Automated classification of limb fractures from free-text radiology reports using a clinician-informed gazetteer methodology

Background Timely diagnosis and reporting of patient symptoms in hospital emergency departments (ED) is a critical component of health services delivery. However, due to dispersed information resources and a vast amount of manual processing of unstructured information, accurate point-of-care diagnosis is often difficult. Aims The aim of this research is to report initial experimental evaluation of a clinician-informed automated method for the issue of initial misdiagnoses associated with delayed receipt of unstructured radiology reports. Method A method was developed that resembles clinical reasoning for identifying limb abnormalities. The method consists of a gazetteer of keywords related to radiological findings; the method classifies an X-ray report as abnormal if it contains evidence contained in the gazetteer. A set of 99 narrative reports of radiological findings was sourced from a tertiary hospital. Reports were manually assessed by two clinicians and discrepancies were validated by a third expert ED clinician; the final manual classification generated by the expert ED clinician was used as ground truth to empirically evaluate the approach. Results The automated method that attempts to individuate limb abnormalities by searching for keywords expressed by clinicians achieved an F-measure of 0.80 and an accuracy of 0.80. Conclusion While the automated clinician-driven method achieved promising performances, a number of avenues for improvement were identified using advanced natural language processing (NLP) and machine learning techniques.

The impact of viral respiratory infection on the severity and recovery from an asthma exacerbation

Background Viral respiratory illness triggers asthma exacerbations, but the influence of respiratory illness on the acute severity and recovery of childhood asthma is unknown. Our objective was to evaluate the impact of a concurrent acute respiratory illness (based on a clinical definition and PCR detection of a panel of respiratory viruses, Mycoplasma pneumoniae and Chlamydia pneumoniae) on the severity and resolution of symptoms in children with a nonhospitalized exacerbation of asthma. Methods Subjects were children aged 2 to 15 years presenting to an emergency department for an acute asthma exacerbation and not hospitalized. Acute respiratory illness (ARI) was clinically defined. Nasopharyngeal aspirates (NPA) were examined for respiratory viruses, Chlamydia and Mycoplasma using PCR. The primary outcome was quality of life (QOL) on presentation, day 7 and day 14. Secondary outcomes were acute asthma severity score, asthma diary, and cough diary scores on days 5, 7,10, and 14. Results On multivariate regression, presence of ARI was statistically but not clinically significantly associated with QOL score on presentation (B = 0.36, P = 0.025). By day 7 and 14, there was no difference between groups. Asthma diary score was significantly higher in children with ARI (B = 0.41, P = 0.039) on day 5 but not on presentation or subsequent days. Respiratory viruses were detected in 54% of the 78 NPAs obtained. There was no difference in the any of the asthma outcomes of children grouped by positive or negative NPA. Conclusions The presence of a viral respiratory illness has a modest influence on asthma severity, and does not influence recovery from a nonhospitalized asthma exacerbation.

Radiographic imaging for traumatic ankle injuries : a demand profile and investigation of radiological reporting timeframes from an Australian tertiary facility

Background Radiographic examinations of the ankle are important in the clinical management of ankle injuries in hospital emergency departments. National (Australian) Emergency Access Targets (NEAT) stipulate that 90 percent of presentations should leave the emergency department within 4 hours. For a radiological report to have clinical usefulness and relevance to clinical teams treating patients with ankle injuries in emergency departments, the report would need to be prepared and available to the clinical team within the NEAT 4 hour timeframe; before the patient has left the emergency department. However, little is known about the demand profile of ankle injuries requiring radiographic examination or time until radiological reports are available for this clinical group in Australian public hospital emergency settings. Methods This study utilised a prospective cohort of consecutive cases of ankle examinations from patients (n=437) with suspected traumatic ankle injuries presenting to the emergency department of a tertiary hospital facility. Time stamps from the hospital Picture Archiving and Communication System were used to record the timing of three processing milestones for each patient's radiographic examination; the time of image acquisition, time of a provisional radiological report being made available for viewing by referring clinical teams, and time of final verification of radiological report. Results Radiological reports and all three time stamps were available for 431 (98.6%) cases and were included in analysis. The total time between image acquisition and final radiological report verification exceeded 4?hours for 404 (92.5%) cases. The peak demand for radiographic examination of ankles was on weekend days, and in the afternoon and evening. The majority of examinations were provisionally reported and verified during weekday daytime shift hours. Conclusions Provisional or final radiological reports were frequently not available within 4 hours of image acquisition among this sample. Effective and cost-efficient strategies to improve the support provided to referring clinical teams from medical imaging departments may enhance emergency care interventions for people presenting to emergency departments with ankle injuries; particularly those with imaging findings that may be challenging for junior clinical staff to interpret without a definitive radiological report.

