Effect of an Artificial Intelligence Decision Support Tool on Palliative Care Referral in Hospitalized Patients: A Randomized Clinical Trial.

CONTEXT: Palliative care services are commonly provided to hospitalized patients, but accurately predicting who needs them remains a challenge. OBJECTIVES: To assess the effectiveness on clinical outcomes of an artificial intelligence (AI)/machine learning (ML) decision support tool for predicting patient need for palliative care services in the hospital. METHODS: The study design was a pragmatic, cluster-randomized, stepped-wedge clinical trial in 12 nursing units at two hospitals over a 15-month period between August 19, 2019, and November 17, 2020. Eligible patients were randomly assigned to either a medical service consultation recommendation triggered by an AI/ML tool predicting the need for palliative care services or usual care. The primary outcome was palliative care consultation note. Secondary outcomes included: hospital readmissions, length of stay, transfer to intensive care and palliative care consultation note by unit. RESULTS: A total of 3183 patient hospitalizations were enrolled. Of eligible patients, A total of 2544 patients were randomized to the decision support tool (1212; 48%) and usual care (1332; 52%). Of these, 1717 patients (67%) were retained for analyses. Patients randomized to the intervention had a statistically significant higher incidence rate of palliative care consultation compared to the control group (IRR, 1.44 [95% CI, 1.11-1.92]). Exploratory evidence suggested that the decision support tool group reduced 60-day and 90-day hospital readmissions (OR, 0.75 [95% CI, 0.57, 0.97]) and (OR, 0.72 [95% CI, 0.55-0.93]) respectively. CONCLUSION: A decision support tool integrated into palliative care practice and leveraging AI/ML demonstrated an increased palliative care consultation rate among hospitalized patients and reductions in hospitalizations.

Temporal trends in the incidence of post-dural puncture headache following labor neuraxial analgesia in the United States, 2006 to 2015.

BACKGROUND: Labor neuraxial analgesia utilization has increased in the United States (U.S.) but its impact on maternal safety is unknown. This study analyzed the temporal trends in the incidence of post-dural puncture headache (PDPH) in obstetrics. METHODS: Data for vaginal or intrapartum cesarean deliveries came from the National Inpatient Sample 2006-2015, a U.S. 20% representative sample of hospital discharge records. The outcome was PDPH (ICD-9-CM codes 349.0 and 03.95) categorized into (1) PDPH coded without epidural blood patch (EBP), and (2) PDPH coded with EBP. Temporal trends in incidence were described using the percent change between 2006 and 2015 and its 95% confidence interval (CI). RESULTS: Of the 29 011 472 deliveries studied, 86 558 (29.8 per 10 000; 95% CI: 29.3 to 30.2) recorded a diagnosis of PDPH, including 34 019 without EBP (11.7 per 10 000; 95% CI 11.4 to 12.0) and 52 539 with EBP (18.1 per 10 000; 95% CI 17.8 to 18.4). A significant decrease in the incidence of PDPH was observed from 31.5 per 10 000 in 2006 to 29.2 per 10 000 in 2015 (-7.5%; 95% CI -2.2 to -0.5; P=0.001). The decrease in the incidence of PDPH was significant irrespective of the presence of EBP. The decrease was observed in the three categories of hospitals examined (rural, urban non-teaching, and urban teaching). CONCLUSIONS: During the study period, the reported incidence of PDPH in the U.S. has decreased modestly. Intervention programs are needed to address this persistent and preventable cause of maternal morbidity.

Observational study evaluating obstetric anesthesiologist residents' well-being, anxiety and stress in a North American academic program.

