Acute Deterioration Research Articles

Complicaciones agudas del paciente cirrótico. Ascitis, encefalopatía hepática y síndrome hepatorrenal

Hepatic cirrhosis is a disease that is initially silent (compensated cirrhosis) until advanced stages, when the patient presents with a symptomatic event known as decompensation, which is the consequence of progressive deterioration of liver function and an increase in portal pressure. Ascites, hepatic encephalopathy, and gastrointestinal bleeding due to varices are the classic decompensations of cirrhosis and their onset entails a marked worsening of the prognosis. The treatment of hepatic encephalopathy and ascites based on hygienic and dietary measures and a large treatment arsenal allows for a substantial improvement in quality of life. However, these patients must be evaluated for liver transplant, which is the only curative treatment of decompensated cirrhosis. Likewise, usually in the context of an infection or other triggering event, patients with cirrhosis and portal hypertension may present with acute deterioration of renal function known as hepatorenal syndrome (HRS), which emerges as a consequence of the local compensatory vasoconstriction due to loss of effective volume. The treatment of HRS is based on avoiding nephrotoxins, albumin infusion, and starting splanchnic vasoconstrictors, though again, liver transplant is the only curative treatment.

Inpatient nurses' preferences and decisions with risk information visualization.

We examined the influence of 4 different risk information formats on inpatient nurses' preferences and decisions with an acute clinical deterioration decision-support system. We conducted a comparative usability evaluation in which participants provided responses to multiple user interface options in a simulated setting. We collected qualitative data using think aloud methods. We collected quantitative data by asking participants which action they would perform after each time point in 3 different patient scenarios. More participants (n = 6) preferred the probability format over relative risk ratios (n = 2), absolute differences (n = 2), and number of persons out of 100 (n = 0). Participants liked average lines, having a trend graph to supplement the risk estimate, and consistent colors between trend graphs and possible actions. Participants did not like too much text information or the presence of confidence intervals. From a decision-making perspective, use of the probability format was associated with greater concordance in actions taken by participants compared to the other 3 risk information formats. By focusing on nurses' preferences and decisions with several risk information display formats and collecting both qualitative and quantitative data, we have provided meaningful insights for the design of clinical decision-support systems containing complex quantitative information. This study adds to our knowledge of presenting risk information to nurses within clinical decision-support systems. We encourage those developing risk-based systems for inpatient nurses to consider expressing risk in a probability format and include a graph (with average line) to display the patient's recent trends.

The differences in code status conversation approaches reported by emergency medicine and palliative care clinicians: A mixed-method study.

During acute health deterioration, emergency medicine and palliative care clinicians routinely discuss code status (e.g., shared decision making about mechanical ventilation) with seriously ill patients. Little is known about their approaches. We sought to elucidate how code status conversations are conducted by emergency medicine and palliative care clinicians and why their approaches are different. We conducted a sequential-explanatory, mixed-method study in three large academic medical centers in the Northeastern United States. Attending physicians and advanced practice providers working in emergency medicine and palliative care were eligible. Among the survey respondents, we purposefully sampled the participants for follow-up interviews. We collected clinicians' self-reported approaches in code status conversations and their rationales. A survey with a 5-point Likert scale ("very unlikely" to "very likely") was used to assess the likelihood of asking about medical procedures (procedure based) and patients' values (value based) during code status conversations, followed by semistructured interviews. Among 272 clinicians approached, 206 completed the survey (a 76% response rate). The reported approaches differed greatly (e.g., 91% of palliative care clinicians reported asking about a patient's acceptable quality of life compared to 59% of emergency medicine clinicians). Of the 206 respondents, 118 (57%) agreed to subsequent interviews; our final number of semistructured interviews included seven emergency medicine clinicians and nine palliative care clinicians. The palliative care clinicians stated that the value-based questions offer insight into patients' goals, which is necessary for formulating a recommendation. In contrast, emergency medicine clinicians stated that while value-based questions are useful, they are vague and necessitate extended discussions, which are inappropriate during emergencies. Emergency medicine and palliative care clinicians reported conducting code status conversations differently. The rationales may be shaped by their clinical practices and experiences.

Different outcomes between iso-osmolar and low-osmolar contrast media in acute myocardial infarction with renal impairment.

