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Montazeri S, Nevalainen P, Metsäranta M, Stevenson NJ, Vanhatalo S. Clinical outcome prediction with an automated EEG trend, Brain State of the Newborn, after perinatal asphyxia. Clin Neurophysiol 2024; 162:68-76. [PMID: 38583406 DOI: 10.1016/j.clinph.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 02/13/2024] [Accepted: 03/11/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVE To evaluate the utility of a fully automated deep learning -based quantitative measure of EEG background, Brain State of the Newborn (BSN), for early prediction of clinical outcome at four years of age. METHODS The EEG monitoring data from eighty consecutive newborns was analyzed using the automatically computed BSN trend. BSN levels during the first days of life (a of total 5427 hours) were compared to four clinical outcome categories: favorable, cerebral palsy (CP), CP with epilepsy, and death. The time dependent changes in BSN-based prediction for different outcomes were assessed by positive/negative predictive value (PPV/NPV) and by estimating the area under the receiver operating characteristic curve (AUC). RESULTS The BSN values were closely aligned with four visually determined EEG categories (p < 0·001), as well as with respect to clinical milestones of EEG recovery in perinatal Hypoxic Ischemic Encephalopathy (HIE; p < 0·003). Favorable outcome was related to a rapid recovery of the BSN trend, while worse outcomes related to a slow BSN recovery. Outcome predictions with BSN were accurate from 6 to 48 hours of age: For the favorable outcome, the AUC ranged from 95 to 99% (peak at 12 hours), and for the poor outcome the AUC ranged from 96 to 99% (peak at 12 hours). The optimal BSN levels for each PPV/NPV estimate changed substantially during the first 48 hours, ranging from 20 to 80. CONCLUSIONS We show that the BSN provides an automated, objective, and continuous measure of brain activity in newborns. SIGNIFICANCE The BSN trend discloses the dynamic nature that exists in both cerebral recovery and outcome prediction, supports individualized patient care, rapid stratification and early prognosis.
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Affiliation(s)
- Saeed Montazeri
- BABA Center, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland.
| | - Päivi Nevalainen
- BABA Center, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Clinical Neurophysiology, Epilepsia Helsinki, Full Member of ERN Epicare, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjo Metsäranta
- Department of Pediatrics, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nathan J Stevenson
- Brain Modelling Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Sampsa Vanhatalo
- BABA Center, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland; Department of Clinical Neurophysiology, Epilepsia Helsinki, Full Member of ERN Epicare, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Han R, Acosta JN, Shakeri Z, Ioannidis JPA, Topol EJ, Rajpurkar P. Randomised controlled trials evaluating artificial intelligence in clinical practice: a scoping review. Lancet Digit Health 2024; 6:e367-e373. [PMID: 38670745 PMCID: PMC11068159 DOI: 10.1016/s2589-7500(24)00047-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/28/2024]
Abstract
This scoping review of randomised controlled trials on artificial intelligence (AI) in clinical practice reveals an expanding interest in AI across clinical specialties and locations. The USA and China are leading in the number of trials, with a focus on deep learning systems for medical imaging, particularly in gastroenterology and radiology. A majority of trials (70 [81%] of 86) report positive primary endpoints, primarily related to diagnostic yield or performance; however, the predominance of single-centre trials, little demographic reporting, and varying reports of operational efficiency raise concerns about the generalisability and practicality of these results. Despite the promising outcomes, considering the likelihood of publication bias and the need for more comprehensive research including multicentre trials, diverse outcome measures, and improved reporting standards is crucial. Future AI trials should prioritise patient-relevant outcomes to fully understand AI's true effects and limitations in health care.
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Affiliation(s)
- Ryan Han
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA; Department of Computer Science, Stanford University, Stanford, CA, USA; University of California Los Angeles-Caltech Medical Scientist Training Program, Los Angeles, CA, USA
| | - Julián N Acosta
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA; Rad AI, San Francisco, CA, USA
| | - Zahra Shakeri
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, CA, USA; Meta-Research Innovation Center at Stanford, Stanford University, Stanford, CA, USA
| | - Eric J Topol
- Scripps Research Translational Institute, Scripps Research, La Jolla, CA, USA.
| | - Pranav Rajpurkar
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
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3
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Ryan MAJ, Malhotra A. Electrographic monitoring for seizure detection in the neonatal unit: current status and future direction. Pediatr Res 2024:10.1038/s41390-024-03207-2. [PMID: 38684885 DOI: 10.1038/s41390-024-03207-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 05/02/2024]
Abstract
Neonatal neurocritical intensive care is dedicated to safeguarding the newborn brain by prioritising clinical practices that promote early identification, diagnosis and treatment of brain injuries. The most common newborn neurological emergency is neonatal seizures, which may also be the initial clinical indication of neurological disease. A high seizure burden in the newborn period independently contributes to increased mortality and morbidity. The majority of seizures in newborns are subclinical (without clinical presentation), and hence identification may be difficult. Neuromonitoring techniques most frequently used to monitor brain wave activity include conventional electroencephalography (cEEG) or amplitude-integrated EEG (aEEG). cEEG with video is the gold standard for diagnosing and treating seizures. Many neonatal units do not have access to cEEG, and frequently those that do, have little access to real-time interpretation of monitoring. IMPACT: EEG monitoring is of no benefit to an infant without expert interpretation. Whilst EEG is a reliable cot-side tool and of diagnostic and prognostic use, both conventional EEG and amplitude-integrated EEG have strengths and limitations, including sensitivity to seizure activity and ease of interpretation. Automated seizure detection requires a sensitive and specific algorithm that can interpret EEG in real-time and identify seizures, including their intensity and duration.
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Affiliation(s)
- Mary Anne J Ryan
- INFANT Research Centre, University College Cork, Cork, Ireland.
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
| | - Atul Malhotra
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
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4
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Roychaudhuri S, Hannon K, Sunwoo J, Garvey AA, El-Dib M. Quantitative EEG and prediction of outcome in neonatal encephalopathy: a review. Pediatr Res 2024:10.1038/s41390-024-03138-y. [PMID: 38503980 DOI: 10.1038/s41390-024-03138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/18/2024] [Accepted: 03/01/2024] [Indexed: 03/21/2024]
Abstract
Electroencephalogram (EEG) is an important biomarker for neonatal encephalopathy (NE) and has significant predictive value for brain injury and neurodevelopmental outcomes. Quantitative analysis of EEG involves the representation of complex EEG data in an objective, reproducible and scalable manner. Quantitative EEG (qEEG) can be derived from both a limited channel EEG (as available during amplitude integrated EEG) and multi-channel conventional EEG. It has the potential to enable bedside clinicians to monitor and evaluate details of cortical function without the necessity of continuous expert input. This is particularly useful in NE, a dynamic and evolving condition. In these infants, continuous, detailed evaluation of cortical function at the bedside is a valuable aide to management especially in the current era of therapeutic hypothermia and possible upcoming neuroprotective therapies. This review discusses the role of qEEG in newborns with NE and its use in informing monitoring and therapy, along with its ability to predict imaging changes and short and long-term neurodevelopmental outcomes. IMPACT: Quantitative representation of EEG data brings the evaluation of continuous brain function, from the neurophysiology lab to the NICU bedside and has a potential role as a biomarker for neonatal encephalopathy. Clinical and research applications of quantitative EEG in the newborn are rapidly evolving and a wider understanding of its utility is valuable. This overview summarizes the role of quantitative EEG at different timepoints, its relevance to management and its predictive value for short- and long-term outcomes in neonatal encephalopathy.
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Affiliation(s)
- Sriya Roychaudhuri
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Katie Hannon
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - John Sunwoo
- Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Aisling A Garvey
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA
- INFANT Research Centre, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Mohamed El-Dib
- Division of Newborn Medicine, Department of Pediatrics, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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5
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Pavel AM, Rennie JM, de Vries LS, Mathieson SR, Livingstone V, Finder M, Foran A, Shah DK, Pressler RM, Weeke LC, Dempsey EM, Murray DM, Boylan GB. Temporal evolution of electrographic seizures in newborn infants with hypoxic-ischaemic encephalopathy requiring therapeutic hypothermia: a secondary analysis of the ANSeR studies. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:214-224. [PMID: 38246187 PMCID: PMC10864190 DOI: 10.1016/s2352-4642(23)00296-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 01/23/2024]
Abstract
BACKGROUND Despite extensive research on neonatal hypoxic-ischaemic encephalopathy, detailed information about electrographic seizures during active cooling and rewarming of therapeutic hypothermia is sparse. We aimed to describe temporal evolution of seizures and determine whether there is a correlation of seizure evolution with 2-year outcome. METHODS This secondary analysis included newborn infants recruited from eight European tertiary neonatal intensive care units for two multicentre studies (a randomised controlled trial [NCT02431780] and an observational study [NCT02160171]). Infants were born at 36+0 weeks of gestation with moderate or severe hypoxic-ischaemic encephalopathy and underwent therapeutic hypothermia with prolonged conventional video-electroencephalography (EEG) monitoring for 10 h or longer from the start of rewarming. Seizure burden characteristics were calculated based on electrographic seizures annotations: hourly seizure burden (minutes of seizures within an hour) and total seizure burden (minutes of seizures within the entire recording). We categorised infants into those with electrographic seizures during active cooling only, those with electrographic seizures during cooling and rewarming, and those without seizures. Neurodevelopmental outcomes were determined using the Bayley's Scales of Infant and Toddler Development, Third Edition (BSID-III), the Griffiths Mental Development Scales (GMDS), or neurological assessment. An abnormal outcome was defined as death or neurodisability at 2 years. Neurodisability was defined as a composite score of 85 or less on any subscales for BSID-III, a total score of 87 or less for GMDS, or a diagnosis of cerebral palsy (dyskinetic cerebral palsy, spastic quadriplegia, or mixed motor impairment) or epilepsy. FINDINGS Of 263 infants recruited between Jan 1, 2011, and Feb 7, 2017, we included 129 infants: 65 had electrographic seizures (43 during active cooling only and 22 during and after active cooling) and 64 had no seizures. Compared with infants with seizures during active cooling only, those with seizures during and after active cooling had a longer seizure period (median 12 h [IQR 3-28] vs 68 h [35-86], p<0·0001), more seizures (median 12 [IQR 5-36] vs 94 [24-134], p<0·0001), and higher total seizure burden (median 69 min [IQR 22-104] vs 167 min [54-275], p=0·0033). Hourly seizure burden peaked at about 20-24 h in both groups, and infants with seizures during and after active cooling had a secondary peak at 85 h of age. When combined, worse EEG background (major abnormalities and inactive background) at 12 h and 24 h were associated with the seizure group: compared with infants with a better EEG background (normal, mild, or moderate abnormalities), infants with a worse EEG background were more likely to have seizures after cooling at 12 h (13 [54%] of 24 vs four [14%] of 28; odds ratio 7·09 [95% CI 1·88-26·77], p=0·0039) and 24 h (14 [56%] of 25 vs seven [18%] of 38; 5·64 [1·81-17·60], p=0·0029). There was a significant relationship between EEG grade at 12 h (four categories) and seizure group (p=0·020). High total seizure burden was associated with increased odds of an abnormal outcome at 2 years of age (odds ratio 1·007 [95% CI 1·000-1·014], p=0·046), with a medium negative correlation between total seizure burden and BSID-III cognitive score (rS=-0·477, p=0·014, n=26). INTERPRETATION Overall, half of infants with hypoxic-ischaemic encephalopathy had electrographic seizures and a third of those infants had seizures beyond active cooling, with worse outcomes. These results raise the importance of prolonged EEG monitoring of newborn infants with hypoxic-ischaemic encephalopathy not only during active cooling but throughout the rewarming phase and even longer when seizures are detected. FUNDING Wellcome Trust, Science Foundation Ireland, and the Irish Health Research Board.
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Affiliation(s)
- Andreea M Pavel
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Janet M Rennie
- Institute for Women's Health, University College London, London, UK
| | - Linda S de Vries
- Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Sean R Mathieson
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Mikael Finder
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden; Division of Paediatrics, Department CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Adrienne Foran
- Department of Neonatal Medicine, Rotunda Hospital, Dublin, Ireland
| | - Divyen K Shah
- Royal London Hospital, London, UK; London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ronit M Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Lauren C Weeke
- Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Eugene M Dempsey
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Deirdre M Murray
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
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6
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Saab K, Tang S, Taha M, Lee-Messer C, Ré C, Rubin DL. Towards trustworthy seizure onset detection using workflow notes. NPJ Digit Med 2024; 7:42. [PMID: 38383884 PMCID: PMC10881468 DOI: 10.1038/s41746-024-01008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 01/10/2024] [Indexed: 02/23/2024] Open
Abstract
A major barrier to deploying healthcare AI is trustworthiness. One form of trustworthiness is a model's robustness across subgroups: while models may exhibit expert-level performance on aggregate metrics, they often rely on non-causal features, leading to errors in hidden subgroups. To take a step closer towards trustworthy seizure onset detection from EEG, we propose to leverage annotations that are produced by healthcare personnel in routine clinical workflows-which we refer to as workflow notes-that include multiple event descriptions beyond seizures. Using workflow notes, we first show that by scaling training data to 68,920 EEG hours, seizure onset detection performance significantly improves by 12.3 AUROC (Area Under the Receiver Operating Characteristic) points compared to relying on smaller training sets with gold-standard labels. Second, we reveal that our binary seizure onset detection model underperforms on clinically relevant subgroups (e.g., up to a margin of 6.5 AUROC points between pediatrics and adults), while having significantly higher FPRs (False Positive Rates) on EEG clips showing non-epileptiform abnormalities (+19 FPR points). To improve model robustness to hidden subgroups, we train a multilabel model that classifies 26 attributes other than seizures (e.g., spikes and movement artifacts) and significantly improve overall performance (+5.9 AUROC points) while greatly improving performance among subgroups (up to +8.3 AUROC points) and decreasing false positives on non-epileptiform abnormalities (by 8 FPR points). Finally, we find that our multilabel model improves clinical utility (false positives per 24 EEG hours) by a factor of 2×.
