Clinical Deterioration Research Articles

Right-to-left ventricular ratio is higher in systole than diastole in patients with acute pulmonary embolism.

In acute pulmonary embolism (PE), the right ventricle (RV) may dilate compromising left ventricular (LV) size, thereby increasing RV/LV ratio. End-diastolic RV/LV ratio is often used in PE risk stratification, though the cause of death is RV systolic failure. We aimed to confirm our pre-clinical observations of higher RV/LV ratio in systole compared to diastole in human patients with PE. We blinded and independently analyzed echocardiograms from 606 patients with PE, evaluated by a Pulmonary Embolism Response Team. We measured RV/LV ratios in end-systole and end-diastole and fractional area change (FAC). Our primary outcome was a composite of 7-day clinical deterioration, treatment escalation or death. Secondary outcomes were 7-day and 30-day all-cause mortality. RV/LV ratio was higher in systole compared to diastole (median 1.010 [.812-1.256] vs. .975 [.843-1.149], p<.0001). RV/LV in systole and diastole were correlated (slope=1.30 [95% CI 1.25-1.35], p<.0001vs. slope=1). RV/LV ratios in both systole and diastole were associated with the primary composite outcome but not with all-cause mortality. The RV/LV ratio is higher when measured in systole versus in diastole in patients with acute PE. The two approaches had similar associations with clinical outcomes, that is, it appears reasonable to measure RV/LV ratio in diastole.

Blood Immune Cell Alterations in Patients with Hypertensive Left Ventricular Hypertrophy and Heart Failure with Preserved Ejection Fraction.

(1) Background: Chronic inflammation and fibrosis are key players in cardiac remodeling associated with left ventricular hypertrophy (LVH) and heart failure with a preserved ejection fraction (HFpEF). Monocytes and T-helpers (Th) are involved in both pro-inflammatory and fibrotic processes, while regulatory T-cells (Treg) could be considered to suppress chronic inflammation in the hypertrophied myocardium. We aimed to estimate the relationship between the frequencies of circulating CD4+ T-cell and monocyte subpopulations and the variables of left ventricular (LV) diastolic function in patients with LVH depending on the presence of HFpEF. (2) Methods: We enrolled 57 patients with asymptomatic hypertensive LVH (n = 21), or LVH associated with HFpEF (n = 36). A clinical assessment and echocardiographs were analyzed. CD4+ Treg, activated Th (Th-act), and monocyte (classical, intermediate, and non-classical) subpopulations were evaluated via direct immunofluorescence and flow cytometry. (3) Results: Patients with HFpEF had a lower Treg/Th-act ratio (p = 0.001). Though asymptomatic patients and patients with HFpEF were comparable in terms of both the total monocyte number and monocyte subsets, there were moderate correlations between intermediate monocyte count and conventional and novel echocardiographic variables of LV diastolic dysfunction in patients with HFpEF. (4) Conclusions: In patients with LVH, the clinical deterioration (transition to HFpEF) and progression of LV diastolic dysfunction are probably associated with T-cell disbalance and an increase in intermediate monocyte counts.

When Not to Operate in Spinal Deformity: Identifying Subsets of Patients with Simultaneous Clinical Deterioration, Major Complications, and Reoperation.