BACKGROUND: The obstetric work environment has a unique set of stressors that may be associated with burnout. We investigated how well-being during the obstetric anesthesia (ObA) rotation compared to other rotations; which workplace environment characteristics precipitated the greatest stress; and whether anxiety and stress levels changed in trainees before and after an ObA rotation. METHODS: Using a survey, anesthesia residents (n=36) ranked their well-being on each anesthesia rotation and answered questions about their work environment. A separate survey measured anxiety and stress before and after an ObA rotation. Friedman's test was used to compare ranking data and Likert responses. T-tests were used to compare stress and anxiety scores. RESULTS: Residents' ranking of well-being on ObA was higher than that on another high demand rotation (cardiothoracic anesthesia, P=0.007). Work environment stress scores were significantly higher among community and fairness domains than for workload (P=0.002 and P=0.0001, respectively). While stress and anxiety scores did not significantly differ before and after the ObA rotation, they were higher than the reference population scores. CONCLUSIONS: We provide the first example of tools for assessing work environment stressors in ObA. Our study illustrates that beyond excessive workload, lack of fairness and community values are areas that impact physician well-being. Use of these tools can guide initiatives to address work environment concerns, and presents a need for a validated well-being instrument to gauge physician well-being, in order to create a cultural shift from burnout to one of well-being.

Duration of general anaesthetic exposure in early childhood and long-term language and cognitive ability.

BACKGROUND: The anaesthetic dose causing neurotoxicity in animals has been evaluated, but the relationship between duration of volatile anaesthetic (VA) exposure and neurodevelopment in children remains unclear. METHODS: Data were obtained from the Western Australian Pregnancy Cohort (Raine) Study, with language (Clinical Evaluation of Language Fundamentals: Receptive [CELF-R] and Expressive [CELF-E] and Total [CELF-T]) and cognition (Coloured Progressive Matrices [CPM]) assessed at age 10 yr. Medical records were reviewed, and children divided into quartiles based on total VA exposure duration before age three yr. The association between test score and exposure duration quartile was evaluated using linear regression, adjusting for patient characteristics and comorbidity. RESULTS: Of 1622 children with available test scores, 148 had documented VA exposure and were split into the following quartiles: ≤25, >25 to ≤35, >35 to ≤60 and >60 min. Compared with unexposed children, CELF-T scores for children in the first and second quartiles did not differ, but those in the third and fourth quartiles had significantly lower scores ([3 rd quartile - Unexposed] -5.3; 95% confidence interval [CI], (-10.2 - -0.4), [4 th quartile - Unexposed] -6.2; 95% CI, (-11.6 - -0.9). CELF-E showed similar findings, but significant differences were not found in CELF-R or CPM for any quartile. CONCLUSIONS: Children with VA exposures ≤35 min did not differ from unexposed children, but those with exposures >35 min had lower total and expressive language scores. It remains unclear if this is a dose-response relationship, or if children requiring longer exposures for longer surgeries have other clinical reasons for lower scores.

Can a Novel ICU Data Display Positively Affect Patient Outcomes and Save Lives?

The aim of this study was to quantify the impact of ProCCESs AWARE, Ambient Clinical Analytics, Rochester, MN, a novel acute care electronic medical record interface, on a range of care process and patient health outcome metrics in intensive care units (ICUs). ProCCESs AWARE is a novel acute care EMR interface that contains built-in tools for error prevention, practice surveillance, decision support and reporting. We compared outcomes before and after AWARE implementation using a prospective cohort and a historical control. The study population included all critically ill adult patients (over 18 years old) admitted to four ICUs at Mayo Clinic, Rochester, MN, who stayed in hospital at least 24 h. The pre-AWARE cohort included 983 patients from 2010, and the post-AWARE cohort included 856 patients from 2014. We analyzed patient health outcomes, care process quality, and hospital charges. After adjusting for patient acuity and baseline demographics, overall in-hospital and ICU mortality odds ratios associated with AWARE intervention were 0.45 (95% confidence interval 0.30 to 0.70) and 0.38 (0.22, 0.66). ICU length of stay decreased by about 50%, hospital length of stay by 37%, and total charges for hospital stay by 30% in post AWARE cohort (by $43,745 after adjusting for patient acuity and demographics). Better organization of information in the ICU with systems like AWARE has the potential to improve important patient outcomes, such as mortality and length of stay, resulting in reductions in costs of care.

