Health system-scale language models are all-purpose prediction engines.

Physicians make critical time-constrained decisions every day. Clinical predictive models can help physicians and administrators make decisions by forecasting clinical and operational events. Existing structured data-based clinical predictive models have limited use in everyday practice owing to complexity in data processing, as well as model development and deployment1-3. Here we show that unstructured clinical notes from the electronic health record can enable the training of clinical language models, which can be used as all-purpose clinical predictive engines with low-resistance development and deployment. Our approach leverages recent advances in natural language processing4,5 to train a large language model for medical language (NYUTron) and subsequently fine-tune it across a wide range of clinical and operational predictive tasks. We evaluated our approach within our health system for five such tasks: 30-day all-cause readmission prediction, in-hospital mortality prediction, comorbidity index prediction, length of stay prediction, and insurance denial prediction. We show that NYUTron has an area under the curve (AUC) of 78.7-94.9%, with an improvement of 5.36-14.7% in the AUC compared with traditional models. We additionally demonstrate the benefits of pretraining with clinical text, the potential for increasing generalizability to different sites through fine-tuning and the full deployment of our system in a prospective, single-arm trial. These results show the potential for using clinical language models in medicine to read alongside physicians and provide guidance at the point of care.

Gestión de calidad en equipos de gases en sangre POCT. Expandiendo las fronteras del laboratorio / Quality management in POCT blood gas equipment. Expanding the frontiers of the laboratory

La realización de pruebas de laboratorio en el lugar de atención del paciente (POCT) de equipos de gases en sangre representa un desafío continuo tanto para los usuarios como para el laboratorio. La vulnerabilidad al error y la amenaza del riesgo que rodea esta forma de trabajo obliga a establecer un sistema de trabajo robusto para la obtención de un "resultado confiable" cerca del paciente crítico. La formación de un grupo interdisciplinario, la capacitación de usuarios externos al laboratorio, el aseguramiento de la calidad analítica y la conectividad, son los cuatro pilares sobre los cuales se sostiene el éxito de esta nueva era de laboratorio clínico. Además es necesaria la reinvención de la imagen bioquímica, asumiendo un rol de líder, comunicador, asesor e integrado al sistema de salud (AU)

Point of care laboratory testing (POCT) with blood gas equipment is an ongoing challenge for both the users and the laboratory. The vulnerability to error and the threat of risk that surrounds this way of working necessitates the establishment of a robust working system to obtain "reliable results" for the critically ill patient. The creation of an interdisciplinary group, the training of external users, analytical quality assurance, and connectivity are the four pillars on which the success of this new era of clinical laboratories is based. It is also necessary to reinvent the biochemical image, assuming the role of leader, communicator, and advisor integrated into the health system (AU)

Sample Preparation and Diagnostic Methods for a Variety of Settings: A Comprehensive Review.

Sample preparation is an essential step for nearly every type of biochemical analysis in use today. Among the most important of these analyses is the diagnosis of diseases, since their treatment may rely greatly on time and, in the case of infectious diseases, containing their spread within a population to prevent outbreaks. To address this, many different methods have been developed for use in the wide variety of settings for which they are needed. In this work, we have reviewed the literature and report on a broad range of methods that have been developed in recent years and their applications to point-of-care (POC), high-throughput screening, and low-resource and traditional clinical settings for diagnosis, including some of those that were developed in response to the coronavirus disease 2019 (COVID-19) pandemic. In addition to covering alternative approaches and improvements to traditional sample preparation techniques such as extractions and separations, techniques that have been developed with focuses on integration with smart devices, laboratory automation, and biosensors are also discussed.

