Identifying subgroups in heart failure patients with multimorbidity by clustering and network analysis.

This study presents a workflow for identifying and characterizing patients with Heart Failure (HF) and multimorbidity utilizing data from Electronic Health Records. Multimorbidity, the co-occurrence of two or more chronic conditions, poses a significant challenge on healthcare systems. Nonetheless, understanding of patients with multimorbidity, including the most common disease interactions, risk factors, and treatment responses, remains limited, particularly for complex and heterogeneous conditions like HF. We conducted a clustering analysis of 3745 HF patients using demographics, comorbidities, laboratory values, and drug prescriptions. Our analysis revealed four distinct clusters with significant differences in multimorbidity profiles showing differential prognostic implications regarding unplanned hospital admissions. These findings underscore the considerable disease heterogeneity within HF patients and emphasize the potential for improved characterization of patient subgroups for clinical risk stratification through the use of EHR data.

Impact of a wearable-based physical activity and sleep intervention in multimorbidity patients: protocol for a randomized controlled trial.

BACKGROUND: The benefits of physical activity (PA) and adequate sleep are well documented, and their importance strengthens with the increasing prevalence of chronic diseases and multimorbidity (MM). Interventions to promote physical activity and sleep that use commercial activity trackers may be useful non-pharmacological approaches to managing individual health; however, limited evidence exists on their use to improve physical activity in older adult patients with MM. METHODS: This study aims to measure the effects of behavioral change techniques (BCTs) delivered by a wearable device on physical activity and quality of sleep (QS) in older adult patients with MM. We designed an open-label randomized controlled trial with participants recruited through primary care and a specialist outpatient clinic. Participants must be more than 65 years old, have MM, and have access to smartphones. All eligible participants will receive PA promotion content and will be randomly assigned to wear a smartwatch. The primary outcome will be the participants' PA measurement at baseline and at six months using the International Physical Activity Questionnaire - Short Form (IPAQ-SF). Secondary outcomes will include changes in the participants' frailty status, biometric measurements, quality of life, and biopsychosocial assessments. A sample size of 40 participants per arm was calculated to detect group differences, with 50 participants planned to recruit and randomize into each arm. DISCUSSION: This study aims to contribute to a better understanding of PA patterns and the impact of wearable-based PA interventions in patients with MM. In addition, we aim to contribute to more knowledge about the relationship between PA patterns, Patient Reported Outcomes Measures (PROMs), and healthcare resource utilization in patients with MM. To achieve this, the study will leverage a locally developed PROMs registry and assess data from participants' medical records, in order to understand the added impact of wearable data and medical information data on predicting PROMs and unplanned hospital admissions. TRIAL REGISTRATION: NCT05777291.

Risk Management in Clinical Trials: Assessment of Current Practices at Portuguese Clinical Trial Sites.

Purpose: Over the last years, in response to the increasing complexity and demand of clinical trials, there has been a growing concern with the application of efficient risk management methodologies. The main objective of this work is to assess the current level of implementation of risk management activities by clinical trials sites' teams and identify points of improvement. Methods: A cross-sectional study was conducted through an original, non-validated questionnaire created to assess the risk management practices at Portuguese clinical trial sites. The web-based survey was sent by e-mail to the clinical trial sites identified, and it was available for one month. Descriptive statistics were used to summarize the findings. Results: In total, 46 clinical trial sites accepted to participate in this study. The surveys' answers showed that although 57.0% of sites reported the use of a systematic risk management tool, only nine sites (19.6%) described a standard tool or document that captured systematically the analysis of risks at the site level. Most of the sites (87.0%) showed willing to use a risk management tool specifically tailored for their operational needs, with the lack of knowledge about risk management being the main reason against its implementation. Conclusion: This work indicates that the surveyed clinical trial sites generally recognize the importance of risk management methodologies as an opportunity to anticipate difficulties in the trial conduct and optimize the use of sites' resources. However, mainly due to lack of experience with risk management methodologies, sites are not currently implementing these strategies in the management of their trial-related operations. The development of a risk management tool for sites can be useful in this context.

PIÑATA: Pinpoint insertion of intravenous needles via augmented reality training assistance.

