Objective: Reflex testing protocols allow clinical laboratories to perform second line diagnostic tests on existing specimens based on the results of initially ordered tests. Reflex testing can support optimal clinical laboratory test ordering and diagnosis. In current clinical practice, reflex testing typically relies on simple "if-then" rules; however, this limits their scope since most test ordering decisions involve more complexity than a simple rule will allow. Here, using the analyte ferritin as an example, we propose an alternative machine learning-based approach to "smart" reflex testing with a wider scope and greater impact than traditional rule-based approaches. Methods: Using patient data, we developed a machine learning model to predict whether a patient getting CBC testing will also have ferritin testing ordered, consider applications of this model to "smart" reflex testing, and evaluate the model by comparing its performance to possible rule-based approaches. Results: Our underlying machine learning models performed moderately well in predicting ferritin test ordering and demonstrated greater suitability to reflex testing than rule-based approaches. Using chart review, we demonstrate that our model may improve ferritin test ordering. Finally, as a secondary goal, we demonstrate that ferritin test results are missing not at random (MNAR), a finding with implications for unbiased imputation of missing test results. Conclusions: Machine learning may provide a foundation for new types of reflex testing with enhanced benefits for clinical diagnosis and laboratory utilization management.

Early evaluation of patients who require special care and who have high death-expectancy in COVID-19, and the effective determination of relevant biomarkers on large sample-groups are important to reduce mortality. This study aimed to reveal the routine blood-value predictors of COVID-19 mortality and to determine the lethal-risk levels of these predictors during the disease process. The dataset of the study consists of 38 routine blood-values of 2597 patients who died (n = 233) and those who recovered (n = 2364) from COVID-19 in August-December, 2021. In this study, the histogram-based gradient-boosting (HGB) model was the most successful machine-learning classifier in detecting living and deceased COVID-19 patients (with squared F1 metrics F1^2 = 1). The most efficient binary combinations with procalcitonin were obtained with D-dimer, ESR, D-Bil and ferritin. The HGB model operated with these feature pairs correctly detected almost all of the patients who survived and those who died (precision > 0.98, recall > 0.98, F1^2 > 0.98). Furthermore, in the HGB model operated with a single feature, the most efficient features were procalcitonin (F1^2 = 0.96) and ferritin (F1^2 = 0.91). In addition, according to the two-threshold approach, ferritin values between 376.2 mkg/L and 396.0 mkg/L (F1^2 = 0.91) and pro-calcitonin values between 0.2 mkg/L and 5.2 mkg/L (F1^2 = 0.95) were found to be fatal risk levels for COVID-19. Considering all the results, we suggest that many features combined with these features, especially procalcitonin and ferritin, operated with the HGB model, can be used to achieve very successful results in the classification of those who live, and those who die from COVID-19. Moreover, we strongly recommend that clinicians consider the critical levels we have found for procalcitonin and ferritin properties, to reduce the lethality of the COVID-19 disease.

As high throughput biological sequencing becomes faster and cheaper, the need to extract useful information from sequencing becomes ever more paramount, often limited by low throughput experimental characterizations. For proteins, accurate prediction of their functions directly from their primary amino acid sequences has been a long standing challenge. Here, machine learning using artificial recurrent neural networks (RNN) was applied towards classification of protein function directly from primary sequence without sequence alignment, heuristic scoring or feature engineering. The RNN models containing long short term memory (LSTM) units trained on public, annotated datasets from UniProt achieved high performance for in class prediction of four important protein functions tested, particularly compared to other machine learning algorithms using sequence derived protein features. RNN models were used also for out of class predictions of phylogenetically distinct protein families with similar functions, including proteins of the CRISPR associated nuclease, ferritin like iron storage and cytochrome P450 families. Applying the trained RNN models on the partially unannotated UniRef100 database predicted not only candidates validated by existing annotations but also currently unannotated sequences. Some RNN predictions for the ferritin like iron sequestering function were experimentally validated, even though their sequences differ significantly from known, characterized proteins and from each other and cannot be easily predicted using popular bioinformatics methods. As sequencing and experimental characterization data increases rapidly, the machine learning approach based on RNN could be useful for discovery and prediction of homologues for a wide range of protein functions. Introduction As the cost of DNA sequencing is decreasing drastically over the last decade, the volume of biological sequences particularly for new proteins is also increasing rapidly. Discovering the functions of these new proteins not only could allow one to better understand their roles in their native contexts, but also utilize them in synthetic biology to assembled new biological circuits and pathways for useful applications such as production of valuable compounds or treating disease. However, the experimental characterization of proteins' properties such as structure and function can be slow and resource demanding using techniques such as x ray crystallography, cryo TEM, or functional assays, significantly outpaced by sequencing.