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Affiliation(s)
- Khaled Saab
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA.
| | - Siyi Tang
- Department of Electrical Engineering, Stanford University, Stanford, CA, USA
| | - Mohamed Taha
- Department of Neurology, Stanford University, Stanford, CA, USA
| | | | - Christopher Ré
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Daniel L Rubin
- Department of Biomedical Data Science, Radiology, and Medicine, Stanford University, Stanford, CA, USA.
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Numis AL, Glass HC, Comstock BA, Gonzalez F, Maitre NL, Massey SL, Mayock DE, Mietzsch U, Natarajan N, Sokol GM, Bonifacio S, Van Meurs K, Thomas C, Ahmad K, Heagerty P, Juul SE, Wu YW, Wusthoff CJ. Relationship of Neonatal Seizure Burden Before Treatment and Response to Initial Antiseizure Medication. J Pediatr 2024; 268:113957. [PMID: 38360261 DOI: 10.1016/j.jpeds.2024.113957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To assess among a cohort of neonates with hypoxic-ischemic encephalopathy (HIE) the association of pretreatment maximal hourly seizure burden and total seizure duration with successful response to initial antiseizure medication (ASM). STUDY DESIGN This was a retrospective review of data collected from infants enrolled in the HEAL Trial (NCT02811263) between January 25, 2017, and October 9, 2019. We evaluated a cohort of neonates born at ≥36 weeks of gestation with moderate-to-severe HIE who underwent continuous electroencephalogram monitoring and had acute symptomatic seizures. Poisson regression analyzed associations between (1) pretreatment maximal hourly seizure burden, (2) pretreatment total seizure duration, (3) time from first seizure to initial ASM, and (4) successful response to initial ASM. RESULTS Among 39 neonates meeting inclusion criteria, greater pretreatment maximal hourly seizure burden was associated with lower chance of successful response to initial ASM (adjusted relative risk for each 5-minute increase in seizure burden 0.83, 95% CI 0.69-0.99). There was no association between pretreatment total seizure duration and chance of successful response. Shorter time-to-treatment was paradoxically associated with lower chance of successful response to treatment, although this difference was small in magnitude (relative risk 1.007, 95% CI 1.003-1.010). CONCLUSIONS Maximal seizure burden may be more important than other, more commonly used measures in predicting response to acute seizure treatments.
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Affiliation(s)
- Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA; Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA.
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA; Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Fernando Gonzalez
- Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
| | - Nathalie L Maitre
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Niranjana Natarajan
- Division of Pediatric Neurology, Department of Neurology, University of Washington School of Medicine, Seattle, WA
| | - Gregory M Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Sonia Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Krisa Van Meurs
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kaashif Ahmad
- Pediatrix Medical Group of San Antonio, Children's Hospital of San Antonio, San Antonio, TX
| | - Patrick Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Yvonne W Wu
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA; Department of Pediatrics UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA
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Sullivan BA, Beam K, Vesoulis ZA, Aziz KB, Husain AN, Knake LA, Moreira AG, Hooven TA, Weiss EM, Carr NR, El-Ferzli GT, Patel RM, Simek KA, Hernandez AJ, Barry JS, McAdams RM. Transforming neonatal care with artificial intelligence: challenges, ethical consideration, and opportunities. J Perinatol 2024; 44:1-11. [PMID: 38097685 PMCID: PMC10872325 DOI: 10.1038/s41372-023-01848-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023]
Abstract
Artificial intelligence (AI) offers tremendous potential to transform neonatology through improved diagnostics, personalized treatments, and earlier prevention of complications. However, there are many challenges to address before AI is ready for clinical practice. This review defines key AI concepts and discusses ethical considerations and implicit biases associated with AI. Next we will review literature examples of AI already being explored in neonatology research and we will suggest future potentials for AI work. Examples discussed in this article include predicting outcomes such as sepsis, optimizing oxygen therapy, and image analysis to detect brain injury and retinopathy of prematurity. Realizing AI's potential necessitates collaboration between diverse stakeholders across the entire process of incorporating AI tools in the NICU to address testability, usability, bias, and transparency. With multi-center and multi-disciplinary collaboration, AI holds tremendous potential to transform the future of neonatology.
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Affiliation(s)
- Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kristyn Beam
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Khyzer B Aziz
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Ameena N Husain
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lindsey A Knake
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Alvaro G Moreira
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Thomas A Hooven
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Elliott M Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, WA, USA
| | - Nicholas R Carr
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - George T El-Ferzli
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ravi M Patel
- Division of Neonatology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kelsey A Simek
- Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Antonio J Hernandez
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - James S Barry
- Division of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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9
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Taha S, Simpson RB, Sharkey D. The critical role of technologies in neonatal care. Early Hum Dev 2023; 187:105898. [PMID: 37944264 DOI: 10.1016/j.earlhumdev.2023.105898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/03/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
Neonatal care has made significant advances in the last few decades. As a result, mortality and morbidity in high-risk infants, such as extremely preterm infants or those infants with birth-related brain injury, has reduced significantly. Many of these advances have been facilitated or delivered through development of medical technologies allowing clinical teams to be better supported with the care they deliver or provide new therapies and diagnostics to improve management. The delivery of neonatal intensive care requires the provision of medical technologies that are easy to use, reliable, accurate and ideally developed for the unique needs of the newborn population. Many technologies have been developed and commercialised following adult trials without ever being studied in neonatal patients despite the unique characteristics of this population. Increasingly, funders and industry are recognising this major challenge which has resulted in initiatives to develop new ideas from concept through to clinical care. This review explores some of the key medical technologies used in neonatal care and the evidence to support their adoption to improve outcomes. A number of devices have yet to realise their full potential and will require further development to optimise and find their ideal target population and clinical benefit. Examples of emerging technologies, which may soon become more widely used, are also discussed. As neonatal care relies more on medical technologies, we need to be aware of the impact on care pathways, especially from a human factors approach, the associated costs and subsequent benefits to patients alongside the supporting evidence.
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Affiliation(s)
- Syed Taha
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Rosalind B Simpson
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Don Sharkey
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom.
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Keles E, Bagci U. The past, current, and future of neonatal intensive care units with artificial intelligence: a systematic review. NPJ Digit Med 2023; 6:220. [PMID: 38012349 PMCID: PMC10682088 DOI: 10.1038/s41746-023-00941-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 10/05/2023] [Indexed: 11/29/2023] Open
Abstract
Machine learning and deep learning are two subsets of artificial intelligence that involve teaching computers to learn and make decisions from any sort of data. Most recent developments in artificial intelligence are coming from deep learning, which has proven revolutionary in almost all fields, from computer vision to health sciences. The effects of deep learning in medicine have changed the conventional ways of clinical application significantly. Although some sub-fields of medicine, such as pediatrics, have been relatively slow in receiving the critical benefits of deep learning, related research in pediatrics has started to accumulate to a significant level, too. Hence, in this paper, we review recently developed machine learning and deep learning-based solutions for neonatology applications. We systematically evaluate the roles of both classical machine learning and deep learning in neonatology applications, define the methodologies, including algorithmic developments, and describe the remaining challenges in the assessment of neonatal diseases by using PRISMA 2020 guidelines. To date, the primary areas of focus in neonatology regarding AI applications have included survival analysis, neuroimaging, analysis of vital parameters and biosignals, and retinopathy of prematurity diagnosis. We have categorically summarized 106 research articles from 1996 to 2022 and discussed their pros and cons, respectively. In this systematic review, we aimed to further enhance the comprehensiveness of the study. We also discuss possible directions for new AI models and the future of neonatology with the rising power of AI, suggesting roadmaps for the integration of AI into neonatal intensive care units.
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Affiliation(s)
- Elif Keles
- Northwestern University, Feinberg School of Medicine, Department of Radiology, Chicago, IL, USA.
| | - Ulas Bagci
- Northwestern University, Feinberg School of Medicine, Department of Radiology, Chicago, IL, USA
- Northwestern University, Department of Biomedical Engineering, Chicago, IL, USA
- Department of Electrical and Computer Engineering, Chicago, IL, USA
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11
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Stephens CM, Mathieson SR, McNamara B, McSweeney N, O'Brien R, O'Mahony O, Boylan GB, Murray DM. Electroencephalography Quality and Application Times in a Pediatric Emergency Department Setting: A Feasibility Study. Pediatr Neurol 2023; 148:82-85. [PMID: 37690268 DOI: 10.1016/j.pediatrneurol.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/06/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Status epilepticus is the most common neurological emergency presenting to pediatric emergency departments. Nonconvulsive status epilepticus can be extremely challenging to diagnose, however, requiring electroencephalographic (EEG) confirmation for definitive diagnosis. We aimed to determine the feasibility of achieving a good-quality pediatric EEG recording within 20 minutes of presentation to the emergency department. METHODS Single-center prospective feasibility study in Cork University Hospital, Ireland, between July 2021 and June 2022. Two-channel continuous EEG was recorded from children (1) aged <16 years and (2) with Glasgow Coma Scale <11 or a reduction in baseline Glasgow Coma Scale in the case of a child with a neurodisability. RESULTS Twenty patients were included. The median age at presentation was 65.8 months (interquartile range, 23.2 to 119.0); 50% had a background diagnosis of epilepsy. The most common reason for EEG monitoring was status epilepticus (85%) followed by suspected nonconvulsive status (10%) and reduced consciousness of unknown etiology (5%). The mean length of recording was 93.1 minutes (S.D. 47.4). The mean time to application was 41.3 minutes (S.D. 11.7). The mean percent of artifact in all recordings was 19.3% (S.D. 15.9). Thirteen (65%) EEGs had <25% artifact. Artifact was higher in cases in which active airway management was ongoing. CONCLUSIONS EEG monitoring can be achieved in a pediatric emergency department setting within one hour of presentation. Overall, artifact percentage was low outside of periods of airway manipulation. Future studies are required to determine its use in early seizure detection and its support role in clinical decision-making in these patients.