The selection of appropriate contrast media (CM) remains an important issue in terms of renal preservation in patients with acute myocardial infarction (AMI) and renal impairment scheduled for percutaneous coronary intervention (PCI). We compared the clinical outcomes of patients with AMI and renal impairment, depending on the CM type (iso-osmolar CM [IOCM] vs. low-osmolar CM [LOCM]) that was used during PCI. From the Convergent Registry of Catholic and Chonnam University for Acute Myocardial Infarction, 3174 post-PCI patients with AMI and renal impairment were subdivided into two groups (IOCM [n = 2101] and LOCM [n = 1073]). Regarding in-hospital clinical outcomes, the IOCM group had a higher peak creatinine (Cr) level and lower "Cr differential" than the LOCM group. A higher proportion of dialysis was noted in the IOCM group. In 30-day clinical outcomes, the IOCM group showed higher incidence of new-onset heart failure (HF) but lower incidence of revascularization than the LOCM group. The differences in in-hospital and 30-day clinical outcomes were attenuated after inverse probability of treatment weighting, except for new-onset HF. All other variables in 30-day clinical outcomes, including all-cause death, non-fatal myocardial infarction, cerebrovascular accidents, stent thrombosis, and any dialysis events, were similar between the two groups. IOCM use did not prevent future incidence of dialysis compared to LOCM use in AMI patients with renal impairment.

Mortality around the anniversary of a sibling’s death. Findings from Swedish register-data

Abstract Background Studies have found that the death of a sibling is associated with adverse health in bereaved siblings. Anniversaries may trigger grief reactions and contribute to an acute deterioration of health and are exogenous to shared intergenerational characteristics and may provide an indication of a causal effect of bereavement. Previous studies have found anniversary effects following the loss of a child and parent. We examined whether mortality increases among adult siblings around the anniversary following sibling death. Methods This case-crossover study used Swedish register-based longitudinal data from 1990 to 2016, based on the entire population. Participants included all adults aged 18 to 65 years who experienced sibling death and subsequently died. Conditional logistic regression was used to quantify the association between the anniversary (or preanniversary and postanniversary periods) and mortality, controlling for time-invariant confounding. All analyses were stratified by sex of the bereaved. Further analyses will also be stratified by socio-demographic characteristics such as the sex of the deceased sibling, time since sibling death, age, marital status and cause of sibling death. Results The results show that the anniversary of a siblings’ death is not associated with an increased mortality risk in bereaved siblings. We rather found somewhat reduced mortality risks around the anniversary dates in men (OR 0.78 95% CI 0.55-1.10 for the period ranging from 2 days before up to the anniversary) and women (OR 0.44 95% CI 0.20-0.97 for the anniversary). Further analysis will scrutinize whether anniversary effects are found when the analysis are stratified by socio-demographic characteristics and cause of sibling death. Conclusions Anniversaries following sibling death might not trigger grief to the same extent as anniversaries following the death of a parent or child. Sibling bereavement may still have health consequences although not during anniversaries. Key messages • Anniversaries following sibling death might not trigger grief to the same extent as child and parental bereavement. • Sibling bereavement may still have health consequences although not around anniversaries.

Effect of acupoint catgut embedding combined with western medicine on patients with stable COPD: Acupoint catgut embedding treating stable COPD meta-analysis.

Although bronchodilators and glucocorticoids can reduce the symptoms of cough and asthma to a certain extent, the adverse drug reactions and recurrence after recovery still trouble clinicians. Acupoint catgut embedding is effective in preventing and treating acute recurrence and deterioration of COPD, but its clinical efficacy remains controversial. Therefore, this study evaluated the clinical efficacy and safety of acupoint catgut embedding combined with conventional Western medicine for COPD through meta-analysis. Pubmed, the Cochrane Library, Web of Science, Sinomed, China Knowledge Network, VIP, and Wanfang databases were searched, with a time frame from database creation to November 2022. Meta-analysis was performed with Revman 5.3. Publication bias was assessed by Stata 15.0. Seventeen studies were listed, with a total sample size of 1516 cases. Meta-analysis showed that compared with conventional western medicine, acupoint catgut embedding combined with conventional western medicine could effectively improve the total effective rate of clinical symptoms of stable COPD [RR = 1.21, 95%CI (1.13, 1.29), P < .00001], forced expiratory volume in 1 second (FEV1) [mean difference (MD) = 0.04, 95%CI (0.00, 0.09), P = .04],the percentage of forced expiratory volume in 1 second predicted value [MD = 1.13, 95%CI (0.38,1.88), P = .003], acute exacerbation of chronic obstructive pulmonary disease [MD = -0.73, 95%CI (-1.04, -0.42), P < .00001], COPD assessment test score [MD = -2.39, 95%CI (-3.65, -1.13), P = .0002], the improved medical research council respiratory questionnaire score (mMRC score) [MD = -0.15, 95%CI (-0.29, -0.02),P = .03], 6-minute walk distance [MD = 28.16, 95%CI (17.31, 39.00), P < .00001], the production of inflammatory factor interleukin-8 [MD = -9.65, 95%CI (-10.44, -8.86), P < .00001], but the adverse event rate was comparable[RR = 1.39, 95%CI (0.28,6.91), P = .69]. However, there was no significant difference in forced expiratory volume in 1 second/forced vital capacity and TNF-α between the acupoint catgut embedding combined group and the conventional western medication group. Harbord test showed no significant publication bias. The clinical efficacy of acupoint catgut embedding combined with conventional western medicine for stable COPD is better than that of conventional western medicine, and the safety may be equivalent to that of conventional western medicine, which has the value of further research exploration.

