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Introduction: Emergency department (ED) crowding is a major problem across Canada. We studied the ability of artificial intelligence methods to improve patient flow through the ED by predicting patient disposition using information available at triage and shortly after patients’ arrival in the ED. Methods: This retrospective study included all visits to an urban, academic, adult ED between May 2012 and June 2019. For each visit, 489 variables were extracted including triage data that had been collected for use in the Canadian Triage Assessment Scale (CTAS) and information regarding laboratory tests, radiological tests, consultations and admissions. A training set consisting of all visits from April 2012 up to December 2018 was used to train 5 classes of machine learning models to predict admission to the hospital from the ED. The models were trained to predict admission at the time of the patient's arrival in the ED and every 30 minutes after arrival until 6 hours into their ED stay. The performance of models was compared using the area under the ROC curve (AUC) on a test set consisting of all visits from January 2019 to June 2019. Results: The study included 536,332 visits and the admission rate was 15.0%. Gradient boosting models generally outperformed other machine learning models. A gradient boosting model using all available data at 2 hours after patient arrival in the ED yielded a test set AUC 0.92 [95% CI 0.91-0.93], while a model using only data available at triage yielded an AUC 0.90 [95% CI 0.89-0.91]. The quality of predictions generally improved as predictions were made later in the patient's ED stay leading to an AUC 0.95 [95% CI 0.93-0.96] at 6 hours after arrival. A gradient boosting model with 20 variables available at 2 hours after patient arrival in the ED yielded an AUC 0.91 [95% CI 0.89-0.93]. A gradient boosting model that makes predictions at 2 hours after arrival in ED using only variables that are available at all EDs in the province of Quebec yielded an AUC 0.91 [95% 0.89-0.92]. Conclusion: Machine learning can predict admission to a hospital from the ED using variables that area collected as part of routine ED care. Machine learning tools may potentially be used to help ED physicians to make faster and more appropriate disposition decisions, to decrease unnecessary testing and alleviate ED crowding.
Objectives: Cognitive reserve moderates the effects of gray matter (GM) atrophy on cognitive function in neurological disease. Broadly speaking, Reserve explains how persons maintain function in the face of cerebral injury in cognitive and other functional domains (e.g., physical, social). Personality, as operationalized by the Five Factor Model (FFM), is also implicated as a moderator of this relationship. It is conceivable that these protective mechanisms are related. Prior studies suggest links between Reserve and personality, but the degree to which these constructs overlap and buffer the clinical effects of neuropathology is unclear. Methods: We evaluated Reserve and FFM traits—Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness—in a cohort of 67 multiple sclerosis (MS) patients. We also examined the extent to which FFM traits and aspects of Reserve interact in predicting cognitive processing speed. Results: Retrospectively reported educational/occupational achievement was associated with higher Openness, and childhood social engagement was associated with higher Extraversion, Agreeableness, and Conscientiousness. Current involvement in exercise activities and social activities was associated with Extraversion, current involvement in hobbies was associated with Neuroticism, and current receptive behaviors were associated with Agreeableness and Conscientiousness. When tested as predictors, Conscientiousness and childhood enrichment activities interacted in predicting cognitive processing speed after accounting for age, disease duration, disability, and GM volume. Conclusions: Childhood enrichment activities and Conscientiousness have a synergistic effect on cognitive processing speed. Current findings have implications for using psychological interventions to foster both Reserve and adaptive personality characteristics to stave off clinical symptoms in MS. (JINS, 2016, 22, 920–927)
Small bowel obstruction (SBO) is a common cause of acute abdominal pain presenting to the emergency department (ED). Although the literature is limited, point-of-care ultrasonography (POCUS) has been found to have superior diagnostic accuracy for SBO compared to plain radiography; however, it is rarely used in North America for this. We present the case of a middle-aged man who presented with abdominal pain where POCUS by the emergency physician early in the hospital course expedited the diagnosis of SBO and led to earlier surgical consultation. The application of POCUS for SBO is easily learned and applied in the ED. POCUS for SBO may obviate the need for plain radiography and expedite patient care.
