Combination of machine learning algorithms with natural language processing may increase the probability of bacteremia detection in the emergency department: A retrospective, big-data analysis of 94,482 patients.

Background: Prompt diagnosis of bacteremia in the emergency department (ED) is of utmost importance. Nevertheless, the average time to first clinical laboratory finding range from 1 to 3 days. Alongside a myriad of scoring systems for occult bacteremia prediction, efforts for applying artificial intelligence (AI) in this realm are still preliminary. In the current study we combined an AI algorithm with a Natural Language Processing (NLP) algorithm that would potentially increase the yield extracted from clinical ED data. Methods: This study involved adult patients who visited our emergency department and at least one blood culture was taken to rule out bacteremia. Using both tabular and free text data, we built an ensemble model that leverages XGBoost for structured data, and logistic regression (LR) on a word-analysis technique called bag-of-words (BOW) Term Frequency-Inverse Document Frequency (TF-IDF), for textual data. All algorithms were designed in order to predict the risk for bacteremia with ED patients whose blood cultures were sent to the laboratory. Results: The study cohort comprised 94,482 individuals, of whom 52% were males. The prevalence of bacteremia in the entire cohort was 9.7%. The model trained on the tabular data yielded an area under the curve (AUC) of 73.7% for XGBoost, while the LR that was trained on the free text achieved an AUC of 71.3%. After checking a range of weights, the best combination was for 55% weight on the XGBoost prediction and 45% weight on the LR prediction. The final model prediction yielded an AUC of 75.6%. Conclusion: Harnessing artificial intelligence to the task of bacteremia surveillance in the ED settings by a combination of both free text and tabular data analysis improved predictive performance compared to using tabular data alone. We recommend that future AI applications based on our findings should be assimilated into the clinical routines of ED physicians.

Optimizing outcomes: A retrospective analysis of discharge safety for elderly mTBI patients on anticoagulation therapy.

BACKGROUND: Mild traumatic brain injuries (mTBIs) pose a significant risk, particularly in the elderly population on anticoagulation therapy. The safety of discharging these patients from the emergency department (ED) with a negative initial computed tomography (CT) scan has been debated due to the risk of delayed intracranial hemorrhage (d-ICH). OBJECTIVE: To compare outcomes, including d-ICH, between elderly patients on anticoagulation therapy presenting with mTBI who were admitted versus discharged from the ED after an initial negative head CT scan. METHODS: We conducted a retrospective observational study at the Chaim Sheba Medical Center, assessing outcomes of 1598 elderly patients on anticoagulation therapy who presented with mTBI and an initial negative head CT scan. Patients were either admitted for 24-h observation (Group A, n = 829) or discharged immediately from the ED (Group B, n = 769). The primary outcome was incidence of d-ICH within 14 days. RESULTS: Among the 1598 patients included in the study, 46 admitted patients and 1 discharged patient returned within 14 days for repeat CT, identifying one asymptomatic hemorrhage in the discharged patient. Mortality at 30 days was significantly higher in admitted patients compared to discharged patients (4.8% vs. 1.8%, p = 0.001), though cause of death was unrelated to head injury in both groups. CONCLUSION: In elderly patients on anticoagulation with mTBI and a negative initial CT, admission was associated with a higher risk of d-ICH compared to discharge. These findings have implications for clinical decision-making in this high-risk population.

Physical Trauma Following Rocket Warning Sirens in Israel.

INTRODUCTION: Civilians constitute a significant wartime target, and trauma accounts for most of their injuries. Air raid sirens have long been used to alert civilians of incoming attacks and have since expanded to warn from natural disasters. Sirens are known to cause significant emotional distress and physiological changes. Injuries inflicted from trauma while moving for shelter have yet to be described in the medical literature. METHODS: During the recent Israel-Gaza conflict of May 2021, most of Israel's population experienced rocket warning sirens. We collected all adult (18<) patients arriving at a major tertiary medical center emergency department (ED), attesting to having suffered their injury while rushing for shelter. Clinical and demographic data were retrieved and analyzed. RESULTS: A total of 48 patients were identified, with a mean age of 59.6 ± 20.0. Ten (21%) patients were admitted, and their mean length of stay was 4.4 ± 3.7 days. Women had a higher probability of being hospitalized (42.9% vs. 5.9%, P = .04), and those hospitalized tended to be older (68.8 ± 16.4 vs. 54.8 ± 20.8, P = .06). Elderly patients (65<) had a higher risk of injury. Extremity injuries were most common (50%), before head trauma (29%) and torso injuries (25%). Most patients (38/48, 79.2%) were discharged from the ED, and the rest were hospitalized for observation or surgery. One patient died from a head injury. CONCLUSIONS: This study implies that injuries while moving for shelter were a prevalent cause of physical injury to Israeli civilians during the Israel-Gaza 2021 conflict. Warning sirens injuries should be given appropriate attention-from prevention by directed media campaigns to post-conflict reimbursement.