End of Life Decision Making and Palliative Care

1. An emergency department attendance represents an opportunity to set goals for care during the attendance and beyond. 2. End of life discussions and advance care planning assist early decision-making about treatment goals and end of life care. 3. Knowledge of the law assists decision-making at the end of life. 4. Not all dying patients require the skill set of a palliative care specialist but every dying patient will benefit from a palliative approach. 5. Palliative care does not preclude active treatment where the intent is understood by patient and family. 6. Failure to diagnose dying can compromise patient care. 7. The emergency department should foster close relationships with local specialist palliative care providers to improve and ensure timely access for patients and families and so that emergency staff have access to the knowledge and skills provided.

Impact of temperature on childhood pneumonia estimated from satellite remote sensing

The effect of temperature on childhood pneumonia in subtropical regions is largely unknown so far. This study examined the impact of temperature on childhood pneumonia in Brisbane, Australia. A quasi-Poisson generalized linear model combined with a distributed lag non linear model was used to quantify the main effect of temperature on emergency department visits (EDVs) for childhood pneumonia in Brisbane from 2001 to 2010. The model residuals were checked to identify added effects due to heat waves or cold spells. Both high and low temperatures were associated with an increase in EDVs for childhood pneumonia. Children aged 2–5 years, and female children were particularly vulnerable to the impacts of heat and cold, and Indigenous children were sensitive to heat. Heat waves and cold spells had significant added effects on childhood pneumonia, and the magnitude of these effects increased with intensity and duration. There were changes over time in both the main and added effects of temperature on childhood pneumonia. Children, especially those female and Indigenous, should be particularly protected from extreme temperatures. Future development of early warning systems should take the change over time in the impact of temperature on children’s health into account.

Temperature variability and childhood pneumonia : an ecological study

Background Few data on the relationship between temperature variability and childhood pneumonia are available. This study attempted to fill this knowledge gap. Methods A quasi-Poisson generalized linear regression model combined with a distributed lag nonlinear model was used to quantify the impacts of diurnal temperature range (DTR) and temperature change between two neighbouring days (TCN) on emergency department visits (EDVs) for childhood pneumonia in Brisbane, from 2001 to 2010, after controlling for possible confounders. Results An adverse impact of TCN on EDVs for childhood pneumonia was observed, and the magnitude of this impact increased from the first five years (2001–2005) to the second five years (2006–2010). Children aged 5–14 years, female children and Indigenous children were particularly vulnerable to TCN impact. However, there was no significant association between DTR and EDVs for childhood pneumonia. Conclusions As climate change progresses, the days with unstable weather pattern are likely to increase. Parents and caregivers of children should be aware of the high risk of pneumonia posed by big TCN and take precautionary measures to protect children, especially those with a history of respiratory diseases, from climate impacts.

Assessment of the temperature effect on childhood diarrhea using satellite imagery

A quasi-Poisson generalized linear model combined with a distributed lag non-linear model was used to quantify the main effect of temperature on emergency department visits (EDVs) for childhood diarrhea in Brisbane from 2001 to 2010. Residual of the model was checked to examine whether there was an added effect due to heat waves. The change over time in temperature-diarrhea relation was also assessed. Both low and high temperatures had significant impact on childhood diarrhea. Heat waves had an added effect on childhood diarrhea, and this effect increased with intensity and duration of heat waves. There was a decreasing trend in the main effect of heat on childhood diarrhea in Brisbane across the study period. Brisbane children appeared to have gradually adapted to mild heat, but they are still very sensitive to persistent extreme heat. Development of future heat alert systems should take the change in temperature-diarrhea relation over time into account.

