Evaluating the Predictive Validity of the Fordham Risk Screening Tool (FRST) for Violent Behavior during Inpatient Psychiatric Hospitalization.

Violence is a critical problem in the emergency department (ED) and patients experiencing mental health crises are at greater violence risk; however, tools appropriate for assessing violence risk in the ED are limited. Our goal was to evaluate the utility of the Fordham Risk Screening Tool (FRST) in reliability assessing violence risk in adult ED patients with acute mental health crises through evaluation of test characteristics as compared to a reference standard. We evaluated performance of the FRST when used with a convenience sample of ED patients undergoing acute psychiatric evaluation. Participants underwent assessment with the FRST and an established reference standard, the Historical Clinical Risk Management-20, version 3 (HCR-20, v3). Diagnostic performance was assessed through evaluation of test characteristics and area under the receiver operating characteristic (AUROC) curve. Psychometric assessments examined the measurement properties of the FRST. 105 participants were enrolled. In comparison to the reference standard, the AUROC for the predictive ability of the FRST was 0.88 (SE 0.39), 95% CI: 0.81-0.96. Sensitivity was 84% (95% CI: 69-94%) while specificity was 93% (95% CI: 83-98%). The positive predictive value was 87% (95% CI: 73-94%) and negative predictive value was 91% (95% CI: 83-86%). Psychometric analyses provided reliability and validity evidence for the FRST when used in the ED setting. Findings support the potential utility of the FRST when used to assess violence risk in adult ED patients experiencing a mental health crisis. Future research with more diverse populations and ED settings is warranted.

Introduction: Survival to hospital discharge is better for PEA than asystole in out-of-hospital cardiac arrest. Point of care ultrasound (PoCUS) is widely used in cardiac arrest, although not mandated by ACLS guidelines. This study examines if initial PoCUS findings combined with cardiac rhythm are predictive of outcomes including return of spontaneous circulation (ROSC), survival to hospital admission (SHA), and hospital discharge (SHD). Methods: A database review was completed for patients arriving to a tertiary ED in asystole or PEA arrest from 2010 to 2014. Patients under 19y or with a previous DNR were excluded. Patients were grouped into those with cardiac activity on PoCUS and PEA on ECG (Positive group); those with no cardiac activity recorded on PoCUS and asystole on ECG (Negative group); and those with a mix of positive and negative findings (Indeterminate group). Data was analyzed for the frequency of ROSC, SHA, and SHD. Results: 186 patients met the study criteria, with 14 (8%) in the positive group, 134 (72%) in the negative group, and 38 (20%) in the indeterminate group. The positive group had significantly better initial outcomes than the negative group: ROSC: 78% (95% CI 49-95%) vs 17% (11-25%); OR 17.70 (4.57-168.5; p < 0.0001) and SHA: 29% (8-58%) vs 7% (3-12%); OR 5.56 (1.45-21.28; p = 0.022), and then the combined negative and indeterminate groups: ROSC: 22% (16-29%), OR 12.93 (3.43-48.73; p < 0.0001; SHA: 8% (5-13%); OR 4.51 (1.25-16.27; p = 0.033). There was no difference between the positive group and either the negative or combined groups for final outcome of SHD: 0% (0-23%) vs 1% (0-5%); OR 1.83 (0.08-39.97; p = 1.00; and vs 1% (0-5%); OR 1.67 (0.08-33.96; p = 1.00). The negative group had worse initial outcomes than the combined positive and indeterminate groups: ROSC 17% (11-25%) vs. 50% (36-64%) OR 0.21 (0.10-0.42; p < 0.0001); SHA 6% (3-12%) vs. 8% (5-13%) OR 0.34 (0.13-0.92; p = 0.0490). There was no difference in SHD: 1% (0-5%) vs. 1% (0-5%) OR 0.77 (0.07-8.71; p = 1.00). Conclusion: Our results suggest that although finding positive cardiac activity on ECG (PEA) and also on PoCUS is associated with greater ROSC and SHA, it does not identify patients with a final outcome of SHD.