Recent research indicates that cognitive reserve mitigates the clinical expression of neuropsychological impairment in multiple sclerosis (MS). This literature primarily uses premorbid intelligence and lifetime experiences as indicators. However, changes in current recreational activities may also contribute to the maintenance of neural function despite brain atrophy. We examined the moderation effects of current changes in recreational activity on the relationship between brain atrophy and information processing speed in 57 relapsing-remitting MS patients. Current enrichment was assessed using the Recreation and Pastimes subscale from the Sickness Impact Profile. In patients reporting current declines in recreational activities, brain atrophy was negatively associated with cognition, but there was no such association in participants reporting stable participation. The MRI metric-by-recreational activity interaction was significant in separate hierarchical regression analyses conducted using third ventricle width, neocortical volume, T2 lesion volume, and thalamic volume as brain measures. Results suggest that recreational activities protect against brain atrophy's detrimental influence on cognition. (JINS, 2013, 19, 1–6)
We examined cognitive predictors of speech and articulation rate in 50 individuals with multiple sclerosis (MS) and 23 healthy controls. We measured speech and articulation rate from audio-recordings of participants reading aloud and talking extemporaneously on a topic of their choice (i.e., self-generated speech). Articulation rate was calculated for each speech sample by removing lexically irrelevant vocalizations and pauses of >200 ms. Speech rate was similarly calculated including pauses. Concurrently, the Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS) battery, as well as standardized tests of sentence intelligibility and syllable repetition were administered. Analysis of variance showed that MS patients were slower on three of the four rate measures. Greater variance in rate measures was accounted for by cognitive variables for the MS group than controls. An information processing speed composite, as measured by the Symbol Digit Modalities Test (SDMT) and the Paced Auditory Serial Addition Test (PASAT), was the strongest predictor among cognitive tests. A composite of memory tests related to self-generated speech, above and beyond information processing speed, but not to oral reading. Self-generated speech, in this study, was not found to relate more strongly to cognitive tests than simple reading. Implications for further research are discussed. (JINS, 2012, 18, 1–8)
The potent immunomodulatory properties of mesenchymal stem cells (MSCs) are particularly relevant for multiple sclerosis (MS). MSCs inhibit T-cell proliferation stimulated by polyclonal activators, cognate antigen and allogeneic mixed lymphocyte reaction. MSCs inhibit B-cell proliferation in culture via soluble factors, accompanied by inhibition of B-cell differentiation and production of IgM, IgG, and IgA. The property of MSCs relevant to MS is their potential ability to lessen damage and augment repair in numerous tissue injury models. In general, MSC transplantation in humans, including with allogeneic MSCs, has been very well tolerated. The several potential adverse events (AEs) that require close attention in planned trials are: infusion-related toxicity, infection, cancer, ectopic tissue formation, rejection, and autoimmunity. MSCs have potential immunomodulatory, tissue protective, and repair promoting properties. There is rapidly accumulating experience with both autologous and allogeneic MSC transplantation in a number of conditions.
