Bedside Clinical Assessment Research Articles

Bedside clinical assessment of patients with common upper limb tremor and algorithmic approach.

The diagnostic approach for patients with tremor is challenging due to the complex and overlapping phenotypes among tremor syndromes. The first step in the evaluation of tremor is to identify the tremulous movement and exclude the tremor mimics. The second step is to classify the tremor syndrome based on the characteristics of tremor from historical clues and focused examination (Axis 1). Comprehensive tremor examinations involve the assessment of tremor in different conditions (rest, action or mixed, position or task-specific), distribution of tremor (upper limb, lower limb, head, jaw), positive signs for functional tremor (FT) if suspected (distractibility, entrainment, co-contraction), and associated neurological signs including parkinsonism, dystonic posture, cerebellar/brainstem signs, neuropathy, and cognitive impairment. A pivotal feature in this step is to determine any distinct feature of a specific isolated or combined tremor syndrome. In this review, we propose an algorithm to assess upper limb tremors. Ancillary testing should be performed if clinical evaluation is unclear. The choice of investigation depends on the types of tremors considered to narrow down the spectrum of etiology (Axis 2). Laboratory blood tests are considered for acute onset and acute worsening of tremors, while structural neuroimaging is indicated in unilateral tremors with acute onset, nonclassical presentations, and a combination of neurological symptoms. Neurophysiological study is an important tool that aids in distinguishing between tremor and myoclonus, etiology of tremor and document specific signs of FT. Treatment is mainly symptomatic based depending on the etiology of the tremor and the patient's disabilities.

Clinical significance of an elevated on-admission beta-hydroxybutyrate in acutely ill adult patients without diabetes.

To determine the relationship between point-of-care β-hydroxybutyrate (BHB) concentration and outcomes in adult patients without diabetes admitted through ED. This was a prospective study from 10 March to 2 July 2021. Admitted patients without diabetes had capillary BHB sampled in ED. Outcomes of length-of-stay (LOS), composite mortality/ICU admission rates and clinical severity scores (Quick Sepsis Organ Failure Assessment score/National Early Warning Score [qSOFA/NEWS]) were measured. BHB was assessed as a continuous variable and between those with BHB above and equal to 1.0 mmol/L and those below 1.0 mmol/L. A total of 311 patients were included from 2377 admissions. Median length-of-stay was 4.1 days (IQR 2.1-9.8), 18 (5.8%) died and 37 (11.8%) were admitted to ICU. Median BHB was 0.2 mmol/L (IQR 0.1-0.4). Twenty-five patients had BHB ≥1.0 mmol/L and five were >3.0 mmol/L. There was no significant difference in median LOS for patients with BHB ≥1.0 mmol/L compared to non-ketotic patients, 5.3 days (IQR 2.2-7.5) versus 4.1 days, respectively (IQR 2.0-9.8) (P = 0.69). BHB did not correlate with LOS (Spearman ρ = 0.116, 95% confidence interval: 0.006-0.223). qSOFA and NEWS also did not differ between these cohorts. For those 25 patients with BHB ≥1.0 mmol/L, an infective/inflammatory diagnosis was present in 11 (44%), at least 2 days of fasting in 10 (40%) and ethanol intake >40 g within 48 h in 4 (16%). Routine BHB measurement in patients without diabetes does not add to clinical bedside assessment and use should be limited to when required to confirm a clinical impression.

Abstract 15237: Feasibility and Diagnostic Accuracy of Handheld Echocardiography in Patients Hospitalized With Acute Coronary Syndrome

