Background: Decision making in the Emergency Department (ED) requires timely identification of clinical information relevant to the complaints. Existing information retrieval solutions for the electronic health record (EHR) focus on patient cohort identification and lack clinical relevancy ranking. We aimed to compare knowledge-based (KB) and unsupervised statistical methods for ranking EHR information by relevancy to a chief complaint of chest or back pain among ED patients. Methods: We used Pointwise-mutual information (PMI) with corpus level significance adjustment (cPMId), which modifies PMI to reward co-occurrence patterns with a higher absolute count. cPMId for each pair of medication/problem and chief complaint was estimated from a corpus of 100,000 un-annotated ED encounters. Five specialist physicians ranked the relevancy of medications and problems to each chief complaint on a 0-4 Likert scale to form the KB ranking. Reverse chronological order was used as a baseline. We directly compared the three methods on 1010 medications and 2913 problems from 99 patients with chest or back pain, where each item was manually labeled as relevant or not to the chief complaint, using mean average-precision. Results: cPMId out-performed KB ranking on problems (86.8% vs. 81.3%, p < 0.01) but under-performed it on medications (93.1% vs. 96.8%, p < 0.01). Both methods significantly outperformed the baseline for both medications and problems (71.8% and 72.1%, respectively, p < 0.01 for both comparisons). The two complaints represented virtually completely different information needs (average Jaccard index of 0.008). Conclusion: A fully unsupervised statistical method can provide a reasonably accurate, low-effort and scalable means for situation-specific ranking of clinical information within the EHR.

Objective: To assess the role of speech recognition (SR) technology in clinicians' documentation workflows by examining use of, experience with and opinions about this technology. Materials and Methods: We distributed a survey in 2016-2017 to 1731 clinician SR users at two large medical centers in Boston, Massachusetts and Aurora, Colorado. The survey asked about demographic and clinical characteristics, SR use and preferences, perceived accuracy, efficiency, and usability of SR, and overall satisfaction. Associations between outcomes (e.g., satisfaction) and factors (e.g., error prevalence) were measured using ordinal logistic regression. Results: Most respondents (65.3%) had used their SR system for under one year. 75.5% of respondents estimated seeing 10 or fewer errors per dictation, but 19.6% estimated half or more of errors were clinically significant. Although 29.4% of respondents did not include SR among their preferred documentation methods, 78.8% were satisfied with SR, and 77.2% agreed that SR improves efficiency. Satisfaction was associated positively with efficiency and negatively with error prevalence and editing time. Respondents were interested in further training about using SR effectively but expressed concerns regarding software reliability, editing and workflow. Discussion: Compared to other documentation methods (e.g., scribes, templates, typing, traditional dictation), SR has emerged as an effective solution, overcoming limitations inherent in other options and potentially improving efficiency while preserving documentation quality. Conclusion: While concerns about SR usability and accuracy persist, clinicians expressed positive opinions about its impact on workflow and efficiency. Faster and better approaches are needed for clinical documentation, and SR is likely to play an important role going forward.

The red-hair phenotype, which is often produced by mutations in the melanocortin-1 receptor gene, has been associated with an increase in sedative, anesthetic, and analgesic requirements in both animal and human studies. Nevertheless, the clinical implications of this phenomenon in red-haired patients undergoing surgery are currently unknown.In a secondary analysis of a prospective trial of intraoperative awareness, red-haired patients were identified and matched with five control patients, and the relative risk for intraoperative awareness was determined. Overall anesthetic management between groups was compared using Hotelling's T-2 statistic. Inhaled anesthetic requirements were compared between cohorts by evaluating the relationship between end-tidal anesthetic concentration and the bispectral index with a linear mixed-effects model. Time to recovery was compared using Kaplan-Meier analysis, and differences in postoperative pain and nausea/vomiting were evaluated with Chi square tests.A cohort of 319 red-haired patients was matched with 1,595 control patients for a sample size of 1,914. There were no significant differences in the relative risk of intraoperative awareness (relative risk = 1.67; 95% confidence interval 0.34 to 8.22), anesthetic management, recovery times, or postoperative pain between red-haired patients and control patients. The relationship between pharmacokinetically stable volatile anesthetic concentrations and bispectral index values differed significantly between red-haired patients and controls (P < 0.001), but without clinical implications.There were no demonstrable differences between red-haired patients and controls in response to anesthetic and analgesic agents or in recovery parameters. These findings suggest that perioperative anesthetic and analgesic management should not be altered based on self-reported red-hair phenotype.

BACKGROUND Low bispectral index values frequently reflect EEG suppression and have been associated with postoperative mortality. This study investigated whether intraoperative EEG suppression was an independent predictor of 90 day postoperative mortality and explored risk factors for EEG suppression. METHODS This observational study included 2662 adults enrolled in the B-Unaware or BAG-RECALL trials. A cohort was defined with >5 cumulative minutes of EEG suppression, and 1:2 propensity-matched to a non-suppressed cohort (≤5 min suppression). We evaluated the association between EEG suppression and mortality using multivariable logistic regression, and examined risk factors for EEG suppression using zero-inflated mixed effects analysis. RESULTS Ninety day postoperative mortality was 3.9% overall, 6.3% in the suppressed cohort, and 3.0% in the non-suppressed cohort {odds ratio (OR) [95% confidence interval (CI)]=2.19 (1.48-3.26)}. After matching and multivariable adjustment, EEG suppression was not associated with mortality [OR (95% CI)=0.83 (0.55-1.25)]; however, the interaction between EEG suppression and mean arterial pressure (MAP) <55 mm Hg was [OR (95% CI)=2.96 (1.34-6.52)]. Risk factors for EEG suppression were older age, number of comorbidities, chronic obstructive pulmonary disease, and higher intraoperative doses of benzodiazepines, opioids, or volatile anaesthetics. EEG suppression was less likely in patients with cancer, preoperative alcohol, opioid or benzodiazepine consumption, and intraoperative nitrous oxide exposure. CONCLUSIONS Although EEG suppression was associated with increasing anaesthetic administration and comorbidities, the hypothesis that intraoperative EEG suppression is a predictor of postoperative mortality was only supported if it was coincident with low MAP. CLINICAL TRIAL REGISTRATION NCT00281489 and NCT00682825.