The geographical co-distribution and socio-ecological drivers of childhood pneumonia and diarrhoea in Queensland, Australia

This study aimed to explore the spatiotemporal patterns, geographic co-distribution, and socio-ecological drivers of childhood pneumonia and diarrhea in Queensland. A Bayesian conditional autoregressive model was used to quantify the impacts of socio-ecological factors on both childhood pneumonia and diarrhea at a postal area level. A distinct seasonality of childhood pneumonia and diarrhea was found. Childhood pneumonia and diarrhea mainly distributed in northwest of Queensland. Mount Isa was the high-risk cluster where childhood pneumonia and diarrhea co-distributed. Emergency department visits (EDVs) for pneumonia increased by 3% per 10-mm increase in monthly average rainfall, in wet seasons. In comparison, a 10-mm increase in monthly average rainfall may increase 4% of EDVs for diarrhea. Monthly average temperature was negatively associated with EDVs for childhood diarrhea, in wet seasons. Low socioeconomic index for areas (SEIFA) was associated with high EDVs for childhood pneumonia. Future pneumonia and diarrhea prevention and control measures in Queensland should focus more on Mount Isa.

Socio-demographic vulnerability to heatwave impacts in Brisbane, Australia : a time series analysis

Objective: Examining the association between socioeconomic disadvantage and heat-related emergency department (ED) visits during heatwave periods in Brisbane, 2000–2008. Methods: Data from 10 public EDs were analysed using a generalised additive model for disease categories, age groups and gender. Results: Cumulative relative risks (RR) for non-external causes other than cardiovascular and respiratory diseases were 1.11 and 1.05 in most and least disadvantaged areas, respectively. The pattern persisted on lags 0–2. Elevated risks were observed for all age groups above 15 years in all areas. However, with RRs of 1.19–1.28, the 65–74 years age group in more disadvantaged areas stood out, compared with RR=1.08 in less disadvantaged areas. This pattern was observed on lag 0 but did not persist. The RRs for male presentations were 1.10 and 1.04 in most and less disadvantaged areas; for females, RR was 1.04 in less disadvantaged areas. This pattern persisted across lags 0–2. Conclusions: Heat-related ED visits increased during heatwaves. However, due to overlapping confidence intervals, variations across socioeconomic areas should be interpreted cautiously. Implications: ED data may be utilised for monitoring heat-related health impacts, particularly on the first day of heatwaves, to facilitate prompt interventions and targeted resource allocation.

Integrated chronic disease management in primary-secondary care : a systematic literature review of the evidence

Introduction: Diabetes has traditionally been managed as a single chronic disease state, but it exists with co-morbidities such as depression and metabolic syndrome. Treatment is multifaceted, requiring both primary and secondary care, however, the delivery of diabetes care is often fragmented. Integrated chronic disease management is a growing model of interest, and is underpinned by the chronic care model (CCM), devised as a guide for primary care management of patients with chronic conditions. The model identifies six key elements for effective care, and has shown promise in improving the management of diabetes. Aim: To find empirical evidence of integrated care interventions targeted at co-morbidities including diabetes, across primary/secondary care. Method: A systematic review of peer reviewed literature from PubMed, CINAHL, Embase, Cochrane Library and Joanna Briggs was performed. Studies were reviewed according to inclusion criteria- studies published in English, between 2004-2014, empirical studies, studies with evidence of primary/secondary implementation, and those dealing with chronic co-morbid disease states. Results: 51 studies met the inclusion criteria. Included studies were mostly from the US (38), with five from Australia, UK (2), Canada (2), Netherlands (1), Norway (1), Ireland (1), and one multi-country study. It was found that all interventions adopted at least one (average 3-4) of the chronic care model, with the majority implementing delivery system redesign activities within the primary care practice/s. We found evidence of interventions which significantly reduced emergency department and hospital admissions, improved processes of care, patient health outcomes such as HbA1c, improved patient satisfaction, and reduced costs. Conclusion/Implications for practice: Diabetes exists as a co-morbid disease, requiring both primary and secondary care. We found that integrated care interventions adopting elements of the chronic care model positively impacted on patient outcomes, service utilisation, as well as costs. This review has highlighted that it may not be necessary to adopt all CCM elements to improve clinical outcomes, patient satisfaction and costs.