Introduction: Transthoracic echocardiography (TTE) is recommended in every acute coronary syndrome (ACS) patient, but is time-consuming and not always deliverable. Development of handheld echocardiography (HHE) devices provide a fast, low-cost method to facilitate rapid bedside clinical assessment of those patients. Hypothesis: We hypothesized that evaluation of hospitalized ACS patients using HHE is feasible and provide similar information to standard TTE in detecting important cardiac pathology. Methods: Patients admitted with ACS were prospectively enrolled, and underwent both bedside HHE (Philips Lumify) and clinical TTE evaluation. Independent analysis of HHE and TTE images was performed by a blinded expert team to determine key predetermined imaging findings that might alter management of ACS patients (Table 1). The TTE analysis was repeated for these variables after 1 month. Agreement of HHE vs TTE was assessed with kappa statistics and compared to agreement of TTE vs TTE as reference standard. Results: The analysis included 108 patients (mean age 65y, 78% male). Duration of HHE was a third faster than targeted clinical TTE (8.2±1.8min vs 12.1±5.0min; p<0.001). Agreement in detecting the following variables was good (>0.60) and similar for HHE vs TTE compared to TTE vs TTE: left ventricle (LV) dilatation, LV hypertrophy, LV ejection fraction <40%, anterior and inferior wall motion abnormalities, right ventricle (RV) dilatation, pericardial effusion, aortic stenosis, ventricle septum defect, and takotsubo cardiomyopathy. Agreement between HHE vs TTE was less good than TTE vs TTE for detection of lateral wall motion abnormalities, RV dysfunction, and LV thrombus. Conclusions: In ACS patients, bedside HHE is faster and provides similar diagnostic information to TTE for the majority of key echo findings. However, important exceptions exist, in particular HHE is less good at detecting lateral wall motion abnormalities, RV dysfunction and LV thrombus.

Design and testing of an optical instrument for skin flap monitoring

Flap procedures are complex surgical tools widely used in reconstructive surgery. Flap ischemia is one of the most dangerous complications, both during the surgical procedure and during the patient's recovery, which can quickly lead to tissue necrosis (flap loss) with serious medical and psychological consequences. Today, bedside clinical assessment remains the gold standard for flap monitoring, but timely detection of flap ischemia is a difficult and challenging task, so auxiliary techniques are needed to support flap monitoring. Here we present a prototype of a new optical diagnostic tool, based on visible light absorption in diffuse reflectance spectroscopy, for non-invasive, continuous, real-time monitoring of flaps. The proposed approach is assessed by monitoring flap ischemic scenarios induced on pig animal models. The results obtained support that the proposed approach has great potential, not only for prompt detection of ischemia (in seconds), but also for clear differentiation between an arterial occlusion and venous occlusion.

24 Benefit of therapeutic oral trials in dysphagia rehabilitation

Abstract Background Therapeutic oral trials (also known as ‘swallow trials’) are one therapeutic approach offered by Speech and Language Therapists (SLTs) as part of dysphagia rehabilitation. It involves offering prescribed amounts of a specified consistency of food and/or fluids to patients whom it is felt would not safely take full portions of oral intake due to risk of aspiration. These patients typically receive the majority of their nutrition and hydration artificially with the purpose of therapeutic oral trials being comfort, enjoyment and an opportunity to swallow in a functional manner (incorporating principles of neuroplasticity such as specificity, intensity and grading). Methods Three patients >60 years age from a variety of patient cohorts (stroke, cardiothoracic surgery, critical care) presented with moderate–severe dysphagia (confirmed on instrumental assessment). All received full nutrition and hydration via nasogastric tube. All received baseline clinical bedside assessment and Fibreoptic Endoscopic Evaluation of Swallowing (FEES). Based on the results of same, programme of dysphagia rehabilitation exercises were provided. All patients also received daily swallow rehab consisting of therapeutic oral trials (ice chips, fluids, diet) along with traditional exercises. Repeat FEES was completed after three weeks to assess progress and guide recommendations for oral intake and rehab. Results After three weeks, all patients showed two point improvements on dysphagia outcome severity scale. After six weeks, all patients were on full oral intake, no longer receiving artificial nutrition. Anecdotally, all patients reported that therapeutic oral trials provided significant enjoyment and added to quality of life. SLTs subjectively noted improved engagement and improved oral hygiene versus swallow rehab alone. Conclusion The concept of therapeutic oral trials builds on principles of neuroplasticity and are a useful adjunct in the dysphagia rehab toolbox of the SLT. They can have clinical benefit and support traditional rehabilitation. Importantly, patients report significant enjoyment and improved swallow-related quality of life when receiving them.

