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Brief Hospital Course (BHC) summaries are succinct summaries of an entire hospital encounter, embedded within discharge summaries, written by senior clinicians responsible for the overall care of a patient. Methods to automatically produce summaries from inpatient documentation would be invaluable in reducing clinician manual burden of summarising documents under high time-pressure to admit and discharge patients. Automatically producing these summaries from the inpatient course, is a complex, multi-document summarisation task, as source notes are written from various perspectives (e.g. nursing, doctor, radiology), during the course of the hospitalisation. We demonstrate a range of methods for BHC summarisation demonstrating the performance of deep learning summarisation models across extractive and abstractive summarisation scenarios. We also test a novel ensemble extractive and abstractive summarisation model that incorporates a medical concept ontology (SNOMED) as a clinical guidance signal and shows superior performance in 2 real-world clinical data sets.

Background The National Early Warning Score (NEWS2) is currently recommended in the UK for the risk stratification of COVID-19 patients, but little is known about its ability to detect severe cases. We aimed to evaluate NEWS2 for the prediction of severe COVID-19 outcome and identify and validate a set of blood and physiological parameters routinely collected at hospital admission to improve upon the use of NEWS2 alone for medium-term risk stratification. Methods Training cohorts comprised 1276 patients admitted to King’s College Hospital National Health Service (NHS) Foundation Trust with COVID-19 disease from 1 March to 30 April 2020. External validation cohorts included 6237 patients from five UK NHS Trusts (Guy’s and St Thomas’ Hospitals, University Hospitals Southampton, University Hospitals Bristol and Weston NHS Foundation Trust, University College London Hospitals, University Hospitals Birmingham), one hospital in Norway (Oslo University Hospital), and two hospitals in Wuhan, China (Wuhan Sixth Hospital and Taikang Tongji Hospital). The outcome was severe COVID-19 disease (transfer to intensive care unit (ICU) or death) at 14 days after hospital admission. Age, physiological measures, blood biomarkers, sex, ethnicity, and comorbidities (hypertension, diabetes, cardiovascular, respiratory and kidney diseases) measured at hospital admission were considered in the models. Results A baseline model of ‘NEWS2 + age’ had poor-to-moderate discrimination for severe COVID-19 infection at 14 days (area under receiver operating characteristic curve (AUC) in training cohort = 0.700, 95% confidence interval (CI) 0.680, 0.722; Brier score = 0.192, 95% CI 0.186, 0.197). A supplemented model adding eight routinely collected blood and physiological parameters (supplemental oxygen flow rate, urea, age, oxygen saturation, C-reactive protein, estimated glomerular filtration rate, neutrophil count, neutrophil/lymphocyte ratio) improved discrimination (AUC = 0.735; 95% CI 0.715, 0.757), and these improvements were replicated across seven UK and non-UK sites. However, there was evidence of miscalibration with the model tending to underestimate risks in most sites. Conclusions NEWS2 score had poor-to-moderate discrimination for medium-term COVID-19 outcome which raises questions about its use as a screening tool at hospital admission. Risk stratification was improved by including readily available blood and physiological parameters measured at hospital admission, but there was evidence of miscalibration in external sites. This highlights the need for a better understanding of the use of early warning scores for COVID.

ObjectivesThe first aim of this study was to design and develop a valid and replicable strategy to extract physical health conditions from clinical notes which are common in mental health services. Then, we examined the prevalence of these conditions in individuals with severe mental illness (SMI) and compared their individual and combined prevalence in individuals with bipolar (BD) and schizophrenia spectrum disorders (SSD).DesignObservational study.SettingSecondary mental healthcare services from South LondonParticipantsOur maximal sample comprised 17 500 individuals aged 15 years or older who had received a primary or secondary SMI diagnosis (International Classification of Diseases, 10th edition, F20-31) between 2007 and 2018.MeasuresWe designed and implemented a data extraction strategy for 21 common physical comorbidities using a natural language processing pipeline, MedCAT. Associations were investigated with sex, age at SMI diagnosis, ethnicity and social deprivation for the whole cohort and the BD and SSD subgroups. Linear regression models were used to examine associations with disability measured by the Health of Nations Outcome Scale.ResultsPhysical health data were extracted, achieving precision rates (F1) above 0.90 for all conditions. The 10 most prevalent conditions were diabetes, hypertension, asthma, arthritis, epilepsy, cerebrovascular accident, eczema, migraine, ischaemic heart disease and chronic obstructive pulmonary disease. The most prevalent combination in this population included diabetes, hypertension and asthma, regardless of their SMI diagnoses.ConclusionsOur data extraction strategy was found to be adequate to extract physical health data from clinical notes, which is essential for future multimorbidity research using text records. We found that around 40% of our cohort had multimorbidity from which 20% had complex multimorbidity (two or more physical conditions besides SMI). Sex, age, ethnicity and social deprivation were found to be key to understand their heterogeneity and their differential contribution to disability levels in this population. These outputs have direct implications for researchers and clinicians.