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Affiliation(s)
- Carol M Stephens
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
| | - Sean R Mathieson
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Brian McNamara
- Department of Neurophysiology, Cork University Hospital, Cork, Ireland
| | - Niamh McSweeney
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland; Department of Paediatric Neurology, Cork University Hospital, Cork, Ireland
| | - Rory O'Brien
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
| | - Olivia O'Mahony
- Department of Paediatric Neurology, Cork University Hospital, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Deirdre M Murray
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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12
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Variane GFT, Dahlen A, Pietrobom RFR, Rodrigues DP, Magalhães M, Mimica MJ, Llaguno NS, Leandro DMK, Girotto PN, Sampaio LB, Van Meurs KP. Remote Monitoring for Seizures During Therapeutic Hypothermia in Neonates With Hypoxic-Ischemic Encephalopathy. JAMA Netw Open 2023; 6:e2343429. [PMID: 37966836 PMCID: PMC10652158 DOI: 10.1001/jamanetworkopen.2023.43429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 10/04/2023] [Indexed: 11/16/2023] Open
Abstract
Importance Neonates with hypoxic-ischemic encephalopathy (HIE) undergoing therapeutic hypothermia (TH) frequently experience seizures, which are associated with adverse outcomes. Efforts to rapidly identify seizures and reduce seizure burden may positively change neurologic and neurodevelopmental outcomes. Objective To describe the onset, treatment, and evolution of seizures in a large cohort of newborns with HIE during TH assisted by a telehealth model and remote neuromonitoring approach. Design, Setting, and Participants This was a prospective, observational, multicenter cohort study performed between July 2017 and December 2021 in 32 hospitals in Brazil. Participants were newborns with HIE meeting eligibility criteria and receiving TH. Data were analyzed from November 2022 to April 2023. Exposure Infants with HIE receiving TH were remotely monitored with 3-channel amplitude-integrated electroencephalography (aEEG) including raw tracing and video imaging, and bedside clinicians received assistance from trained neonatologists and neurologists. Main Outcomes and Measures Data on modified Sarnat examination, presence, timing and seizure type, aEEG background activity, sleep-wake cycling, and antiepileptic drugs used were collected. Descriptive statistical analysis was used with independent t test, χ2, Mann-Whitney test, and post hoc analyses applied for associations. Results A total of 872 cooled newborns were enrolled; the median (IQR) gestational age was 39 (38-40) weeks, 518 (59.4%) were male, and 59 (6.8%) were classified as having mild encephalopathy by modified Sarnat examination, 504 (57.8%) as moderate, and 180 (20.6%) as severe. Electrographic seizures were identified in 296 newborns (33.9%), being only electrographic in 213 (71.9%) and clinical followed by electroclinical uncoupling in 50 (16.9%). Early abnormal background activity had a significant association with seizures. Infants with flat trace had the highest rate of seizures (58 infants [68.2%]) and the greatest association with the incidence of seizures (odds ratio [OR], 12.90; 95% CI, 7.57-22.22) compared with continuous normal voltage. The absence of sleep-wake cycling was also associated with a higher occurrence of seizures (OR, 2.22; 95% CI, 1.67-2.96). Seizure onset was most frequent between 6 and 24 hours of life (181 infants [61.1%]); however, seizure occurred in 34 infants (11.5%) during rewarming. A single antiepileptic drug controlled seizures in 192 infants (64.9%). The first line antiepileptic drug was phenobarbital in 294 (99.3%). Conclusions and Relevance In this cohort study of newborns with HIE treated with TH, electrographic seizure activity occurred in 296 infants (33.9%) and was predominantly electrographic. Seizure control was obtained with a single antiepileptic drug in 192 infants (64.9%). These findings suggest neonatal neurocritical care can be delivered at remote limited resource hospitals due to innovations in technology and telehealth.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
| | - Alex Dahlen
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, California
| | - Rafaela Fabri Rodrigues Pietrobom
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Daniela Pereira Rodrigues
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maurício Magalhães
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Marcelo Jenné Mimica
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Nathalie Salles Llaguno
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Danieli Mayumi Kimura Leandro
- Division of Neonatology, Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
| | - Paula Natale Girotto
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Division of Neurosurgery, Associação Paulista para o Desenvolvimento da Medicina, Hospital de Transplantes Euryclides de Jesus Zerbini, São Paulo, São Paulo, Brazil
| | - Leticia Brito Sampaio
- Protecting Brains and Saving Futures Organization, Clinical Research Department, São Paulo, Brazil
- Division of Pediatric Neurology, Faculdade de Medicina Hospital das Clínicas, Instituto da Criança, Universidade de São Paulo, São Paulo, Brazil
| | - Krisa Page Van Meurs
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital Stanford, Palo Alto, California
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Abiramalatha T, Thanigainathan S, Ramaswamy VV, Pressler R, Brigo F, Hartmann H. Anti-seizure medications for neonates with seizures. Cochrane Database Syst Rev 2023; 10:CD014967. [PMID: 37873971 PMCID: PMC10594593 DOI: 10.1002/14651858.cd014967.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Newborn infants are more prone to seizures than older children and adults. The neuronal injury caused by seizures in neonates often results in long-term neurodevelopmental sequelae. There are several options for anti-seizure medications (ASMs) in neonates. However, the ideal choice of first-, second- and third-line ASM is still unclear. Further, many other aspects of seizure management such as whether ASMs should be initiated for only-electrographic seizures and how long to continue the ASM once seizure control is achieved are elusive. OBJECTIVES 1. To assess whether any ASM is more or less effective than an alternative ASM (both ASMs used as first-, second- or third-line treatment) in achieving seizure control and improving neurodevelopmental outcomes in neonates with seizures. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 2. To assess maintenance therapy with ASM versus no maintenance therapy after achieving seizure control. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 3. To assess treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, Epistemonikos and three databases in May 2022 and June 2023. These searches were not limited other than by study design to trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) that included neonates with EEG-confirmed or clinically diagnosed seizures and compared (1) any ASM versus an alternative ASM, (2) maintenance therapy with ASM versus no maintenance therapy, and (3) treatment of clinical or EEG seizures versus treatment of clinical seizures alone. DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility, risk of bias and independently extracted data. We analysed treatment effects in individual trials and reported risk ratio (RR) for dichotomous data, and mean difference (MD) for continuous data, with respective 95% confidence interval (CI). We used GRADE to assess the certainty of evidence. MAIN RESULTS We included 18 trials (1342 infants) in this review. Phenobarbital versus levetiracetam as first-line ASM in EEG-confirmed neonatal seizures (one trial) Phenobarbital is probably more effective than levetiracetam in achieving seizure control after first loading dose (RR 2.32, 95% CI 1.63 to 3.30; 106 participants; moderate-certainty evidence), and after maximal loading dose (RR 2.83, 95% CI 1.78 to 4.50; 106 participants; moderate-certainty evidence). However, we are uncertain about the effect of phenobarbital when compared to levetiracetam on mortality before discharge (RR 0.30, 95% CI 0.04 to 2.52; 106 participants; very low-certainty evidence), requirement of mechanical ventilation (RR 1.21, 95% CI 0.76 to 1.91; 106 participants; very low-certainty evidence), sedation/drowsiness (RR 1.74, 95% CI 0.68 to 4.44; 106 participants; very low-certainty evidence) and epilepsy post-discharge (RR 0.92, 95% CI 0.48 to 1.76; 106 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Phenobarbital versus phenytoin as first-line ASM in EEG-confirmed neonatal seizures (one trial) We are uncertain about the effect of phenobarbital versus phenytoin on achieving seizure control after maximal loading dose of ASM (RR 0.97, 95% CI 0.54 to 1.72; 59 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Maintenance therapy with ASM versus no maintenance therapy in clinically diagnosed neonatal seizures (two trials) We are uncertain about the effect of short-term maintenance therapy with ASM versus no maintenance therapy during the hospital stay (but discontinued before discharge) on the risk of repeat seizures before hospital discharge (RR 0.76, 95% CI 0.56 to 1.01; 373 participants; very low-certainty evidence). Maintenance therapy with ASM compared to no maintenance therapy may have little or no effect on mortality before discharge (RR 0.69, 95% CI 0.39 to 1.22; 373 participants; low-certainty evidence), mortality at 18 to 24 months (RR 0.94, 95% CI 0.34 to 2.61; 111 participants; low-certainty evidence), neurodevelopmental disability at 18 to 24 months (RR 0.89, 95% CI 0.13 to 6.12; 108 participants; low-certainty evidence) and epilepsy post-discharge (RR 3.18, 95% CI 0.69 to 14.72; 126 participants; low-certainty evidence). Treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates (two trials) Treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation (MD -1871.16, 95% CI -4525.05 to 782.73; 68 participants; low-certainty evidence), mortality before discharge (RR 0.59, 95% CI 0.28 to 1.27; 68 participants; low-certainty evidence) and epilepsy post-discharge (RR 0.75, 95% CI 0.12 to 4.73; 35 participants; low-certainty evidence). The trials did not report on mortality or neurodevelopmental disability at 18 to 24 months. We report data from the most important comparisons here; readers are directed to Results and Summary of Findings tables for all comparisons. AUTHORS' CONCLUSIONS Phenobarbital as a first-line ASM is probably more effective than levetiracetam in achieving seizure control after the first loading dose and after the maximal loading dose of ASM (moderate-certainty evidence). Phenobarbital + bumetanide may have little or no difference in achieving seizure control when compared to phenobarbital alone (low-certainty evidence). Limited data and very low-certainty evidence preclude us from drawing any reasonable conclusion on the effect of using one ASM versus another on other short- and long-term outcomes. In neonates who achieve seizure control after the first loading dose of phenobarbital, maintenance therapy compared to no maintenance ASM may have little or no effect on all-cause mortality before discharge, mortality by 18 to 24 months, neurodevelopmental disability by 18 to 24 months and epilepsy post-discharge (low-certainty evidence). In neonates with hypoxic-ischaemic encephalopathy, treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation, all-cause mortality before discharge and epilepsy post-discharge (low-certainty evidence). All findings of this review apply only to term and late preterm neonates. We need well-designed RCTs for each of the three objectives of this review to improve the precision of the results. These RCTs should use EEG to diagnose seizures and should be adequately powered to assess long-term neurodevelopmental outcomes. We need separate RCTs evaluating the choice of ASM in preterm infants.
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Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology, KMCH Institute of Health Sciences and Research (KMCHIHSR), Coimbatore, Tamil Nadu, India
- KMCH Research Foundation, Coimbatore, Tamil Nadu, India
| | | | | | - Ronit Pressler
- Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
- Clinical Neurophysiology and Neonatology, Cambridge University Hospital, Cambridge, UK
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK
| | - Francesco Brigo
- Neurology, Hospital of Merano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, Merano-Meran, Italy
- Innovation Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano-Bozen, Italy
| | - Hans Hartmann
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Lundy C, Boylan GB, Mathieson S, Proietti J, O'Toole JM. Quantitative analysis of high-frequency activity in neonatal EEG. Comput Biol Med 2023; 165:107468. [PMID: 37722158 DOI: 10.1016/j.compbiomed.2023.107468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE To determine the presence and potential utility of independent high-frequency activity recorded from scalp electrodes in the electroencephalogram (EEG) of newborns. METHODS We compare interburst intervals and continuous activity at different frequencies for EEGs retrospectively recorded at 256 Hz from 4 newborn groups: 1) 36 preterms (<32 weeks' gestational age, GA); 2) 12 preterms (32-37 weeks' GA); 3) 91 healthy full terms; 4) 15 full terms with hypoxic-ischemic encephalopathy (HIE). At 4 standard frequency bands (delta, 0.5-3 Hz; theta, 3-8 Hz; alpha, 8-15 Hz; beta, 15-30 Hz) and 3 higher-frequency bands (gamma1, 30-48 Hz; gamma2, 52-99 Hz; gamma3, 107-127 Hz), we compared power spectral densities (PSDs), quantitative features, and machine learning model performance. Feature selection and further machine learning methods were performed on one cohort. RESULTS We found significant (P < 0.01) differences in PSDs, quantitative analysis, and machine learning modelling at the higher-frequency bands. Machine learning models using only high-frequency features performed best in preterm groups 1 and 2 with a median (95% confidence interval, CI) Matthews correlation coefficient (MCC) of 0.71 (0.12-0.88) and 0.66 (0.36-0.76) respectively. Interburst interval-detector models using both high- and standard-bandwidths produced the highest median MCCs in all four groups. High-frequency features were largely independent of standard-bandwidth features, with only 11/84 (13.1%) of correlations statistically significant. Feature selection methods produced 7 to 9 high-frequency features in the top 20 feature set. CONCLUSIONS This is the first study to identify independent high-frequency activity in newborn EEG using in-depth quantitative analysis. Expanding the EEG bandwidths of analysis has the potential to improve both quantitative and machine-learning analysis, particularly in preterm EEG.
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Affiliation(s)
- Christopher Lundy
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Sean Mathieson
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jacopo Proietti
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Neurosciences, Biomedicine and Movement, University of Verona, Italy
| | - John M O'Toole
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
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15
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Raeisi K, Khazaei M, Tamburro G, Croce P, Comani S, Zappasodi F. A Class-Imbalance Aware and Explainable Spatio-Temporal Graph Attention Network for Neonatal Seizure Detection. Int J Neural Syst 2023; 33:2350046. [PMID: 37497802 DOI: 10.1142/s0129065723500466] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Seizures are the most prevalent clinical indication of neurological disorders in neonates. In this study, a class-imbalance aware and explainable deep learning approach based on Convolutional Neural Networks (CNNs) and Graph Attention Networks (GATs) is proposed for the accurate automated detection of neonatal seizures. The proposed model integrates the temporal information of EEG signals with the spatial information on the EEG channels through the graph representation of the multi-channel EEG segments. One-dimensional CNNs are used to automatically develop a feature set that accurately represents the differences between seizure and nonseizure epochs in the time domain. By employing GAT, the attention mechanism is utilized to emphasize the critical channel pairs and information flow among brain regions. GAT coefficients were then used to empirically visualize the important regions during the seizure and nonseizure epochs, which can provide valuable insight into the location of seizures in the neonatal brain. Additionally, to tackle the severe class imbalance in the neonatal seizure dataset using under-sampling and focal loss techniques are used. Overall, the final Spatio-Temporal Graph Attention Network (ST-GAT) outperformed previous benchmarked methods with a mean AUC of 96.6% and Kappa of 0.88, demonstrating its high accuracy and potential for clinical applications.