Point of care ultrasound knowledge among resident doctors in Madrid's university hospitals. Influence of the induction in emergency departments with point of care ultrasound practice / Grado de conocimiento de la ecografía a pie de cama, entre una muestra de médicos residentes de hospitales universitarios de Madrid. Influencia de la inducción en los servicios de urgencias con uso habitual de ecografía a pie de cama

BACKGROUND: Point of care ultrasound study (POCUS) is a relatively new technique in Spanish Emergency Departments (EDs). Nonetheless, its use is increasing, and the number of emergency doctors and the number of papers published in our country has skyrocketed in last decade. Despite this fact, there is still no evidence of how POCUS is taught in our medical schools. OBJECTIVE: To ascertain the level of knowledge about POCUS in first year resident doctors of three hospitals in Madrid, and one year after having worked in ED with POCUS practice. METHODS AND STUDY DESIGN: The study looked at demographic aspects, POCUS knowledge, and opinions about its usefulness in the ED, prior to and after working in ED with routine use of POCUS. RESULTS: Of the 265 questionnaires, 197 were first-year residents (Group 1) and 68 second-year residents (Group 2). Another 55 senior medical students completed the questionnaire (Group 3). The majority of Groups 1 and 3 stated to have a very low POCUS level. Almost three-quarters (73%) of Group 2 stated having an intermediate or high level, and 26% even declared having full knowledge. More than half of the students agreed that POCUS was a useful tool in ED. CONCLUSIONS: There is a low level of knowledge about POCUS among first-year residents. After working in POCUS qualified EDs, these resident doctors state both the importance and their higher level of knowledge of POCUS

INTRODUCCIÓN: La ecografía a pie de cama (EPC) es una técnica diagnóstica cada día más utilizada por los médicos urgenciólogos en los servicios de urgencias hospitalarios españoles. No obstante, desconocemos el nivel de la EPC de nuestros médicos residentes de primer año (R1). OBJETIVO: Determinar el nivel de conocimientos sobre la EPC de los R1, en 3 hospitales universitarios de Madrid, y el conocimiento un año después de haber trabajado en servicios de urgencias con utilización habitual de la EPC. MÉTODOS: Nuestra encuesta investigaba datos demográficos, nivel previo de conocimiento de la EPC y opinión acerca de su utilidad en el servicio de urgencias. También se aplicó la encuesta a 55 estudiantes de medicina del último curso (EM6). RESULTADOS: De 265 encuestas: 197 fueron de R1 y 68 de R2. También se pasó la encuesta a otros 55 estudiantes de medicina del último curso (EM6). La mayoría de los R1 y EM6, revelaron un nivel previo muy bajo de conocimientos de la EPC. En cambio, el 73% de los R2, manifestaron un nivel intermedio o alto, e incluso un 26% declararon un conocimiento amplio. Más de la mitad de los encuestados manifestó estar de acuerdo en que la EPC era una herramienta muy útil en el servicio de urgencias. CONCLUSIONES: Existe un bajo nivel de conocimientos sobre la EPC entre los R1. Después de haber trabajado en servicios de urgencias con práctica habitual de EPC, estos mismos médicos residentes, reconocieron tanto la importancia de la EPC como su alto nivel de conocimientos de la EPC

A critical review of point-of-care diagnostic technologies to combat viral pandemics.

The COVID-19 global pandemic of 2019-2020 pointedly revealed the lack of diagnostic solutions that are able to keep pace with the rapid spread of the virus. Despite the promise of decades of lab-on-a-chip research, no commercial products were available to deliver rapid results or enable testing in the field at the onset of the pandemic. In this critical review, we assess the current state of progress on the development of point-of-care technologies for the diagnosis of viral diseases that cause pandemics. While many previous reviews have reported on progress in various lab-on-a-chip technologies, here we address the literature from the perspective of the testing needs of a rapidly expanding pandemic. First, we recommend a set of requirements to heed when designing point-of-care diagnostic technologies to address the testing needs of a pandemic. We then review the current state of assay technologies with a focus on isothermal amplification and lateral-flow immunoassays. Though there is much progress on assay development, we argue that the largest roadblock to deployment exists in sample preparation. We summarize current approaches to automate sample preparation and discuss both the progress and shortcomings of these developments. Finally, we provide our recommendations to the field of specific challenges to address in order to prepare for the next pandemic.

Damage control resuscitation and surgery for indigenous combat casualties: a prospective observational study.