Laboratory testing is an important target for high-value care initiatives, constituting the highest volume of medical procedures. Prior studies have found that up to half of all inpatient laboratory tests may be medically unnecessary, but a systematic method to identify these unnecessary tests in individual cases is lacking. To systematically identify low-yield inpatient laboratory testing through personalized predictions. In this retrospective diagnostic study with multivariable prediction models, 116 637 inpatients treated at Stanford University Hospital from January 1, 2008, to December 31, 2017, a total of 60 929 inpatients treated at University of Michigan from January 1, 2015, to December 31, 2018, and 13 940 inpatients treated at the University of California, San Francisco from January 1 to December 31, 2018, were assessed. Diagnostic accuracy measures, including sensitivity, specificity, negative predictive values (NPVs), positive predictive values (PPVs), and area under the receiver operating characteristic curve (AUROC), of machine learning models when predicting whether inpatient laboratory tests yield a normal result as defined by local laboratory reference ranges. In the recent data sets (July 1, 2014, to June 30, 2017) from Stanford University Hospital (including 22 664 female inpatients with a mean [SD] age of 58.8 [19.0] years and 22 016 male inpatients with a mean [SD] age of 59.0 [18.1] years), among the top 20 highest-volume tests, 792 397 were repeats of orders within 24 hours, including tests that are physiologically unlikely to yield new information that quickly (eg, white blood cell differential, glycated hemoglobin, and serum albumin level). The best-performing machine learning models predicted normal results with an AUROC of 0.90 or greater for 12 stand-alone laboratory tests (eg, sodium AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 98%; specificity, 35%; PPV, 66%; NPV, 93%; lactate dehydrogenase AUROC, 0.93 [95% CI, 0.93-0.94]; sensitivity, 96%; specificity, 65%; PPV, 71%; NPV, 95%; and troponin I AUROC, 0.92 [95% CI, 0.91-0.93]; sensitivity, 88%; specificity, 79%; PPV, 67%; NPV, 93%) and 10 common laboratory test components (eg, hemoglobin AUROC, 0.94 [95% CI, 0.92-0.95]; sensitivity, 99%; specificity, 17%; PPV, 90%; NPV, 81%; creatinine AUROC, 0.96 [95% CI, 0.96-0.97]; sensitivity, 93%; specificity, 83%; PPV, 79%; NPV, 94%; and urea nitrogen AUROC, 0.95 [95% CI, 0.94, 0.96]; sensitivity, 87%; specificity, 89%; PPV, 77%; NPV 94%). The findings suggest that low-yield diagnostic testing is common and can be systematically identified through data-driven methods and patient context-aware predictions. Implementing machine learning models appear to be able to quantify the level of uncertainty and expected information gained from diagnostic tests explicitly, with the potential to encourage useful testing and discourage low-value testing that incurs direct costs and indirect harms.

Prediction of pancreatic fistula after pancreatectomy by virtual touch tissue imaging and quantification (VTIQ) technology

Computer-Based Classification of Dermoscopy Images of Melanocytic Lesions on Acral Volar Skin