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Affiliation(s)
- Khadijeh Raeisi
- Department of Neuroscience, Imaging and Clinical Sciences, Universita Gabriele d'Annunzio, Chieti 66100, Italy
| | - Mohammad Khazaei
- Department of Neuroscience, Imaging and Clinical Sciences, Universita Gabriele d'Annunzio, Chieti 66100, Italy
| | - Gabriella Tamburro
- Department of Neuroscience, Imaging and Clinical Sciences-Behavioral Imaging and Neural Dynamics Center, Universita Gabriele d'Annunzio, Chieti 66100, Italy
| | - Pierpaolo Croce
- Department of Neuroscience, Imaging and Clinical Sciences-Behavioral Imaging and Neural Dynamics Center, Universita Gabriele d'Annunzio, Chieti 66100, Italy
| | - Silvia Comani
- Department of Neuroscience, Imaging and Clinical Sciences-Behavioral Imaging and Neural Dynamics Center, Universita Gabriele d'Annunzio, Chieti 66100, Italy
| | - Filippo Zappasodi
- Department of Neuroscience, Imaging and Clinical Sciences-Behavioral, Imaging and Neural Dynamics Center-Institute for, Advanced Biomedical Technologies, Universita Gabriele d'Annunzio, Chieti 66100, Italy
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16
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Tveit J, Aurlien H, Plis S, Calhoun VD, Tatum WO, Schomer DL, Arntsen V, Cox F, Fahoum F, Gallentine WB, Gardella E, Hahn CD, Husain AM, Kessler S, Kural MA, Nascimento FA, Tankisi H, Ulvin LB, Wennberg R, Beniczky S. Automated Interpretation of Clinical Electroencephalograms Using Artificial Intelligence. JAMA Neurol 2023; 80:805-812. [PMID: 37338864 PMCID: PMC10282956 DOI: 10.1001/jamaneurol.2023.1645] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/23/2023] [Indexed: 06/21/2023]
Abstract
Importance Electroencephalograms (EEGs) are a fundamental evaluation in neurology but require special expertise unavailable in many regions of the world. Artificial intelligence (AI) has a potential for addressing these unmet needs. Previous AI models address only limited aspects of EEG interpretation such as distinguishing abnormal from normal or identifying epileptiform activity. A comprehensive, fully automated interpretation of routine EEG based on AI suitable for clinical practice is needed. Objective To develop and validate an AI model (Standardized Computer-based Organized Reporting of EEG-Artificial Intelligence [SCORE-AI]) with the ability to distinguish abnormal from normal EEG recordings and to classify abnormal EEG recordings into categories relevant for clinical decision-making: epileptiform-focal, epileptiform-generalized, nonepileptiform-focal, and nonepileptiform-diffuse. Design, Setting, and Participants In this multicenter diagnostic accuracy study, a convolutional neural network model, SCORE-AI, was developed and validated using EEGs recorded between 2014 and 2020. Data were analyzed from January 17, 2022, until November 14, 2022. A total of 30 493 recordings of patients referred for EEG were included into the development data set annotated by 17 experts. Patients aged more than 3 months and not critically ill were eligible. The SCORE-AI was validated using 3 independent test data sets: a multicenter data set of 100 representative EEGs evaluated by 11 experts, a single-center data set of 9785 EEGs evaluated by 14 experts, and for benchmarking with previously published AI models, a data set of 60 EEGs with external reference standard. No patients who met eligibility criteria were excluded. Main Outcomes and Measures Diagnostic accuracy, sensitivity, and specificity compared with the experts and the external reference standard of patients' habitual clinical episodes obtained during video-EEG recording. Results The characteristics of the EEG data sets include development data set (N = 30 493; 14 980 men; median age, 25.3 years [95% CI, 1.3-76.2 years]), multicenter test data set (N = 100; 61 men, median age, 25.8 years [95% CI, 4.1-85.5 years]), single-center test data set (N = 9785; 5168 men; median age, 35.4 years [95% CI, 0.6-87.4 years]), and test data set with external reference standard (N = 60; 27 men; median age, 36 years [95% CI, 3-75 years]). The SCORE-AI achieved high accuracy, with an area under the receiver operating characteristic curve between 0.89 and 0.96 for the different categories of EEG abnormalities, and performance similar to human experts. Benchmarking against 3 previously published AI models was limited to comparing detection of epileptiform abnormalities. The accuracy of SCORE-AI (88.3%; 95% CI, 79.2%-94.9%) was significantly higher than the 3 previously published models (P < .001) and similar to human experts. Conclusions and Relevance In this study, SCORE-AI achieved human expert level performance in fully automated interpretation of routine EEGs. Application of SCORE-AI may improve diagnosis and patient care in underserved areas and improve efficiency and consistency in specialized epilepsy centers.
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Affiliation(s)
| | - Harald Aurlien
- Holberg EEG, Bergen, Norway
- Department of Clinical Neurophysiology, Haukeland University Hospital, Bergen, Norway
| | - Sergey Plis
- Tri-institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State University, Georgia Institute of Technology, Emory University, Atlanta
| | - Vince D. Calhoun
- Tri-institutional Center for Translational Research in Neuroimaging and Data Science (TReNDS), Georgia State University, Georgia Institute of Technology, Emory University, Atlanta
| | | | - Donald L. Schomer
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Vibeke Arntsen
- Department of Neurology and Clinical Neurophysiology, St Olavs Hospital, Trondheim University Hospital, Norway
| | - Fieke Cox
- Department of Clinical Neurophysiology, Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Firas Fahoum
- Department of Neurology, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - William B. Gallentine
- Department of Neurology and Pediatrics, Stanford University Lucile Packard Children’s Hospital, Palo Alto, California
| | - Elena Gardella
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Cecil D. Hahn
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Aatif M. Husain
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
- Neurodiagnostic Center, Veterans Affairs Medical Center, Durham, North Carolina
| | - Sudha Kessler
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mustafa Aykut Kural
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Fábio A. Nascimento
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Line B. Ulvin
- Department of Neurology, Oslo University Hospital, Norway
| | - Richard Wennberg
- Division of Neurology, Department of Medicine, Krembil Brain Institute, University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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17
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Hagan B, Mujumdar R, Sahoo JP, Das A, Dutta A. Technical feasibility of multimodal imaging in neonatal hypoxic-ischemic encephalopathy from an ovine model to a human case series. Front Pediatr 2023; 11:1072663. [PMID: 37425273 PMCID: PMC10323750 DOI: 10.3389/fped.2023.1072663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 06/02/2023] [Indexed: 07/11/2023] Open
Abstract
Hypoxic-ischemic encephalopathy (HIE) secondary to perinatal asphyxia occurs when the brain does not receive enough oxygen and blood. A surrogate marker for "intact survival" is necessary for the successful management of HIE. The severity of HIE can be classified based on clinical presentation, including the presence of seizures, using a clinical classification scale called Sarnat staging; however, Sarnat staging is subjective, and the score changes over time. Furthermore, seizures are difficult to detect clinically and are associated with a poor prognosis. Therefore, a tool for continuous monitoring on the cot side is necessary, for example, an electroencephalogram (EEG) that noninvasively measures the electrical activity of the brain from the scalp. Then, multimodal brain imaging, when combined with functional near-infrared spectroscopy (fNIRS), can capture the neurovascular coupling (NVC) status. In this study, we first tested the feasibility of a low-cost EEG-fNIRS imaging system to differentiate between normal, hypoxic, and ictal states in a perinatal ovine hypoxia model. Here, the objective was to evaluate a portable cot-side device and perform autoregressive with extra input (ARX) modeling to capture the perinatal ovine brain states during a simulated HIE injury. So, ARX parameters were tested with a linear classifier using a single differential channel EEG, with varying states of tissue oxygenation detected using fNIRS, to label simulated HIE states in the ovine model. Then, we showed the technical feasibility of the low-cost EEG-fNIRS device and ARX modeling with support vector machine classification for a human HIE case series with and without sepsis. The classifier trained with the ovine hypoxia data labeled ten severe HIE human cases (with and without sepsis) as the "hypoxia" group and the four moderate HIE human cases as the "control" group. Furthermore, we showed the feasibility of experimental modal analysis (EMA) based on the ARX model to investigate the NVC dynamics using EEG-fNIRS joint-imaging data that differentiated six severe HIE human cases without sepsis from four severe HIE human cases with sepsis. In conclusion, our study showed the technical feasibility of EEG-fNIRS imaging, ARX modeling of NVC for HIE classification, and EMA that may provide a biomarker of sepsis effects on the NVC in HIE.
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Affiliation(s)
- Brian Hagan
- School of Engineering, University of Lincoln, Lincoln, United Kingdom
| | - Radhika Mujumdar
- School of Engineering, University of Lincoln, Lincoln, United Kingdom
| | - Jagdish P. Sahoo
- Department of Neonatology, IMS & SUM Hospital, Bhubaneswar, India
| | - Abhijit Das
- Department of Neurology, The Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Anirban Dutta
- School of Engineering, University of Lincoln, Lincoln, United Kingdom
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Barsh GR, Wusthoff CJ. Can electronic medical records predict neonatal seizures? Lancet Digit Health 2023; 5:e175-e176. [PMID: 36963906 DOI: 10.1016/s2589-7500(23)00041-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/13/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Gabrielle R Barsh
- Department of Neurology, Division of Child Neurology, Stanford University, Palo Alto, CA 94304, USA
| | - Courtney J Wusthoff
- Department of Neurology, Division of Child Neurology, Stanford University, Palo Alto, CA 94304, USA.
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19
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O'Toole JM, Mathieson SR, Raurale SA, Magarelli F, Marnane WP, Lightbody G, Boylan GB. Neonatal EEG graded for severity of background abnormalities in hypoxic-ischaemic encephalopathy. Sci Data 2023; 10:129. [PMID: 36899033 PMCID: PMC10006081 DOI: 10.1038/s41597-023-02002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 02/03/2023] [Indexed: 03/12/2023] Open
Abstract
This report describes a set of neonatal electroencephalogram (EEG) recordings graded according to the severity of abnormalities in the background pattern. The dataset consists of 169 hours of multichannel EEG from 53 neonates recorded in a neonatal intensive care unit. All neonates received a diagnosis of hypoxic-ischaemic encephalopathy (HIE), the most common cause of brain injury in full term infants. For each neonate, multiple 1-hour epochs of good quality EEG were selected and then graded for background abnormalities. The grading system assesses EEG attributes such as amplitude, continuity, sleep-wake cycling, symmetry and synchrony, and abnormal waveforms. Background severity was then categorised into 4 grades: normal or mildly abnormal EEG, moderately abnormal EEG, majorly abnormal EEG, and inactive EEG. The data can be used as a reference set of multi-channel EEG for neonates with HIE, for EEG training purposes, or for developing and evaluating automated grading algorithms.
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Affiliation(s)
- John M O'Toole
- INFANT Research Centre, University College Cork, Cork, Ireland.
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
| | - Sean R Mathieson
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Sumit A Raurale
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Fabio Magarelli
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - William P Marnane
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Electronic and Electrical Engineering, University College Cork, Cork, Ireland
| | - Gordon Lightbody
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Electronic and Electrical Engineering, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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20
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Chioma R, Sbordone A, Patti ML, Perri A, Vento G, Nobile S. Applications of Artificial Intelligence in Neonatology. APPLIED SCIENCES 2023; 13:3211. [DOI: 10.3390/app13053211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
The development of artificial intelligence methods has impacted therapeutics, personalized diagnostics, drug discovery, and medical imaging. Although, in many situations, AI clinical decision-support tools may seem superior to rule-based tools, their use may result in additional challenges. Examples include the paucity of large datasets and the presence of unbalanced data (i.e., due to the low occurrence of adverse outcomes), as often seen in neonatal medicine. The most recent and impactful applications of AI in neonatal medicine are discussed in this review, highlighting future research directions relating to the neonatal population. Current AI applications tested in neonatology include tools for vital signs monitoring, disease prediction (respiratory distress syndrome, bronchopulmonary dysplasia, apnea of prematurity) and risk stratification (retinopathy of prematurity, intestinal perforation, jaundice), neurological diagnostic and prognostic support (electroencephalograms, sleep stage classification, neuroimaging), and novel image recognition technologies, which are particularly useful for prompt recognition of infections. To have these kinds of tools helping neonatologists in daily clinical practice could be something extremely revolutionary in the next future. On the other hand, it is important to recognize the limitations of AI to ensure the proper use of this technology.