THU619 Atypical Clinical Presentation Of Adrenal Hemorrhage

Abstract Disclosure: T.L. Madsen-Barbosa: None. F.H. Antoni: None. A. Ghazi: None. Introduction: Adrenal hemorrhage (AH) is an uncommon condition that is challenging to diagnose due to its nonspecific findings. We illustrate a case of AH that presented with acute clinical deterioration and had catecholamine overproduction. Case: A 58-year-old woman with a history of migraine headaches and prediabetes presented to the emergency department for “the worst headache of her life” and palpitations of 4 hours duration. On admission, her blood pressure was 224/139 mmHg and heart rate was 102 bpm. Her physical examination was significant for diaphoresis and active vomiting. Initial laboratory tests showed hyperglycemia and leukocytosis. Her ECG, non-contrast CT scan of the head and CT angiography of the head and neck were unremarkable. Her hospital course was complicated by recurrent hypertensive episodes, arrhythmias including Torsades de pointes, and left flank pain. A CT chest, abdomen, and pelvis revealed a large left retroperitoneal hemorrhagic collection which seemed to arise from the inferior aspect of the left adrenal gland. She subsequently underwent successful IR embolization of the left inferior suprarenal artery. Further workup showed elevated urinary fractionated metanephrine and normetanephrine levels, as well as elevated levels of plasma free metanephrine and normetanephrine. Given concern for pheochromocytoma, phenoxybenzamine was started. A repeat CT abdomen after six days demonstrated shrinkage in hematoma and a 7 mm hypoattenuating nodule arising from the medial limb of the left adrenal gland. Outpatient follow-up CT abdomen showed left adrenal thickening with a 2.3 cm nodular area with 78.9 Hounsfield units and absolute washout of 60.9% suggestive of adenoma. After one month, repeat catecholamine levels normalized. Discussion: The clinical manifestation of AH varies widely. Acute adrenal insufficiency is seen if bilateral glands and 90% of the cortices are compromised. However, unilateral AH is most often asymptomatic - found incidentally on imaging. Having elevated catecholamines is described in 30% of patients in one case series. Differentiating spontaneous AH from hemorrhagic adrenal tumors is also a dilemma. Among the hemorrhagic adrenal masses, pheochromocytoma is the most common. Conclusion: This case highlights that clinicians should be aware of clinical manifestations of catecholamine excess when evaluating patients with AH. A catecholamine producing adrenal mass (pheochromocytoma) should also be ruled out in these situations. Reference:1- Elhassan YS, Ronchi C, Wijewickrama P, Balvedeweg SE. Approach to the patient with adrenal hemorrhage. J Clin Endocrinol Metab. 2023, 108 (4):995-1006.2- Karwacka IM, Obolonczyk L, Sworczak K. Adrenal hemorrhage: a single center experience and literature review. Adv Clin Exp Med. 2018; 27 (5): 681-687. Presentation: Thursday, June 15, 2023

Secondary Spontaneous Pneumothorax in Patients with Silicosis.

Background and aims: Patients with silicosis are at increased risk of pneumothorax. However, the true incidence of pneumothorax in these patients is yet unknown. Our objective was to study the proportion of secondary spontaneous pneumothorax (SSP) in patients with silicosis who present with acute respiratory deterioration. We also analyzed the risk factors, clinical course, actual management, and treatment outcomes of pneumothorax in patients with silicosis. Materials and methods: It was a hospital-based descriptive cross-sectional study. A total of hundred silicosis patients presenting with any acute worsening respiratory symptoms (dyspnea, cough, and chest pain) warranting admission were enrolled. A detailed history, clinical examination, and radiological investigations were done in all cases. Results: A total of 100 patients were included in this study. The mean age of subjects was 51.6 years. Breathlessness was the most common presenting symptom followed by chest pain. A total of 43 (43%) patients had pneumothorax at presentation. Right-sided pneumothorax was seen in 26 (26%) cases, left-sided in 11 (11%) cases, and six patients (6%) had bilateral pneumothorax. No significant correlation of smoking with pneumothorax was observed in the present study. Around 42% of patients had pulmonary tuberculosis which was microbiologically confirmed. Conclusion: The present study emphasizes that all patients of silicosis who present with acute worsening shortness of breath and or chest pain need to be evaluated for pneumothorax. How to cite this article: Bairwa M, Sharma A, Luniwal M. Secondary Spontaneous Pneumothorax in Patients with Silicosis. J Assoc Physicians India 2023;71(10):64-66.