Testing modes of computerized sepsis alert notification delivery systems.

BACKGROUND: The number of electronic health record (EHR)-based notifications continues to rise. One common method to deliver urgent and emergent notifications (alerts) is paging. Despite of wide presence of smartphones, the use of these devices for secure alerting remains a relatively new phenomenon. METHODS: We compared three methods of alert delivery (pagers, EHR-based notifications, and smartphones) to determine the best method of urgent alerting in the intensive care unit (ICU) setting. ICU clinicians received randomized automated sepsis alerts: pager, EHR-based notification, or a personal smartphone/tablet device. Time to notification acknowledgement, fatigue measurement, and user preferences (structured survey) were studied. RESULTS: Twenty three clinicians participated over the course of 3 months. A total of 48 randomized sepsis alerts were generated for 46 unique patients. Although all alerts were acknowledged, the primary outcome was confounded by technical failure of alert delivery in the smartphone/tablet arm. Median time to acknowledgment of urgent alerts was shorter by pager (102 mins) than EHR (169 mins). Secondary outcomes of fatigue measurement and user preference did not demonstrate significant differences between these notification delivery study arms. CONCLUSIONS: Technical failure of secure smartphone/tablet alert delivery presents a barrier to testing the optimal method of urgent alert delivery in the ICU setting. Results from fatigue evaluation and user preferences for alert delivery methods were similar in all arms. Further investigation is thus necessary to understand human and technical barriers to implementation of commonplace modern technology in the hospital setting.

Simulation Studies of Ion Permeation and Selectivity in Voltage-Gated Sodium Channels.

Voltage-gated ion channels are responsible for the generation and propagation of action potentials in electrically excitable cells. Molecular dynamics simulations have become a useful tool to study the molecular basis of ion transport in atomistic models of voltage-gated ion channels. The elucidation of several three-dimensional structures of bacterial voltage-gated sodium channels (Nav) in 2011 and 2012 opened the way to detailed computational investigations of this important class of membrane proteins. Here we review the numerous simulation studies of Na(+) permeation and selectivity in bacterial Nav channels published in the past 5years. These studies use a variety of simulation methodologies differing in force field parameters, molecular models, sampling algorithms, and simulation times. Although results disagree on the details of ion permeation mechanisms, they concur in the presence of two primary Na(+) binding sites in the selectivity filter and support a loosely coupled knock-on mechanism of Na(+) permeation. Comparative studies of Na(+), K(+), and Ca(2+) permeation reveal sites within Nav channels that are Na(+) selective, yet a consensus model of selectivity has not been established. We discuss the agreement between simulation and experimental results and propose strategies that may be used to resolve discrepancies between simulation studies in order to improve future computational studies of permeation and selectivity in ion channels.

Automatic quality improvement reports in the intensive care unit: One step closer toward meaningful use.

AIM: To examine the feasibility and validity of electronic generation of quality metrics in the intensive care unit (ICU). METHODS: This minimal risk observational study was performed at an academic tertiary hospital. The Critical Care Independent Multidisciplinary Program at Mayo Clinic identified and defined 11 key quality metrics. These metrics were automatically calculated using ICU DataMart, a near-real time copy of all ICU electronic medical record (EMR) data. The automatic report was compared with data from a comprehensive EMR review by a trained investigator. Data was collected for 93 randomly selected patients admitted to the ICU during April 2012 (10% of admitted adult population). This study was approved by the Mayo Clinic Institution Review Board. RESULTS: All types of variables needed for metric calculations were found to be available for manual and electronic abstraction, except information for availability of free beds for patient-specific time-frames. There was 100% agreement between electronic and manual data abstraction for ICU admission source, admission service, and discharge disposition. The agreement between electronic and manual data abstraction of the time of ICU admission and discharge were 99% and 89%. The time of hospital admission and discharge were similar for both the electronically and manually abstracted datasets. The specificity of the electronically-generated report was 93% and 94% for invasive and non-invasive ventilation use in the ICU. One false-positive result for each type of ventilation was present. The specificity for ICU and in-hospital mortality was 100%. Sensitivity was 100% for all metrics. CONCLUSION: Our study demonstrates excellent accuracy of electronically-generated key ICU quality metrics. This validates the feasibility of automatic metric generation.