The purpose of this study was to investigate the effect of integrated evaluation of resting static computed tomography perfusion (CTP) and coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFR CT ) on therapeutic decision-making and predicting major adverse cardiovascular events (MACEs) in patients with suspected coronary artery disease. In this post hoc analysis of a prospective trial of CCTA in patients assigned to either CCTA or CCTA plus FFR CT arms, 500 patients in the CCTA plus FFR CT arm were analyzed. Both resting static CTP and FFR CT were evaluated by using the conventional CCTA. Perfusion defects in the myocardial segments with ≥50% degree of stenosis in the supplying vessels were defined as resting static CTP positive, and any vessel with an FFR CT value of ≤0.80 was considered positive. Patients were divided into 3 groups: (1) negative CTP-FFR CT match group (resting static CTP-negative and FFR CT -negative group); (2) mismatch CTP-FFR CT group (resting static CTP-positive and FFR CT -negative or resting static CTP-negative and FFR CT -positive group); and (3) positive CTP-FFR CT match group (resting static CTP-positive and FFR CT -positive group). We compared the revascularization-to-invasive coronary angiography ratio and the MACE rate among 3 subgroups at 1- and 3-year follow-ups. The adjusted Cox hazard proportional model was used to assess the prognostic value of FFR CT and resting static CTP to determine patients at risk of MACE. Patients in the positive CTP-FFR CT match group were more likely to undergo revascularization at the time of invasive coronary angiography compared with those in the mismatch CTP-FFR CT group (81.4% vs 57.7%, P =0.033) and the negative CTP-FFR CT match group (81.4% vs 33.3%, P= 0.001). At 1- and 3-year follow-ups, patients in the positive CTP-FFR CT match group were more likely to have MACE than those in the mismatch CTP-FFR CT group (10.5% vs 4.2%, P= 0.046; 35.6% vs 9.4%, P <0.001) and the negative CTP-FFR CT match group (10.5% vs 0.9%, P <0.001; 35.6% vs 5.4%, P <0.001). A positive CTP-FFR CT match was strongly related to MACE at 1-year (hazard ratio=8.06, P= 0.003) and 3-year (hazard ratio=6.23, P <0.001) follow-ups. In patients with suspected coronary artery disease, the combination of FFR CT with resting static CTP could guide therapeutic decisions and have a better prognosis with fewer MACE in a real-world scenario.

Objective To summarize the clinical data of atypical hemolytic uremic syndrome (aHUS) and analyze the treatment and prognosis. Methods A prospective cohort study was conducted on 66 cases in Beijing Children's Hospital affiliated to Capital Medical University from January 2011 to December 2017. The children were divided into positive and negative auto-antibody groups according to the results of anti-factor H autoantibody test. The clinical characteristics, treatment plan and prognosis of the two groups were compared. Results Among the 66 children who met the inclusion criteria, there were 43 cases (65.2%) in the positive group, with an average onset age of(8.0±2.9) years. There were 23 cases (34.8%) in the negative group, with an average onset age of (3.0±2.6) years. On the basis of plasma treatment, in the positive group, the usage rate of hormone was 83.3%(35/42) and the usage rate of immunosuppressive agents was 42.9%(18/42), while in the negative group, the rates were 63.6%(14/22) and 13.6%(3/22) respectively. The average follow-up time was 19.3 months. One child in each group was lost to follow-up. In the positive group, 8 cases recurred (19.0%) and the average recurrence interval time was 16.1 months. In the negative group, 7 cases recurred (31.8%) and the average recurrence interval time was 9.3 months. And the recurrent interval time in the positive group was more longer than the negative group (P<0.05). A total of 85.9%(55/64) children had complete hemolysis control and complete recovery of renal function, in which the positive group was 85.7%(36/42) and negative group was 86.4%(19/22). However, 7.8%(5/64) children had abnormal renal function, in which the positive group was 9.5%(4/42) and the negative group was 4.5%(1/22). And 4.7%(3/64) children died, in which the positive group was 2.4%(1/42) and the negative group was 9.1%(2/22). The one left (1.6%) showed dialysis dependence, which was positive for the auto-antibody. Multifactor Cox regression analysis showed that the age of less than 3 years old was the risk factor of poor prognosis (HR=4.651, 95% CI 0.988-21.898, P=0.047). Conclusions The positive proportion of anti-factor H autoantibody in children with aHUS is high. The age of these children is older. Individualized therapy based on anti-factor H autoantibody and immunosuppressive therapy is of great significance for disease remission, preventing recurrence and improving the prognosis. Age less than 3 years old is the risk factor for poor prognosis. Key words: Hemolytic-uremic syndrome; Immunosuppression; Prognosis; Complement Factor H; Plasma exchange