Impacts of the development of acute-on-chronic liver failure and bacterial infections on β-cell function and glucose homeostasis in patients with liver cirrhosis

BackgroundThe pathogenesis involved in glucose metabolism disorders (GMDs) in patients with liver cirrhosis remains unclear. AimsWe investigated the effects of acute-on-chronic liver failure (ACLF) development and bacterial infections (BIs) on pancreatic β-cell function and glucose homeostasis in individuals with liver cirrhosis. MethodsA retrospective analysis was conducted on 327 patients experiencing acute deterioration of liver cirrhosis. Oral glucose tolerance tests (OGTTs) and OGTT-based β-cell function indices were employed to assess β-cell function and glucose homeostasis. Univariate and multivariate logistic regression analyses were employed to identify GMD-associated risk factors. ResultsBoth the development of ACLF and BIs significantly increased the prevalence of GMDs. Both ACLF and BIs markedly elevated the homeostasis model of assessment 2-insulin resistance (HOMA2-IR). ACLF significantly impaired glucose-stimulated insulin secretion, as evidenced by reduced insulinogenic index (IGI). Patients with GMDs exhibited significantly lower IGI levels than those without GMDs. Independent risk factors associated with GMDs were prothrombin activity (odds ratio [OR]=0.981, 95% confidence interval [CI]: 0.960–0.995), HOMA2-IR (OR=1.749, 95% CI: 1.130–2.707), and IGI (OR=0.963, 95% CI: 0.947–0.978). ConclusionsIn liver cirrhosis, the onset of ACLF impairs glucose-stimulated insulin secretion from β-cells. Both liver impairment and BIs contribute to increased insulin resistance, ultimately disturbing glucose homeostasis.

Occult myocardial injury is prevalent amongst elderly patients in the hospital-at-home setting. A retrospective analysis of 213 patients

BackgroundHospital-at-Home (HAH) is a valid alternative for in-hospital stay for a wide variety of clinical indications. Occult myocardial injury, associated with acute illness, mainly occurs in patients with a background of non-obstructive coronary disease. The aim of this study was to describe the prevalence of this phenomenon in our HAH population. MethodsA retrospective description and analysis of data collected for patients admitted to the Sheba beyond's HAH services during 14 months. ResultsDuring a period of 14 months (7/10/21–6/12/22), blood troponin measurements were available for 213 patients (median age 78 years, 52% males) hospitalized mainly for infectious causes. The median HS (highly sensitive) troponin level was 7.7 ng/L (IQR = 13.2 ng/L) (the normal upper limit is 12 ng/L) with 31% of all patients demonstrating an abnormally increased troponin level (68/213). Of all patients, 64% had a background diagnosis of a cardiovascular disease (138/213), of whom, 49% had abnormal HS troponin levels (68/138). No patient suffered from acute cardiac function deterioration and no patient died during their hospital-at-home stay. ConclusionThe prevalence of occult myocardial injury amongst elderly patients admitted to hospital-at-home stay for diagnoses other than myocardial infarction is relatively high but it is not associated with worse short-term clinical outcomes.

42 Enacting Meaningful Change in the Face of Adversity – Use of a Sentinel Event to Pilot the Creation of a Rapid Response System in a Tertiary Paediatric Care Centre

