A Knowledge-based Clinical Toxicology Consultant for Diagnosing Multiple Exposures

Objective: This paper presents continued research toward the development of a knowledge-based system for the diagnosis of human toxic exposures. In particular, this research focuses on the challenging task of diagnosing exposures to multiple toxins. Although only 10% of toxic exposures in the United States involve multiple toxins, multiple exposures account for more than half of all toxin-related fatalities. Using simple medical mathematics, we seek to produce a practical decision support system capable of supplying useful information to aid in the diagnosis of complex cases involving multiple unknown substances. Methods: The system is automatically trained using data mining techniques to extract prior probabilities and likelihood ratios from a database managed by the Florida Poison Information Center (FPIC). When supplied with observed clinical effects, the system produces a ranked list of the most plausible toxic exposures. During testing, the system diagnosed toxins at three levels: identifying the substance, identifying the toxin’s major and minor categories, and identifying the toxin’s major category alone. To enable comparison between these three levels, accuracy was calculated as the percentage of exposures correctly identified in top 10% of trained diagnoses. Results: System evaluation utilized a dataset of 8,901 multiple exposure cases and 37,617 single exposure cases. Initial system testing using only multiple exposure cases yielded poor results, with diagnosis accuracies ranging from 18.5-50.1%. Further investigation revealed that the system’s inability to diagnose multiple disorders resulted from insufficient data and that the clinical effects observed in multiple exposures are dominated by a single substance. Including single exposures when training, the system achieved accuracies as high as 83.5% when 2 diagnosing the primary contributors in multiple exposure cases by substance, 86.9% when diagnosing by major and minor categories, and 79.9% when diagnosing by major category alone. Conclusions: Although the system failed to completely diagnose exposures to multiple toxins, the ability to identify the primary contributor in such cases may prove valuable in aiding medical personnel as they seek to diagnose and treat patients. As time passes and more cases are added to the FPIC database, we believe system accuracy will continue to improve, producing a viable decision support system for clinical toxicology

Introduction to this Special Issue: Intelligent Data Analysis on Electromyography and Electroneurography

Computer-aided electromyography (EMG) and elec- troneurography (ENG) have become indispensable tools in the daily activities of neurophysiology laboratories in facilitating quantitative analysis and decision making in clinical neurophysiology, rehabilitation, sports medicine, and studies of human physiology. These tools form the basis of a new era in the practice of neurophysiology facilitating the: (i) Standardization . Diagnoses obtained with similar criteria in different laboratories can be veri- fied. (ii) Sensitivity . Neurophysiological findings in a particular subject under investigation may be compared with a database of normal values to determine whether abnormality exists or not. (iii) Specificity . Findings may be compared with databases derived from patients with known diseases, to evaluate whether they fit a specific diagnosis. (iv) Equivalence . Results from serial examin- ations on the same patient may be compared to decide whether there is evidence of disease progression or of response to treatment. Also, findings obtained from dif- ferent quantitative methods may be contrasted to deter- mine which are most sensitive and specific. Different methodologies have been developed in com- puter-aided EMG and ENG analysis ranging from simple quantitative measures of the recorded potentials, to more complex knowledge-based and neural network systems that enable the automated assessment of neuromuscular disorders. However, the need still exists for the further advancement and standardization of these method- ologies, especially nowadays with the emerging health telematics technologies which will enable their wider application in the neurophysiological laboratory. The main objective of this Special Issue of Medical Engin- eering & Physics is to provide a snapshot of current activities and methodologies in intelligent data analysis in peripheral neurophysiology. A total of 12 papers are published in this Special Issue under the following topics: Motor Unit Action Potential (MUAP) Analysis, Surface EMG (SEMG) Analysis, Electroneurography, and Decision Systems. In this intro- duction, the papers are briefly introduced, following a brief review of the major achievements in quantitative electromyography and electroneuropathy