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Affiliation(s)
- Roberto Chioma
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Annamaria Sbordone
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Maria Letizia Patti
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Alessandro Perri
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giovanni Vento
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Stefano Nobile
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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21
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Pavel AM, O'Toole JM, Proietti J, Livingstone V, Mitra S, Marnane WP, Finder M, Dempsey EM, Murray DM, Boylan GB. Machine learning for the early prediction of infants with electrographic seizures in neonatal hypoxic-ischemic encephalopathy. Epilepsia 2023; 64:456-468. [PMID: 36398397 PMCID: PMC10107538 DOI: 10.1111/epi.17468] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 10/26/2022] [Accepted: 11/15/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess if early clinical and electroencephalography (EEG) features predict later seizure development in infants with hypoxic-ischemic encephalopathy (HIE). METHODS Clinical and EEG parameters <12 h of birth from infants with HIE across eight European Neonatal Units were used to develop seizure-prediction models. Clinical parameters included intrapartum complications, fetal distress, gestational age, delivery mode, gender, birth weight, Apgar scores, assisted ventilation, cord pH, and blood gases. The earliest EEG hour provided a qualitative analysis (discontinuity, amplitude, asymmetry/asynchrony, sleep-wake cycle [SWC]) and a quantitative analysis (power, discontinuity, spectral distribution, inter-hemispheric connectivity) from full montage and two-channel amplitude-integrated EEG (aEEG). Subgroup analysis, only including infants without anti-seizure medication (ASM) prior to EEG was also performed. Machine-learning (ML) models (random forest and gradient boosting algorithms) were developed to predict infants who would later develop seizures and assessed using Matthews correlation coefficient (MCC) and area under the receiver-operating characteristic curve (AUC). RESULTS The study included 162 infants with HIE (53 had seizures). Low Apgar, need for ventilation, high lactate, low base excess, absent SWC, low EEG power, and increased EEG discontinuity were associated with seizures. The following predictive models were developed: clinical (MCC 0.368, AUC 0.681), qualitative EEG (MCC 0.467, AUC 0.729), quantitative EEG (MCC 0.473, AUC 0.730), clinical and qualitative EEG (MCC 0.470, AUC 0.721), and clinical and quantitative EEG (MCC 0.513, AUC 0.746). The clinical and qualitative-EEG model significantly outperformed the clinical model alone (MCC 0.470 vs 0.368, p-value .037). The clinical and quantitative-EEG model significantly outperformed the clinical model (MCC 0.513 vs 0.368, p-value .012). The clinical and quantitative-EEG model for infants without ASM (n = 131) had MCC 0.588, AUC 0.832. Performance for quantitative aEEG (n = 159) was MCC 0.381, AUC 0.696 and clinical and quantitative aEEG was MCC 0.384, AUC 0.720. SIGNIFICANCE Early EEG background analysis combined with readily available clinical data helped predict infants who were at highest risk of seizures, hours before they occur. Automated quantitative-EEG analysis was as good as expert analysis for predicting seizures, supporting the use of automated assessment tools for early evaluation of HIE.
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Affiliation(s)
- Andreea M. Pavel
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | - John M. O'Toole
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | | | - Vicki Livingstone
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | | | - William P. Marnane
- INFANT Research CentreUniversity College CorkCorkIreland
- Electrical & Electronic EngineeringSchool of EngineeringUniversity College CorkCorkIreland
| | - Mikael Finder
- Department of Neonatal MedicineKarolinska University HospitalStockholmSweden
- Division of Paediatrics, Department CLINTECKarolinska InstitutetStockholmSweden
| | - Eugene M. Dempsey
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | - Deirdre M. Murray
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | - Geraldine B. Boylan
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
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22
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Pavel A, Mathieson SR, Livingstone V, O’Toole JM, Pressler RM, de Vries LS, Rennie JM, Mitra S, Dempsey EM, Murray DM, Marnane WP, Boylan GB. Heart rate variability analysis for the prediction of EEG grade in infants with hypoxic ischaemic encephalopathy within the first 12 h of birth. Front Pediatr 2023; 10:1016211. [PMID: 36683815 PMCID: PMC9845713 DOI: 10.3389/fped.2022.1016211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/16/2022] [Indexed: 01/06/2023] Open
Abstract
Background and aims Heart rate variability (HRV) has previously been assessed as a biomarker for brain injury and prognosis in neonates. The aim of this cohort study was to use HRV to predict the electroencephalography (EEG) grade in neonatal hypoxic-ischaemic encephalopathy (HIE) within the first 12 h. Methods We included 120 infants with HIE recruited as part of two European multi-centre studies, with electrocardiography (ECG) and EEG monitoring performed before 12 h of age. HRV features and EEG background were assessed using the earliest 1 h epoch of ECG-EEG monitoring. HRV was expressed in time, frequency and complexity features. EEG background was graded from 0-normal, 1-mild, 2-moderate, 3-major abnormalities to 4-inactive. Clinical parameters known within 6 h of birth were collected (intrapartum complications, foetal distress, gestational age, mode of delivery, gender, birth weight, Apgar at 1 and 5, assisted ventilation at 10 min). Using logistic regression analysis, prediction models for EEG severity were developed for HRV features and clinical parameters, separately and combined. Multivariable model analysis included 101 infants without missing data. Results Of 120 infants included, 54 (45%) had normal-mild and 66 (55%) had moderate-severe EEG grade. The performance of HRV model was AUROC 0.837 (95% CI: 0.759-0.914) and clinical model was AUROC 0.836 (95% CI: 0.759-0.914). The HRV and clinical model combined had an AUROC of 0.895 (95% CI: 0.832-0.958). Therapeutic hypothermia and anti-seizure medication did not affect the model performance. Conclusions Early HRV and clinical information accurately predicted EEG grade in HIE within the first 12 h of birth. This might be beneficial when EEG monitoring is not available in the early postnatal period and for referral centres who may want some objective information on HIE severity.
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Affiliation(s)
- Andreea M Pavel
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Sean R Mathieson
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - John M O’Toole
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Ronit M Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - Linda S de Vries
- Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Janet M Rennie
- Institute for Women's Health, University College London, London, United Kingdom
| | - Subhabrata Mitra
- Institute for Women's Health, University College London, London, United Kingdom
| | - Eugene M Dempsey
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Deirdre M Murray
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - William P Marnane
- INFANT Research Centre, University College Cork, Cork, Ireland
- School of Engineering, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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23
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Abstract
A key goal of neonatal neurocritical care is improved outcomes, and brain monitoring plays an essential role. The recent NEST trial reported no outcome benefits using aEEG monitoring compared to clinical seizure identification among neonates treated for seizures. However, the study failed to prove the effects of monitoring on seizure treatment in the first place.
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El-Dib M, Abend NS, Austin T, Boylan G, Chock V, Cilio MR, Greisen G, Hellström-Westas L, Lemmers P, Pellicer A, Pressler RM, Sansevere A, Tsuchida T, Vanhatalo S, Wusthoff CJ, Wintermark P, Aly H, Chang T, Chau V, Glass H, Lemmon M, Massaro A, Wusthoff C, deVeber G, Pardo A, McCaul MC. Neuromonitoring in neonatal critical care part I: neonatal encephalopathy and neonates with possible seizures. Pediatr Res 2022:10.1038/s41390-022-02393-1. [PMID: 36476747 DOI: 10.1038/s41390-022-02393-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 12/12/2022]
Abstract
The blooming of neonatal neurocritical care over the last decade reflects substantial advances in neuromonitoring and neuroprotection. The most commonly used brain monitoring tools in the neonatal intensive care unit (NICU) are amplitude integrated EEG (aEEG), full multichannel continuous EEG (cEEG), and near-infrared spectroscopy (NIRS). While some published guidelines address individual tools, there is no consensus on consistent, efficient, and beneficial use of these modalities in common NICU scenarios. This work reviews current evidence to assist decision making for best utilization of neuromonitoring modalities in neonates with encephalopathy or with possible seizures. Neuromonitoring approaches in extremely premature and critically ill neonates are discussed separately in the companion paper. IMPACT: Neuromonitoring techniques hold promise for improving neonatal care. For neonatal encephalopathy, aEEG can assist in screening for eligibility for therapeutic hypothermia, though should not be used to exclude otherwise eligible neonates. Continuous cEEG, aEEG and NIRS through rewarming can assist in prognostication. For neonates with possible seizures, cEEG is the gold standard for detection and diagnosis. If not available, aEEG as a screening tool is superior to clinical assessment alone. The use of seizure detection algorithms can help with timely seizures detection at the bedside.
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Affiliation(s)
- Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA
| | - Topun Austin
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Geraldine Boylan
- INFANT Research Centre & Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - Valerie Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - M Roberta Cilio
- Department of Pediatrics, Division of Pediatric Neurology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital & Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lena Hellström-Westas
- Department of Women's and Children's Health, Uppsala University, and Division of Neonatology, Uppsala University Hospital, Uppsala, Sweden
| | - Petra Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain; Neonatology Group, IdiPAZ, Madrid, Spain
| | - Ronit M Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Trust, and Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK
| | - Arnold Sansevere
- Department of Neurology and Pediatrics, George Washington University School of Medicine and Health Sciences; Children's National Hospital Division of Neurophysiology, Epilepsy and Critical Care, Washington, DC, USA
| | - Tammy Tsuchida
- Department of Neurology and Pediatrics, George Washington University School of Medicine and Health Sciences; Children's National Hospital Division of Neurophysiology, Epilepsy and Critical Care, Washington, DC, USA
| | - Sampsa Vanhatalo
- Department of Clinical Neurophysiology, Children's Hospital, BABA Center, Neuroscience Center/HILIFE, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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25
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Moghadam SM, Airaksinen M, Nevalainen P, Marchi V, Hellström-Westas L, Stevenson NJ, Vanhatalo S. An automated bedside measure for monitoring neonatal cortical activity: a supervised deep learning-based electroencephalogram classifier with external cohort validation. Lancet Digit Health 2022; 4:e884-e892. [PMID: 36427950 DOI: 10.1016/s2589-7500(22)00196-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/06/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Electroencephalogram (EEG) monitoring is recommended as routine in newborn neurocritical care to facilitate early therapeutic decisions and outcome predictions. EEG's larger-scale implementation is, however, hindered by the shortage of expertise needed for the interpretation of spontaneous cortical activity, the EEG background. We developed an automated algorithm that transforms EEG recordings to quantified interpretations of EEG background and provides simple intuitive visualisations in patient monitors. METHODS In this method-development and proof-of-concept study, we collected visually classified EEGs from infants recovering from birth asphyxia or stroke. We used unsupervised learning methods to explore latent EEG characteristics, which guided the supervised training of a deep learning-based classifier. We assessed the classifier performance using cross-validation and an external validation dataset. We constructed a novel measure of cortical function, brain state of the newborn (BSN), from the novel EEG background classifier and a previously published sleep-state classifier. We estimated clinical utility of the BSN by identification of two key items in newborn brain monitoring, the onset of continuous cortical activity and sleep-wake cycling, compared with the visual interpretation of the raw EEG signal and the amplitude-integrated (aEEG) trend. FINDINGS We collected 2561 h of EEG from 39 infants (gestational age 35·0-42·1 weeks; postnatal age 0-7 days). The external validation dataset included 105 h of EEG from 31 full-term infants. The overall accuracy of the EEG background classifier was 92% in the whole cohort (95% CI 91-96; range 85-100 for individual infants). BSN trend values were closely related to the onset of continuous EEG activity or sleep-wake cycling, and BSN levels showed robust difference between aEEG categories. The temporal evolution of the BSN trends showed early diverging trajectories in infants with severely abnormal outcomes. INTERPRETATION The BSN trend can be implemented in bedside patient monitors as an EEG interpretation that is intuitive, transparent, and clinically explainable. A quantitative trend measure of brain function might harmonise practices across medical centres, enable wider use of brain monitoring in neurocritical care, and might facilitate clinical intervention trials. FUNDING European Training Networks Funding Scheme, the Academy of Finland, Finnish Pediatric Foundation (Lastentautiensäätiö), Aivosäätiö, Sigrid Juselius Foundation, HUS Children's Hospital, HUS Diagnostic Center, National Health and Medical Research Council of Australia.
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Affiliation(s)
- Saeed Montazeri Moghadam
- BABA Center, Pediatric Research Center, Department of Clinical Neurophysiology, Children's Hospital, HUS imaging, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland.
| | - Manu Airaksinen
- BABA Center, Pediatric Research Center, Department of Clinical Neurophysiology, Children's Hospital, HUS imaging, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland
| | - Päivi Nevalainen
- BABA Center, Pediatric Research Center, Department of Clinical Neurophysiology, Children's Hospital, HUS imaging, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Viviana Marchi
- Department of Developmental Neuroscience, Stella Maris Scientific Institute, IRCCS Fondazione Stella Maris Foundation, Pisa, Italy
| | | | - Nathan J Stevenson
- Brain Modelling Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Sampsa Vanhatalo
- BABA Center, Pediatric Research Center, Department of Clinical Neurophysiology, Children's Hospital, HUS imaging, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland
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Montazeri S, Nevalainen P, Stevenson NJ, Vanhatalo S. Sleep State Trend (SST), a bedside measure of neonatal sleep state fluctuations based on single EEG channels. Clin Neurophysiol 2022; 143:75-83. [PMID: 36155385 DOI: 10.1016/j.clinph.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/27/2022] [Accepted: 08/31/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To develop and validate an automated method for bedside monitoring of sleep state fluctuations in neonatal intensive care units. METHODS A deep learning-based algorithm was designed and trained using 53 EEG recordings from a long-term (a)EEG monitoring in 30 near-term neonates. The results were validated using an independent dataset from 30 polysomnography recordings. In addition, we constructed Sleep State Trend (SST), a bedside-ready means for visualizing classifier outputs. RESULTS The accuracy of quiet sleep detection in the training data was 90%, and the accuracy was comparable (85-86 %) in all bipolar derivations available from the 4-electrode recordings. The algorithm generalized well to a polysomnography dataset, showing 81% overall accuracy despite different signal derivations. SST allowed an intuitive, clear visualization of the classifier output. CONCLUSIONS Fluctuations in sleep states can be detected at high fidelity from a single EEG channel, and the results can be visualized as a transparent and intuitive trend in the bedside monitors. SIGNIFICANCE The Sleep State Trend (SST) may provide caregivers and clinical studies a real-time view of sleep state fluctuations and its cyclicity.