Background: Patients with a history of intraoperative awareness with explicit recall (AWR) are hypothesized to be at higher risk for AWR than the general surgical population. In this study, the authors assessed whether patients with a history of AWR (1) are actually at higher risk for AWR; (2) receive different anesthetic management; and (3) are relatively resistant to the hypnotic actions of volatile anesthetics.Methods: Patients with a history of AWR and matched controls from three randomized clinical trials investigating prevention of AWR were compared for relative risk of AWR. Anesthetic management was compared with the use of the Hotelling's T-2 statistic. A linear mixed model, including previously identified covariates, assessed the effects of a history of AWR on the relationship between end-tidal anesthetic concentration and bispectral index.Results: The incidence of AWR was 1.7% (4 of 241) in patients with a history of AWR and 0.3% (4 of 1,205) in control patients (relative risk = 5.0; 95% CI, 1.3-19.9). Anesthetic management did not differ between cohorts, but there was a significant effect of a history of AWR on the end-tidal anesthetic concentration versus bispectral index relationship.Conclusions: Surgical patients with a history of AWR are five times more likely to experience AWR than similar patients without a history of AWR. Further consideration should be given to modifying perioperative care and postoperative evaluation of patients with a history of AWR.

Our recent study (1) has compelled us to reach a conclusion that differs from the widely held idea that chemical features of odors can be systematically mapped to spatial locations in the olfactory bulb (2⇓–4). In an alternative analysis using our data, Yablonka et al. (5) claim to observe substantial correlations between the physicochemical descriptors and odor-evoked responses, which challenge our conclusion. This discrepancy, as we show below, results from imparity in data processing and data selection.

In the mammalian brain, similar features of the sensory stimuli are often represented in proximity in the sensory areas. However, how chemical features are represented in the olfactory bulb has been controversial. Questions have been raised as to whether specific chemical features of the odor molecules are represented by spatially clustered olfactory glomeruli. Using a sensitive probe, we have analyzed the glomerular response to large numbers of odorants at single glomerulus resolution. Contrary to the general view, we find that the representation of chemical features is spatially distributed in the olfactory bulb with no discernible chemotopy. Moreover, odor-evoked pattern of activity does not correlate directly with odor structure in general. Despite the lack of spatial clustering or preference with respect to chemical features, some structurally related odors can be similarly represented by ensembles of spatially distributed glomeruli, providing an explanation of their perceptual similarity. Whereas there is no chemotopic organization, and the glomeruli are tuned to odors from multiple classes, we find that the glomeruli are hierarchically arranged into clusters according to their odor-tuning similarity. This tunotopic arrangement provides a framework to understand the spatial organization of the glomeruli that conforms to the organizational principle found in other sensory systems.

BACKGROUNDUnintended intraoperative awareness, which occurs when general anesthesia is not achieved or maintained, affects up to 1% of patients at high risk for this complication. We tested the hypothesis that a protocol incorporating the electroencephalogram-derived bispectral index (BIS) is superior to a protocol incorporating standard monitoring of end-tidal anesthetic-agent concentration (ETAC) for the prevention of awareness.METHODSWe conducted a prospective, randomized, evaluator-blinded trial at three medical centers. We randomly assigned 6041 patients at high risk for awareness to BIS-guided anesthesia (with an audible alert if the BIS value was <40 or >60, on a scale of 0 to 100, with 0 indicating the suppression of detectable brain electrical activity and 100 indicating the awake state) or ETAC-guided anesthesia (with an audible alert if the ETAC was <0.7 or >1.3 minimum alveolar concentration). In addition to audible alerts, the protocols included structured education and checklists. Superiority of the BIS protocol was assessed with the use of a one-sided Fisher's exact test.RESULTSA total of 7 of 2861 patients (0.24%) in the BIS group, as compared with 2 of 2852 (0.07%) in the ETAC group, who were interviewed postoperatively had definite intraoperative awareness (a difference of 0.17 percentage points; 95% confidence interval [CI], -0.03 to 0.38; P = 0.98). Thus, the superiority of the BIS protocol was not demonstrated. A total of 19 cases of definite or possible intraoperative awareness (0.66%) occurred in the BIS group, as compared with 8 (0.28%) in the ETAC group (a difference of 0.38 percentage points; 95% CI, 0.03 to 0.74; P = 0.99), with the superiority of the BIS protocol again not demonstrated. There was no difference between the groups with respect to the amount of anesthesia administered or the rate of major postoperative adverse outcomes.CONCLUSIONSThe superiority of the BIS protocol was not established; contrary to expectations, fewer patients in the ETAC group than in the BIS group experienced awareness. (Funded by the Foundation for Anesthesia Education and Research and others; BAG-RECALL ClinicalTrials.gov number, NCT00682825.)