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Kidney Int ; 97(2): 383-392, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31883805


Symptoms are common in patients on maintenance hemodialysis but identification is challenging. New informatics approaches including natural language processing (NLP) can be utilized to identify symptoms from narrative clinical documentation. Here we utilized NLP to identify seven patient symptoms from notes of maintenance hemodialysis patients of the BioMe Biobank and validated our findings using a separate cohort and the MIMIC-III database. NLP performance was compared for symptom detection with International Classification of Diseases (ICD)-9/10 codes and the performance of both methods were validated against manual chart review. From 1034 and 519 hemodialysis patients within BioMe and MIMIC-III databases, respectively, the most frequently identified symptoms by NLP were fatigue, pain, and nausea/vomiting. In BioMe, sensitivity for NLP (0.85 - 0.99) was higher than for ICD codes (0.09 - 0.59) for all symptoms with similar results in the BioMe validation cohort and MIMIC-III. ICD codes were significantly more specific for nausea/vomiting in BioMe and more specific for fatigue, depression, and pain in the MIMIC-III database. A majority of patients in both cohorts had four or more symptoms. Patients with more symptoms identified by NLP, ICD, and chart review had more clinical encounters. NLP had higher specificity in inpatient notes but higher sensitivity in outpatient notes and performed similarly across pain severity subgroups. Thus, NLP had higher sensitivity compared to ICD codes for identification of seven common hemodialysis-related symptoms, with comparable specificity between the two methods. Hence, NLP may be useful for the high-throughput identification of patient-centered outcomes when using electronic health records.

BMC Infect Dis ; 19(1): 739, 2019 Aug 22.
Artigo em Inglês | MEDLINE | ID: mdl-31438872


BACKGROUND: Incidence of the opportunistic infection Pneumocystis jirovecii pneumonia (PJP) in solid organ transplant patients ranges from 5 to 15% with a mortality of up to 38%. CASE PRESENTATION: We present a liver transplant recipient who developed hypoxemic respiratory failure related to PJP soon after treatment for allograft rejection. His presentation was preceded by severe hypercalcemia of 14.6 mg/dL and an ionized calcium of 1.7 mmol/L which remained elevated despite usual medical management and eventually required renal replacement therapy. As approximately 5% of PJP cases have granulomas, here we review the role of pulmonary macrophages and inflammatory cytokines in the pathophysiology of granuloma-mediated hypercalcemia. We also discuss the interpretation of our patient's laboratory studies, response to medical therapy, and clinical risk factors which predisposed him to PJP. CONCLUSIONS: It is important for clinicians to consider PJP as an etiology of granulomatous pneumonia and non-parathyroid hormone mediated hypercalcemia in chronically immunosuppressed organ transplant recipients for timely diagnosis and management.

Hipercalcemia/diagnóstico , Transplante de Fígado , Pneumocystis carinii , Pneumonia por Pneumocystis/diagnóstico , Sintomas Prodrômicos , Transplantados , Idoso , Diagnóstico Diferencial , Humanos , Hipercalcemia/etiologia , Hospedeiro Imunocomprometido , Transplante de Fígado/efeitos adversos , Masculino , Infecções Oportunistas/complicações , Infecções Oportunistas/diagnóstico , Pneumonia por Pneumocystis/complicações , Índice de Gravidade de Doença
Crit Pathw Cardiol ; 16(4): 126-128, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29135619


Chest pain is a common complaint in emergency departments. Several guidelines and tools exist to help the clinician determine need for hospitalization. For low-risk patients, clinical judgment can underestimate a patient's risk of major adverse cardiac event. Implementation of an advanced diagnostic protocol with the HEART Pathway can reduce hospital cost. For our academic institution, we saw an approximate $1 million in total savings during the initial implementation year along with increased outpatient visits. In addition, an increase in outpatient visits confirmed previous estimates that implementation of the HEART Pathway results in >20% reduction of hospital costs. We also identify challenges and considerations for facilities looking to repeat our successes.

Dor no Peito/terapia , Gerenciamento Clínico , Serviço Hospitalar de Emergência/economia , Custos Hospitalares , Dor no Peito/economia , Redução de Custos , Seguimentos , Humanos , Estudos Prospectivos
Case Rep Infect Dis ; 2016: 8165414, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26904326


A 31-year-old Hispanic male with no medical history was admitted for fevers, pleurisy, and cough after recent oral surgery and completing demolition and construction work in Juarez, Mexico. Imaging showed a 4.4 cm cavitary lesion and bilateral tree-in-bud opacities. Initial suspicion of bacterial infection confirmed with clinical improvement on culture specific antibiotics, but after discharge he returned with progression of symptoms and new dyspnea. Radiograph showed a pyopneumothorax. Chest computed tomography after thoracostomy showed worsening infiltrates and another cavitary lesion. Symptoms persisted despite addition of broad spectrum antibiotics. Surgical repair for persistent air leak was required. Weeks after discharge, cultures and serologies returned positive for Coccidioidomycosis immitis. Coccidioides species cause up to 30% of community-acquired pneumonia and incidental cavitary lesions in endemic regions. Symptoms are nonspecific yet usually involve fatigue, cough, and pleurisy. Most hosts have spontaneous resolution; however, certain demographics such as Hispanics and diabetics, later diagnosed in our patient, have higher morbidity. As seen with our patient, cavitary rupture and bronchopleural fistulas are rare occurring in 2.6% of cavitary lesions. High suspicion based on symptoms and host demographics is important to assist in early diagnosis and treatment to avoid and treat this common pathogen's presentations.