Objective To evaluate the diagnostic values of endothelial cell specific molecule-1 (ESM-1), procalcitonin (PCT), C reactive protein (CRP), interleukin-6 (IL-6) in patients with sepsis. Methods This study totally enrolled 90 patients who were admitted to our hospital from July 2014 to February 2016 were divided into sepsis group (n=32), and common infection group (n=58). Serum levels of ESM-1 were detected by enzyme-linked immunosorbent assay (ELISA); The levels of PCT and IL-6 were measured by automatic electrochemiluminescene (ECL) analyzer; The levels of CRP were measured by rate immunonephelometric analyzer. The diagnostic powers of this four biomarkers were constructed by receiver operating characteristic (ROC) curve. Results The values of ESM-1, PCT, IL-6 and CRP in sepsis group were 3.93 ng/ml, 4.05 ng/ml, 83.20 mg/L, 61.80 ng/L, respectively; The values of ESM-1, PCT, IL-6 and CRP in common infection group were 0.69 ng/ml, 0.41 ng/ml, 64.35 mg/L, 17.20 ng/L, respectively; P=0.001, 0.001, 0.003, 0.001, respectively; there were statistically significant differences. The area under the ROC curve (AUC) of ESM-1, PCT, CRP, IL-6 were 0.911, 0.893, 0.667, 0.760; The AUC of ESM-1 was higer than that of CRP (P=0.001); The AUC of ESM-1 was higer than that of IL-6 (P=0.003); The AUC of PCT was higer than that of CRP (P=0.001); The AUC of PCT was higer than that of IL-6 (P=0.002); There was no significant difference in ESM-1 and the PCT. As an early diagnostic indicator of sepsis, the cut-off value of ESM-1 was 2.215 ng/ml, with sensitivity of 81.3%, specificity of 93.1%, Youden index was 0.744, positive predictive value was 0.867, negative predictive value was 0.900, positive likelihood ratio was 11.781, negative likelihood ratio was 0.201. As an early diagnostic indicator of sepsis, the cut-off value of PCT was 1.875 ng/ml, with sensitivity of 84.4%, specificity of 82.8%, Youden index was 0.672, positive predictive value was 0.730, negative predictive value was 0.906, positive likelihood ratio was 4.894, negative likelihood ratio was 0.189. Conclusion ESM-1, PCT as early biomarkers for sepsis are superior to CRP, IL-6, both have high value for the early diagnosis of the patients with sepsis. Key words: Endothelial cell specific molecule-1; Procalcitonin; C reactive protein; Interleukin-6; Sepsis

The aim of this study was to evaluate the diagnostic performance of strain elastography, acoustic radiation force impulse (ARFI) imaging and point shear wave elastography (p-SWE) for assessment of the predominant types of intestinal stenosis in Crohn disease. Twenty-five patients were enrolled in this study, among whom 25 suspicious stenoses in 25 intestinal segments were studied using gray scale ultrasonography. All 3 elastography methods were performed, and all patients underwent endoscopy within 24 hours with pathologic biopsy. The sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), Youden index, and area under the receiver operating characteristic curve (AUROC) were calculated. Pathologic findings were regarded as the gold standard. For SE, the optimal cutoff value was a score of 4 or greater (sensitivity, 75%; specificity, 66.7%; accuracy, 68%; PPV, 30%; NPV, 93.3%; AUROC, 0.708; however, P > .05). The results of ARFI imaging were similar: the optimal cutoff value was a score of 4 or greater (sensitivity, 50%; specificity, 81%; accuracy, 76%; PPV, 33.3%; NPV, 89.4%; AUROC, 0.669; P < .05). However, for p-SWE, the optimal cutoff value was reached when the shear wave velocity exceeded 2.73 m/s (sensitivity, 75%; specificity, 100%; accuracy, 96%; PPV, 100%; NPV, 95.5%; AUROC, 0.833; P < .05). p-SWE had the best performance for evaluating and differentiating intestinal stenosis in Crohn disease, while neither SE nor ARFI imaging achieved satisfactory outcomes for evaluating inflammatory stenosis and fibrotic stenosis of Crohn disease.