Conventional needle insertion training relies on medical dummies that simulate surface anatomy and internal structures such as veins or arteries. These dummies offer an interesting space to augment with useful information to assist training practices, namely, internal anatomical structures (subclavian artery and vein, internal jugular vein and carotid artery) along with target point, desired inclination, position and orientation of the needle. However, limited research has been conducted on Optical See-Through Augmented Reality (OST-AR) interfaces for training needle insertion, especially for central venous catheterization (CVC). In this work we introduce PIÑATA, an interactive tool to explore the benefits of OST-AR in CVC training using a dummy of the upper torso and neck; andexplore if PIÑATA complements conventional training practices.. Our design contribution also describes the observation and co-design sessions used to collect user requirements, usability aspects and user preferences. This was followed by a comparative study with 18 participants - attending specialists and medical residents - that performed needle insertion tasks for CVC with PIÑATAand the conventional training system. The performance was objectively measured by task completion time and number of needle insertion errors. A correlation was found between the task completion time in the two training methods, suggesting the concurrent validity of our OST-AR tool. An inherent difference in the task completion time (p =0.040) and in the number of errors (p = 0.036) between novices and experts proved the construct validity of the new tool. The qualitative answers of the participants also suggest its face and content validity, a high acceptability rate and a medium perceived workload. Finally, the result of semi-structured interviews with these 18 participants revealed that 14 of them considered that PIÑATA can complement the conventional training system, especially due to the visibility of the vessels inside the simulator. 13 agreed that OST-AR adoption in these scenarios is likely, particularly during early stages of training. Integration with ultrasound information was highlighted as necessary future work. In sum, the overall results show that the OST-AR tool proposed can complement the conventional training of CVC.

Challenges and Best Practices in Ethical Review of Human and Organizational Factors Studies in Health Technology: a Synthesis of Testimonies.

OBJECTIVE: Human and Organizational Factors (HOF) studies in health technology involve human beings and thus require Institutional Review Board (IRB) approval. Yet HOF studies have specific constraints and methods that may not fit standard regulations and IRB practices. Gaining IRB approval may pose difficulties for HOF researchers. This paper aims to provide a first overview of HOF study challenges to get IRB review by exploring differences and best practices across different countries. METHODS: HOF researchers were contacted by email to provide a testimony about their experience with IRB review and approval. Testimonies were thematically analyzed and synthesized to identify and discuss shared themes. RESULTS: Researchers from seven European countries, Argentina, Canada, Australia, and the United States answered the call. Four themes emerged that indicate shared challenges in legislation, IRB inefficiencies and inconsistencies, general regulation and costs, and lack of HOF study knowledge by IRB members. We propose a model for IRB review of HOF studies based on best practices. CONCLUSION: International criteria are needed that define low and high-risk HOF studies, to allow identification of studies that can undergo an expedited (or exempted) process from those that need full IRB review. Enhancing IRB processes in such a way would be beneficial to the conduct of HOF studies. Greater knowledge and promotion of HOF methods and evidence-based HOF study designs may support the evolving discipline. Based on these insights, training and guidance to IRB members may be developed to support them in ensuring that appropriate ethical issues for HOF studies are considered.

Risk of mortality and cardiopulmonary arrest in critical patients presenting to the emergency department using machine learning and natural language processing.

Emergency department triage is the first point in time when a patient's acuity level is determined. The time to assign a priority at triage is short and it is vital to accurately stratify patients at this stage, since under-triage can lead to increased morbidity, mortality and costs. Our aim was to present a model that can assist healthcare professionals in triage decision making, namely in the stratification of patients through the risk prediction of a composite critical outcome-mortality and cardiopulmonary arrest. Our study cohort consisted of 235826 adult patients triaged at a Portuguese Emergency Department from 2012 to 2016. Patients were assigned to emergent, very urgent or urgent priorities of the Manchester Triage System (MTS). Demographics, clinical variables routinely collected at triage and the patients' chief complaint were used. Logistic regression, random forests and extreme gradient boosting were developed using all available variables. The term frequency-inverse document frequency (TF-IDF) natural language processing weighting factor was applied to vectorize the chief complaint. Stratified random sampling was used to split the data into train (70%) and test (30%) data sets. Ten-fold cross validation was performed in train to optimize model hyper-parameters. The performance obtained with the best model was compared against the reference model-a regularized logistic regression trained using only triage priorities. Extreme gradient boosting exhibited good calibration properties and yielded areas under the receiver operating characteristic and precision-recall curves of 0.96 (95% CI 0.95-0.97) and 0.31 (95% CI 0.26-0.36), respectively. The predictors ranked with higher importance by this model were the Glasgow coma score, the patients' age, pulse oximetry and arrival mode. Compared to the reference, the extreme gradient boosting model using clinical variables and the chief complaint presented higher recall for patients assigned MTS-3 and can identify those who are at risk of the composite outcome.