Motor impairments and cognitive dysfunction are common in multiple sclerosis (MS). We aimed to delineate the relationship between cognitive capacity and upper and lower motor function in 211 MS patients, and 120 healthy volunteers. Lower and upper motor function were assessed with the Timed 25 Foot Walk (T25FW) and the Nine Hole Peg Test (NHPT) as implemented in the Multiple Sclerosis Functional Composite (MSFC). Subjects also underwent neuropsychological evaluation. Hierarchical linear regression analysis was conducted separately for the MS and healthy groups with the T25FW and NHPT serving as the outcome measures. Cognitive performance indices served as predictors. As expected, healthy subjects performed better than the MS group on all measures. Processing speed and executive function tests were significant predictors of lower and upper motor function in both groups. Correlations were more robust in the MS group, where cognitive tests predicted variability in motor function after controlling for disease duration and physical disability. In conclusion, we find evidence of higher order cognitive control of motor function that appears to be particularly salient in this large and representative MS sample. The findings may have implications for risk assessment and treatment of mobility dysfunction in MS. (JINS, 2011, 17, 643–653)
In children and adolescents, multiple sclerosis (MS) has an impact on the developing central nervous system, and can result in transient or fixed deficits of gross motor and/or fine motor skills, sensory perceptual processing, bowel/bladder function, vision, balance, and coordination. In this chapter, the evaluation and care of patients with symptoms of pediatric demyelinating disease are addressed as individual systems with discussion of anatomy and typical features, evaluation measures, and treatment options, including both non-pharmacologic and pharmacologic approaches. Fatigue is the most common symptom experienced by MS patients and is adversely correlated with quality of life. Minimizing fatigue in the pediatric MS population requires a multifaceted approach of eliminating unnecessary energy demands, improving sleep hygiene and optimizing symptomatic medication and disease-modifying treatment (DMT) regimens. The PedsSQ Multidimensional Fatigue Scale has been validated and used in other pediatric chronic diseases such as cancer, inflammatory bowel disease, and rheumatological diseases.
Radiocarbon and tritium determinations were carried out in 2 adjacent small aquifers in Israel. These aquifers have small storage capacities and good hydraulic properties. Darcy calculations suggest that the aquifers contain young waters, ≃50 yr in age. 14C concentrations in the Pleistocene aquifer are between 23–60 pMC, with the lowest activity related to contamination by petroleum-based fertilizers with no 14C. 14C concentrations in the Judea Group aquifer range from 62 to 95 pMC. An apparent difference of ≃1000 yr is indicated for the average recharge age between the 2 aquifers. The tritium data suggests that the water in both aquifers is quite young. The 1000-yr difference is an artifact of initial isotopic fractionation differences through the unsaturated zone as established elsewhere for these 2 aquifers. When these individual fractionation factors (0.54 for the Pleistocene and 0.62 for the Judea Group) are used, it is revealed that both aquifers contain young water, in agreement with the Darcy calculation, which was recharged at the beginning of the period of thermonuclear atmospheric testing in the early 1960s.
Cognitive reserve is widely recognized as a moderator of cognitive decline in patients with senile dementias such as Alzheimer’s disease. The same effect may occur in multiple sclerosis (MS), an immunologic disorder affecting the central nervous system. While MS is traditionally considered an inflammatory, white matter disease, degeneration of gray matter is increasingly recognized as the primary contributor to progressive cognitive decline. Our aim was to determine if individual differences in estimated cognitive reserve protect against the progression of cognitive dysfunction in MS. Ninety-one patients assessed twice roughly 5 years apart were identified retrospectively. Cognitive testing emphasized mental processing speed. Cognitive reserve was estimated by years of education and by performance on the North American Adult Reading Test (NAART). After controlling for baseline characteristics, both years of education (p = .013) and NAART scores (p = .049) significantly improved regression models predicting cognitive decline. Symbol Digit Modalities Test (SDMT) performance showed no significant change in patients with > 14 years of education, whereas it declined significantly in patients with ≤ 14 years of education. We conclude that greater cognitive reserve as indexed by either higher premorbid intelligence or more years of education protects against the progression of cognitive dysfunction in MS. (JINS, 2010, 16, 829–835.)
The Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS) is a consensus neuropsychological battery with established reliability and validity. One of the difficulties in implementing the MACFIMS in clinical settings is the reliance on manualized norms from disparate sources. In this study, we derived regression-based norms for the MACFIMS, using a unique data set to control for standard demographic variables (i.e., age, age2, sex, education). Multiple sclerosis (MS) patients (n = 395) and healthy volunteers (n = 100) did not differ in age, level of education, sex, or race. Multiple regression analyses were conducted on the performance of the healthy adults, and the resulting models were used to predict MS performance on the MACFIMS battery. This regression-based approach identified higher rates of impairment than manualized norms for many of the MACFIMS measures. These findings suggest that there are advantages to developing new norms from a single sample using the regression-based approach. We conclude that the regression-based norms presented here provide a valid alternative to identifying cognitive impairment as measured by the MACFIMS. (JINS, 2010, 16, 6–16.)