The ability to perform accurate prognosis of patients is crucial for proactive clinical decision making, informed resource management and personalised care. Existing outcome prediction models suffer from a low recall of infrequent positive outcomes. We present a highly-scalable and robust machine learning framework to automatically predict adversity represented by mortality and ICU admission from time-series vital signs and laboratory results obtained within the first 24 hours of hospital admission. The stacked platform comprises two components: a) an unsupervised LSTM Autoencoder that learns an optimal representation of the time-series, using it to differentiate the less frequent patterns which conclude with an adverse event from the majority patterns that do not, and b) a gradient boosting model, which relies on the constructed representation to refine the prediction, incorporating static features of demographics, admission details and clinical summaries. The model is used to assess a patient's risk of adversity over time and provides visual justifications of its prediction, based on the patient's static features and dynamic signals. Results of three case studies for predicting mortality and ICU admission show that the model outperforms all existing outcome prediction models, achieving average Precision-Recall Areas Under the Curve (PR-AUCs) of 0.93 (95% CI: 0.878 - 0.969) in predicting mortality in ICU and general ward settings and 0.987 (95% CI: 0.985-0.995) in predicting ICU admission.

The current mode of use of Electronic Health Records (EHR) elicits text redundancy. Clinicians often populate new documents by duplicating existing notes, then updating accordingly. Data duplication can lead to propagation of errors, inconsistencies and misreporting of care. Therefore, measures to quantify information redundancy play an essential role in evaluating innovations that operate on clinical narratives. This work is a quantitative examination of information redundancy in EHR notes. We present and evaluate two methods to measure redundancy: an information-theoretic approach and a lexicosyntactic and semantic model. Our first measure trains large Transformer-based language models using clinical text from a large openly available US-based ICU dataset and a large multi-site UK based Hospital. By comparing the information-theoretic efficient encoding of clinical text against open-domain corpora, we find that clinical text is ∼ 1.5 × to ∼ 3 × less efficient than open-domain corpora at conveying information. Our second measure, evaluates automated summarisation metrics Rouge and BERTScore to evaluate successive note pairs demonstrating lexicosyntactic and semantic redundancy, with averages from ∼ 43 to ∼ 65%.

Wearable technologies offer the opportunity to record human physiological signals in real time, in a noninvasive way, and the data can be used to aid in the early detection of abnormal health conditions. Here, we demonstrate how the interconnected porosity can be used to increase the sensitivity and linearity of capacitive pressure sensors. The finite element analysis supports the experimental observation that the movement of air during the dynamic mechanical loading is responsible for the high sensitivity observed (0.18 ± 0.01 kPa

PurposeElectronic Patient Records (EPR) are ideal sources of information to provide evidence for the optimisation of health management. However, beyond direct patient care, their use for secondary purposes such as research or service improvement has been limited.AimsWe aimed to explore the feasibility of using novel patient data analytics tools (CogStack & MedCAT) at King’s College Hospital trust (KCH) to identify suspected first seizure patients and compare their man- agement against NICE guidelines.MethodWe utilised CogStack to search 1.4 billion EPR documents at KCH to identify suspected first seizure patients. We then retrieved their subsequent records, and used a combination of manual extraction and a natural language processing tool (MedCAT), to extract information about their symptomatic presenta- tion, final diagnosis, timing of investigations, and specialist appointments.Results226 patients attended the emergency department with suspected first seizures. MedCAT could be feasibly trained with expert knowledge to increase the accuracy of automatically extracting relevant textual information from EPR. Our analysis of patient records identified steps in the clinical pathway that frequently fell short of the NICE guidelines.ConclusionEPR are feasible to be mined at scale for the rapid analysis of service demand and monitoring patient health trajectories. The insights of this study have been used to improve first seizure management in KCH, demonstrating the value of NLP application in healthcare.anthony.shek@kcl.ac.uk107