CT perfusion for Assessment of poor Neurological outcome in Comatose Cardiac Arrest Patients (CANCCAP): protocol for a prospective study

IntroductionCardiac arrest remains one of the most common causes of death with the majority occurring outside of hospitals (out of hospital cardiac arrest). Despite advancements in resuscitation management, approximately 50%...

Reliability and validity of the Slovenian Translation of the Functional Oral Intake Scale (FOIS-SI)

Background: It is crucial that each and every stroke patient gets a systematic assessment of swallowing disorders, performed by a dysphagia specialist. Therefore, there is a need to use a standardized scale among professionals. The aim of this study was to translate, adapt, and obtain the statistical characteristics of the Functional Oral Intake Scale (FOIS), which is an observer-rated dysphagia severity scale primarily developed for stroke patients, into the Slovenian language.
 Methods: We performed a 5-step translation and adaptation process. Six speech and language pathologists had evaluated 30 clinical records of patients with an acute ischemic stroke in the carotid artery territory with the Slovenian translation of the Functional Oral Intake Scale (FOIS-SI). Every clinical record included a speech and language clinical bedside assessment of dysphagia, the sex, age, National Institutes of Health Stroke Scale (NIHSS), comorbidities of patients and lesion location. We examined interrater and intrarater reliability and additionally convergent validity of FOIS-SI with the theoretically related IDDSI-Functional Diet Scale (IDDSI-FDS).
 Results: The average measure Intraclass Correlation Coefficient (ICC) for the interrater reliability (ICC=0.959) and the intrarater reliability (ICC=0.979 and ICC=0.991) for both raters was excellent. The FOIS-SI scores correlated very high with the IDDSI-FDS (rs=0.927).
 Conclusion: The results of this study show that the Slovenian translation of the FOIS has an excellent interrater and intrarater reliability and very high validity, which implies the FOIS-SI can be used as a tool to quantitatively assess the severity of dysphagia in clinical practice and research in patients with stroke in carotid artery territory across the country in all medical and care settings.

Psychiatrists should investigate their patients less.

Psychiatrists often order investigations such as blood tests, neuroimaging and electroencephalograms for their patients. Rationales include ruling out 'organic' causes of psychiatric presentations, providing baseline parameters before starting psychotropic medications, and screening for general cardiometabolic health. Hospital protocols often recommend an extensive panel of blood tests on admission to a psychiatric ward. In this Against the Stream article, we argue that many of these investigations are at best useless and at worst harmful: the yield of positive findings that change clinical management is extremely low; special investigations are a poor substitute for a targeted history and examination; and incidental findings may cause anxiety and further unwarranted investigation. Cognitive and cultural reasons why over-investigation continues are discussed. We conclude by encouraging a more targeted approach guided by a thorough bedside clinical assessment.

Associations between the PARIS ischaemic and bleeding risk scores and 1-year mortality in an all-comers Australian national PCI cohort

