Developing and Validating Multi-Modal Models for Mortality Prediction in COVID-19 Patients: a Multi-center Retrospective Study

The unprecedented global crisis brought about by the COVID-19 pandemic has sparked numerous efforts to create predictive models for the detection and prognostication of SARS-CoV-2 infections with the goal of helping health systems allocate resources. Machine learning models, in particular, hold promise for their ability to leverage patient clinical information and medical images for prediction. However, most of the published COVID-19 prediction models thus far have little clinical utility due to methodological flaws and lack of appropriate validation. In this paper, we describe our methodology to develop and validate multi-modal models for COVID-19 mortality prediction using multi-center patient data. The models for COVID-19 mortality prediction were developed using retrospective data from Madrid, Spain (N = 2547) and were externally validated in patient cohorts from a community hospital in New Jersey, USA (N = 242) and an academic center in Seoul, Republic of Korea (N = 336). The models we developed performed differently across various clinical settings, underscoring the need for a guided strategy when employing machine learning for clinical decision-making. We demonstrated that using features from both the structured electronic health records and chest X-ray imaging data resulted in better 30-day mortality prediction performance across all three datasets (areas under the receiver operating characteristic curves: 0.85 (95% confidence interval: 0.83-0.87), 0.76 (0.70-0.82), and 0.95 (0.92-0.98)). We discuss the rationale for the decisions made at every step in developing the models and have made our code available to the research community. We employed the best machine learning practices for clinical model development. Our goal is to create a toolkit that would assist investigators and organizations in building multi-modal models for prediction, classification, and/or optimization.

Left innominate vein creation using left internal jugular vein tunneled to right internal jugular vein

BACKGROUND

Left innominate vein occlusion is a known complication of pacemaker and central venous catheter placement. For dialysis-dependent patients with an arteriovenous fistula (AVF), this can prevent successful hemodialysis and may require surgical intervention.

CASE REPORT

An 8-month-old male was diagnosed with hemolytic uremic syndrome and became dialysis-dependent at 11 months of age. After multiple vascular access and peritoneal dialysis complications, the patient had construction of a brachiobasalic AVF in his left arm at 13 years old. While waiting for the AVF to mature, an attempt to remove a previously placed left subclavian vein port-a-cath was unsuccessful and a follow-up imaging revealed that the vessel had become occluded. The fistula remained patent, but due to arm swelling and venous obstruction, his fistula was not accessible. Multiple attempts to percutaneously cross the left innominate vein were unsuccessful and the patient was referred for surgical intervention. At 15 years old, the patient was taken to the operating room for transposition of the left internal jugular vein (LIJ) to the right internal jugular vein (RIJ). The LIJ was transected under the mandible and anastomosed to the RIJ. Subsequently the patient underwent VWING insertion rather than venous transposition for constant site dialysis. Although he has required frequent transcatheter dilation of the LIJ-RIJ anastomosis, the patient was successfully dialyzed using this fistula for 5 years. The patient received a cadaveric renal transplant at 5 years 20 days.

CONCLUSIONS

In cases of left innominate vein stenosis, transposing the LIJ can create a new left innominate vein that can alleviate venous hypertension and preserve fistula function. This procedure avoids sternotomy and only requires one anastomosis.

Adult congenital pulmonary valve insertion using a new bioprosthetic aortic valve: Inspiris

We describe successful placement of the Inspiris Resilia aortic valve in the pulmonary position. This valve has advantages for immediate benefit and future percutaneous interventions, making it a promising prosthesis for adult congenital patients.

Oblique coronary artery prolongation in anomalous left coronary artery arising from the pulmonary artery: A case series

BACKGROUND

Anomalous left coronary artery (LMCA) arising from the pulmonary artery (ALCAPA) is a life-threatening congenital birth defect. Prompt surgical correction by reimplantation of the LMCA into the aorta is the treatment of choice, however, unfavorable LCA location or length can make direct reimplantation difficult or even impossible without causing significant stretching or tension on the LMCA. This tension can lead to stenosis of the artery and coronary ischemia and must be avoided if possible.

METHODS

A chart review from January 2010 to December 2018 of patients who had ALCAPA repair. Patients were excluded if direct reimplantation was possible. Herein, we describe four cases in which remote LMCA position necessitated the creation of a tubular prolongation of the LMCA.

RESULTS

A generous coronary button from the pulmonary artery along with the oblique flap of aorta served as the prolongation of the left main coronary artery. This allowed for a tension-free anastomosis using native tissue with the ability to grow with the patient. The pulmonary artery and the aorta were then patched using pericardial tissue. All four patients had improvement in left ventricular function and degree of mitral regurgitation within weeks of surgery. No patient required extracorporeal membrane oxygenation support. Subsequent long-term angiographic follow-up has revealed excellent durability and patency of these coronary conduits.

CONCLUSIONS

The variable nature of ALCAPA requires modification of the surgical approach on a patient by patient basis, and the above described technique adds an alternate and reliable long-term treatment option.

22q11.2 microduplication syndrome with associated esophageal atresia/tracheo-esophageal fistula and vascular ring

This case report describes a patient with a 22q11.2 duplication. His features, which include VACTERL association with an esophageal atresia/tracheo‐esophageal fistula and a vascular ring, expand the previously described phenotype for this duplication.

Oblique Coronary Artery Prolongation Approach in Anomalous Left Coronary Artery From the Pulmonary Artery in a Low-Birth-Weight Neonate

A 19-day-old newborn girl weighing 1.9-kg was born with anomalous origin of the left coronary artery (LCA) from the pulmonary artery (PA). Because of the small anatomic structures and long distance between the anomalous origin of the LCA high within the left posterior sinus of the main PA, a simple transfer of the anomalous LCA to the aorta was deemed impossible. A coronary button was created with an oblique flap of tissue cut from the posterior pulmonary arterial wall. An oblique flap was created from the anterior aortic wall. The two flaps were used to create a tubular prolongation that connected the LCA to the aorta. This created a tension-free anastomosis with potential for growth. The aorta and PA were then patched with pericardium. A left coronary angiogram three years after surgery demonstrated a patent coronary tube.