Alzheimer's Dementia (AD) is an incurable, debilitating, and progressive neurodegenerative condition that affects cognitive function. Early diagnosis is important as therapeutics can delay progression and give those diagnosed vital time. Developing models that analyse spontaneous speech could eventually provide an efficient diagnostic modality for earlier diagnosis of AD. The Alzheimer's Dementia Recognition through Spontaneous Speech task offers acoustically pre-processed and balanced datasets for the classification and prediction of AD and associated phenotypes through the modelling of spontaneous speech. We exclusively analyse the supplied textual transcripts of the spontaneous speech dataset, building and comparing performance across numerous models for the classification of AD vs controls and the prediction of Mental Mini State Exam scores. We rigorously train and evaluate Support Vector Machines (SVMs), Gradient Boosting Decision Trees (GBDT), and Conditional Random Fields (CRFs) alongside deep learning Transformer based models. We find our top performing models to be a simple Term Frequency-Inverse Document Frequency (TF-IDF) vectoriser as input into a SVM model and a pre-trained Transformer based model `DistilBERT' when used as an embedding layer into simple linear models. We demonstrate test set scores of 0.81-0.82 across classification metrics and a RMSE of 4.58., Submitted to INTERSPEECH 2020: Alzheimer's Dementia Recognition through Spontaneous Speech The ADReSS Challenge Workshop

Clinical coding is currently a labour-intensive, error-prone, but critical administrative process whereby hospital patient episodes are manually assigned codes by qualified staff from large, standardised taxonomic hierarchies of codes. Automating clinical coding has a long history in NLP research and has recently seen novel developments setting new state of the art results. A popular dataset used in this task is MIMIC-III, a large intensive care database that includes clinical free text notes and associated codes. We argue for the reconsideration of the validity MIMIC-III's assigned codes that are often treated as gold-standard, especially when MIMIC-III has not undergone secondary validation. This work presents an open-source, reproducible experimental methodology for assessing the validity of codes derived from EHR discharge summaries. We exemplify the methodology with MIMIC-III discharge summaries and show the most frequently assigned codes in MIMIC-III are under-coded up to 35%.

AIMS: The SARS-CoV-2 virus binds to the angiotensin-converting enzyme 2 (ACE2) receptor for cell entry. It has been suggested that angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB), which are commonly used in patients with hypertension or diabetes and may raise tissue ACE2 levels, could increase the risk of severe COVID-19 infection. METHODS AND RESULTS: We evaluated this hypothesis in a consecutive cohort of 1200 acute inpatients with COVID-19 at two hospitals with a multi-ethnic catchment population in London (UK). The mean age was 68 ± 17 years (57% male) and 74% of patients had at least one comorbidity. Overall, 415 patients (34.6%) reached the primary endpoint of death or transfer to a critical care unit for organ support within 21 days of symptom onset. A total of 399 patients (33.3%) were taking ACEi or ARB. Patients on ACEi/ARB were significantly older and had more comorbidities. The odds ratio for the primary endpoint in patients on ACEi and ARB, after adjustment for age, sex and co-morbidities, was 0.63 (95% confidence interval 0.47-0.84, P < 0.01). CONCLUSIONS: There was no evidence for increased severity of COVID-19 in hospitalised patients on chronic treatment with ACEi or ARB. A trend towards a beneficial effect of ACEi/ARB requires further evaluation in larger meta-analyses and randomised clinical trials.