Abstract Introduction/Background Although rare, in-hospital paediatric mortality occurs at a rate of 12.66 per 1000 admissions. Delayed recognition of clinical deterioration is a modifiable factor in such adverse events. In paediatric patients, subtle changes in vital signs often precede acute deterioration and provide an opportunity for early intervention and prevention of further deterioration. Based on this rationale, rapid response systems (RRS), which include a critical care response team (CCRT) and a Paediatric Early Warning Score (PEWS), have been established to facilitate the detection of clinical deterioration and mobilize resources for timely treatment. There is evidence that RRS can significantly decrease inpatient clinical deterioration events and PICU utilization. Objectives At our institution, serious patient safety events identified system failures in recognition, communication, and escalation of care in response to clinical deterioration. The root cause analysis led to a quality improvement and patient safety initiative to implement an RRS at our tertiary paediatric care centre. Design/Methods Process implementation of this pilot project required consultations with key stakeholders and designation of unit champions to mobilize resources and promote buy-in. Based on other successful implementation strategies, we adopted the Modified Brighton PEWS, defined a response algorithm, created bedside tools, constructed an interdisciplinary CCRT, and organized simulation activities to implement the new process. We used the Plan-Do-Study-Act method to carry out change based on weekly feedback from frontline workers. To assess the feasibility and acceptability of this initiative, all CCRT activations during the pilot phase were reviewed and a survey was distributed pre- and post-implementation. The number of code blues and mortality data will also be measured. Results The pilot period spanned June to September 2022 on our medical inpatient unit. Average response time to CCRT activation was 12 minutes (IQR 7-13.5), a median of three therapeutic interventions were required per activation, and 33% of activations resulted in PICU admissions. Among the 27 post–implementation survey respondents, 87% identified CCRT as a useful addition to optimize care and address patient safety concerns. Qualitatively, it has created a shared safety culture and empowered junior members of healthcare teams to escalate care. Conclusion This quality improvement initiative pilot study has demonstrated feasibility and acceptability of RRS implementation with a positive impact on patient safety culture and earlier detection and intervention for deteriorating patients. Further prospective comparative clinical benefits and cost-benefit analyses are needed to support hospital-wide implementation.

641 Impact of Frailty on Patient Outcomes After Cardiac Surgery: An Updated Systematic Review and Meta-Analysis

Abstract Aim To determine the impact of frailty on patient outcomes after undergoing cardiac surgery. Method An analysis of frail versus non-frail patients who had undergone cardiac surgery was conducted using data from Pubmed/Medline, EMBASE, Cochrane, Web of Science, Scopus, and grey literature, all searched in April 2022. The primary outcomes of early postoperative mortality and major adverse cardiovascular events (MACE) were examined, as well as secondary outcomes, including long-term mortality and complications. Data were analyzed using R version 4.0.3. Results A total of 22 studies, including 102,323 frail and 2,187,814 non-frail patients, were included in the analysis. Frailty was found to be significantly associated with higher early mortality (RR: 2.93; 95% CI, 2.19–3.93; P &amp;lt; 0.01; I2 = 17.2%) and MACE (RR: 2.07; 95% CI, 1.21–3.55; P = 0.03; I2 = 22.9%) compared to non-frail patients. Frailty was also associated with a higher risk of acute kidney injury and renal impairment (RR: 3.67; 95% CI, 2.85–4.73; P = 0.03; I2 = 3.9%). In the long term, a higher mortality rate was observed in frail patients (RR: 2.93; 95% CI, 1.69–5.07; P = 0.02; I2 = 22.4%). However, no significant differences were found in pneumonia, respiratory complications, sepsis, or reoperation rates between frail and non-frail patients. Conclusions Frailty is associated with higher mortality and MACE in patients undergoing cardiac surgery and a higher risk of acute kidney injury. Frailty should be considered an important factor in preoperative risk assessment and perioperative care for these patients.