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Affiliation(s)
- Saeed Montazeri
- BABA Center, Department of Clinical Neurophysiology, HUS diagnostic center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland.
| | - Päivi Nevalainen
- BABA Center, Department of Clinical Neurophysiology, HUS diagnostic center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nathan J Stevenson
- Brain Modeling Group, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Sampsa Vanhatalo
- BABA Center, Department of Clinical Neurophysiology, HUS diagnostic center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Physiology, University of Helsinki, Helsinki, Finland
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27
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Molloy EJ, El-Dib M, Juul SE, Benders M, Gonzalez F, Bearer C, Wu YW, Robertson NJ, Hurley T, Branagan A, Michael Cotten C, Tan S, Laptook A, Austin T, Mohammad K, Rogers E, Luyt K, Bonifacio S, Soul JS, Gunn AJ. Neuroprotective therapies in the NICU in term infants: present and future. Pediatr Res 2022:10.1038/s41390-022-02295-2. [PMID: 36195634 PMCID: PMC10070589 DOI: 10.1038/s41390-022-02295-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 08/09/2022] [Accepted: 08/18/2022] [Indexed: 01/13/2023]
Abstract
Outcomes of neonatal encephalopathy (NE) have improved since the widespread implementation of therapeutic hypothermia (TH) in high-resource settings. While TH for NE in term and near-term infants has proven beneficial, 30-50% of infants with moderate-to-severe NE treated with TH still suffer death or significant impairments. There is therefore a critical need to find additional pharmacological and non-pharmacological interventions that improve the outcomes for these children. There are many potential candidates; however, it is unclear whether these interventions have additional benefits when used with TH. Although primary and delayed (secondary) brain injury starting in the latent phase after HI are major contributors to neurodisability, the very late evolving effects of tertiary brain injury likely require different interventions targeting neurorestoration. Clinical trials of seizure management and neuroprotection bundles are needed, in addition to current trials combining erythropoietin, stem cells, and melatonin with TH. IMPACT: The widespread use of therapeutic hypothermia (TH) in the treatment of neonatal encephalopathy (NE) has reduced the associated morbidity and mortality. However, 30-50% of infants with moderate-to-severe NE treated with TH still suffer death or significant impairments. This review details the pathophysiology of NE along with the evidence for the use of TH and other beneficial neuroprotective strategies used in term infants. We also discuss treatment strategies undergoing evaluation at present as potential adjuvant treatments to TH in NE.
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Affiliation(s)
- Eleanor J Molloy
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland. .,Children's Hospital Ireland (CHI) at Tallaght, Dublin, Ireland. .,Neonatology, CHI at Crumlin, Dublin, Ireland. .,Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland.
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Manon Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Fernando Gonzalez
- Department of Neurology, Division of Child Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Cynthia Bearer
- Division of Neonatology, Department of Pediatrics, Rainbow Babies & Children's Hospital, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Yvonne W Wu
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, UK.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Tim Hurley
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland.,Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | - Aoife Branagan
- Paediatrics, Trinity College Dublin, Trinity Research in Childhood Centre (TRICC), Dublin, Ireland.,Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
| | | | - Sidhartha Tan
- Pediatrics, Division of Neonatology, Children's Hospital of Michigan, Detroit, MI, USA.,Wayne State University School of Medicine, Detroit, MI, 12267, USA.,Pediatrics, Division of Neonatology, Central Michigan University, Mount Pleasant, MI, USA
| | - Abbot Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, RI, USA
| | - Topun Austin
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Elizabeth Rogers
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Karen Luyt
- Translational Health Sciences, University of Bristol, Bristol, UK.,Neonatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Sonia Bonifacio
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Suite 315, Palo Alto, CA, 94304, USA
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alistair J Gunn
- Departments of Physiology and Paediatrics, School of Medical Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
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Abstract
Neonatal care is becoming increasingly complex with large amounts of rich, routinely recorded physiological, diagnostic and outcome data. Artificial intelligence (AI) has the potential to harness this vast quantity and range of information and become a powerful tool to support clinical decision making, personalised care, precise prognostics, and enhance patient safety. Current AI approaches in neonatal medicine include tools for disease prediction and risk stratification, neurological diagnostic support and novel image recognition technologies. Key to the integration of AI in neonatal medicine is the understanding of its limitations and a standardised critical appraisal of AI tools. Barriers and challenges to this include the quality of datasets used, performance assessment, and appropriate external validation and clinical impact studies. Improving digital literacy amongst healthcare professionals and cross-disciplinary collaborations are needed to harness the full potential of AI to help take the next significant steps in improving neonatal outcomes for high-risk infants.
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Plana D, Shung DL, Grimshaw AA, Saraf A, Sung JJY, Kann BH. Randomized Clinical Trials of Machine Learning Interventions in Health Care: A Systematic Review. JAMA Netw Open 2022; 5:e2233946. [PMID: 36173632 PMCID: PMC9523495 DOI: 10.1001/jamanetworkopen.2022.33946] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Despite the potential of machine learning to improve multiple aspects of patient care, barriers to clinical adoption remain. Randomized clinical trials (RCTs) are often a prerequisite to large-scale clinical adoption of an intervention, and important questions remain regarding how machine learning interventions are being incorporated into clinical trials in health care. OBJECTIVE To systematically examine the design, reporting standards, risk of bias, and inclusivity of RCTs for medical machine learning interventions. EVIDENCE REVIEW In this systematic review, the Cochrane Library, Google Scholar, Ovid Embase, Ovid MEDLINE, PubMed, Scopus, and Web of Science Core Collection online databases were searched and citation chasing was done to find relevant articles published from the inception of each database to October 15, 2021. Search terms for machine learning, clinical decision-making, and RCTs were used. Exclusion criteria included implementation of a non-RCT design, absence of original data, and evaluation of nonclinical interventions. Data were extracted from published articles. Trial characteristics, including primary intervention, demographics, adherence to the CONSORT-AI reporting guideline, and Cochrane risk of bias were analyzed. FINDINGS Literature search yielded 19 737 articles, of which 41 RCTs involved a median of 294 participants (range, 17-2488 participants). A total of 16 RCTS (39%) were published in 2021, 21 (51%) were conducted at single sites, and 15 (37%) involved endoscopy. No trials adhered to all CONSORT-AI standards. Common reasons for nonadherence were not assessing poor-quality or unavailable input data (38 trials [93%]), not analyzing performance errors (38 [93%]), and not including a statement regarding code or algorithm availability (37 [90%]). Overall risk of bias was high in 7 trials (17%). Of 11 trials (27%) that reported race and ethnicity data, the median proportion of participants from underrepresented minority groups was 21% (range, 0%-51%). CONCLUSIONS AND RELEVANCE This systematic review found that despite the large number of medical machine learning-based algorithms in development, few RCTs for these technologies have been conducted. Among published RCTs, there was high variability in adherence to reporting standards and risk of bias and a lack of participants from underrepresented minority groups. These findings merit attention and should be considered in future RCT design and reporting.
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Affiliation(s)
| | - Dennis L Shung
- Department of Medicine, Yale University, New Haven, Connecticut
| | - Alyssa A Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut
| | - Anurag Saraf
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Joseph J Y Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Benjamin H Kann
- Artificial Intelligence in Medicine Program, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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30
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Lam TYT, Cheung MFK, Munro YL, Lim KM, Shung D, Sung JJY. Randomized Controlled Trials of Artificial Intelligence in Clinical Practice: Systematic Review. J Med Internet Res 2022; 24:e37188. [PMID: 35904087 PMCID: PMC9459941 DOI: 10.2196/37188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/13/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The number of artificial intelligence (AI) studies in medicine has exponentially increased recently. However, there is no clear quantification of the clinical benefits of implementing AI-assisted tools in patient care. OBJECTIVE This study aims to systematically review all published randomized controlled trials (RCTs) of AI-assisted tools to characterize their performance in clinical practice. METHODS CINAHL, Cochrane Central, Embase, MEDLINE, and PubMed were searched to identify relevant RCTs published up to July 2021 and comparing the performance of AI-assisted tools with conventional clinical management without AI assistance. We evaluated the primary end points of each study to determine their clinical relevance. This systematic review was conducted following the updated PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. RESULTS Among the 11,839 articles retrieved, only 39 (0.33%) RCTs were included. These RCTs were conducted in an approximately equal distribution from North America, Europe, and Asia. AI-assisted tools were implemented in 13 different clinical specialties. Most RCTs were published in the field of gastroenterology, with 15 studies on AI-assisted endoscopy. Most RCTs studied biosignal-based AI-assisted tools, and a minority of RCTs studied AI-assisted tools drawn from clinical data. In 77% (30/39) of the RCTs, AI-assisted interventions outperformed usual clinical care, and clinically relevant outcomes improved with AI-assisted intervention in 70% (21/30) of the studies. Small sample size and single-center design limited the generalizability of these studies. CONCLUSIONS There is growing evidence supporting the implementation of AI-assisted tools in daily clinical practice; however, the number of available RCTs is limited and heterogeneous. More RCTs of AI-assisted tools integrated into clinical practice are needed to advance the role of AI in medicine. TRIAL REGISTRATION PROSPERO CRD42021286539; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=286539.
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Affiliation(s)
- Thomas Y T Lam
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong
- Stanley Ho Big Data Decision Analytics Research Centre, The Chinese University of Hong Kong., Hong Kong, Hong Kong
| | - Max F K Cheung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Yasmin L Munro
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Kong Meng Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Dennis Shung
- Department of Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT, United States
| | - Joseph J Y Sung
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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31
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Wang Y, Li Z, Zhang Y, Long Y, Xie X, Wu T. Classification of partial seizures based on functional connectivity: A MEG study with support vector machine. Front Neuroinform 2022; 16:934480. [PMID: 36059865 PMCID: PMC9435583 DOI: 10.3389/fninf.2022.934480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/27/2022] [Indexed: 11/22/2022] Open
Abstract
Temporal lobe epilepsy (TLE) is a chronic neurological disorder that is divided into two subtypes, complex partial seizures (CPS) and simple partial seizures (SPS), based on clinical phenotypes. Revealing differences among the functional networks of different types of TLE can lead to a better understanding of the symbology of epilepsy. Whereas Although most studies had focused on differences between epileptic patients and healthy controls, the neural mechanisms behind the differences in clinical representations of CPS and SPS were unclear. In the context of the era of precision, medicine makes precise classification of CPS and SPS, which is crucial. To address the above issues, we aimed to investigate the functional network differences between CPS and SPS by constructing support vector machine (SVM) models. They mainly include magnetoencephalography (MEG) data acquisition and processing, construction of functional connectivity matrix of the brain network, and the use of SVM to identify differences in the resting state functional connectivity (RSFC). The obtained results showed that classification was effective and accuracy could be up to 82.69% (training) and 81.37% (test). The differences in functional connectivity between CPS and SPS were smaller in temporal and insula. The differences between the two groups were concentrated in the parietal, occipital, frontal, and limbic systems. Loss of consciousness and behavioral disturbances in patients with CPS might be caused by abnormal functional connectivity in extratemporal regions produced by post-epileptic discharges. This study not only contributed to the understanding of the cognitive-behavioral comorbidity of epilepsy but also improved the accuracy of epilepsy classification.
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Affiliation(s)
- Yingwei Wang
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhongjie Li
- College of Intelligence and Computing, Tianjin Key Laboratory of Cognitive Computing and Application, Tianjin University, Tianjin, China
| | - Yujin Zhang
- National Laboratory of Pattern Recognition, Institute of Automation, Chinese Academy of Sciences, Beijing, China
- Brainnetome Center, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Yingming Long
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Xinyan Xie
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Ting Wu
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Magnetoencephalography, Nanjing Brain Hospital, Affiliated to Nanjing Medical University, Nanjing, China
- *Correspondence: Ting Wu
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32
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Hensel KO, Powell J. Viewpoint: digital paediatrics-so close yet so far away. Arch Dis Child 2022; 107:703-707. [PMID: 34588169 DOI: 10.1136/archdischild-2021-322719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/24/2021] [Indexed: 11/03/2022]
Abstract
Technology is driving a revolution in healthcare, but paediatric services have not fully harnessed the potential. Digital health solutions yet to achieve their promise in paediatrics include electronic health records, decision support systems, telemedicine and remote consultations, despite the accelerated uptake during the COVID-19 pandemic. There are also significant potential benefits in digitally enabled research, including systems to identify and recruit participants online or through health records, tools to extract data points from routine data sets rather than new data collection, and remote approaches to outcome measurement. Children and their families are increasingly becoming digital health citizens, able to manage their own health and use of health services through mobile apps and wearables such as fitness trackers. Ironically, one barrier to the uptake of these technologies is that the fast pace of change in this area means the evidence base behind many of these tools remains underdeveloped. Clinicians are often sceptical of innovations which appear largely driven by enthusiasts rather than science. Rigorous studies are needed to demonstrate safety and effectiveness. Regulators need to be agile and responsive. Implementation needs adequate resource and time, and needs to minimise risks and address concerns, such as worries over losing human contact. Digital health care needs to be embedded in medical education and training so that clinicians are trained in the use of innovations and can understand how to embed within services. In this way, digital paediatrics can deliver benefits to the profession, to services and to our patients.