Predicting Intensive Care Unit admission among patients presenting to the emergency department using machine learning and natural language processing.

The risk stratification of patients in the emergency department begins at triage. It is vital to stratify patients early based on their severity, since undertriage can lead to increased morbidity, mortality and costs. Our aim was to present a new approach to assist healthcare professionals at triage in the stratification of patients and in identifying those with higher risk of ICU admission. Adult patients assigned Manchester Triage System (MTS) or Emergency Severity Index (ESI) 1 to 3 from a Portuguese and a United States Emergency Departments were analyzed. Variables routinely collected at triage were used and natural language processing was applied to the patient chief complaint. Stratified random sampling was applied to split the data in train (70%) and test (30%) sets and 10-fold cross validation was performed for model training. Logistic regression, random forests, and a random undersampling boosting algorithm were used. We compared the performance obtained with the reference model-using only triage priorities-with the models using additional variables. For both hospitals, a logistic regression model achieved higher overall performance, yielding areas under the receiver operating characteristic and precision-recall curves of 0.91 (95% CI 0.90-0.92) and 0.30 (95% CI 0.27-0.33) for the United States hospital and of 0.85 (95% CI 0.83-0.86) and 0.06 (95% CI 0.05-0.07) for the Portuguese hospital. Heart rate, pulse oximetry, respiratory rate and systolic blood pressure were the most important predictors of ICU admission. Compared to the reference models, the models using clinical variables and the chief complaint presented higher recall for patients assigned MTS/ESI 3 and can identify patients assigned MTS/ESI 3 who are at risk for ICU admission.

Clinical Decision Support Systems for Triage in the Emergency Department using Intelligent Systems: a Review.

MOTIVATION: Emergency Departments' (ED) modern triage systems implemented worldwide are solely based upon medical knowledge and experience. This is a limitation of these systems, since there might be hidden patterns that can be explored in big volumes of clinical historical data. Intelligent techniques can be applied to these data to develop clinical decision support systems (CDSS) thereby providing the health professionals with objective criteria. Therefore, it is of foremost importance to identify what has been hampering the application of such systems for ED triage. OBJECTIVES: The objective of this paper is to assess how intelligent CDSS for triage have been contributing to the improvement of quality of care in the ED as well as to identify the challenges they have been facing regarding implementation. METHODS: We applied a standard scoping review method with the manual search of 6 digital libraries, namely: ScienceDirect, IEEE Xplore, Google Scholar, Springer, MedlinePlus and Web of Knowledge. Search queries were created and customized for each digital library in order to acquire the information. The core search consisted of searching in the papers' title, abstract and key words for the topics "triage", "emergency department"/"emergency room" and concepts within the field of intelligent systems. RESULTS: From the review search, we found that logistic regression was the most frequently used technique for model design and the area under the receiver operating curve (AUC) the most frequently used performance measure. Beside triage priority, the most frequently used variables for modelling were patients' age, gender, vital signs and chief complaints. The main contributions of the selected papers consisted in the improvement of a patient's prioritization, prediction of need for critical care, hospital or Intensive Care Unit (ICU) admission, ED Length of Stay (LOS) and mortality from information available at the triage. CONCLUSIONS: In the papers where CDSS were validated in the ED, the authors found that there was an improvement in the health professionals' decision-making thereby leading to better clinical management and patients' outcomes. However, we found that more than half of the studies lacked this implementation phase. We concluded that for these studies, it is necessary to validate the CDSS and to define key performance measures in order to demonstrate the extent to which incorporation of CDSS at triage can actually improve care.

Neurochemical changes in basal ganglia affect time perception in parkinsonians.