Abstract Background Prediction scores can complement bedside clinical risk assessment in patients undergoing PCI. Purpose We sought to validate the PARIS ischaemic and bleeding risk scores in a national cohort of all-comer PCI patients in Australia, and to examine impact on 1-year mortality. Methods We retrospectively analysed the GenesisCare Outcomes multicentre Registry of prospectively collected data in patients undergoing PCI from 2008–2020. The ischaemic and bleeding scores were assessed in separate cohorts. Patients were included if all defining variables were available. The ischaemic integer score included diabetes, acute coronary syndrome, current smoking, GFR <60ml/min, prior PCI or CABG, and patients were grouped according as low (0 to 2), intermediate (3 or 4), and high (≥5) thrombotic risk. The bleeding integer score included age, body mass index, current smoking, GFR <60ml/min, anaemia and discharge on triple therapy after PCI, and patients were grouped as low (0 to 3), intermediate (4 to 7) and high (≥8) bleeding risk. One-year ischaemic and in-hospital bleeding endpoints were examined. Adjusted risk of 1-year mortality was assessed accounting for age, sex, family history, smoking, vascular disease, presentation status, hypertension, diabetes, obesity and dyslipidaemia. Results A total of 16,961 patients were included in the ischaemic risk cohort and 6431 patients in the bleeding risk cohort. The patient distributions by risk category for both scores are shown in the figure. Increasing ischaemic risk was associated with greater incidence of in-hospital (0.2% vs. 0.5% vs. 0.5%, p=0.01), and 1-year death (0.7% vs. 2.1% vs. 3.1%). Increasing bleeding risk was associated with greater in-hospital death (0.0% vs. 0.3% vs. 0.9%, p<0.01) and bleeding (0.6% vs. 0.9% vs. 3.2%, p<0.01), and greater 1-year death (0.3% vs. 1.4% vs. 2.8%, p<0.01). At 1-year compared to the low bleeding risk group, high risk patients had lower use of aspirin, P2Y12 inhibitors and statins. Similarly, compared to low ischaemic risk group, high-risk patients had lower use of aspirin and statins but higher use of P2Y12 inhibitors. With both risk scores, compared to low-risk patients, high-risk patients had significantly greater adjusted risk of 1-year mortality (See Figure). Conclusions The PARIS ischaemic and bleeding risk scores were associated with greater risk of in-hospital and medium-term adverse outcomes after PCI to 1-year. Prospective use of the scores can assist in guiding adherence to secondary prevention and optimal anti-thrombotic strategies to improve overall outcomes. Funding Acknowledgement Type of funding sources: None.

Safety of transport and retrieval of patients on extracorporeal membrane oxygenation during the peak of COVID-19 pandemic in the State of Qatar

Background: Transport and retrieval of patients on extracorporeal membrane oxygenation (ECMO) support can be hazardous with complications reported for up to 27% of patients1. Transport of COVID-19 patients on ECMO requires appropriate training, resource allocation, meticulous planning, effective communication and co-ordination. Strict adherence to infection control procedures and appropriate use of personal protective equipment is recommended2. The Extracorporeal Life Support Organisation registry reports 43% in-hospital mortality of COVID-19 patients supported on ECMO. This includes in-house and retrieval ECMO cases3. Methods: Between March 1st and September 30th 2020, 32 confirmed COVID-19 positive patients underwent peripheral cannulation followed by transportation to the Medical Intensive Care Unit (MICU) at Hamad General Hospital. Mobile ECMO is complex and time consuming. Following arrival at the bedside and thorough clinical assessment, the ECMO consultant may decline, recommend optimisation of the care provided, or opt for cannulation and initiation of ECMO. Cannulation can be performed at the bedside or in the operating room. Following stabilisation, the patient is transferred for computed tomography imaging and then transported by ambulance to hospital (Figure 1). Finally, another transfer from hospital entrance to the MICU takes place. All these phases pose risks for errors and complications unless vigilance, teamwork and continuous effective monitoring and co-ordination is observed. Patients were evaluated for age and severity of illness (Table 1). In addition, all major transport-related adverse events were reported and analysed. Major transport events are cardiac arrest, ECMO emergencies (membrane or mechanical failure, air embolism, accidental decannulation, or significant cannula dislodgement), significant arrhythmia, severe bleeding or cardio-respiratory instability, and vehicle breakdown/malfunction. Findings: The majority of our patients were critically ill with high probability of mortality as depicted by SOFA and APACHE2 score. 29 out of 32 patients were male. None of our patients suffered major complications during transportation. Conclusion: This small case series demonstrates transport and retrieval on ECMO for COVID-19 positive patients can be safely undertaken provided appropriate expertise, protocols and resources are used.