Cognitive impairment occurs in roughly 50% of patients with multiple
sclerosis (MS). It is well known that processing speed and episodic memory
deficits are the most common neuropsychological (NP) sequelae in this
illness. Consensus has emerged about the specific tests that prove most
helpful for routine monitoring of MS associated cognitive impairment. The
purpose of this study was to examine the validity of the Minimal
Assessment of Cognitive Function in MS (MACFIMS), a recommended battery
based on the findings of an international conference held in 2001. We
tested 291 MS patients and 56 healthy controls. Frequencies of impairment
paralleled those reported in previous work for both individual cognitive
domains and general impairment. All tests were impaired in the MS group,
and distinguished relapsing-remitting (RR) from secondary progressive (SP)
course. Principle components analysis showed a distinct episodic memory
component. Most of the MACFIMS tests discriminated disabled from employed
patients. However, in regression models accounting for all NP tests, those
emphasizing verbal memory and executive function were most predictive of
vocational status. We conclude that the MACFIMS is a valid approach to
routine NP assessment of MS patients. Future work is planned to determine
its psychometric properties in a longitudinal study. (JINS, 2006,
Although numerous studies have shown that brain-damaged patients tend
to underestimate neuropsychological (NP) impairment when self-ratings are
compared to informant ratings, the meaning of such discrepancies is not
well studied in multiple sclerosis (MS). We compared patient self- and
informant-report questionnaire ratings of NP functioning in 122 MS
patients and 37 age- and education-matched normal controls. In addition to
completing the Multiple Sclerosis Neuropsychological Questionnaire (MSNQ),
participants underwent NP testing and assessment of depression,
personality, and neuropsychiatric symptoms. Based on the normal
distribution of discrepancy scores, patients were classified according to
whether they overestimated or underestimated their cognitive ability,
relative to informant ratings. ANOVAs comparing test scores derived from
overestimators, underestimators, and accurate estimators were significant
for multiple measures of cognitive function, depression, personality, and
neuropsychiatric symptoms. Overestimators were characterized by less
depression and conscientiousness, and greater degrees of cognitive
impairment, euphoric behavioral disinhibition, and unemployment as
compared to underestimators. We conclude that patient/informant
discrepancy scores on the MSNQ are associated with the aforementioned
neuropsychiatric features, and that the MSNQ has potential utility for
predicting euphoria and disinhibition syndromes in MS. (JINS,
2005, 11, 574–583.)All
authors are from the State University of New York (SUNY) at Buffalo School
of Medicine, Department of Neurology, Division of Departmental and
Behavioral Neurosciences, and the Jacobs Neurological Institute, Buffalo
General Hospital, Buffalo, NY.
Patients with Parkinsonism have a progressive disorder requiring substantial expertise to manage effectively.
Over a six-year period we evaluated physician utilization and related costs for a large, unselected cohort of 15,304 Parkinsonian patients from the general population, comparing them to 30,608 age- and sex-matched controls within a universal health care system in Ontario, Canada.
On average, 45% of Parkinsonian patients saw neurologists annually. The cumulative rate of at least one neurological consultation was only 59.5% over the six years. Patients aged <65 had a much greater likelihood of consulting a neurologist (73.3%) compared to those ≥65 (37.2%). Most Parkinsonian patients (97.2%), regardless of age, saw family physicians/general practitioners each year; 50.4% saw internal medicine consultants.
Parkinsonian patients had increased likelihood of utilizing neurologists, primary care physicians and internists compared to controls; related costs of physicians’ services were higher. Further research is necessary to evaluate differences in outcomes and costs between neurologists and other physician service providers.