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Affiliation(s)
- Kai O Hensel
- Department of Paediatrics, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK .,Helios University Medical Centre Wuppertal - Children's Hospital, Witten/Herdecke University, Wuppertal, Germany.,Department of Paediatric Cardiology, Intensive Care and Neonatology, University Medical Centre Göttingen - Children's Hospital, Göttingen, Germany
| | - John Powell
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
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33
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Giraud A, Stephens CM, Boylan GB, Walsh BH. Conventional electroencephalography for accurate assessment of brain maturation in preterm infants following perinatal inflammation. Pediatr Res 2022; 93:1118-1119. [PMID: 35854083 PMCID: PMC10132968 DOI: 10.1038/s41390-022-02185-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/22/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Antoine Giraud
- INFANT Research Centre, University College Cork, Cork, Ireland.,INSERM, U1059 SAINBIOSE, Université Jean Monnet, Saint-Étienne, France
| | - Carol M Stephens
- INFANT Research Centre, University College Cork, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland. .,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
| | - Brian H Walsh
- INFANT Research Centre, University College Cork, Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.,Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
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34
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Han JH, Yoon SJ, Lee HS, Park G, Lim J, Shin JE, Eun HS, Park MS, Lee SM. Application of Machine Learning Approaches to Predict Postnatal Growth Failure in Very Low Birth Weight Infants. Yonsei Med J 2022; 63:640-647. [PMID: 35748075 PMCID: PMC9226835 DOI: 10.3349/ymj.2022.63.7.640] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 01/05/2023] Open
Abstract
PURPOSE The aims of the study were to develop and evaluate a machine learning model with which to predict postnatal growth failure (PGF) among very low birth weight (VLBW) infants. MATERIALS AND METHODS Of 10425 VLBW infants registered in the Korean Neonatal Network between 2013 and 2017, 7954 infants were included. PGF was defined as a decrease in Z score >1.28 at discharge, compared to that at birth. Six metrics [area under the receiver operating characteristic curve (AUROC), accuracy, precision, sensitivity, specificity, and F1 score] were obtained at five time points (at birth, 7 days, 14 days, 28 days after birth, and at discharge). Machine learning models were built using four different techniques [extreme gradient boosting (XGB), random forest, support vector machine, and convolutional neural network] to compare against the conventional multiple logistic regression (MLR) model. RESULTS The XGB algorithm showed the best performance with all six metrics across the board. When compared with MLR, XGB showed a significantly higher AUROC (p=0.03) for Day 7, which was the primary performance metric. Using optimal cut-off points, for Day 7, XGB still showed better performances in terms of AUROC (0.74), accuracy (0.68), and F1 score (0.67). AUROC values seemed to increase slightly from birth to 7 days after birth with significance, almost reaching a plateau after 7 days after birth. CONCLUSION We have shown the possibility of predicting PGF through machine learning algorithms, especially XGB. Such models may help neonatologists in the early diagnosis of high-risk infants for PGF for early intervention.
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Affiliation(s)
- Jung Ho Han
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - So Jin Yoon
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Goeun Park
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Joohee Lim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Eun Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Seon Eun
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Park
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.
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35
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Tapani KT, Nevalainen P, Vanhatalo S, Stevenson NJ. Validating an SVM-based neonatal seizure detection algorithm for generalizability, non-inferiority and clinical efficacy. Comput Biol Med 2022; 145:105399. [DOI: 10.1016/j.compbiomed.2022.105399] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/21/2022] [Accepted: 03/09/2022] [Indexed: 01/01/2023]
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36
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Heart Rate Variability Analysis for Seizure Detection in Neonatal Intensive Care Units. Bioengineering (Basel) 2022; 9:bioengineering9040165. [PMID: 35447725 PMCID: PMC9031489 DOI: 10.3390/bioengineering9040165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/28/2022] [Accepted: 04/05/2022] [Indexed: 12/03/2022] Open
Abstract
In Neonatal Intensive Care Units (NICUs), the early detection of neonatal seizures is of utmost importance for a timely clinical intervention. Over the years, several neonatal seizure detection systems were proposed to detect neonatal seizures automatically and speed up seizure diagnosis, most based on the EEG signal analysis. Recently, research has focused on other possible seizure markers, such as electrocardiography (ECG). This work proposes an ECG-based NSD system to investigate the usefulness of heart rate variability (HRV) analysis to detect neonatal seizures in the NICUs. HRV analysis is performed considering time-domain, frequency-domain, entropy and multiscale entropy features. The performance is evaluated on a dataset of ECG signals from 51 full-term babies, 29 seizure-free. The proposed system gives results comparable to those reported in the literature: Area Under the Receiver Operating Characteristic Curve = 62%, Sensitivity = 47%, Specificity = 67%. Moreover, the system’s performance is evaluated in a real clinical environment, inevitably affected by several artefacts. To the best of our knowledge, our study proposes for the first time a multi-feature ECG-based NSD system that also offers a comparative analysis between babies suffering from seizures and seizure-free ones.
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37
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Numis AL, Shellhaas RA. Neonatal Seizure Management: What Is Timely Treatment and Does It Influence Neurodevelopment? J Pediatr 2022; 243:7-8. [PMID: 34896429 DOI: 10.1016/j.jpeds.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/07/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience and Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Renée A Shellhaas
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
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38
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Pavel AM, Rennie JM, de Vries LS, Blennow M, Foran A, Shah DK, Pressler RM, Kapellou O, Dempsey EM, Mathieson SR, Pavlidis E, Weeke LC, Livingstone V, Murray DM, Marnane WP, Boylan GB. Neonatal Seizure Management: Is the Timing of Treatment Critical? J Pediatr 2022; 243:61-68.e2. [PMID: 34626667 PMCID: PMC9067353 DOI: 10.1016/j.jpeds.2021.09.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/23/2021] [Accepted: 09/30/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To assess the impact of the time to treatment of the first electrographic seizure on subsequent seizure burden and describe overall seizure management in a large neonatal cohort. STUDY DESIGN Newborns (36-44 weeks of gestation) requiring electroencephalographic (EEG) monitoring recruited to 2 multicenter European studies were included. Infants who received antiseizure medication exclusively after electrographic seizure onset were grouped based on the time to treatment of the first seizure: antiseizure medication within 1 hour, between 1 and 2 hours, and after 2 hours. Outcomes measured were seizure burden, maximum seizure burden, status epilepticus, number of seizures, and antiseizure medication dose over the first 24 hours after seizure onset. RESULTS Out of 472 newborns recruited, 154 (32.6%) had confirmed electrographic seizures. Sixty-nine infants received antiseizure medication exclusively after the onset of electrographic seizure, including 21 infants within 1 hour of seizure onset, 15 between 1 and 2 hours after seizure onset, and 33 at >2 hours after seizure onset. Significantly lower seizure burden and fewer seizures were noted in the infants treated with antiseizure medication within 1 hour of seizure onset (P = .029 and .035, respectively). Overall, 258 of 472 infants (54.7%) received antiseizure medication during the study period, of whom 40 without electrographic seizures received treatment exclusively during EEG monitoring and 11 with electrographic seizures received no treatment. CONCLUSIONS Treatment of neonatal seizures may be time-critical, but more research is needed to confirm this. Improvements in neonatal seizure diagnosis and treatment are also needed.
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Affiliation(s)
- Andreea M. Pavel
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Janet M. Rennie
- Institute for Women's Health, University College London, London, United Kingdom
| | - Linda S. de Vries
- Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mats Blennow
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden,Division of Pediatrics, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Adrienne Foran
- Department of Neonatal Medicine, Rotunda Hospital, Dublin, Ireland
| | - Divyen K. Shah
- Department of Neonatology, Royal London Hospital, London, United Kingdom,The London School of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Ronit M. Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - Olga Kapellou
- Department of Neonatology, Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | - Eugene M. Dempsey
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Sean R. Mathieson
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Elena Pavlidis
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Lauren C. Weeke
- Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Vicki Livingstone
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - Deirdre M. Murray
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland
| | - William P. Marnane
- INFANT Research Centre, Cork, Ireland,Department of Electrical & Electronic Engineering, School of Engineering, University College Cork, Cork, Ireland
| | - Geraldine B. Boylan
- INFANT Research Centre, Cork, Ireland,Department of Pediatrics and Child Health, University College Cork, Cork, Ireland,Reprint requests: Geraldine B. Boylan, PhD, INFANT Research Centre and Department of Paediatrics and Child Health, University College Cork, Paediatric Academic Unit, 2nd Floor, Cork University Hospital, Wilton, Cork, Ireland T12 DFK4
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Monsour R, Dutta M, Mohamed AZ, Borkowski A, Viswanadhan NA. Neuroimaging in the Era of Artificial Intelligence: Current Applications. Fed Pract 2022; 39:S14-S20. [PMID: 35765692 PMCID: PMC9227741 DOI: 10.12788/fp.0231] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
BACKGROUND Artificial intelligence (AI) in medicine has shown significant promise, particularly in neuroimaging. AI increases efficiency and reduces errors, making it a valuable resource for physicians. With the increasing amount of data processing and image interpretation required, the ability to use AI to augment and aid the radiologist could improve the quality of patient care. OBSERVATIONS AI can predict patient wait times, which may allow more efficient patient scheduling. Additionally, AI can save time for repeat magnetic resonance neuroimaging and reduce the time spent during imaging. AI has the ability to read computed tomography, magnetic resonance imaging, and positron emission tomography with reduced or without contrast without significant loss in sensitivity for detecting lesions. Neuroimaging does raise important ethical considerations and is subject to bias. It is vital that users understand the practical and ethical considerations of the technology. CONCLUSIONS The demonstrated applications of AI in neuroimaging are numerous and varied, and it is reasonable to assume that its implementation will increase as the technology matures. AI's use for detecting neurologic conditions holds promise in combatting ever increasing imaging volumes and providing timely diagnoses.
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Affiliation(s)
- Robert Monsour
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Mudit Dutta
- University of South Florida Morsani College of Medicine, Tampa, Florida
| | | | - Andrew Borkowski
- University of South Florida Morsani College of Medicine, Tampa, Florida
- James A. Haley Veterans’ Hospital, Tampa, Florida
| | - Narayan A. Viswanadhan
- University of South Florida Morsani College of Medicine, Tampa, Florida
- James A. Haley Veterans’ Hospital, Tampa, Florida
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Chalia M, Hartmann H, Pressler R. Practical Approaches to the Treatment of Neonatal Seizures. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00711-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abiramalatha T, Thanigainathan S, Ramaswamy VV, Pressler R, Brigo F, Hartmann H. Antiseizure medications for neonates with seizures. Hippokratia 2022. [DOI: 10.1002/14651858.cd014967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology; Kovai Medical Center and Hospital (KMCH); KMCH Institute of Health Sciences and Research; Coimbatore India
| | | | | | | | - Francesco Brigo
- Department of Neurological and Movement Sciences. Section of Clinical Neurology; University of Verona; Verona Italy
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Variane GFT, Camargo JPV, Rodrigues DP, Magalhães M, Mimica MJ. Current Status and Future Directions of Neuromonitoring With Emerging Technologies in Neonatal Care. Front Pediatr 2022; 9:755144. [PMID: 35402367 PMCID: PMC8984110 DOI: 10.3389/fped.2021.755144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Neonatology has experienced a significant reduction in mortality rates of the preterm population and critically ill infants over the last few decades. Now, the emphasis is directed toward improving long-term neurodevelopmental outcomes and quality of life. Brain-focused care has emerged as a necessity. The creation of neonatal neurocritical care units, or Neuro-NICUs, provides strategies to reduce brain injury using standardized clinical protocols, methodologies, and provider education and training. Bedside neuromonitoring has dramatically improved our ability to provide assessment of newborns at high risk. Non-invasive tools, such as continuous electroencephalography (cEEG), amplitude-integrated electroencephalography (aEEG), and near-infrared spectroscopy (NIRS), allow screening for seizures and continuous evaluation of brain function and cerebral oxygenation at the bedside. Extended and combined uses of these techniques, also described as multimodal monitoring, may allow practitioners to better understand the physiology of critically ill neonates. Furthermore, the rapid growth of technology in the Neuro-NICU, along with the increasing use of telemedicine and artificial intelligence with improved data mining techniques and machine learning (ML), has the potential to vastly improve decision-making processes and positively impact outcomes. This article will cover the current applications of neuromonitoring in the Neuro-NICU, recent advances, potential pitfalls, and future perspectives in this field.
