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Nature Jul 2023Physicians make critical time-constrained decisions every day. Clinical predictive models can help physicians and administrators make decisions by forecasting clinical...
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 deployment. 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 processing 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.
Topics: Humans; Electronic Health Records; Natural Language Processing; Physicians; Clinical Decision-Making; Patient Readmission; Hospital Mortality; Comorbidity; Length of Stay; Insurance Coverage; Area Under Curve; Point-of-Care Systems; Clinical Trials as Topic
PubMed: 37286606
DOI: 10.1038/s41586-023-06160-y -
Indian Journal of Medical Ethics 2023Custodial death is generally linked in the public mind with police brutality and torture, not with indirect brutality through negligence and callous treatment in jail...
Custodial death is generally linked in the public mind with police brutality and torture, not with indirect brutality through negligence and callous treatment in jail custody. Yet it is not known how many of the thousands of prisoners who die in our jails every year die due to neglect by the jail authorities. The official Prison Statistics India (PSI) in its most recent report states that 1,879 men and women died due to "natural causes" in prisons across India in 2021. Natural causes are defined in the report as "illness" and "ageing". According to the report, 185 more prisoners died of "unnatural" causes, and 52 of "causes not yet known". [1: p 179]. "Unnatural deaths" include "deaths due to negligence or excesses by jail personnel"a. The vagueness of this classification in the PSI data had been noted by Justice Lokur in a landmark Supreme Court judgment, in 2013, when he said: "The distinction made by the NCRB [National Crime Records Bureau] between natural and unnatural deaths is unclear. For example, if a prisoner dies due to a lack of proper medical attention or timely medical attention, would that be classified as a natural death or an unnatural death?" [2].
Topics: Male; Humans; Female; Prisons; Prisoners; Aging; Police; India
PubMed: 37718540
DOI: 10.20529/IJME.2023.040 -
Frontiers in Medicine 2023Hormone-based contraception disrupts hormonal balance, creating artificial states of anovulation and threatening women's health. We reviewed its main adverse effects and... (Review)
Review
Hormone-based contraception disrupts hormonal balance, creating artificial states of anovulation and threatening women's health. We reviewed its main adverse effects and mechanisms on accelerated ovarian aging, mental health (emotional disruptions, depression, and suicide), sexuality (reduced libido), cardiovascular (brain stroke, myocardial infarction, hypertension, and thrombosis), and oncological (breast, cervical, and endometrial cancers). Other "collateral damage" includes negative effects on communication, scientific mistrust, poor physician-patient relationships, increased patient burden, economic drain on the healthcare system, and environmental pollution. Hormone-sensitive tumors present a dilemma owing to their potential dual effects: preventing some cancers vs. higher risk for others remains controversial, with denial or dismissal as non-relevant adverse effects, information avoidance, and modification of scientific criteria. This lack of clinical assessment poses challenges to women's health and their right to autonomy. Overcoming these challenges requires an anthropological integration of sexuality, as the focus on genital bodily union alone fails to encompass the intimate relational expression of individuals, complete sexual satisfaction, and the intertwined feelings of trust, safety, tenderness, and endorsement of women's femininity.
PubMed: 37457571
DOI: 10.3389/fmed.2023.1167504 -
ELife Jan 2024After hitting rock bottom a few months into a prestigious fellowship, a postdoc recounts how they found their way to ADHD medication, therapy, and better mental health.
After hitting rock bottom a few months into a prestigious fellowship, a postdoc recounts how they found their way to ADHD medication, therapy, and better mental health.
Topics: Humans; Health Personnel; Mental Health; Research Personnel
PubMed: 38265066
DOI: 10.7554/eLife.96286 -
Cureus Nov 2023Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune condition characterized by recurrent episodes of optic neuritis (ON) and transverse myelitis. This case...
Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune condition characterized by recurrent episodes of optic neuritis (ON) and transverse myelitis. This case report aims to highlight the importance of considering atypical presentations of NMOSD when confronted with MRI-detected Wernicke's encephalopathy. The primary target in NMOSD is the aquaporin-4 (AQP4) protein, predominantly located on astrocyte surfaces. Antibodies binding to AQP4 can lead to astrocyte dysfunction and damage, contributing to NMOSD's distinctive pathology. The associated immune response and inflammation can cause secondary harm to various components of the central nervous system, including oligodendrocytes and neuronal axons. This inflammatory process results in perivascular demyelination and axonal injury, further aggravating neurological deficits in NMOSD. In this case, we present a 39-year-old female with no prior medical or surgical history who sought medical attention due to a three-week history of progressive eyelid heaviness and somnolence. NMOSD is an autoimmune condition primarily targeting the AQP4 protein, resulting in recurrent ON and transverse myelitis. The patient was initially misdiagnosed with myasthenia gravis due to somnolence and ptosis. Due to concerns about myasthenia gravis due to diffuse fatigue and bilateral ptosis, the patient was initially treated with intravenous immunoglobulin (IVIG) and admitted to the neurology service. On the first day of her hospitalization, MRI with and without contrast revealed extensive, non-enhancing T2-weighted-fluid-attenuated inversion recovery (T2-FLAIR) hyperintensities surrounding the third ventricle and affecting the periaqueductal grey, medial thalami, and mammillary bodies. There was also an interval increase in T2-FLAIR hyperintensity within the right medial temporal lobe, extending more posteriorly and inferiorly, abutting the temporal horn. Subsequent CSF encephalitis panel results showed positive West Nile virus (WNV) IgG but negative WNV IgM, and AQP4 antibodies were positive. Given the high specificity of AQP4 antibodies, the patient was diagnosed with neuromyelitis optica (NMO) encephalitis. This case underscores the importance of considering atypical presentations of NMO when confronted with MRI-detected Wernicke's encephalopathy. Since our patient primarily displayed somnolence and eye-related symptoms, neither NMO nor Wernicke's encephalopathy were initially considered in the differential diagnosis. Furthermore, despite MRI findings suggestive of Wernicke's encephalopathy, it was considered less likely due to the absence of thiamine deficiency and consistent denials by family members regarding alcohol use, gastrointestinal issues, or inadequate oral intake. This case underscores the importance of considering NMOSD in patients with atypical symptoms, even when initial presentations suggest other conditions. Timely diagnosis is crucial to prevent mismanagement and improve patient outcomes. Clinicians should maintain a high level of suspicion for NMOSD, especially when MRI findings do not align with the initial diagnosis, as early recognition and treatment can significantly impact patient care and prognosis.
PubMed: 38046734
DOI: 10.7759/cureus.48168 -
International Journal of Chronic... 2023Poor adherence to COPD mobile health (mHealth) has been reported, but its association with exacerbation-related outcomes is unknown. We explored the effects of mHealth...
PURPOSE
Poor adherence to COPD mobile health (mHealth) has been reported, but its association with exacerbation-related outcomes is unknown. We explored the effects of mHealth adherence on exacerbation-free weeks and self-management behavior. We also explored differences in self-efficacy and stages of grief between adherent and non-adherent COPD patients.
PATIENTS AND METHODS
We conducted secondary analyses using data from a recent randomized controlled trial (RCT) that compared the effects of mHealth (intervention) with a paper action plan (comparator) for COPD exacerbation self-management. We used data from the intervention group only to assess differences in exacerbation-free weeks (primary outcome) between patients who were adherent and non-adherent to the mHealth tool. We also assessed differences in the type and timing of self-management actions and scores on self-efficacy and stages of grief (secondary outcomes). We used generalized negative binomial regression analyses with correction for follow-up length to analyze exacerbation-free weeks and multilevel logistic regression analyses with correction for clustering for secondary outcomes.
RESULTS
We included data of 38 patients of whom 13 (34.2%) (mean (SD) age 69.2 (11.2) years) were adherent and 25 (65.8%) (mean (SD) age 68.7 (7.8) years) were non-adherent. Adherent patients did not differ from non-adherent patients in exacerbation-free weeks (mean (SD) 31.5 (14.5) versus 33.5 (10.2); p=0.63). Although statistically not significant, adherent patients increased their bronchodilator use more often and more timely, contacted a healthcare professional and/or initiated prednisolone and/or antibiotics more often, and showed at baseline higher scores of self-efficacy and disease acceptance and lower scores of denial, resistance, and sorrow, compared with non-adherent patients.
CONCLUSION
Adherence to mHealth may be positively associated with COPD exacerbation self-management behavior, self-efficacy and disease acceptance, but its association with exacerbation-free weeks remains unclear. Our results should be interpreted with caution by this pilot study's explorative nature and small sample size.
Topics: Aged; Humans; Pulmonary Disease, Chronic Obstructive; Quality of Life; Self-Management; Telemedicine; Randomized Controlled Trials as Topic; Middle Aged
PubMed: 37933244
DOI: 10.2147/COPD.S431199 -
Psychiatry, Psychology, and Law : An... 2024In many Western jurisdictions, criminal suspects undergoing police interrogations have the right to remain silent. In this experiment, we examined the effects of...
In many Western jurisdictions, criminal suspects undergoing police interrogations have the right to remain silent. In this experiment, we examined the effects of remaining silent during police questioning on laypersons' perceptions of a suspect. Participants ( = 126) read one of three mock-interview transcripts (i.e. admission, denial or silence) and indicated the extent to which they agreed or disagreed that a male suspect in a missing person case was guilty, cooperative, trustworthy and rational. Participants expressed stronger agreement that the suspect was guilty when he admitted guilt than when he denied involvement or remained silent. When the suspect remained silent, participants viewed the suspect as less cooperative than when the suspect denied or admitted guilt and as less rational than when the suspect denied committing the crime. Our findings provide some support for the notion that remaining silent during police questioning may be viewed unfavourably by external observers.
PubMed: 38628249
DOI: 10.1080/13218719.2023.2175074