Sars-Cov-2 Infection in People with Type 1 Diabetes and Hospital Admission: An Analysis of Risk Factors for England.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus (coronavirus disease 2019 [COVID-19]) pandemic revealed the vulnerability of specific population groups in relation to susceptibility to acute deterioration in their health, including hospital admission and mortality. There is less data on outcomes for people with type 1 diabetes (T1D) following SARS-CoV-2 infection than for those with type 2 diabetes (T2D). In this study we set out to determine the relative likelihood of hospital admission following SARS-CoV-2 infection in people with T1D when compared to those without T1D. This study was conducted as a retrospective cohort study and utilised an all-England dataset. Electronic health record data relating to people in a national England database (NHS England's Secure Data Environment, accessed via the BHF Data Science Centre's CVD-COVID-UK/COVID-IMPACT consortium) were analysed. The cohort consisted of patients with a confirmed SARS-CoV-2 infection, and the exposure was whether or not an individual had T1D prior to infection (77,392 patients with T1D). The patients without T1D were matched for sex, age and approximate date of the positive COVID-19 test, with three SARS-CoV-2-infected people living without diabetes (n = 223,995). Potential factors influencing the relative likelihood of the outcome of hospital admission within 28days were ascertained using univariable and multivariable logistic regression. Median age of the people living with T1D was 37 (interquartile range 25-52) years, 47.4% were female and 89.6% were of white ethnicity. Mean body mass index was 27 (standard error [SE] 0.022)kg/m2, and mean glycated haemoglobin (HbA1c) was 67.3 (SE 0.069) mmol/mol (8.3%). A significantly higher proportion of people with T1D (10.7%) versus matched non-diabetes individuals (3.9%) were admitted to hospital. In combined analysis including individuals with T1D and matched controls, multiple regression modelling indicated that the factors independently relating to a higher likelihood of hospital admission were: T1D (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.62-1.80]), age (OR 1.02, 95% CI 1.02-1.03), social deprivation (higher Townsend deprivation score: OR 1.07, 95% CI 1.06-1.08), lower estimated glomerular filtration rate (eGFR) value (OR 0.975, 95% CI 0.974-0.976), non-white ethnicity (OR black 1.19, 95% CI 1.06-1.33/OR Asian 1.21, 95% CI 1.05-1.39) and having asthma (OR 1.27, 95% CI 1.19-1.35]), chronic obstructive pulmonary disease (OR 2.10, 95% CI 1.89-2.32), severe mental illness (OR 1.83, 95% CI 1.57-2.12) or hypertension (OR 1.44, 95% CI 1.37-1.52). In this all-England study, we describe that, following confirmed infection with SARS-CoV-2, the risk factors for hospital admission for people living with T1D are similar to people without diabetes following confirmed SARS-CoV-2 infection, although the former were more likely to be admitted to hospital. The younger age of individuals with T1D in relation to risk stratification must be taken into account in any ongoing risk reduction strategies regarding COVID-19/future viral pandemics.

O07 Faceless PHACES

Abstract PHACES syndrome (posterior fossa – haemangioma – arterial – cardiac – eye – sternal) is a multisystem disorder which often presents first with a facial, segmental infantile haemangioma (IH). Prompt recognition of this subtype of IH is key to enable early detection of neurological/ophthalmological/cardiac anomalies. As per international consensus guidelines, the presence of a facial segmental haemangioma &amp;gt; 5 cm triggers screening for associated extracutaneous anomalies. We present three infants with absent/minimal facial haemangioma, but who fulfilled extracutaneous criteria of PHACES syndrome. Patient 1 was a 3-week-old female who presented with a 1–2-cm linear superficial left post-auricular IH. PHACES screening revealed an atrial septal defect, intracranial haemangiomas and hypoplastic cerebrovasculature. Patient 2, a 9-month-old girl, was admitted to intensive care following acute respiratory deterioration. Examination revealed a segmental IH of the occipital scalp. PHACES screening revealed a vascular ring, right aortic arch, aberrant subclavian artery, subglottic and mediastinal IH and narrowing/tortuosity of the left internal carotid artery. Patient 3, a 4-month-old male, was referred for evaluation of three superficial IH, all &amp;lt; 0.5 cm, one on the right post-auricular skin and two on the right forehead. He suffered acute collapse at 2 weeks of life leading to a diagnosis of obstructed total anomalous pulmonary–venous connection requiring emergency surgical correction. PHACES screening revealed bilateral dysplastic/torturous internal carotid arteries. We present three cases of PHACES syndrome without the classic facial segmental IH. Clinicians should be aware of the spectrum of IH observed in PHACES syndrome to enable prompt screening of those presenting with atypical scalp and post-auricular lesions.

Feeling like the enemy: the emotion management and alienation of hospital doctors.

Globally, an epidemic of psychological distress, burnout, and workforce attrition signify an acute deterioration in hospital doctors' relationship with their work-intensified by COVID-19. This deterioration is more complicated than individual responses to workplace stress, as it is heavily regulated by social, professional, and organizational structures. Moving past burnout as a discrete "outcome," we draw on theories of emotion management and alienation to analyze the strategies through which hospital doctors continue to provide care in the face of resource-constraints and psychological strain. We used Mobile Instant Messaging Ethnography (MIME), a novel form of remote ethnography comprising a long-term exchange of digital messages to elicit "live" reflections on work-life experiences and feelings. The results delineate two primary emotion-management strategies-acquiescence and depersonalization-used by the hospital doctors to suppress negative feelings and emotions (e.g., anger, frustration, and guilt) stemming from the disconnect between professional norms of expertise and self-sacrifice, and organizational realities of impotence and self-preservation. Illustrating the continued relevant of alienation, extending its application to doctors who disconnect to survive, we show how the socio-cultural ideals of the medical profession (expertise and self-sacrifice) are experienced through the emotion-management and self-estrangement of hospital doctors. Practically, the deterioration of hospital doctors' relationship with work is a threat to health systems and organizations. The paper highlights the importance of understanding the social structures and disconnects that shape this deteriorating relationship and the broad futility of self-care interventions embedded in work contexts of unrealized professional ideals, organizational resource deficits and unhappy doctors, patients, and families.