An update of the severe trauma scoring system using the Korean National Emergency Department Information System (NEDIS) database

Category:Ankle; OtherIntroduction/Purpose:Total ankle arthroplasty (TAA) is included in the Centers of Medicare andMedicaid Services' (CMS) Bundled Payments for Care Improvement (BPCI)initiative for lower extremity joint replacements. This model has beendemonstrated to be for total hip arthroplasty (THA) and total kneearthroplasty (TKA). However, there remains concern that the modelunderestimates expected costs for TAA due to the unique healthcare needs ofTAA patients including higher implant costs, longer procedures, and anincreased demand for postoperative acute care services due tonon-weightbearing. The purpose of this study was to analyze the breakdown ofcosts associated with inpatient and outpatient care and assess thedifference between Medicare beneficiary reimbursements and actual costs forthe episode of care.Methods:An IRB-approved retrospective review was conducted of patients with Medicarewho underwent TAA between July 2014 and June 2018. The surgeries wereperformed at seven facilities affiliated with a singular institutionhospital system. Patients undergoing TAA in this time period were identifiedusing an institutional arthroplasty database and were eligible for study. Of99 patients who met this criterion, financial data was available for 72.Demographics including age, gender, BMI, and comorbidities were collectedvia chart review. Episode start and end dates, first post-acute caredischarge destination, and total episode costs were recorded. Total episodecost was subdivided into inpatient facility cost, surgeon fees, andpost-acute care discharge costs (inpatient rehab facility costs, skillednursing facility expenses, or home health aide fees). Patients werestratified into two groups based on 90-day costs of care, a 'positive group'not exceeding the bundled payment allocation and a 'negative group' whichdid exceed.Results:No statistically significant difference was found among demographics betweenthe positive and negative patient groups. Average group age was 70.5 yearsand 72.9 years, respectively, and both groups had average BMI of 29.3kg/m2. Age-adjusted Charlson Comorbidity Index was 3.35 forthe positive group and 3.40 for the negative group. Total episode costs were50% higher in the negative group compared to the positive group ($31,462 vs.$15,845). The total post discharge costs for the negative group were $17,912which is significantly higher than those of the positive group ($2,502)(P<0.001). Thirteen patients (18.1%) attended skilled nursing facilities,and 12 of these patients exceeded the allocated budget. Average SNF cost was$13,089, which nearly matched the entire inpatient cost (facility + surgeonfees) of $13,400. Home health aide requirement was significant at 39%(n=28), and 15 of these patients (54%) also came in over budget.Conclusion:Results suggest that there is a considerable possibility for patientsundergoing TAA to have post-acute care requirements that drive cost overbudget, including admittance to skilled nursing facilities and home healthaide, likely sue to the added necessity for extended immobilization in anolder patient population. Such parameters should be factored into the BPCIreimbursement model for TAA.

BackgroundAll obese pregnant women are considered at equal high risk with respect to complications in pregnancy and birth, and are commonly managed through resource-intensive care pathways. However, the identification of maternal characteristics associated with normal pregnancy outcomes could assist in the management of these pregnancies. The present study aims to identify the factors associated with uncomplicated pregnancy and birth in obese women, and to assess their predictive performance.MethodsData form obese women (BMI ≥ 30 kg/m2) with singleton pregnancies included in the UPBEAT trial were used in this analysis. Multivariable logistic regression was used to identify sociodemographic, clinical and biochemical factors at 15+0 to 18+6 weeks’ gestation associated with uncomplicated pregnancy and birth, defined as delivery of a term live-born infant without antenatal or labour complications. Predictive performance was assessed using area under the receiver operating characteristic curve (AUROC). Internal validation and calibration were also performed. Women were divided into fifths of risk and pregnancy outcomes were compared between groups. Sensitivity, specificity, and positive and negative predictive values were calculated using the upper fifth as the positive screening group.ResultsAmongst 1409 participants (BMI 36.4, SD 4.8 kg/m2), the prevalence of uncomplicated pregnancy and birth was 36% (505/1409). Multiparity and increased plasma adiponectin, maternal age, systolic blood pressure and HbA1c were independently associated with uncomplicated pregnancy and birth. These factors achieved an AUROC of 0.72 (0.68–0.76) and the model was well calibrated. Prevalence of gestational diabetes, preeclampsia and other hypertensive disorders, preterm birth, and postpartum haemorrhage decreased whereas spontaneous vaginal delivery increased across the fifths of increasing predicted risk of uncomplicated pregnancy and birth. Sensitivity, specificity, and positive and negative predictive values were 38%, 89%, 63% and 74%, respectively. A simpler model including clinical factors only (no biomarkers) achieved an AUROC of 0.68 (0.65–0.71), with sensitivity, specificity, and positive and negative predictive values of 31%, 86%, 56% and 69%, respectively.ConclusionClinical factors and biomarkers can be used to help stratify pregnancy and delivery risk amongst obese pregnant women. Further studies are needed to explore alternative pathways of care for obese women demonstrating different risk profiles for uncomplicated pregnancy and birth.

