respect to code frequency. We find that we achieve greater improvement on infrequent codes compared to improvements in most frequent codes.

EMR Coding with Semi-Parametric Multi-Head Matching Networks.

Coding EMRs with diagnosis and procedure codes is an indispensable task for billing, secondary data analyses, and monitoring health trends. Both speed and accuracy of coding are critical. While coding errors could lead to more patient-side financial burden and mis-interpretation of a patient's well-being, timely coding is also needed to avoid backlogs and additional costs for the healthcare facility. In this paper, we present a new neural network architecture that combines ideas from few-shot learning matching networks, multi-label loss functions, and convolutional neural networks for text classification to significantly outperform other state-of-the-art models. Our evaluations are conducted using a well known deidentified EMR dataset (MIMIC) with a variety of multi-label performance measures.

Few-Shot and Zero-Shot Multi-Label Learning for Structured Label Spaces.

Large multi-label datasets contain labels that occur thousands of times (frequent group), those that occur only a few times (few-shot group), and labels that never appear in the training dataset (zero-shot group). Multi-label few- and zero-shot label prediction is mostly unexplored on datasets with large label spaces, especially for text classification. In this paper, we perform a fine-grained evaluation to understand how state-of-the-art methods perform on infrequent labels. Furthermore, we develop few- and zero-shot methods for multi-label text classification when there is a known structure over the label space, and evaluate them on two publicly available medical text datasets: MIMIC II and MIMIC III. For few-shot labels we achieve improvements of 6.2% and 4.8% in R@10 for MIMIC II and MIMIC III, respectively, over prior efforts; the corresponding R@10 improvements for zero-shot labels are 17.3% and 19%.

Extracting chemical-protein relations with ensembles of SVM and deep learning models.

Mining relations between chemicals and proteins from the biomedical literature is an increasingly important task. The CHEMPROT track at BioCreative VI aims to promote the development and evaluation of systems that can automatically detect the chemical-protein relations in running text (PubMed abstracts). This work describes our CHEMPROT track entry, which is an ensemble of three systems, including a support vector machine, a convolutional neural network, and a recurrent neural network. Their output is combined using majority voting or stacking for final predictions. Our CHEMPROT system obtained 0.7266 in precision and 0.5735 in recall for an F-score of 0.6410 during the challenge, demonstrating the effectiveness of machine learning-based approaches for automatic relation extraction from biomedical literature and achieving the highest performance in the task during the 2017 challenge.Database URL: http://www.biocreative.org/tasks/biocreative-vi/track-5/.

Data and systems for medication-related text classification and concept normalization from Twitter: insights from the Social Media Mining for Health (SMM4H)-2017 shared task.

Objective: We executed the Social Media Mining for Health (SMM4H) 2017 shared tasks to enable the community-driven development and large-scale evaluation of automatic text processing methods for the classification and normalization of health-related text from social media. An additional objective was to publicly release manually annotated data. Materials and Methods: We organized 3 independent subtasks: automatic classification of self-reports of 1) adverse drug reactions (ADRs) and 2) medication consumption, from medication-mentioning tweets, and 3) normalization of ADR expressions. Training data consisted of 15 717 annotated tweets for (1), 10 260 for (2), and 6650 ADR phrases and identifiers for (3); and exhibited typical properties of social-media-based health-related texts. Systems were evaluated using 9961, 7513, and 2500 instances for the 3 subtasks, respectively. We evaluated performances of classes of methods and ensembles of system combinations following the shared tasks. Results: Among 55 system runs, the best system scores for the 3 subtasks were 0.435 (ADR class F1-score) for subtask-1, 0.693 (micro-averaged F1-score over two classes) for subtask-2, and 88.5% (accuracy) for subtask-3. Ensembles of system combinations obtained best scores of 0.476, 0.702, and 88.7%, outperforming individual systems. Discussion: Among individual systems, support vector machines and convolutional neural networks showed high performance. Performance gains achieved by ensembles of system combinations suggest that such strategies may be suitable for operational systems relying on difficult text classification tasks (eg, subtask-1). Conclusions: Data imbalance and lack of context remain challenges for natural language processing of social media text. Annotated data from the shared task have been made available as reference standards for future studies (http://dx.doi.org/10.17632/rxwfb3tysd.1).

Extracting Drug-Drug Interactions with Word and Character-Level Recurrent Neural Networks.

Drug-drug interactions (DDIs) are known to be responsible for nearly a third of all adverse drug reactions. Hence several current efforts focus on extracting signal from EMRs to prioritize DDIs that need further exploration. To this end, being able to extract explicit mentions of DDIs in free text narratives is an important task. In this paper, we explore recurrent neural network (RNN) architectures to detect and classify DDIs from unstructured text using the DDIExtraction dataset from the SemEval 2013 (task 9) shared task. Our methods are in line with those used in other recent deep learning efforts for relation extraction including DDI extraction. However, to our knowledge, we are the first to investigate the potential of character-level RNNs (Char-RNNs) for DDI extraction (and relation extraction in general). Furthermore, we explore a simple but effective model bootstrapping method to (a). build model averaging ensembles, (b). derive confidence intervals around mean micro-F scores (MMF), and (c). assess the average behavior of our methods. Without any rule based filtering of negative examples, a popular heuristic used by most earlier efforts, we achieve an MMF of 69.13. By adding simple replicable heuristics to filter negative instances we are able to achieve an MMF of 70.38. Furthermore, our best ensembles produce micro F-scores of 70.81 (without filtering) and 72.13 (with filtering), which are superior to metrics reported in published results. Although Char-RNNs turnout to be inferior to regular word based RNN models in overall comparisons, we find that ensembling models from both architectures results in nontrivial gains over simply using either alone, indicating that they complement each other.

A novel surgical approach to symptomatic left renal vein aneurysm.

Visceral venous aneurysms are uncommon and renal vein aneurysms are among the rarest in this subset. Renal vein aneurysms are frequently asymptomatic, but patients may present with flank pain or hematuria. Complications of untreated visceral venous aneurysms include thrombus formation and, very rarely, rupture. Treatment of renal vein aneurysms ranges from watchful waiting to surgical repair. We describe a patient with renal vein aneurysm presenting with recurrent pulmonary embolus with no other identifiable source. Furthermore, we propose a novel surgical treatment with complete resection of the aneurysm and reconstruction of venous return by transposing the inferior mesenteric vein to the remaining left renal vein.

Isolated lower extremity vasculitis leading to progressive critical limb ischemia.

Giant cell arteritis is a large- and medium-vessel vasculitis that has been described as a systemic disease process with disseminated vessel involvement. Advances in vascular imaging techniques have demonstrated that involvement of the large vessels of the upper and lower limbs may be more prevalent than was once thought, although the clinical implications of this are unknown. Isolated lower extremity claudication without systemic or classic cranial symptoms, especially as a primary manifestation of giant cell arteritis, is rare. We present the case of a patient with isolated bilateral limb claudication that rapidly progressed to critical limb ischemia requiring urgent surgical intervention after steroid therapy. Our patient has consented to the publication of this report.

Transperitoneal Intervascular Approach for Repair of the Lumbar Spine.

This report describes a novel anterior surgical approach to the midlumbar spine. A transperitoneal dissection separating the tissue planes between the infrarenal vena cava and abdominal aorta allows for ample exposure in the reconstruction of midlumbar vertebral body fractures.