Comparison between Levosimendan versus Beta Agonists in Preservation of Renal Function in Cardiac Surgery Patients with Low Cardiac Output Syndrome

Abstract Background Acute kidney injury post cardiac surgery in patients who develop low cardiac output syndrome (LCOS) postoperatively is a serious complication. Many studies have been performed to assess the effect of inotropic agents on cardiac function when administered postoperatively, some studies performed to evaluate the nephroprotective effect of conventional inotropic agents as compared to levosimendan. Objective To evaluate the possible nephroprotective effect of Levosimendan as compared to betaagonists in cardiac surgery patients with LCOS. Patients and Methods It is a randomized prospective comparative study at Ain Shams university hospitals from December 2020 to May 2021. A total of 60 patients who have developed low cardiac output syndrome post cardiac surgery divided into two groups of 30 patients each. Group A received beta-agonists (dobutamine 2 - 20 µ/kg/min or adrenaline 0.01 to 0.5 mcg/kg/minute) and Group B received levosimendan for 24 h at a rate of 0.1 mcg/kg/min to a target dose of 12.5 mg. we assessed the incidence of renal failure in these patients. We assessed the progress of acute kidney injury in patients who developed acute renal impairment at diagnosis of LCOS in both treatment groups. Parameters assessed include hemodynamics and renal function parameters. Results The incidence of acute kidney injury at diagnosis of LCOS postoperative was 30% (n = 9) in each group, 44% of them in the control group (n = 4) developed renal failure at discharge from ICU and none of the study group patients developed renal failure at discharge. At time of discharge from ICU the incidence of renal failure in beta – agonist group was 13.3% while the incidence in the levosimendan group was 0%. Conclusion Levosimendan has a nephroprotective effect that plays a role in preservation of renal functions and decreasing the incidence of kidney failure in patients with LCOS post cardiac surgery as compared to beta – agonists.

Predicting acute clinical deterioration with interpretable machine learning to support emergency care decision making

The emergency department (ED) is a fast-paced environment responsible for large volumes of patients with varied disease acuity. Operational pressures on EDs are increasing, which creates the imperative to efficiently identify patients at imminent risk of acute deterioration. The aim of this study is to systematically compare the performance of machine learning algorithms based on logistic regression, gradient boosted decision trees, and support vector machines for predicting imminent clinical deterioration for patients based on cross-sectional patient data extracted from electronic patient records (EPR) at the point of entry to the hospital. We apply state-of-the-art machine learning methods to predict early patient deterioration, based on their first recorded vital signs, observations, laboratory results, and other predictors documented in the EPR. Clinical deterioration in this study is measured by in-hospital mortality and/or admission to critical care. We build on prior work by incorporating interpretable machine learning and fairness-aware modelling, and use a dataset comprising 118, 886 unplanned admissions to Salford Royal Hospital, UK, to systematically compare model variations for predicting mortality and critical care utilisation within 24 hours of admission. We compare model performance to the National Early Warning Score 2 (NEWS2) and yield up to a 0.366 increase in average precision, up to a 21.16% reduction in daily alert rate, and a median 0.599 reduction in differential bias amplification across the protected demographics of age and sex. We use Shapely Additive exPlanations to justify the models’ outputs, verify that the captured data associations align with domain knowledge, and pair predictions with the causal context of each patient’s most influential characteristics. Introducing our modelling to clinical practice has the potential to reduce alert fatigue and identify high-risk patients with a lower NEWS2 that might be missed currently, but further work is needed to trial the models in clinical practice. We encourage future research to follow a systematised approach to data-driven risk modelling to obtain clinically applicable support tools.