A time series analysis of presentations to Queensland health facilities for alcohol-related conditions, following the increase in 'alcopops' tax

Objective: In response to concerns about the health consequences of high-risk drinking by young people, the Australian Government increased the tax on pre-mixed alcoholic beverages ('alcopops') favoured by this demographic. We measured changes in admissions for alcohol-related harm to health throughout Queensland, before and after the tax increase in April 2008. Methods: We used data from the Queensland Trauma Register, Hospitals Admitted Patients Data Collection, and the Emergency Department Information System to calculate alcohol-related admission rates per 100,000 people, for 15 - 29 year-olds. We analysed data over 3 years (April 2006 - April 2009), using interrupted time-series analyses. This covered 2 years before, and 1 year after, the tax increase. We investigated both mental and behavioural consequences (via F10 codes), and intentional/unintentional injuries (S and T codes). Results: We fitted an auto-regressive integrated moving average (ARIMA) model, to test for any changes following the increased tax. There was no decrease in alcohol-related admissions in 15 - 29 year-olds. We found similar results for males and females, as well as definitions of alcohol-related harms that were narrow (F10 codes only) and broad (F10, S and T codes). Conclusions: The increased tax on 'alcopops' was not associated with any reduction in hospital admissions for alcohol-related harms in Queensland 15 - 29 year-olds.

Injury narrative text classification using factorization model

Narrative text is a useful way of identifying injury circumstances from the routine emergency department data collections. Automatically classifying narratives based on machine learning techniques is a promising technique, which can consequently reduce the tedious manual classification process. Existing works focus on using Naive Bayes which does not always offer the best performance. This paper proposes the Matrix Factorization approaches along with a learning enhancement process for this task. The results are compared with the performance of various other classification approaches. The impact on the classification results from the parameters setting during the classification of a medical text dataset is discussed. With the selection of right dimension k, Non Negative Matrix Factorization-model method achieves 10 CV accuracy of 0.93.

Towards a consistent definition of a significant delta troponin with z-scores: A way out of chaos?

Aims: We assessed the diagnostic performance of z-scores to define a significant delta cardiac troponin (cTn) in a cohort of patients with well-defined clinical outcomes. Methods: We calculated z-scores, which are dependent on the analytical precision and biological variation, to report changes in cTn. We compared the diagnostic performances of a relative delta (%Δ), actual delta (Δ), and z-scores in 762 emergency department patients with symptoms of suspected acute coronary syndrome. cTn was measured with sensitive cTnI (Beckman Coulter), highly sensitive cTnI (Abbott), and highly sensitive cTnT (Roche) assays. Results: Receiver operating characteristic analysis showed no statistically significant differences in the areas under the curve (AUC) of z-scores and Δ with both superior compared to %Δ for all three assays (p<0.001). The AUCs of z-scores measured with the Abbott hs-cTnI (0.955) and Roche hs-cTnT (0.922) assays were comparable to Beckman Coulter cTnI (0.933) (p=0.272 and 0.640, respectively). The individualized Δ cut-off values that were required to emulate a z-score of 1.96 were: Beckman Coulter cTnI 30 ng/l, Abbott hs-cTnI 20 ng/l, and Roche hs-cTnT 7 ng/l. Conclusions: z-scores allow the use of a single cut-off value at all cTn levels, for both cTnI and cTnT and for sensitive and highly sensitive assays, with comparable diagnostic performances. This strategy of reporting significant changes as z-scores may obviate the need for the empirical development of assay-specific cut-off rules to define significant troponin changes.

Assessment of temperature effects on childhood pneumonia and diarrhoea

This thesis has identified the high risk areas of childhood pneumonia and diarrhoea in Queensland and quantified the effects of temperature on emergency department visits for childhood pneumonia and diarrhoea. It adds to the increasing evidence about the impacts of climate variability and change on children's health and may have significant implications for developing climate change adaptation strategies and paediatric care policies.