INTRODUCTION: Specialist units that assist indigenous forces (IF) in their strategic aims are supported by medical teams providing point of injury emergency care for casualties, including IF and civilians (Civ). We investigated the activities of a Coalition Forces far-forward medical facility, in order to inform medical providers about the facilities and resources required for medical support to IF and Civ during such operations. METHODS: A prospective observational study (June to August 2017) undertaken at a far-forward Coalition Forces medical support unit (12 rotating personnel) recorded patient details (IF or Civ), mechanism of injury (MOI), number of blood products used, damage control resuscitation (DCR) and damage control surgery (DCS), number of mass casualty (MASCAL) scenarios, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA) and whole blood emergency donor panels (EDP). RESULTS: 680 casualties included 478 IF and 202 Civ (45.5% of the Civ were paediatric). Most common MOIs were blast (n=425; 62.5%) and gunshot wound (n=200; 29.4%). Fifteen (2.2%) casualties died; 627 (92.2%) were transferred to local hospitals. DCR was used for 203 (29.9%), and DCS for 182 (26.8%) casualties. There were 23 MASCAL scenarios, 1220 transfusions and 32 EDPs. REBOA was performed eight times, and thoracotomy was performed 27 times. CONCLUSIONS: A small medical team provided high-tempo emergency resuscitative care for hundreds of IF and Civ casualties within a short space of time using state-of-the-art resuscitative modalities. DCR and DCS were undertaken with a large number of EDPs, and a high survival-to-transfer rate.

CRISPR/Cas9 from bench to bedside: what clinicians need to know before application?

In October 2020, Dr. Emmanuelle Charpentier and Dr. Jennifer Doudna won the Nobel Prize in Chemistry for their pioneering work in precise genome editing using the CRISPR technology. Although CRISPR technology has developed rapidly in the last decade, there are still many uncertainties before eventual use in clinical settings. In this mini review, we summarize the current efforts in addressing the limitations of CRISPR technology and future directions.

Trends in Diagnostic Point-of-Care Ultrasonography Reimbursement for Medicare Beneficiaries Among the US Emergency Medicine Workforce, 2012 to 2016.

STUDY OBJECTIVE: Point-of-care ultrasonography allows rapid diagnosis in the emergency department. A previous study found that a low prevalence of emergency medicine clinicians received point-of-care ultrasonography reimbursement in 2012 (0.7%). We determine nationwide point-of-care ultrasonography reimbursement patterns for 4 subsequent years. METHODS: We performed a cross-sectional study using 2012 to 2016 data from the Centers for Medicare & Medicaid Fee-for-Service Provider Utilization and Payment Data Part B, defining point-of-care ultrasonographic examinations using Current Procedural Terminology codes. The emergency medicine workforce was defined by emergency medicine, family medicine, internal medicine, critical care, and advanced practice providers who received emergency medicine-specific reimbursements. We compared patterns of point-of-care ultrasonography reimbursement among emergency physicians in 2012 versus 2016 through a 2-sample test of proportions. RESULTS: In 2012, 342 (0.7% of total) emergency medicine workforce clinicians were reimbursed for diagnostic point-of-care ultrasonography versus 801 (1.3%) in 2016. Emergency physicians represented an increasing proportion of the total workforce, increasing from 86.0% (95% confidence interval 82.3% to 89.6%) in 2012 (N=294) to 94.6% (95% confidence interval 93.1% to 96.2%) in 2016 (N=758). From 2012 to 2016, total point-of-care ultrasonography reimbursements increased from 13,697 to 31,717, with significant growth from echocardiograms (4,127 to 14,978), abdominal examinations (3,682 to 7,140), and thoracic examinations (801 to 5,278). CONCLUSION: The proportion of emergency medicine workforce clinicians receiving diagnostic point-of-care ultrasonography reimbursements, as well as the number of point-of-care ultrasonographic studies, more than doubled from 2012 to 2016. Efforts are needed to understand barriers to adoption of point-of-care ultrasonography because only a small proportion of the emergency medicine clinician workforce was reimbursed in any year.

Point-of-care ultrasound induced changes in management of unselected patients in the emergency department - a prospective single-blinded observational trial.