Clinicoradiologic Risk Stratification and Outcome Assessment in Symptomatic Intracranial Arachnoid Cyst Managed Over Fifteen Years

Arachnoid cysts (ACs) are developmental anomalies formed by splitting the arachnoid membrane's layers. ACs contribute around 2% of all intracranial space-occupying lesions. ACs are more prevalent in children. Because of varied clinical presentation, there has been a constant need for clinicoradiologic risk stratification with a possible role in outcome prediction. The present study describes the management strategies and outcomes in symptomatic intracranial ACs. All biopsy-proven symptomatic patients who underwent surgical management over last 15 years were included in this study (January 2008-December 2022), while those with non-conclusive biopsies were excluded. Patients presenting with acute deterioration were managed in the emergency department with or without cerebrospinal fluid diversion and decompression of the AC. The microsurgical or endoscopic approach was the preferred surgical modality. Postoperative clinicoradiologic improvement was evaluated at 3 months follow-up visit. A total of 108 patients were analyzed in this retrospective observational study. The median age of the patients was 27.5 years (range, 1 to 76 years). Headache was the most typical clinical presentation. Supratentorial ACs (n= 59, 54.6%) were higher than the infratentorial ACs (n= 49, 45.4%). Forty-seven patients belonged to the pediatric age group (<18 years), and seizure was their presenting complaint. In this observational study, there was no statistical difference in operative duration between microsurgical technique versus endoscopic decompression (P= 0.23). ACs are uncommon brain lesions having a broad spectrum of symptoms. The location and clinical presentation of ACs decide the preferred surgical approach. Individuals in high-risk groups must be treated on priority to achieve long-term relief of symptoms.

Reflections from the frontline of nursing on acute patient deterioration.

To describe medical-surgical nurses' reflections on their experiences with patient deterioration. An extensive body of knowledge exists regarding optimal responses to acute patient deterioration within a hospital environment. Much less attention has focused on the profound psychological and emotional impact these experiences of unexpected deterioration can have on nurses who provided the supportive or rescue care. A triggering event, such as patient deterioration, or direct questioning about these experiences, can lead nurses to reflect further on the situation. Engaging in reflection is believed to enhance learning and improve clinical judgement when future complex situations arise. Findings related to nurses' reflective practice when recalling previous situations with deteriorating patients are limited. This gap in the literature provided the basis for the current project. A qualitative descriptive design. Twenty medical-surgical nurses were interviewed in 2018. The nurses were recruited through purposive sampling. Semi-structured telephone interviews explored nurses' experiences of a patient deterioration. Conventional content analysis with iterative coding and categorising and theme development was used for data analysis. Three themes emerged as participants reflected on their experiences. The themes were, Enduring frustration and regret, Feeling deeply responsible for and to the patient and Making sense of what happened. Medical-surgical nurses who care for acutely deteriorating patients can experience lasting emotional, psychological and physical concerns that often go unrecognised and untreated. Furthermore, nurses with this background commonly reported their perceived increased risk for workplace distress. Findings from this study are important for nurses, healthcare administrators and leaders, and patients. Participating in a rescue attempt often has a negative impact on nurses' perception of workplace stress and on persistent concerns about nurses' mental and physical health. The findings can be useful in informing additional studies about the phenomenon. Findings also can inform the exploration of workplace design. Organisations should assess for factors influencing workplace stress, develop strategies to mitigate the presence of workplace stress and foster nurses' well-being so they can respond to future scenarios of patient deterioration, while maintaining their physical and mental health. This study did not include any patient or public input.

Implementasi Early Warning System (Ews) dalam Mendeteksi Perburukan Akut pada Pasien Dewasa di Ruang Rawat Inap Rumah Sakit

The purpose of this scoping review is to identify how the application of EWS to detecting acute deterioration in adult patients in general ward hospital. The method used was a scoping review and the literature has been obtained from searches derived from four databases originating from PubMed, Scopus, Sage, and CINAHL. The results showed that the implementation of EWS consisted of 6 components (vital sign recording, EWS scoring and reading, EWS protocol, clinical response based on escalation protocol, information assistance process using bundle communication (SBAR), medical emergency team (MET) system activation). Seven main of vital sign have to measured are respiratory rate, oxygen saturation, oxygen supplementation, temperature, pulse, systolic blood pressure, and level of consciousness. Persistence and additional commitment since 2009 were identified as significantly increasing benefits during the implementation of EWS instruments to improve patient outcomes. This success was obtained from experience that can increase the knowledge and competence of nurses. Changes in the risk of the EWS score can be read by nurses as an indication of clinical deterioration that requires stabilization interventions. Innovations have also been carried out since 2013 which have been successfully implemented in various countries, especially in 2019 and 2021 which are called EWS electronic. Based on this study, EWS proved to be accurate in detecting deterioration in patients. Therefore, to improve the implementation of EWS nurses must have good knowledge, because in implementing EWS requires critical thinking, and the ability to analyze numerical score classifications as a basis for decision making.&#x0D; &#x0D; Keywords: Early Warning System, EWS, Nurse Implementation, Patient deterioration.