BackgroundThe National Early Warning Score (NEWS2) is currently recommended in the United Kingdom for risk stratification of COVID outcomes, but little is known about its ability to detect severe cases. We aimed to evaluate NEWS2 for severe COVID outcome and identify and validate a set of routinely-collected blood and physiological parameters taken at hospital admission to improve the score.MethodsTraining cohorts comprised 1276 patients admitted to King’s College Hospital NHS Foundation Trust with COVID-19 disease from 1st March to 30th April 2020. External validation cohorts included 5037 patients from four UK NHS Trusts (Guys and St Thomas’ Hospitals, University Hospitals Southampton, University Hospitals Bristol and Weston NHS Foundation Trust, University College London Hospitals), and two hospitals in Wuhan, China (Wuhan Sixth Hospital and Taikang Tongji Hospital). The outcome was severe COVID disease (transfer to intensive care unit or death) at 14 days after hospital admission. Age, physiological measures, blood biomarkers, sex, ethnicity and comorbidities (hypertension, diabetes, cardiovascular, respiratory and kidney diseases) measured at hospital admission were considered in the models.ResultsA baseline model of ‘NEWS2 + age’ had poor-to-moderate discrimination for severe COVID infection at 14 days (AUC in training sample = 0.700; 95% CI: 0.680, 0.722; Brier score = 0.192; 95% CI: 0.186, 0.197). A supplemented model adding eight routinely-collected blood and physiological parameters (supplemental oxygen flow rate, urea, age, oxygen saturation, CRP, estimated GFR, neutrophil count, neutrophil/lymphocyte ratio) improved discrimination (AUC = 0.735; 95% CI: 0.715, 0.757) and these improvements were replicated across five UK and non-UK sites. However, there was evidence of miscalibration with the model tending to underestimate risks in most sites.ConclusionsNEWS2 score had poor-to-moderate discrimination for medium-term COVID outcome which raises questions about its use as a screening tool at hospital admission. Risk stratification was improved by including readily available blood and physiological parameters measured at hospital admission, but there was evidence of miscalibration in external sites. This highlights the need for a better understanding of the use of early warning scores for COVID.Key messagesThe National Early Warning Score (NEWS2), currently recommended for stratification of severe COVID-19 disease in the UK, showed poor-to-moderate discrimination for medium-term outcomes (14-day transfer to ICU or death) among COVID-19 patients.Risk stratification was improved by the addition of routinely-measured blood and physiological parameters routinely at hospital admission (supplemental oxygen, urea, oxygen saturation, CRP, estimated GFR, neutrophil count, neutrophil/lymphocyte ratio) which provided moderate improvements in a risk stratification model for 14-day ICU/death.This improvement over NEWS2 alone was maintained across multiple hospital trusts but the model tended to be miscalibrated with risks of severe outcomes underestimated in most sites.We benefited from existing pipelines for informatics at KCH such as CogStack that allowed rapid extraction and processing of electronic health records. This methodological approach provided rapid insights and allowed us to overcome the complications associated with slow data centralisation approaches.

AimsThe SARS-Cov2 virus binds to the ACE2 receptor for cell entry. It has been suggested that ACE-inhibitors (ACEi) and Angiotensin-2 Blockers (ARB), which are commonly used in patients with hypertension or diabetes and may raise ACE2 levels, could increase the risk of severe COVID19 infection.Methods and ResultsWe evaluated this hypothesis in a consecutive cohort of 1200 acute inpatients with COVID19 at two hospitals with a multi-ethnic catchment population in London (UK). The mean age was 68±17 years (57% male) and 74% of patients had at least 1 comorbidity. 415 patients (34.6%) reached the primary endpoint of death or transfer to a critical care unit for organ support within 21-days of symptom onset. 399 patients (33.3 %) were taking ACEi or ARB. Patients on ACEi/ARB were significantly older and had more comorbidities. The odds ratio (OR) for the primary endpoint in patients on ACEi and ARB, after adjustment for age, sex and co-morbidities, was 0.63 (CI 0.47-0.84, pConclusionsThere was no evidence for increased severity of COVID19 disease in hospitalised patients on chronic treatment with ACEi or ARB. A trend towards a beneficial effect of ACEi/ARB requires further evaluation in larger meta-analyses and randomised clinical trials.