BACKGROUND: Point-of-Care ultrasound (POCUS) changes the management in specific groups of patients in the Emergency Department (ED). It seems intuitive that POCUS holds an unexploited potential on a wide variety of patients. However, little is known about the effect of ultrasound on the broad spectrum of unselected patients in the ED. This study aimed to identify the effect on the clinical management if POCUS was applied on unselected patients. Secondarily the study aimed to identify predictors of ultrasound changing management. METHODS: This study was a blinded observational single center trial. A basic whole body POCUS protocol was performed in extension to the physical examination. The blinded treating physicians were interviewed about the presumptive diagnosis and plan for the patient. Subsequently the physicians were unblinded to the POCUS results and asked to choose between five options regarding the benefit from POCUS results. RESULTS: A total of 403 patients were enrolled in this study. The treating physicians regarded POCUS examinations influence on the diagnostic workup or treatment as following: 1) No new information: 249 (61.8%), 2) No further action: 45 (11.2%), 3) Further diagnostic workup needed: 52 (12.9%), 4) Presumptive diagnosis confirmed 38 (9.4%), and 5) Immediate treatment needed: 19 (4.7%). Predictors of beneficial ultrasound were: (a) triage > 1, (b) patient comorbidities (cardiac disease, hypertension or lung disease), or (c) patients presenting with abdominal pain, dyspnea, or syncope. CONCLUSION: POCUS was found to be potentially beneficial in 27.0% of all patients. High triage score, known cardiac disease, hypertension, pulmonary diseases, a clinical presentation with abdominal pain, dyspnea, or syncope are predictors of this. Future research should focus on patient-important outcomes when applying POCUS on these patients. TRIAL REGISTRATION: The trail was registered prior to patient inclusion with the Danish Data Protection Agency (https://www.datatilsynet.dk/ Case no: 1-16-02-603-14) and Clinical Trials (www.clinicaltrials.gov/ Protocol ID: DNVK1305018).

Point-of-care ultrasound at Role 1: is it time for a rethink?

INTRODUCTION: The past 20 years have seen a rapid increase in point-of-care ultrasound (POCUS) use in the prehospital sphere. However, in the British Army there is no POCUS capability in the Defence Primary Healthcare (DPHC) or deployed Role 1 setting. POCUS can improve diagnostic capability, influence management decisions and transfer destination, and is a useful triage tool in mass casualty management. METHOD: A survey on POCUS use was sent to 279 clinicians working in the Role 1, civilian prehospital and Defence Primary Healthcare environments. Questions explored current levels of experience and training, indications for use and attitudes towards roll out. Results were analysed using a mixed methods approach. RESULTS: There were 124 respondents (279 recipients; 44.4% response rate). 74.2% (92 respondents) had no experience of using POCUS while 9.7% (12 respondents) were classed as frequent users. The four most common indications for prehospital POCUS were abdominal, cardiac and lung imaging and vascular access. The majority of respondents felt that POCUS would add value in the deployed Role 1 environment; this was even more evident in the frequent user group. Common concerns were difficulty maintaining currency, governance burden and uncertainty over impact on management. CONCLUSION: The majority of doctors surveyed feel that POCUS would add value at Role 1 and is a capability that should be developed. The authors will watch with interest the progress of Project MORPHO.

Microfluidic Point-of-Care Devices: New Trends and Future Prospects for eHealth Diagnostics.

Point-of-care (PoC) diagnostics is promising for early detection of a number of diseases, including cancer, diabetes, and cardiovascular diseases, in addition to serving for monitoring health conditions. To be efficient and cost-effective, portable PoC devices are made with microfluidic technologies, with which laboratory analysis can be made with small-volume samples. Recent years have witnessed considerable progress in this area with "epidermal electronics", including miniaturized wearable diagnosis devices. These wearable devices allow for continuous real-time transmission of biological data to the Internet for further processing and transformation into clinical knowledge. Other approaches include bluetooth and WiFi technology for data transmission from portable (non-wearable) diagnosis devices to cellphones or computers, and then to the Internet for communication with centralized healthcare structures. There are, however, considerable challenges to be faced before PoC devices become routine in the clinical practice. For instance, the implementation of this technology requires integration of detection components with other fluid regulatory elements at the microscale, where fluid-flow properties become increasingly controlled by viscous forces rather than inertial forces. Another challenge is to develop new materials for environmentally friendly, cheap, and portable microfluidic devices. In this review paper, we first revisit the progress made in the last few years and discuss trends and strategies for the fabrication of microfluidic devices. Then, we discuss the challenges in lab-on-a-chip biosensing devices, including colorimetric sensors coupled to smartphones, plasmonic sensors, and electronic tongues. The latter ones use statistical and big data analysis for proper classification. The increasing use of big data and artificial intelligence methods is then commented upon in the context of wearable and handled biosensing platforms for the Internet of things and futuristic healthcare systems.