Physiological Effects of Wearing N95 Respirator on Medical Staff During Prolong Work Hours in Covid-19 Departments.

OBJECTIVE: The objective of the current study was to determine gas exchange abnormalities and physiological changes among healthcare workers during a 4-hour emergency department (ED) shift while wearing the N95 respirator. METHODS: Single-center prospective observational study. Comparisons of paired measurements were performed using a non-parametric Wilcoxon matched-pairs signed-rank test. Results: Forty-one subjects were included. Prolonged N95 respirator use was associated with a significant decline in plasma pH (7.35 mmHg vs 7.34 mmHg, P = 0.02), PvO 2 (23.2 mmHg vs 18.6 mmHg, P < 0.001) and a concurrent increase in EtCO 2 (32.5 mmHg vs 38.5 mmHg, P < 0.0001). PvCO 2 and bicarbonate levels did not differ. No significant change was observed for heart rate or oxygen saturation. CONCLUSION: Using an N95 respirator for prolonged periods by healthcare professionals may provoke changes in gas exchange. The clinical significance of these changes remains to be determined.

The Pandemic's impacts on patients without Covid-19 on multidisciplinary aspects in emergency medicine care.

The emergence of Covid-19 has caused a pandemic and is a major public health concern. Covid-19 has fundamentally challenged the global health care system in all aspects. However, there is a growing concern for the subsequent detrimental effects of continuing delays or adjustments on time-dependent treatments for Covid-19 negative patients. Patients arriving to the ED with STEMIs and acute CVA are currently presumed to have delays due to Covid-19 related concerns. The objective of this paper is to evaluate the implications of the Covid-19 pandemic on non-Covid19 patients in emergency care settings. We conducted a retrospective study from February 2020 to April 2020 and compared this to a parallel period in 2019 to assess the impact of the Covid-19 pandemic on three distinct non-Covid-19 ED diagnosis that require immediate intervention. Our primary outcome measures were time to primary PCI in acute STEMI, time to fibrinolysis in acute CVA, and time to femoral hip fracture correction surgery. Our secondary outcome measure included a composite outcome of length of stay in hospital and mortality. From 1 February 2020 to 30 April 2020, the total referrals to ED diagnosed with STEMI, Hip fracture and CVA of which required intervention were 197 within Covid-19 group 2020 compared to 250 in the control group 2019. Mean duration to intervention (PCI, surgery and tPA, respectively) did not differ between COVID-19 group and 2019 group. Among femoral hip fracture patients', the referral numbers to ED were significantly lower in Covid-19 era (p = 0.040) and the hospitalization stay was significantly shorter (p = 0.003). Among CVA patients', we found statistical differences among the number of referrals and the patients' age. Coping with the Covid-19 pandemic presents a challenge for the general healthcare system. Our results suggest that with proper management, despite the obstacles of isolation policies and social distancing, any negative impact on the quality of health care for the non-Covid-19 patients can be minimized in the emergency department setting.

Infliximab therapy intensification upon loss of response: Is there an optimal trough level?

INTRODUCTION: Loss of response (LOR) to infliximab occurs in ∼30% of IBD patients. At time of LOR, lower infliximab-trough-levels (TL), in the absence of anti-drug-antibodies (ATI), have been associated with the need for therapy escalation. Nevertheless, few studies have examined the outcome of infliximab-therapy intensification, based on different TL. AIM: To evaluate the impact of infliximab-TL on efficacy of therapy intensification (dose-elevation/interval-shortening). METHODS: This was a retrospective observational study performed at two tertiary-centers between 2013-2017. Study population included IBD patients who underwent infliximab therapy escalation (dose elevation/interval shortening) due to clinical LOR. Patients with TL < 3 µg/ml or positive ATI were excluded. TL and clinical scores before intensification and after 6, 12 months were obtained prospectively. RESULTS: Forty-eight IBD patients were included; 23(49%), and 29(60%) reached clinical remission by 6, 12 months before intensification. TL among patients in clinical remission were significantly lower than among those clinically active, both at 6 (p = 0.001, median TL 4.7,8.7 µg/ml, IQR 3.6-8.1, 5.9-16 µg/ml) and 12 months (p = 0.005, median TL 4.6,8.7 µg/ml, IQR 3.6-8, 5.3-16 µg/ml), respectively. CONCLUSIONS: In IBD patients experiencing clinical LOR to infliximab in the absence of ATI, success of doubling the dose was inversely associated with baseline TL. Patients with baseline TL above 9 mcg/ml were very unlikely to reach clinical remission.