A coupled parametric–transverse nonlinearly broadband energy harvester utilizing mechanical stoppers has been designed, fabricated, experimentally tested, and in some cases theoretically verified. An energy harvester with coupled parametric and transverse cantilever beams with additional tip-masses was excited using an electrodynamic shaker. A piezoelectric bimorph has been attached to each cantilever beam; when the excitation frequency was in the vicinity of the parametric or transverse resonances, the mechanical strain developed in the piezo-bimorphs was converted into electrical energy across a purely resistive ac load. For the cases involving no stoppers, a weak softening-type nonlinear frequency–voltage behavior was observed for the parametrically excited cantilever beam; however, with the addition of mechanical stoppers, both the transverse and parametrically excited cantilever beams displayed a strong hardening-type nonlinear frequency–voltage behavior. The stoppers substantially increased the operating bandwidth for both the parametric and transversely excited cantilever beams compared to the case without stoppers. For the theoretical investigations, a good agreement for both the fundamental frequencies and frequency–response curves was obtained. It is shown that by coupling transverse and parametric cantilevers with mechanical stoppers, the nonlinear energy harvested by the system takes place over a much broader frequency-bandwidth when compared to the singular transverse cantilever mechanism (by about 163.5%).

Understanding our enemies is desperately important but enormously difficult. One way to study our enemies is to read biographies of their heroes. Abdallah Azzam is a hero to a wide array of differe...

Electronic health records (EHR) contain large volumes of unstructured text, requiring the application of Information Extraction (IE) technologies to enable clinical analysis. We present the open-source Medical Concept Annotation Toolkit (MedCAT) that provides: a) a novel self-supervised machine learning algorithm for extracting concepts using any concept vocabulary including UMLS/SNOMED-CT; b) a feature-rich annotation interface for customising and training IE models; and c) integrations to the broader CogStack ecosystem for vendor-agnostic health system deployment. We show improved performance in extracting UMLS concepts from open datasets (F1:0.448-0.738 vs 0.429-0.650). Further real-world validation demonstrates SNOMED-CT extraction at 3 large London hospitals with self-supervised training over ~8.8B words from ~17M clinical records and further fine-tuning with ~6K clinician annotated examples. We show strong transferability (F1 > 0.94) between hospitals, datasets, and concept types indicating cross-domain EHR-agnostic utility for accelerated clinical and research use cases., Preprint: 27 Pages, 3 Figures

Skin-inspired materials facilitate the design and fabrication of various biomedical devices capable of real-time monitoring of physiological signals and provide the foundations for mechanically compliant next-generation wearables that behave and operate like an extension of our own integumentary system. These devices need to maintain conformal contact with the body while offering very little mechanical impedance and must be able to sustain the accidental damage that comes in normal, dynamic, everyday life. This work demonstrates how dynamic metal-ligand self-healing chemistry can be used to synthesize multi-wall carbon nanotubes (MWCNT) – silicone nanocomposites with skin-like mechanical elasticity. Highly repeatable, room-temperature self-healing nanocomposites were synthesized with various filler concentrations to study the ability of the material to perform in sensing and electronic interconnect scenarios. An increase in mechanical stiffness from 8 kPa to 102 kPa were achieved at a percolation of 4.8 %wt, maintaining extensibility up to 50%. Further, conductivities as high as 2 × 10−2 S/m were achieved whilst maintaining high flexibility, offering tuneability for a broad range of tailored applications. The gauge factor (GF) performance was independent of healing cycles, maintaining a value of 1.4 after several ruptures, and continually sustains mechanical stiffness matching the dermal layer of the human forearm. These results parallel the human skin's ability to both heal damage elements and respond to stimuli of the world around us and provide expandability to current biomedical systems.

This study investigates the use of stretchable strain sensors as an alternative to the gold standard Ag/AgCl surface electromyography (sEMG) electrodes currently utilised to identify movement intention from a user during common hand gestures. Further building on the research in the companion paper, this study documents a series of strain characterisation experiments undertaken on three conductive textiles, two commercial conductive elastomers and one E-skin elastomer produced on site to determine the linearity of each sensor, along with the magnitude of hysteresis in a single stretch and release cycle, and any creep effects present. Gesture identification testing was performed in vivo on two participants, with the three most effective materials across five hand gestures, to assess the functionality of the materials as biopotential electrodes. For this series of experiments, the electrodes were positioned over the site of greatest strain for each gesture. Using a threshold-crossing paradigm, results demonstrated that a commercially sourced conductive fabric can identify 85% of hand gestures performed. The incorporation of flexible strain sensors in hand prosthetic control systems may further increase functionality of such devices, consequently boosting the quality of life of amputees.