Improving the documentation quality of point-of-care ultrasound scans in the emergency department.

A point-of-care ultrasound scan (POCUS) is a core element of the Royal College of Emergency Medicine (RCEM) specialty training curriculum. However, POCUS documentation quality can be poor, especially in the time-pressured environment of the emergency department (ED). A survey of 10 junior ED clinicians at the Princess Royal University Hospital (PRUH) found that total POCUS documentation was as low as 38% in some examinations.This quality improvement project aimed to increase the coverage and quality of POCUS documentation in the ED. This was done by using a plan-do-study-act (PDSA) regime to improve the quality of POCUS documentation from the original baseline to 80%. There were three discreet PDSA cycles and the interventions included improving education and training about POCUS documentation and the introduction of an original proforma, which incorporated six minimum requirements for POCUS documentation as per the joint RCEM and Royal College of Radiologists (RCR) guidelines for POCUS documentation (patient details, indications, findings, conclusions, signature and date).The project team audited the quality of all documented scans in the resuscitation department of the PRUH against the RCEM/RCR guidelines at baseline and following three discrete PDSA cycles. This was done over an 8-week period, spanning 696 attendances to the resuscitation area of the ED and 42 documented POCUS examinations.Quality recording of the six RCEM/RCR elements of POCUS documentation was poor at baseline but improved following three successful PDSA cycles. There was a demonstrated improvement in five of six documentation elements: patient details on POCUS documentation increased from 53.3% to the 66.7%, indication from 60.0% to 66.7%, conclusion from 13.0% to 83.0%, signature from 86.7% to 100.0% and date from 46.7% to 66.7%.These results suggest that the introduction of a proforma and a vigorous education strategy are effective ways to improve the quality of documentation of ED POCUS.

Check-in Kiosks in the Outpatient Clinical Setting: Fad or the Future?

OBJECTIVES: Check-in kiosks are increasingly used in health care. This project aims to assess the effects of kiosk use upon check-in duration, point of service (POS) financial returns, and patient satisfaction. METHODS: Six kiosks were implemented in a large academic orthopedic clinic, and check-in duration for 8.5 months following implementation and POS returns for 10.5 months before and after implementation were analyzed. Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey and self-devised surveys recorded patient satisfaction. RESULTS: Cumulatively, 28,636 kiosk-based patient encounters were analyzed. Compared with historical norms, check-in duration decreased 2 minutes, 47 seconds (P < 0.001). Daily gross and individual POS returns increased $532.13 and $1.89, respectively (P < 0.001). Satisfaction surveys were completed by 719 of 1376 consecutive patients (52% response rate), revealing 12% improvement (P < 0.001), but Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey responses demonstrated no change (P = 0.146, 0.928, and 0.336). CONCLUSIONS: Kiosks offer to reduce check-in duration and increase POS revenue without negatively affecting patient satisfaction.

Bedside Sonographic Duplex Technique as a Monitoring Tool in Patients after Decompressive Craniectomy: A Single Centre Experience.

BACKGROUND AND OBJECTIVES: Bedside sonographic duplex technique (SDT) may be used as an adjunct to cranial computed tomography (CCT) to monitor brain-injured patients after decompressive craniectomy (DC). The present study aimed to assess the value of SDT in repeated measurements of ventricle dimensions in patients after DC by comparing both techniques. MATERIALS AND METHODS: Retrospective assessment of 20 consecutive patients after DC for refractory intracranial pressure (ICP) increase following subarachnoid hemorrhage (SAH), bleeding and trauma which were examined by SDT and CCT in the context of routine clinical practice. Whenever a repeated CCT was clinically indicated SDT examinations were performed within 24 hours and correlated via measurement of the dimensions of all four cerebral ventricles. Basal cerebral arteries including pathologies such as vasospasms were also evaluated in comparison to selected digital subtraction angiography (DSA). RESULTS: Repeated measurements of all four ventricle diameters showed high correlation between CCT and SDT (right lateral r = 0.997, p < 0.001; left lateral r = 0.997, p < 0.001; third r = 0.991, p < 0.001, fourth ventricle r = 0.977, p < 0.001). SDT performed well in visualizing basal cerebral arteries including pathologies (e.g., vasospasms) as compared to DSA. CONCLUSIONS: Repeated SDT measurements of the dimensions of all four ventricles in patients after DC for refractory ICP increase delivered reproducible results comparable to CCT. SDT may be considered as a valuable bedside monitoring tool in patients after DC.