Adsorption of acid dyes from aqueous solution on activated bleaching earth.

In the present study, activated bleaching earth was used as clay adsorbent for an investigation of the adsorbability and adsorption kinetics of acid dyes (i.e., acid orange 51, acid blue 9, and acid orange 10) with three different molecular sizes from aqueous solution at 25 degrees C in a batch adsorber. The rate of adsorption has been investigated under the most important process parameters (i.e., initial dye concentration). A simple pseudo-second-order model has been tested to predict the adsorption rate constant, equilibrium adsorbate concentration, and equilibrium adsorption capacity by the fittings of the experimental data. The results showed that the adsorbability of the acid acids by activated bleaching earth follows the order: acid orange 51 > acid blue 9 > acid orange 10, parallel to the molecular weights and molecular sizes of the acid dyes. The adsorption removals (below 3%) of acid blue 9 and acid orange 10 onto the clay adsorbent are far lower than that (approximately 24%) of acid orange 51. Further, the adsorption kinetic of acid orange 51 can be well described by the pseudo-second-order reaction model. Based on the isotherm data obtained from the fittings of the adsorption kinetics, the Langmuir model appears to fit the adsorption better than the Freundlich model. The external coefficients of mass transfer of the acid orange 51 molecule across the boundary layer of adsorbent particle have also been estimated at the order of 10(-4)-10(-5) cm s(-1) based on the film-pore model and pseudo-second-order reaction model.

Adsorption of polyethylene glycol (PEG) from aqueous solution onto hydrophobic zeolite.

In the present study, a hydrophobic zeolite was used as an adsorbent for the adsorption of polyethylene glycol (PEG) in water solution and electroplating solution at 25 degrees C. The adsorption capacities were determined through the adsorption isotherms in a thermostated shaker. The rate of adsorption, on the other hand, was investigated in a batch adsorber under controlled process parameters such as initial PEG concentration (30, 70, 110, 150, 200, and 300 mg x dm(-3)), agitation speed (200, 800, and 1000 rpm), and adsorbent particle size (0.72, 1.44, and 2.03 mm). A batch kinetic model, according to a pseudo-second-order mechanism, has been tested to predict the rate constant of adsorption, equilibrium adsorption capacity, time of half-adsorption, and equilibrium concentration by the fitting of the experimental data. The results of the adsorption isotherm and kinetic studies show that the adsorption process can well be described with the Langmuir and Freundlich models and the pseudo-second-order equation, respectively. Comparing the values of adsorption parameters of PEG in water solution and electroplating solution, there are no significant differences. In addition, the effective diffusion coefficient of the PEG molecule in the microporous adsorbent has been estimated at about 3.20 x 10(-8) cm(2)s(-1) based on the restrictive diffusion model.

[An attempt to estimate geographical accessibility to day service facilities among the elderly with a geographical information system].