BACKGROUND: Parkinson's disease is described as resulting from dopaminergic cells progressive degeneration, specifically in the substantia nigra pars compacta that influence the voluntary movements control, decision making and time perception. AIM: This review had a goal to update the relation between time perception and Parkinson's Disease. METHODOLOGY: We used the PRISMA methodology for this investigation built guided for subjects dopaminergic dysfunction in the time judgment, pharmacological models with levodopa and new studies on the time perception in Parkinson's Disease. We researched on databases Scielo, Pubmed / Medline and ISI Web of Knowledge on August 2017 and repeated in September 2017 and February 2018 using terms and associations relevant for obtaining articles in English about the aspects neurobiology incorporated in time perception. No publication status or restriction of publication date was imposed, but we used as exclusion criteria: dissertations, book reviews, conferences or editorial work. RESULTS/DISCUSSION: We have demonstrated that the time cognitive processes are underlying to performance in cognitive tasks and that many are the brain areas and functions involved and the modulators in the time perception performance. CONCLUSIONS: The influence of dopaminergic on Parkinson's Disease is an important research tool in Neuroscience while allowing for the search for clarifications regarding behavioral phenotypes of Parkinson's disease patients and to study the areas of the brain that are involved in the dopaminergic circuit and their integration with the time perception mechanisms.

Quality of life of HIV+ patients undergoing pharmacotherapeutic follow-up

The influence of pharmacotherapeutic follow-up (PTF) on quality of life was evaluated in 45 HIV+ patients, who were undergoing initial antiretroviral therapy at a specialized care center in northeast Brazil. PTF lasted nine months and quality of life was analyzed at the 1st and 9th meetings using a questionnaire validated for Brazil. The study identified 643 problems related to antiretrovirals and there were 590 pharmaceutical interventions during the PTF. The comparative analysis between the results of the 1st and the 9th meeting was statistically significant for all domains of the questionnaire. For asymptomatic patients, only one domain was statistically significant. For symptomatic patients, six domains were significant. Patients with one year of HIV/AIDS diagnosis had statistically significant differences in five domains. The results suggest that the PTF contributed to improving quality of life, particularly for symptomatic patients and those diagnosed for at least one year - important target groups for Pharmaceutical Treatment.

A influência do seguimento farmacoterapêutico (SFT) sobre a qualidade de vida foi avaliada em 45 pacientes HIV+ assistidos em serviço de atendimento especializado do nordeste brasileiro. O SFT teve duração de 9 meses e a qualidade de vida foi analisada no 1º e 9º encontros através de questionário validado no País. Identificaram-se 643 problemas relacionados aos antirretrovirais e realizaram-se 590 intervenções farmacêuticas durante o SFT. A análise comparativa entre os resultados de qualidade de vida do 1º e 9º encontro foi estatisticamente significativa em todos os domínios do questionário. Quando analisados somente os pacientes assintomáticos, apenas um domínio apresentou significância estatística. Entre os sintomáticos, seis domínios foram significativos. Pacientes com até um ano de diagnóstico de HIV/AIDS apresentaram validade estatística em cinco domínios. Os resultados sugerem que o SFT contribuiu para a melhoria da qualidade de vida dos pacientes, sobretudo dos sintomáticos e/ou com até um ano de diagnóstico, representando grupos-alvo para a prática da Atenção Farmacêutica.

Spin-echo MRI underestimates functional changes in microvascular cerebral blood plasma volume using exogenous contrast agent.

While most functional MRI studies using exogenous contrast agent employ gradient-echo (GE) signal, spin echo (SE) imaging would represent an attractive alternative if its detection power were more comparable with GE imaging. This study demonstrates that SE methods systematically underestimate functional changes in microvascular cerebral blood plasma volume (CBV), so that SE detection power in brain tissue cannot match that provided by GE signal. Empirically, the in vivo response of SE-CBV was about 40% smaller than that of GE-CBV in rat brain at low basal values of CBV, a result that is consistent with physics predictions under the simplifying assumption of uniform vessel dilation. However, increasing values of basal CBV were associated with monotonically increasing mean vessel sizes and monotonically decreasing GE to SE ratios of functional changes in CBV (fCBV). This result suggests the presence of large but weakly reactive conduit vessels at high basal values of CBV. Hence, we conclude that GE imaging is the method of choice for functional MRI (fMRI) using exogenous contrast agent in most cases, although SE methods may represent a more spatially linear representation of underlying neural activity that becomes most apparent in regions with high basal CBV, such as the cortical surface.

Characterization of event-related designs using BOLD and IRON fMRI.