Routine use of sugammadex does not shorten Pacu length of stay: A prospective double-blinded randomized controlled trial

BackgroundThe reversal agent sugammadex has been shown to be more efficacious at reversal from neuromuscular blockade (NMB) induced by the aminosteroid class of non-depolarizing muscle relaxants than the traditionally used medication neostigmine. However, whether these differences lead to significantly faster PACU discharge readiness remains unknown. Given the increased acquisition cost of sugammadex as compared to neostigmine we compared these two reversal agents in our surgical population to determine if its pharmacokinetic superiority warranted a change in current practice. MethodsWe conducted a single-center randomized patient and assessor blinded clinical trial. A total of 201 patients presenting for surgery requiring NMB with an estimated duration of ≤ 6 hours were included in the intention-to-treat (ITT) analysis. The primary outcome was time from reversal agent administration to PACU discharge readiness, measured by either the institutional discharge scoring tool or bedside clinical assessment by a PACU physician or advanced practice provider. Secondary outcomes included subjective assessment of recovery by the patient (pain, visual changes, speaking difficulty, swallowing difficulty, PONV, anxiety) and a simple strength assessment. ResultsMedian time from reversal administration to PACU discharge readiness was 3.59 hours (IQR 2.49-5.09) in the neostigmine group and 3.62 hours (IQR 2.70-5.87) in the sugammadex group. Patients who received sugammadex had 8% longer reversal to PACU discharge times (exp(estimate) 1.08, 95% CI [0.87-1.34], p=0.499). Patients age 70 or older had 28% longer reversal to PACU discharge times (exp(estimate) of 1.28, 95% CI [0.91-1.80], P=0.158). In the a modified ITT analysis, sugammadex patients were estimated to be in PACU 13% longer than neostigmine arm patients (exp(estimate) 1.13, 95% CI [0.91-1.40], p=0.265) and patients older than or equal to 70 years 31% longer than patients less than 70 years old (exp(estimate) 1.31, 95% CI [0.93-1.84], p=0.121). Treatment arm was not associated with any of the secondary outcomes. ConclusionThere was no significant difference in time to readiness to discharge from PACU, and there were no subjective or objective clinically relevant differences in recovery from neuromuscular blockade between the groups. Findings of this study support continued use of either agent at the anesthesiologist's discretion.

Early diagnosis of mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI): protocol for a prospective cohort study

IntroductionSevere traumatic brain injury (TBI) is a catastrophic neurological condition with significant economic burden. Early in-hospital mortality (<48 hours) with severe TBI is estimated at 50%. Several clinical examinations exist...

Seromucinous hamartoma of ethmoid sinus in pediatric patient (case report).

Introduction and importanceSeromucinous hamartoma is a rare benign glandular proliferation arising from the respiratory epithelium, which was originally described by Baillie and Batsakis in 1974. Since this time, case reports started to be published on SH, as a middle aged and elderly disease, here we report a case of a pediatric patient who found to have SH.Presentation of the case2-year-old girl, brought by her parent with a complain of a mass at the right medial canthal area for one year.Clinical discussionAs this pediatric patient presented with long standing history of right medial canthal area, we made out differential diagnosis list, with keeping congenital midline nasal masses such as nasal glioma, dermoid, and encephalocele at the top of our differentials, followed by inflammatory disease and lacreimal system disease. After bedside clinical assessment and imaging, patient underwent endoscopic sinus surgery for surgical excision, histopathology analysis came as Seromucinous hamartoma. Postoperative course was unremarkable, patient is disease- free for 18 months, till her most recent follow up. With no additional treatment or recurrence.ConclusionThis case report indicates that seromucinous hamartoma should always be considered in the differential diagnosis of pediatric sinonasal disease. According to the literature review we did; this is the first case reported in such an age group.

Nighttime Calls, Pages, and Interruptions to the On-Call Surgery Resident.

Communication is a keystone to good medical practice. At night, as physician numbers decrease, frequent, nonurgent interruptions have shown to disrupt patient care and impact resident/physician wellness. Potentially, interruptions can lead to an increase in medical errors. The frequency and activities interrupted during night calls have not been fully described. For a period of 44days (August through September), all calls and pages received during the 12-hour night call session were documented. Calls were analyzed by caller, urgency, need for intervention, and resident interrupted by the communication. A total of 494 communications were identified with a mean of 10 calls per shift (IQR 7-14). Communications lasted a mean of 2.7 +/- 2.9minutes. Direct calls occurred in 78% and pages in 22% of the cases. From the non-ED calls (n = 335), most of them came from nursing staff (85%), followed by other specialties (12%). Five percent of the calls were directed to the wrong service. Communications occurred during charting (41%), patient assessment (33%), interrupted resident's sleep (12%), or during a surgical procedure (6%). Communication required no action in 47% of the cases. A physician order was needed in 41%, while bedside clinical assessment was required in 12% of the calls. Communications are common at night, but most did not require clinical assessment. A large portion of communications interrupted direct patient care. An opportunity exists to eliminate nonproductive communications and improve the quality of medical education.