Bedside Technologies to Enhance the Early Detection of Pressure Injuries: A Systematic Review.

BACKGROUND: Hospital-acquired pressure injuries strain organizational resources and negatively impact the quality of life of affected patients. However, early detection of pressure injuries is limited due to challenges with visual assessment, particularly in individuals with dark skin. PURPOSE: The purpose of this systematic review was to determine whether sufficient research evidence exists to support the use of bedside technologies for early detection of pressure injures, which is inclusive of pressure-related blanchable erythema (PrBE), pressure-related nonblanchable erythema (PrNBE), and deep tissue pressure injury (DTPI). SEARCH QUESTION: What available bedside technologies enhance the early detection of pressure injuries? METHODS: A systematic search of Medline, CINAHL, Web of Science, and Cochrane databases was executed. Quantitative studies were included that examined whether accessible technologies could indicate the presence of PrBE, PrNBE, and DTPI. The quality of the research was evaluated using the Johns Hopkins Nursing Evidence-Based Practice Rating Scale. FINDINGS: We identified 18 eligible studies that represented a variety of technologies, including ultrasound (n = 5), thermography (n = 7), subepidermal moisture (SEM) measurement (n = 5), reflectance spectrometry (n = 2), and laser Doppler (n = 1). The methodological rigor in study quality was variable. Subepidermal moisture measurement provided the most consistent findings in the early detection of pressure injury. CONCLUSIONS: Objective methods that provide accurate and timely assessment of DTPIs augment early implementation of optimal prevention and treatment measures. Evidence identified in this systematic review supports the use of SEM measurement devices as effective tools for early pressure injury detection. However, more research in the field of technology-enhanced, pressure injury detection is needed to support the use of existing and emerging devices.

A Prospective Evaluation of Point-of-Care Measurements of Maternal Glucose for the Diagnosis of Gestational Diabetes Mellitus.

BACKGROUND: Point-of-care (POC) measurement of glucose is currently recommended only for the monitoring of gestational diabetes mellitus (GDM). This prospective observational study evaluated the use of POC measurements of maternal glucose to diagnose GDM in women being screened selectively with a 1-step 75 g oral glucose tolerance test (OGTT). METHODS: The strictest preanalytic and analytic international laboratory standards were applied to measure maternal plasma glucose at fasting and at 1 and 2 h post glucose load. The recent International Association of Diabetes and Pregnancy Study Groups diagnostic criteria were used. At the same time, maternal capillary glucose was measured. Because of differences in plasma and capillary glucose measurements, regression analysis of POC capillary glucose results vs laboratory plasma glucose results was conducted. The regression equations for plasma glucose were derived in a derivation cohort (n = 102). These equations were applied in the validation cohort (n = 100). Predicted and actual plasma glucose values were compared. RESULTS: Of the 202 women screened, 36.6% were nulliparous, 56.4% were obese, and 81.2% were Irish-born. Two thirds had a single risk factor for GDM, and a third had multiple risk factors. Based on the plasma measurements, 53.5% had GDM. As a predictor of GDM, the diagnostic accuracy of POC measurement was 83.0% (95% confidence interval, 74.2-89.8). CONCLUSIONS: In high-resource settings where measures to inhibit glycolysis are implemented, the use of POC measurements for the diagnosis of GDM is not justified based on this study. In low- and medium-resource settings, where measures to inhibit glycolysis are not achievable, regression analysis using POC measurements may be acceptable compared with plasma samples subject to glycolysis.