Laryngeal electromyography in dysphonic patients with incomplete glottic closure

The lack of specificity in laryngoscopical examination requires that the diagnosis of superior laryngeal and recurrent laryngeal nerve involvement be carried out with the aid of electromyography. OBJECTIVE: This study aims to assess the electrophysiological function of the superior and inferior laryngeal nerves by measuring the electrical activity of the muscles they innervate in dysphonic patients with incomplete closure of the vocal folds during phonation. METHOD: Thirty-nine patients with incomplete glottic closure were enrolled in a prospective study and had their cricothyroid, thyroarytenoid, and lateral cricoarytenoid muscles examined bilaterally through electromyography. Insertion activity, electrical activity at rest (fibrillation, positive wave and fasciculation) and during muscle voluntary contraction (recruitment, amplitude, potential length and latency between electrical activity and phonation) were measured. RESULTS: No altered test results were observed for parameters insertion activity and electrical activity at rest. None of the patients had recruitment dysfunction. The mean electrical potential amplitude values were within normal range for the tested muscles, as were potential durations and latency times between the onset of electrical activity and phonation. CONCLUSION: No signs of denervation were seen in the thyroarytenoid, cricothyroid, and lateral cricoarytenoid muscles of the studied patients.O diagnóstico de comprometimento do nervo laríngeo superior e de ramos do laríngeo recorrente demanda eletromiografia, pois as alterações à laringoscopia são inespecíficas. OBJETIVO: Avaliar eletrofisiologicamente a função dos nervos laríngeo superior e inferior por meio da atividade elétrica dos músculos por eles inervados, em pacientes com disfonia com coaptação incompleta das pregas vocais à fonação. MÉTODO: Estudo prospectivo; 39 indivíduos com disfonia e fechamento glótico incompleto foram submetidos à eletromiografia dos músculos tireoaritenóideo, cricotireóideo e cricoaritenóideo lateral bilateralmente. Foram avaliadas atividade de inserção, no repouso (fibrilação, onda positiva e fasciculação) e durante contração voluntária dos músculos (recrutamento, amplitude e duração do potencial e latência entre início da atividade elétrica e a sonorização). RESULTADOS: Não observamos alteração na atividade de inserção e no repouso. Nenhum paciente apresentou recrutamento alterado. A média da amplitude dos potenciais elétricos esteve compatível com a normalidade nos músculos testados, assim como a duração do potencial e o tempo de latência entre o início da atividade elétrica e a sonorização. CONCLUSÃO: Não observamos sinais de desnervação nos músculos tireoaritenóideo, cricotireóideo e cricoaritenóideo lateral bilateralmente nos pacientes estudados.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade Federal de São Paulo (UNIFESP) Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço Escola Paulista de MedicinaInternational Federation of ORL SocietiesUNIFESP, EPMUNIFESP, Depto. de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço Escola Paulista de MedicinaSciEL

Psychocognitive Factors and Recovery from Hip Fracture : A Real-life Prospective Cohort Study

The data for this study comprised hip fracture patients aged 65 years or more suffering their first hip fracture and treated in Seinäjoki Central Hospital between 2007 and 2019 (n=2,320). Data were collected on admission, during hospital care, in an outpatient comprehensive geriatric assessment (CGA) 4–6 months post-hip fracture and by telephone interviews after the index fracture. New diagnosed cognitive disorder extracted manually from the electronic patient files was documented in almost one in four patients (23.3%). Cognitive disorders had usually advanced to a moderate to severe stage before diagnosis. Higher age, multiple comorbidities and malnutrition were associated with new cognitive disorders. The array of diagnoses did not differ from general occurrence as Alzheimer’s disease with or without vascular cognitive impairment was the most common diagnosis. Delirium during acute hospital care was a significant predictor of an imminent diagnosis of a cognitive disorder. Depressive mood assessed at the outpatient clinic was associated with poorer physical and cognitive performance, and also with malnutrition. Depressive mood was seldom severe. Fear of falling (FoF) was more common in female patients and in patients with multiple medications in regular use and moreover associated with poorer physical performance. Patients with pre-fracture cognitive disorders reported less FoF than those without. Neither depressive mood nor FoF explained the decreased mobility level, change to more supported living arrangements or mortality in one-year follow-up. Previously undiagnosed cognitive disorders are common in older hip fracture patients. Delirium during hospital care is associated with development of subsequent new diagnoses of cognitive disorders. Depressive mood and FoF are common multifactorial conditions which deserve attention during recovery but do not explain the changes in outcomes one year after the hip fracture. There seems to be significant overlap and co-occurrence of psychocognitive factors in this remarkably heterogeneous population, and thus, CGA should be considered as a standardized protocol throughout the post-hip fracture pathway.Tutkimuksen tavoitteena oli tutkia lonkkamurtuman jälkeisessä seurannassa todettavia uusia muistisairauksia sekä muiden psykokognitiivisten tekijöiden merkitystä sairaalahoidon ja toipumisen aikana. Aineisto koostui Seinäjoen keskussairaalassa vuosina 2007–2019 hoidetuista yli 65-vuotiaista lonkkamurtumapotilaista (n=2320). Tiedot kerättiin sairaalahoidon aikana, polikliinisessä kokonaisvaltaisessa geriatrisessa arvioinnissa (CGA) 4–6 kuukautta murtuman jälkeen, sekä puhelinhaastatteluilla. Muistisairauteen sairastuminen oli yleistä toipumisen aikana. Sairauden vaihe oli yleensä ehtinyt edetä kohtalaiseen tai vakavaan vaikeusasteeseen ennen diagnoosia. Uutta muistisairautta ennusti korkeampi ikä, komorbiditeetit ja vajaaravitsemus. Todettujen muistisairausdiagnoosien kirjo ei poikennut yleisistä esiintyvyyksistä. Sairaalahoidon aikainen delirium oli selvästi yhteydessä uuteen muistisairauteen. Depressiivistä mielialaa todettiin lähes joka kolmannella ja kaatumisen pelkoa lähes joka toisella potilaalla lonkkamurtuman jälkeisessä CGA:ssa. Depressiivinen mieliala oli yhteydessä huonompaan toiminnalliseen, fyysiseen ja kognitiiviseen suorituskykyyn, sekä vajaaravitsemukseen. Vaikeusasteeltaan depressiivinen mieliala oli harvoin vakavaa. Kaatumisen pelko oli yleisempää naisilla ja monilääkityillä. Kaatumisen pelko liittyi myös heikompaan fyysiseen suorituskykyyn. Potilaat, joilla oli todettu muistisairaus ennen lonkkamurtumaa, kokivat vähemmän kaatumisen pelkoa, kuin potilaat, joilla ei ollut todettua muistisairautta. Depressiivinen mieliala tai kaatumisenpelko eivät yksinään selittäneet heikentynyttä liikuntakykyä, muuttoa tuetumpaan asumismuotoon tai kuolleisuutta vuoden kuluttua murtumasta. Aiemmin diagnosoimattomat muistisairaudet ovat yleisiä iäkkäillä lonkkamurtumapotilailla. Sairaalahoidon aikainen delirium on yhteydessä uusiin lonkkamurtuman jälkeen todettuihin muistisairauksiin. Depressiivinen mieliala ja kaatumisen pelko ovat yleisiä, monitekijäisiä ongelmia, jotka on syytä huomioida kuntoutumisen aikana, mutta eivät yksinään selitä tilannetta vuoden kuluttua murtumasta. Psykokognitiiviset tekijät voivat esiintyvät limittäin tai samanaikaisesti tässä hauraassa potilasryhmässä ja siksi lonkkamurtuman jälkeinen CGA olisi tärkeää saada osaksi standardoitua hoitopolkua