Cardiogenic shock with resultant multiple organ dysfunction syndrome.

The prognosis for a patient with multiple organ dysfunction syndrome (MODS)-also known as organ dysfunction or organ failure-is grave, and mortality can be high when three or more organ systems fail. This article reviews ongoing abnormalities of organ-specific parameters and a bedside clinical scoring assessment tool to identify the mortality of MODS, focusing on the management of MODS resulting from cardiogenic shock in ICU patients who require support of failing organs to survive.

Neuro-Clinical Signatures of Language Impairments after Acute Stroke: A VBQ Analysis of Quantitative Native CT Scans

Ischemic stroke affects language production and/or comprehension and leads to devastating long-term consequences for patients and their families. Previous studies have shown that neuroimaging can increase our knowledge of the basic mechanisms of language recovery. Currently, models for predicting patients' outcomes have limited use in the clinic for the evaluation and optimization of rehabilitative strategies mostly because that are often based on high-resolution magnetic resonance imaging (MRI) data, which are not always possible to carry out in the clinical routine. Here, we investigate the use of Voxel-Based Morphometry (VBM), multivariate modelling and native Computed Tomography (nCT) scans routinely acquired in the acute stage of stroke for identifying biological signatures that explicate the relationships between brain anatomy and types of impairments. 80 stroke patients and 30 controls were included. nCT-scans were acquired in the acute ischemia stage and bedside clinical assessment from board-certified neurologist based on the NIH stroke scale. We use a multivariate Principal Component Analyses (PCA) to identify the brain signatures group the patients according to the presence or absence of impairment and identify the association between local Grey Matter (GM) and White Matter (WM) nCT values with the presence or absence of the impairment. Individual patient's nCT scans were compared to a group of controls' with no radiological signs of stroke to provide an automated delineation of the lesion. Consistently across the whole group the regions that presented significant difference GM and WM values overlap with known areas that support language processing. In summary, the method applied to nCT scans performed in the acute stage of stroke provided robust and accurate information about brain lesions' location and size, as well as quantitative values. We found that nCT and VBQ analyses are effective for identifying neural signatures of concomitant language impairments at the individual level, and neuroanatomical maps of aphasia at the population level. The signatures explicate the neurophysiological mechanisms underlying aetiology of the stroke. Ultimately, similar analyses with larger cohorts could lead to a more integrated multimodal model of behaviour and brain anatomy in the early stage of ischemic stroke.

734 A Comparison of Burn Depth Assessment Between Clinical Diagnosis and Laser Doppler Imaging

Abstract Introduction Accurate burn assessment is crucial to prescribing appropriate treatment and is dependent upon the experience of the provider and the timing of diagnosis relative to the burn injury evaluation. Differentiating between a deep partial thickness and full thickness burn may not be easily discernible. To augment the clinical diagnosis of burn depth, a laser doppler image measures the microvascular blood flow of injured tissue to predict burn wound healing. The aim of this study is to evaluate the clinical assessment of burn wounds by experienced burn providers compared to the laser doppler image assessment in predicting which burn wounds should heal spontaneously in 3 weeks. Methods A retrospective chart review from 2012–2016, included 54 subjects. The clinical assessment included a description of burn variables relevant to the determination of spontaneous burn wound healing (burn depth, total body surface area, mechanism of injury, anatomical location, clinical burn depth diagnosis, and laser doppler image). A chi-square analysis compared the clinical diagnosis and the laser doppler assessment of burn wound depth, as well as the correlation between clinical diagnosis versus laser doppler image in predicting spontaneous burn wound healing. Results Comparing partial thickness burn injuries, there were 38 clinically diagnosed partial thickness injuries (by experienced burn providers) and 38 partial thickness burn injures diagnosed via LDI. Deep partial thickness burn injuries were diagnosed clinically in 9 subjects, compared to 10 via LDI. Full thickness burn injuries were diagnosed clinically in 7 subjects and 6 via LDI. A chi-square test was performed to examine the relationship between clinical diagnosis of burn depth and laser doppler image. The relation between these variables was significant,X2= 26.884, p&amp;lt; .000. Comparing clinically diagnosed burn depth to LDI, each approach (clinical or LDI) diagnosed 42 subjects with partial thickness or deep partial thickness burn injuries and all healed spontaneously. Two of the clinically diagnosed full thickness burn injuries required skin grafting. Six patients were lost to follow-up (X2= 17.745, p &amp;lt; .001). Conclusions This study confirms there is no difference between an experienced burn provider’s clinical diagnosis of burn wound depth and prognosis for spontaneous healing compared to a laser doppler image prognosis of burn wound healing. Applicability of Research to Practice In an era of advanced technologies, expert clinical bedside assessment is the standard of care.