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Affiliation(s)
- Gabriel Fernando Todeschi Variane
- Division of Neonatology, Department of Pediatrics, Irmandade de Misericordia da Santa Casa de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Division of Neonatology, Grupo Santa Joana, São Paulo, Brazil
| | - João Paulo Vasques Camargo
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Data Science Department, OPD Team, São Paulo, Brazil
| | - Daniela Pereira Rodrigues
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Pediatric Nursing Department, Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maurício Magalhães
- Division of Neonatology, Department of Pediatrics, Irmandade de Misericordia da Santa Casa de São Paulo, São Paulo, Brazil
- Clinical Research Department, Protecting Brains and Saving Futures Organization, São Paulo, Brazil
- Department of Pediatrics, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Marcelo Jenné Mimica
- Department of Pathology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
- Department of Pediatrics, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
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Clarke SL, Parmesar K, Saleem MA, Ramanan AV. Future of machine learning in paediatrics. Arch Dis Child 2022; 107:223-228. [PMID: 34301619 DOI: 10.1136/archdischild-2020-321023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 07/16/2021] [Indexed: 11/03/2022]
Abstract
Machine learning (ML) is a branch of artificial intelligence (AI) that enables computers to learn without being explicitly programmed, through a combination of statistics and computer science. It encompasses a variety of techniques used to analyse and interpret extremely large amounts of data, which can then be applied to create predictive models. Such applications of this technology are now ubiquitous in our day-to-day lives: predictive text, spam filtering, and recommendation systems in social media, streaming video and e-commerce to name a few examples. It is only more recently that ML has started to be implemented against the vast amount of data generated in healthcare. The emerging role of AI in refining healthcare delivery was recently highlighted in the 'National Health Service Long Term Plan 2019'. In paediatrics, workforce challenges, rising healthcare attendance and increased patient complexity and comorbidity mean that demands on paediatric services are also growing. As healthcare moves into this digital age, this review considers the potential impact ML can have across all aspects of paediatric care from improving workforce efficiency and aiding clinical decision-making to precision medicine and drug development.
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Affiliation(s)
- Sarah Ln Clarke
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- School of Population Health Sciences, University of Bristol, Bristol, UK
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - Kevon Parmesar
- School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Moin A Saleem
- Bristol Renal, University of Bristol, Bristol, UK
- Children's Renal Unit, Bristol Royal Hospital for Children, Bristol, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
- School of Translational Health Sciences, University of Bristol, Bristol, UK
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肖 甜, 窦 亚, 庄 德, 胡 旭, 康 文, 郭 琳, 赵 晓, 张 鹏, 严 恺, 严 卫, 程 国, 周 文. Evaluation of the clinical effect of an artificial intelligence-assisted diagnosis and treatment system for neonatal seizures in the real world: a multicenter clinical study protocol. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:197-203. [PMID: 35209986 PMCID: PMC8884047 DOI: 10.7499/j.issn.1008-8830.2112124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
Neonatal seizures are the most common clinical manifestations of critically ill neonates and often suggest serious diseases and complicated etiologies. The precise diagnosis of this disease can optimize the use of anti-seizure medication, reduce hospital costs, and improve the long-term neurodevelopmental outcomes. Currently, a few artificial intelligence-assisted diagnosis and treatment systems have been developed for neonatal seizures, but there is still a lack of high-level evidence for the diagnosis and treatment value in the real world. Based on an artificial intelligence-assisted diagnosis and treatment systems that has been developed for neonatal seizures, this study plans to recruit 370 neonates at a high risk of seizures from 6 neonatal intensive care units (NICUs) in China, in order to evaluate the effect of the system on the diagnosis, treatment, and prognosis of neonatal seizures in neonates with different gestational ages in the NICU. In this study, a diagnostic study protocol is used to evaluate the diagnostic value of the system, and a randomized parallel-controlled trial is designed to evaluate the effect of the system on the treatment and prognosis of neonates at a high risk of seizures. This multicenter prospective study will provide high-level evidence for the clinical application of artificial intelligence-assisted diagnosis and treatment systems for neonatal seizures in the real world.
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Affiliation(s)
| | - 亚兰 窦
- 国家儿童医学中心复旦大学附属儿科医院临床流行病学研究室和临床试验中心上海201012
| | | | - 旭红 胡
- 成都市妇女儿童中心医院新生儿科,四川成都610000
| | | | - 琳 郭
- 西南医科大学附属医院新生儿科,四川泸州646099
| | | | | | | | - 卫丽 严
- 国家儿童医学中心复旦大学附属儿科医院临床流行病学研究室和临床试验中心上海201012
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Expert consensus on grading management of electroencephalogram monitoring in neonates. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:115-123. [PMID: 35209975 PMCID: PMC8884055 DOI: 10.7499/j.issn.1008-8830.2112129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
Neonatal electroencephalogram (EEG) monitoring guidelines have been published by American Clinical Neurophysiology Society, and the expert consensus on neonatal amplitude-integrated EEG (aEEG) has also been published in China. It is difficult to strictly follow the guidelines or consensus for EEG monitoring in different levels of neonatal units due to a lack of EEG monitoring equipment and professional interpreters. The Subspecialty Group of Neonatology, Society of Pediatrics, Chinese Medical Association, established an expert group composed of professionals in neonatology, pediatric neurology, and brain electrophysiology to review published guidelines and consensuses and the articles in related fields and propose grading management recommendations for EEG monitoring in different levels of neonatal units. Based on the characteristics of video EEG and aEEG, local medical resources, and disease features, the expert group recommends that video EEG and aEEG can complement each other and can be used in different levels of neonatal units. The consensus also gives recommendations for promoting collaboration between professionals in neonatology, pediatric neurology, and brain electrophysiology and implementing remote EEG monitoring.
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Thomas LB, Mastorides SM, Viswanadhan NA, Jakey CE, Borkowski AA. Artificial Intelligence: Review of Current and Future Applications in Medicine. Fed Pract 2022; 38:527-538. [PMID: 35136337 DOI: 10.12788/fp.0174] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The role of artificial intelligence (AI) in health care is expanding rapidly. Currently, there are at least 29 US Food and Drug Administration-approved AI health care devices that apply to numerous medical specialties and many more are in development. Observations With increasing expectations for all health care sectors to deliver timely, fiscally-responsible, high-quality health care, AI has potential utility in numerous areas, such as image analysis, improved workflow and efficiency, public health, and epidemiology, to aid in processing large volumes of patient and medical data. In this review, we describe basic terminology, principles, and general AI applications relating to health care. We then discuss current and future applications for a variety of medical specialties. Finally, we discuss the future potential of AI along with the potential risks and limitations of current AI technology. Conclusions AI can improve diagnostic accuracy, increase patient safety, assist with patient triage, monitor disease progression, and assist with treatment decisions.
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Affiliation(s)
- L Brannon Thomas
- James A. Haley Veterans' Hospital, Tampa, Florida.,University of South Florida, Morsani College of Medicine, Tampa
| | - Stephen M Mastorides
- James A. Haley Veterans' Hospital, Tampa, Florida.,University of South Florida, Morsani College of Medicine, Tampa
| | | | - Colleen E Jakey
- James A. Haley Veterans' Hospital, Tampa, Florida.,University of South Florida, Morsani College of Medicine, Tampa
| | - Andrew A Borkowski
- James A. Haley Veterans' Hospital, Tampa, Florida.,University of South Florida, Morsani College of Medicine, Tampa
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Frassineti L, Lanata A, Mandredi C. HRV analysis: a non-invasive approach to discriminate between newborns with and without seizures . ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:52-55. [PMID: 34891237 DOI: 10.1109/embc46164.2021.9629741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Early neonatal seizures detection is one of the most challenging issues in Neonatal Intensive Care Units. Several EEG-based Neonatal Seizure Detectors were proposed to support the clinical staff. However, less invasive and more easily interpretable methods than EEG are still missing. In this work, we investigated if Heart Rate Variability analysis and related measures as input features of supervised classifiers could be a valid support for discriminating between newborns with seizures and seizure-free ones. The proposed methods were validated on 52 subjects (33 with seizures and 19 seizure-free) of a public dataset collected at the Helsinki University Hospital. Encouraging results are achieved using a Linear Support Vector Machine, obtaining about 87% Area Under ROC Curve. This suggests that Heart Rate Variability analysis might be a non-invasive pre-screening tool to identify newborns with seizures.Clinical Relevance- Heart Rate Variability analysis for detecting newborns with seizures in NICUs could speed up the diagnosis process and appropriate treatments for a better neurodevelopmental outcome of the infant.
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Frassineti L, Manfredi C, Olmi B, Lanata A. A Generalized Linear Model for an ECG-based Neonatal Seizure Detector. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:471-474. [PMID: 34891335 DOI: 10.1109/embc46164.2021.9630841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Seizures represent one of the most challenging issues of the neonatal period's neurological emergency. Due to the heterogeneity of etiologies and clinical characteristics, seizures recognition is tricky and time-consuming. Currently, the gold standard for seizure diagnosis is Electroencephalography (EEG), whose correct interpretation requires a highly specialized team. Thus, to speed up and facilitate the detection of ictal events, several EEG-based Neonatal Seizure Detectors (NSDs) have been proposed in the literature. Research is currently exploiting more simple and less invasive approaches, such as Electrocardiography (ECG). This work aims at developing an ECG-based NSD using a Generalized Linear Model with features extracted from Heart Rate Variability (HRV) measures as input. The method is validated on a public dataset of 52 subjects (33 with seizures and 19 seizure-free). Achieved encouraging results show 69% Concatenated Area Under the ROC Curve (AUCcc) for the automatic detection of windows with seizure events, confirming that HRV features can be useful to catch the cardio-regulatory system alterations due to neonatal seizure events, particularly those related to Hypoxic-Ischaemic Encephalopathies. Thus, results suggest the use of ECG-based NSDs in clinical practice, especially when a timely diagnosis is needed and EEG technologies are not readily available.Clinical Relevance- An ECG-based Neonatal Seizure Detector could be a valid support to speed up the diagnosis of neonatal seizures, especially when EEG technologies for infants' neurological assessment are not readily available.
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Frassineti L, Lanatà A, Olmi B, Manfredi C. Multiscale Entropy Analysis of Heart Rate Variability in Neonatal Patients with and without Seizures. Bioengineering (Basel) 2021; 8:122. [PMID: 34562944 PMCID: PMC8469929 DOI: 10.3390/bioengineering8090122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/16/2022] Open
Abstract
The complex physiological dynamics of neonatal seizures make their detection challenging. A timely diagnosis and treatment, especially in intensive care units, are essential for a better prognosis and the mitigation of possible adverse effects on the newborn's neurodevelopment. In the literature, several electroencephalographic (EEG) studies have been proposed for a parametric characterization of seizures or their detection by artificial intelligence techniques. At the same time, other sources than EEG, such as electrocardiography, have been investigated to evaluate the possible impact of neonatal seizures on the cardio-regulatory system. Heart rate variability (HRV) analysis is attracting great interest as a valuable tool in newborns applications, especially where EEG technologies are not easily available. This study investigated whether multiscale HRV entropy indexes could detect abnormal heart rate dynamics in newborns with seizures, especially during ictal events. Furthermore, entropy measures were analyzed to discriminate between newborns with seizures and seizure-free ones. A cohort of 52 patients (33 with seizures) from the Helsinki University Hospital public dataset has been evaluated. Multiscale sample and fuzzy entropy showed significant differences between the two groups (p-value < 0.05, Bonferroni multiple-comparison post hoc correction). Moreover, interictal activity showed significant differences between seizure and seizure-free patients (Mann-Whitney Test: p-value < 0.05). Therefore, our findings suggest that HRV multiscale entropy analysis could be a valuable pre-screening tool for the timely detection of seizure events in newborns.
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Affiliation(s)
- Lorenzo Frassineti
- Department of Information Engineering, Università degli Studi di Firenze, Via Santa Marta 3, 50139 Firenze, Italy; (A.L.); (B.O.); (C.M.)
- Department of Medical Biotechnologies, Università di Siena, 53100 Siena, Italy
| | - Antonio Lanatà
- Department of Information Engineering, Università degli Studi di Firenze, Via Santa Marta 3, 50139 Firenze, Italy; (A.L.); (B.O.); (C.M.)
| | - Benedetta Olmi
- Department of Information Engineering, Università degli Studi di Firenze, Via Santa Marta 3, 50139 Firenze, Italy; (A.L.); (B.O.); (C.M.)
| | - Claudia Manfredi
- Department of Information Engineering, Università degli Studi di Firenze, Via Santa Marta 3, 50139 Firenze, Italy; (A.L.); (B.O.); (C.M.)
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