Non pitting edema, arthritis and ichthyosis; presenting manifestation of leprosy

Leprosy is a chronic granulomatous infection caused by Mycobacterium leprae. Predominantly involving skin and nerves and having classic clinical description, the diagnosis may be clear-cut in majority of patients but may be challenging in others. Non-pitting edema, ichthyosis and arthritis are uncommon in leprosy and very rare in tuberculoid type where the diagnosis may be challenging unlike relatively clear-cut clinical picture in lepromatous type. Musculoskeletal manifestation is seen in 1-5% of cases and usually associated with reactional states where again the diagnosis sometimes becomes evident. High index of suspicion is therefore recommended in patients with unexplained systemic illness especially in endemic areas. Herein we report a young male with non pitting edema and symmetric peripheral arthritis involving all four limbs, and ichthyosis as presenting manifestation of borderline leprosy where the neuro-cutaneous manifestation developed two months after the said presenting features and in absence of a reactional state.

Three dimensional rotational angiography imaging of double aortic arch vascular ring

BACKGROUND

Three dimensional (3D) rotational angiography is a technique used increasingly for imaging in congenital heart disease.

RESULTS

We describe the use of this technique for imaging of double aortic arch vascular ring and discuss the advantages of this modality.

CONCLUSIONS

3D rotational angiography is an excellent tool for imaging of various vascular anomalies. It provides high quality accurate images through a quick and safe procedure.

Risks of extracorporeal membrane oxygenation in patients with coronary artery anomalies

Extracorporeal membrane oxygenation is widely used to support and rest the heart before or following repair of congenital cardiac lesions in children. The beneficial effects of extracorporeal membrane oxygenation for the failing myocardium are undisputed. It is often an automatic choice whenever the heart seems incapable of supporting the circulation. However, its use may prove detrimental in patients with coronary anomalies, as illustrated by the case reports presented here.

Familial hypoparathyroidism

A family with hereditary (familial) hypoparathyroidism is reported where three of the total four siblings were affected and each presented with different manifestation-one brother with refractory epilepsy since early childhood, another brother with unilateral extrapyramidal features in adult life, and their only sister having recurrent attacks of tingling and numbness due to hypocalcemia since 12 years of age.

Multiple papillary fibroelastomas of the heart

We report the case of a 41-year-old woman who presented with extensive papillary fibroelastomas of the heart after multiple previous surgical procedures for hypertrophic cardiomyopathy. This case is significant because of the locally aggressive nature of the cardiac papillary fibroelastoma.

Splenic metastasis and bleeding manifestations--an unusual association with gastric malignancy

Splenic metastasis is a rare clinical entity--incidence being 0.6% at autopsy and 1.1% at splenectomy. We report the case of a 30 year old female who presented with purpura and melena and who was later diagnosed to have a mucinous adenocarcinoma of stomach with disseminated intravascular coagulation and splenic metastasis.

Oromandibular dystonia and persistent psychiatric symptoms in extra-pontine myelinolysis

A 32 years female presented with gradually progressive dysarthria, dysphagia, oromandibular dystonia and mild generalized weakness. She had several episodes of acute psychotic behavior. She had abnormal saccadic eye movements, generalized hypertonia and exaggerated jerks in upper limbs. She was previously treated in a peripheral hospital for severe vomiting and diarrhea. MRI of brain revealed symmetrical T-2 weighted hyperintensities in bilateral putaminal and caudate region along with pons and midbrain suggesting demyelination due to a metabolic insult. Her power improved gradually over days and the dysarthria, dysphagia and oromandibular dystonia improved gradually over several weeks with supportive measures but the psychiatric manifestations are still persisting.

Late Embolization of Amplatzer Patent Ductus Arteriosus Occlusion Device With Thoracic Aorta Embedment

An 11.5-month-old child was found to have a widely patent ductus arteriosus 8 months after percutaneous Amplatzer device closure of the ductus. Angiography confirmed that the occlusion device had migrated to the descending thoracic aorta. The child underwent surgical removal of the device, which was firmly embedded in the aorta and could not be removed percutaneously.

Primary duodenal lymphoma producing obstructive jaundice

Primary lymphoma of the duodenum presenting with obstructive jaundice is a rare entity. We report a case of primary non-Hodgkin's lymphoma of the duodenum producing obstructive jaundice in a middle aged lady, where the concentric thickening of the duodenal wall also gave rise to symptomatic partial high small bowel obstruction in due course. Guided aspiration and flowcytometry established a diagnosis of diffuse large B-cell lymphoma.

Video-assisted thoracoscopic surgery for closure of patent ductus arteriosus in children

Video-assisted thoracoscopic surgery (VATS) was recently described as an approach to clip the patent ductus arteriosus (PDA). Between May 1994 and May 1996, we performed this procedure on 34 children below 12 years of age (mean 7 years). Thirty-two had an isolated PDA and two had associated small perimembranous ventricular septal defect (VSD), diagnosed on echocardiography and colour flow mapping. None had pulmonary arterial hypertension. The procedure was successful in 33 (97%) children confirmed by absence of residual shunt on serial echocardiography. Complications in the form of pneumothorax (1) and vocal card paralysis (2) were encountered in three children. The overall hospital stay was reduced to five days. In conclusion, the technique of PDA clipping using VATS is easy to learn and highly successful with acceptable risk of complications.