Decision rule to predict pneumonia in children presented with acute febrile respiratory illness.

It is a frequent challenge for physicians to identify pneumonia in patients with acute febrile respiratory symptoms, particularly in stable pediatric patients without respiratory distress. A decision rule is required to assist judgement on the need of ordering a chest radiograph. This was a multicenter prospective study in 3 emergency departments. Children younger than 6years old with an acute onset of fever and respiratory symptoms were recruited. Split sample method was adopted for derivation and validation of the Pediatric Acute Febrile Respiratory Illness rule (PAFRI Rule). PAFRI was derived from logistic regression with weighting based on adjusted odds ratios. Out of 967 children evaluated, 530 had taken chest radiograph examination, with 91 demonstrated evidence of pneumonia on radiograph. PAFRI Rule was derived from logistic regression with 5 weighed predictors: duration of fever <3days (0 points), 3-4days (2 points), 5-6days (4 points), ≥7days (5 points), chills (2 points), nasal symptoms (-2 points), abnormal chest examination (3 points), SpO2 ≤96% or tachypnea (3 points). The Area under ROC curve of the PAFRI Rule, the Bilkis Decision Rule and Bilkis Simpler Rule were 0.733, 0.600 and 0.579 respectively. A PAFRI score of ≥0 gives a sensitivity of 91.7% and negative predictive value of 97.7%. PAFRI rule can be used as a reference tool for guiding the need for taking Chest radiograph examination for pediatric patients. While promising, the PAFRI rule requires further validation. It is often a challenge for physicians to identify pneumonia in children acutely febrile with respiratory symptoms, particularly in those who are stable without respiratory distress. The decision to order chest radiograph was based on clinical assessment with heterogenous practice. A valid and verified clinical prediction rule for ordering chest radiograph examination for stable febrile children without signs of respiratory distress would therefore assist in management of this group of patients. The PAFRI rule, based on parameters from clinical bedside assessment, can be used as a reference tool for guiding the need for referral to emergency department or taking use of chest radiograph for pediatric patients, and triaging for higher priority of clinical care.

Bedside clinical assessment predicts recurrence after hospitalization due to viral lower respiratory tract infection in young children

Infants requiring hospitalization due to a viral lower respiratory tract infection (LRTI) have a high risk of developing recurrent respiratory illnesses in early life and asthma beyond childhood. Notably, all...

Cardiogenic shock with resultant multiple organ dysfunction syndrome

In Brief The prognosis for a patient with multiple organ dysfunction syndrome (MODS)—also known as organ dysfunction or organ failure—is grave, and mortality can be high when three or more organ systems fail. This article reviews ongoing abnormalities of organ-specific parameters and a bedside clinical scoring assessment tool to identify the mortality of MODS. This article focuses on the management of MODS resulting from cardiogenic shock in ICU patients who require support of failing organs to survive. Multiple organ dysfunction syndrome (MODS) is a grave diagnosis for patients because of the high mortality associated with this condition. Clinicians can use the Sequential Organ Failure Assessment to identify mortality in patients with MODS. Treatment for patients with this syndrome is often supportive.