Community Integration After In-Patient Rehabilitation for Lower Extremity Musculoskeletal Disorders: A Pilot Study

Purpose: To investigate change in community integration (CI) and functional status following discharge from in-patient musculoskeletal (MSK) rehabilitation, and to explore the concordance between the Reintegration to Normal Living Index (RNLI) and patient interviews. Participants: Twenty-five individuals with lower extremity MSK disorders discharged home after rehabilitation. Methods: For all outcome measures, categories of change between successive time points were created using the minimal detectable change. Change patterns were evaluated at the group and individual level across four time intervals. Percent agreement quantified concordance between interview and RNLI data. Results: Change over time was confirmed at the group level. However, individual-level analyses revealed much variability in change patterns. High concordance (81%) was found between the two methods of reporting change in CI. Significance: The individual-level findings indicate heterogeneity in recovery patterns, which if assessed as a group would have not been identified. Interview findings support the RNLI for measuring CI for the target population

Extracting the coherent core of human probability judgement: a research program for cognitive psychology

Human intuition is a rich and useful guide to uncertain events in the environment but suffers from probabilistic incoherence in the technical sense. Developing methods for extracting a coherent body of judgement that is maximally consistent with a person's intuition is a challenging task for cognitive psychology, and also relevant to the construction of artificial expert systems. The present article motivates this problem, and outlines one approach to it.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/31673/1/0000609.pd

Cognitive and affective predictors of participation in rehabilitation after acquired brain injury

Objective: The present study aimed to investigate the factors relating to mood and cognition which influence a person’s ability to participate in rehabilitation after Acquired Brain Injury (ABI). It was hypothesised that impairment in cognition, including specific impairment in executive functioning and depression would be associated with poorer engagement in rehabilitation. Method: Twenty-nine patients undergoing rehabilitation following stroke (89.7%) or TBI (10.3%) participated. Individuals recruited completed the Hospital Anxiety and Depression Scale as a measure of mood and an executive functioning test battery. Data collection occurred over a two week period as concurrent ratings of participation were gathered from physiotherapists and occupational therapists using the Pittsburgh Rehabilitation Participation Scale. Results: In support of the hypotheses, correlation analysis showed a significant positive correlation between participation in rehabilitation with executive functioning (p < .05) and a significant negative correlation between participation in rehabilitation and low mood (p < .05). No association was found between general cognitive ability, functional disability, time since injury, age, gender and participation