Protective effects of grape seed proanthocyanidins against iron overload-induced renal oxidative damage in rats

BackgroundHigh-flow nasal cannula has been a promising initial respiratory support measure for patients with acute hypoxemic respiratory failure (AHRF) in the emergency department (ED). However, delayed detection of HFNC failure is associated with increased mortality. The ROX index is a tool that can help predict HFNC success. Nonetheless, its utility in ED patients is limited, and no studies have compared it with the HACOR scale, another tool that may be as accurate in predicting HFNC failure. Therefore, we aimed to compare the prognostic utility of the ROX index and the HACOR scale in emergency AHRF patients.MethodsThis prospective observational study was conducted at the ED of Siriraj Hospital, Thailand, between August 2018 and February 2020. Adult patients with AHRF requiring HFNC in the ED were included. The ROX index and the HACOR scale were measured at 1, 2, and 6 h after HFNC initiation. The primary outcome was HFNC success, defined as no intolerance or escalation towards mechanical ventilation or non-invasive ventilation within 48 h.ResultsA total of 75 patients were enrolled; 52 (69.3%) had a successful treatment. The ROX index was higher in the success group, while the HACOR scale was lower at all timepoints. The ROX index yielded generally higher discrimination capacity based on the area under the receiver operating characteristic curve (AUROC) than the HACOR scale [AUROC at 1, 2, and 6 h = 0.815, 0.784, 0.853 for ROX in predicting HFNC success and 0.733, 0.690, and 0.764 for HACOR in predicting HFNC failure]. The ROX index measured at 6 h at the cut-point of 4.88 had 92.98% sensitivity, 61.11% specificity, 88.33% positive predictive value, and 73.33% negative predictive value with a diagnostic accuracy of 85.33%.ConclusionThe ROX index had superior prognostic utility in predicting HFNC outcome (success/failure) compared to the HACOR scale in patients with AHRF in the ED setting. Moreover, it is less complex and more efficient to be employed at bedside. Therefore, the ROX index is a more appropriate tool to guide further management and potential escalation therapy for AHRF patients with HFNC therapy initiated in the ED.

In heart failure (HF), we observed two patterns of hyperpnea during Cheyne-Stokes respiration with central sleep apnea (CSR-CSA): a positive pattern where end-expiratory lung volume remains at or above functional residual capacity, and a negative pattern where it falls below functional residual capacity. We hypothesized the negative pattern is associated with worse HF. Patients with HF underwent polysomnography. During CSR-CSA, hyperpnea, apnea-hyperpnea cycle, and lung to finger circulation times (LFCT) were measured. Plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration and left ventricular ejection fraction (LVEF) were assessed. Of 33 patients with CSR-CSA (31 men, mean age 68 years), 9 had a negative hyperpnea pattern. There was no difference in age, body mass index, and apnea-hypopnea index between groups. Patients with a negative pattern had longer hyperpnea time (39.5 ± 6.4 versus 25.8 ± 5.9 seconds, P < .01), longer cycle time (67.8 ± 15.9 versus 51.7 ± 9.9 seconds, P < .01), higher NT-proBNP concentrations (2740 [6769] versus 570 [864] pg/ml, P = .01), and worse New York Heart Association class (P = .02) than those with a positive pattern. LFCT and LVEF did not differ between groups. Patients with HF and a negative CSR-CSA pattern have evidence of worse cardiac function than those with a positive pattern. Greater positive expiratory pressure during hyperpnea is likely generated during the negative pattern and might support stroke volume in patients with worse cardiac function. A commentary on this article appears in this issue on page 1227. The trial is registered with Current Controlled Trials (www.controlled-trials.com; ISRCTN67500535) and Clinical Trials (www.clinicaltrials.gov; NCT01128816).