This study is Part 1 of two studies which investigate the use of various flexible surface sensors as an alternative to the gold standard Ag/AgCl surface electromyography (sEMG) electrodes in identifying movement intention from a user during common hand gestures. Three conductive textiles, two commercial conductive elastomers and one E-skin elastomer produced on site were tested as biopotential electrodes to establish the efficacy of each in gathering movement intention from the human brain at the level of the muscle. Testing was performed in vivo on two participants across three hand gestures, with results demonstrating that sEMG electrodes made from a commercially sourced conductive fabric can outperform the traditional Ag/AgCl sEMG electrodes, obtaining substantially larger peak and RMS measurements. Given the disadvantages of Ag/AgCl electrodes over long usage periods, namely their tendency to dry out and significant skin preparation, resulting in variable impedances and skin irritation respectively, the incorporation of flexible surface EMG electrodes in hand prosthetic control systems would increase functionality of the prosthetic devices, consequently increasing the quality of life of prosthetic hand users.

Special operations forces and airpower are the two most flexible, but least understood, elements of Western military power. Misunderstanding has led to missed opportunities which we can no longer afford as we face an expanding array of complex, dynamic threats with shrinking military resources. Integrating airpower and special operations has enormous untapped potential across the spectrum of conflict, and particularly in preventative situations, but only if airmen and special operators work together.Through the use of case studies the authors present examples of successful SOF-airpower integration, but remind the readers that these instances were ad hoc, not addressed in pre-war training and doctrine, and at times resisted by senior leadership from both camps. The article concludes with the suggestion that special operations airmen ought to be the “bridge” between the airpower and special operations communities while seeking opportunities to exploit the advantage airpower offers during peacetime engagemen...

In this work, for the first time, an energy harvester based on the nonlinear dynamical response of a parametrically excited cantilever beam in contact with mechanical stoppers has been fabricated and tested; a 145% increase in the bandwidth at which energy can be effectively harvested has been observed. Experimental and theoretical investigations have been performed in order to assess the increased operating bandwidth of the energy harvester fabricated; for the experimental investigations, an electrodynamic shaker connected to a shaking table has been used to parametrically stimulate the energy harvesting device. Results showed that the parametric energy harvester without stoppers displayed a weak softening-type nonlinear response; however, with the addition of mechanical stoppers the energy harvester displayed a strong hardening-type nonlinear response which is ideal for capturing kinetic energy over larger bandwidths. The addition of mechanical stoppers on a parametrically excited cantilever beam has significant qualitative and quantitative effects on the nonlinear parametric energy harvesting; the energy harvesting bandwidth was increased in the range of 35–145% by adjusting the stoppers.

The effects of temperature on growth and survival of juvenile blackfoot abalone, Haliotis iris, were investigated. Animals of 10, 30 or 60 mm initial shell length were exposed to ambient (6–10°C), 14, 18, 22 and 26°C for 112 days in a flow-through culture system. Maximum growth occurred at 22°C for the 10 and 30 mm size classes and at 18°C for the 60 mm size class. Regression analysis identified the optimal temperature for growth (ToptG) at around 21°C for the 10 and 30 mm size classes and at 17–18°C for the largest size class. In a second experiment, the critical thermal maximum of H. iris was determined as a measure of thermal tolerance. Abalone were subjected to increasing water temperatures at a rate of 2°C h−1 until they detached from the substrate. Abalone of 10 mm displayed greater thermal tolerance than abalone of 30 and 60 mm in length. CT50 temperatures were 28.8, 27.7 and 27.8°C, yielding deduced ToptG values of 19.7, 18.3 and 18.4°C for the 10, 30 and 60 mm size classes respectively. The size-dependent nature of the relationship between growth and temperature could be capitalized upon in recirculating aquaculture systems.

Flexible manipulators have promising applications in minimally invasive surgery as it allows the surgical tools reach targets which are prohibited by conventional rigid surgical instrument. However one of the technical difficulties of implementing the flexible manipulator is to measure the bending curvature. This paper proposes the design of a novel optical sensor for measuring the bending curvature of a flexible manipulator based on light intensity modulation. The sensor is low cost and is temperature independent. A theoretical model of using the sensor design to deduce the curvature of a flexible robot has been created. Implementing the proposed theoretical model, the developed sensor has been used to measure the bend of a section of a flexible segment. Validation tests have been carried out; the results demonstrate that the developed sensor has good accuracy in measuring the bending angles, the orientation of the bending and the bending radius.