Despite many desirable characteristics, event-related (ER) stimulus designs for BOLD and IRON suffer from low detection power relative to block designs because the hemodynamic impulse response function (IRF) acts as a low-pass filter on neural activation to attenuate the size of differential responses to alternate stimuli. While the use of exogenous contrast agent (IRON technique) provides an alternative fMRI method in animal models to improve sensitivity and spatial localization, the inherently slower hemodynamic IRF causes IRON detection efficiency to decrease faster than BOLD efficiency as the interstimulus interval (ISI) is shortened. Using simulations based upon assumptions of stimulus-response linearity and experimental data obtained in awake, non-human primates, this study compared detection efficiencies for fixed, random and semi-random ISI distributions for BOLD and IRON techniques. A larger relative gain in detection efficiency at short ISI was obtained by randomized designs using IRON contrast relative to BOLD contrast due to the slower IRF of the IRON method. To quantify tradeoffs between detection efficiency and the predictability of stimulus presentation, the Shannon entropy was introduced as an objective measure of predictability. Small amounts of entropy can be traded for large gains in efficiency, particularly for the IRON method.

Repeated fMRI using iron oxide contrast agent in awake, behaving macaques at 3 Tesla.

Iron oxide contrast agents have been employed extensively in anesthetized rodents to enhance fMRI sensitivity and to study the physiology of cerebral blood volume (CBV) in relation to blood oxygen level-dependent (BOLD) signal following neuronal activation. This study quantified the advantages of exogenous agent for repeated neuroimaging in awake, nonhuman primates using a clinical 3 Tesla scanner. A monocrystalline iron oxide nanoparticle (MION) solution was injected at iron doses of 8 to 10 mg/kg in two macaque monkeys. Adverse behavioral effects due to contrast agent were not observed in either monkey using cumulative doses in excess of 60 mg/kg. Relative to BOLD imaging at 3 Tesla, MION increased functional sensitivity by an average factor of 3 across the brain for a stimulus of long duration. Rapid stimulus presentation attenuated MION signal changes more than BOLD signal changes, due to the slower time constant of the blood volume response relative to BOLD signal. Overall, the contrast agent produced a dramatic improvement in functional brain imaging results in the awake, behaving primate at this field strength. (c) 2002 Elsevier Science (USA).

Avaliaçäo do trabalho da atendente em postos de saúde da IV. Regiäo de Saúde do Estado de Alagoas / Evaluation of the work of health aides at ambulatory care facilities from the 4th Health Region of the State of Alagoas

Foram avaliadas as atividades desenvolvidas pela atendente de saúde pública a nível da unidade mais simplificada dos serviços básicos de saúde por meio da: verificaçäo da cobertura, por cuidados primários à populaçäo alvo; concentraçäo de atividades nos grupos de gestantes e crianças de 0 a 4 anos; análise dos registros efetuados nas fichas utilizadas na assistência à criança, e identificaçäo do apoio técnico-administrativo da instituiçäo. Para tanto utilizou de dados secundários existentes e registrados em documentos oficiais, e dados primários obtidos através de formulários construidos sobre o último atendimento de enfermagem a criança menor de 1 ano, contendo ítens para avaliaçäo qualitativa baseados em perâmetros de assistência determinados pela instituiçäo. O estudo se desenvolveu na área rural da 4a. regiäo de saúde do Estado de Alagoas, abrangendo 12 postos de saúde, obtidos mediante uma amostra sistemática. O volume físico das atividades foi avaliado segundo os critérios de efetividade e eficácia. A investigaçäo populacional, com valor médio de 33.5%; gestante 50.0%; menor de 1 ano 60.7% e de 1 a 4 anos 202.0%. Na cobertura por tipo de vacina o maior valor foi 19.7%. A concentraçäo de atividades foi baixa nos dois grupos avaliados, evidenciando dificuldades de controle por parte do serviço. A avaliaçäo da qualidade dos registros no último atendimento ao menor de 1 ano apresentou 33.0% de respostas afirmativas quando a fonte foi os módulos, e 52.0% quando a informaçäo partiu da mäe da criança. Concluiu-se que a expansäo da rede física de serviços parece näo ter contribuído para modificar o nível da assistência à saúde da populaçäo marginalizada da área rural, vez que os baixos valores encontrados näo respondem aos objetivos do programa de extensäo de cobertura. A falta de apoio técnico-administrativo representado pela carência dos insumos necessários ao desenvolvimento de atividades básicas, deficiência dos processos de supervisäo e treinamento, contituem os fatores determinantes dos resultados apresentados