OBJECTIVE: The objective of this study was to assess inequality in geographical accessibility to day service among the elderly in a municipality using a geographical information system (GIS). We also examined problems in measuring geographical accessibility and ways to validate results. METHODS: The target was Hachioji City. The following two data sets were constructed: a data set for day service facilities for all of Hachioji City and a data set for the people aged 65 and over, living within 1 km meshes in Hachioji City. These were integrated and displayed on a digital map with GIS software. Geographical accessibility was estimated by measuring the shortest road distance from the center point of each mesh to day service facilities. RESULTS: There were 47 day service facilities serving Hachioji City in October, 2000 and 139 meshes that had elderly residents. Their center points were all located within Hachioji City, which was estimated to have 73,760 elderly in 2000. The mean distance from the center point of each mesh to the nearest day service facility was 1.99 km (SD = 1.75, max = 9.21, min = 0.03). The proportions of the elderly who had 5 or more facilities within 3 km and 5 km from their residence were estimated to be 57.3% and 96.4%, respectively. CONCLUSIONS: The results of this study suggest that there is variation in geographical accessibility to day service facilities among the elderly living in a relatively large municipality. It is now necessary to examine whether the difference in geographical accessibility to day service affects the service utilization.

Progress with implementing local air-quality management in rural areas of England.

Air quality in the UK, although vastly improved from the smogs of the 1950s, now faces a new set of challenges from a variety of sources and pollutants. Poor air quality has long been associated with urban areas, but it is becoming clear that many rural locations also have locations likely to exceed the UK Air Quality Strategy-objectives: This paper will examine the extent to which rural authorities have been engaged in the local air-quality management (LAQM) process, a new regime by which air quality control is being accomplished in the UK. Results are presented from a questionnaire survey of environmental health officers of 100 rural authorities undertaken in January 1999. The paper investigates both the technical aspects of the LAQM process as well as the management approaches. The current progress of rural authorities, and some of the problems they face, are discussed particularly in comparison with urban areas. It is concluded that some rural authorities with air pollution problems stemming either from within or outwith their borough, may face significant challenges from the LAQM review and assessment process, particularly where air pollution responsibilities have only relatively recently been addressed. Rural authorities seem to be embracing these new responsibilities enthusiastically, but it is almost inevitable that they will be trailing behind urban authorities who have several decades of experience and joint working to draw upon.

The effect of various contrast media on the activation of plasminogen by streptokinase or recombinant tissue plasminogen activator in vitro.

RATIONALE AND OBJECTIVES: Radiologic contrast media (CM) may influence processes of coagulation and fibrinolysis. In the current study, the effects of various CM on the formation of plasmin were examined in an in vitro buffer system. METHODS: The effects of three clinically relevant concentrations of seven different iodine-containing CM and gadolinium-DTPA on streptokinase (SK) or recombinant tissue plasminogen activator (rt-PA)-induced plasmin formation was monitored using a plasmin-sensitive chromogenic substrate. RESULTS: Contrast media generally had an inhibitory effect at the plasminogen activation step; this effect was particularly noticeable with the ionic CM. CONCLUSIONS: Contrast media influence plasminogen activation by SK and rt-PA in vitro. Ionic CM have a more pronounced inhibitory effect than the nonionic media. The ionic Gd-DTPA shows a less inhibitory effect than the ionic iodine-containing CM. However, they must be regarded separately because of the different chemical composition of the magnetic resonance imaging and x-ray CM.

Umbilical vs peripheral vein catheterization for parenteral nutrition in sick premature neonates.

The efficacy and safety of using umbilical venous catheters vs. peripheral venous catheters for the delivery of parenteral nutrition was studied in 129 critically ill premature infants who were treated in a neonatal intensive care unit for the first 3 weeks of life. Infants who received parenteral nutrition by umbilical venous catheter had greater parenteral caloric intake, lower physiologic weight loss and greater weight gain during the study as compared to infants who received parenteral nutrition by peripheral vein. While the overall incidence of sepsis was comparable in both groups (19% vs 19.7%), benign and transient episodes of hyperglycemia were seen more commonly in infants receiving parenteral nutrition by umbilical catheters. None of the hyperglycemic infants, however, required insulin therapy. The incidence of other metabolic complication was comparable in both groups. At follow up, no evidence of portal hypertension was detected in any of the infants up to 66 months of age treated with umbilical venous catheters. We conclude that the use of umbilical venous catheter allows for a comparably safe and a more appropriate parenteral nutrition support than peripheral catheters in critically ill premature neonates.