Retrospective review of a prospectively enrolled adult spinal deformity (ASD) database. To investigate what patient factors elevate the risk of sub-optimal outcomes after deformity correction. Currently, it is unknown what factors predict a poor outcome after adult spinal deformity surgery, which may require increased pre-operative consideration and counseling. Patients >18yrs undergoing surgery for ASD(scoliosis≥20°, SVA≥5cm, PT≥25°, or TK≥60°). An unsatisfactory outcome was defined by the following categories met at 2Y: (1) clinical: deteriorating in ODI at 2Y f/u (2) complications/reop: having a reoperation and major complication were deemed high risk for poor outcomes postoperatively (HR). Multivariate analyses assessed predictive factors of HR patients in adult spinal deformity patients. 633 ASD (59.9 years, 79%F, 27.7kg/m2, CCI: 1.74) were included. Baseline severe Schwab modifier incidence (++): 39.2% PI-LL, 28.8% SVA, 28.9% PT. 15.5% of patients deteriorated in ODI by 2 years, while 7.6% underwent a reoperation and had a major complication. This categorized 11 (1.7%) as HR. HR were more comorbid in terms of arthritis (73%) heart disease (36%) and kidney disease (18%), P<0.001. Surgically, HR had greater EBL (4431ccs), underwent more osteotomies (91%), specifically Ponte(36%) and Three Column Osteotomies(55%), which occurred more at L2(91%). HR underwent more PLIFs (45%) and had more blood transfusion units (2641ccs), all P<0.050. The multivariate regression determined a combination of a baseline DRAM score in the 75th percentile, having arthritis and kidney disease, a baseline right lower extremity motor score ≤3, cSVA >65mm, C2 slope >30.2°, CTPA >5.5° for an R2 value of 0.535 (P<0.001). When addressing adult spine deformities, poor outcomes tends to occur in severely comorbid patients with major baseline psychological distress scores, poor neurologic function, and concomitant cervical malalignment.

Surveillance and patient safety in nursing research: A bibliometric analysis from 1993 to 2023.

To identify and characterize the thematic foci, structure and evolution of nursing research on surveillance and patient safety. Bibliometric analysis. Bibliometric methods were employed to analyse 1145 articles, using Bibliometrix and VOSviewer software. The Scopus bibliographic database was searched on April 7, 2023. A keyword co-occurrence analysis found the most frequently occurring keywords to be: patient safety, nursing, nurses, adverse events, monitoring, critical care, quality improvement, vital signs, safety, alarm fatigue, education, nursing care, surveillance, clinical alarms, failure to rescue, evidence-based practice, acute care, clinical deterioration, communication, intensive care. Network mapping, clustering and time-tracking of the keywords revealed the focal themes, structure and evolution of the research field. By assessing critical areas of the nursing research field, this study extends and enriches the current discourse on surveillance and patient safety for nursing researchers and practitioners. Critical challenges still have to be met by nurses, however, including the failure to rescue deteriorating patients. Further knowledge and understanding of surveillance and patient safety must be successfully translated from research to practice. This study highlights the gaps in nursing knowledge with regard to surveillance and patient safety and encourages nursing professionals to turn to evidence-based surveillance practices. In addressing the problem of surveillance and its effect on patient safety, this study found that, in most clinical care settings, preventing failures to rescue and adverse patient outcomes still remains a challenge for the nursing profession. This study should have an impact on nursing academics' future research themes and on nursing professionals' future clinical practices. Relevant EQUATOR guidelines have been adhered to by employing recognized bibliometric reporting methods.

Impact of multimodal intraoperative neurophysiological monitoring of the spinal cord during spine and spinal cord surgeries

BackgroundThere is growing evidence of the valuable role of multimodal intraoperative neurophysiological monitoring (IONM) during spine and spinal cord surgeries, as it provides an opportunity to recognize functional changes of the neural elements, usually in the reversible stage, during complex surgical manipulations. Therefore, it may reduce the risk of postoperative neurological dysfunction and improve functional outcomes. The aim of the current study was to evaluate the efficacy of multimodal IONM for preventing and predicting iatrogenic neurological dysfunction during spinal cord and spine surgeries.ResultsSignificant alerts had occurred in 9 out of 24 patients; however, all the changes were reversible and did not contribute to postoperative clinical deterioration. Only one case got worsened in the early postoperative follow-up period, with stable intraoperative monitoring.ConclusionIntraoperative monitoring is a valuable tool in spine and spinal cord surgeries. Combined transcranial motor-evoked potential (TcMEP), somatosensory-evoked potential (SSEP), and spontaneous electromyography (EMG) monitoring may prevent permanent motor deficit and enhance the postoperative outcomes.

Reduced risk of mortality among COVID-19 patients with in-hospital selective serotonin reuptake inhibitor administration

Abstract Objectives The anti-inflammatory properties of selective serotonin reuptake inhibitors (SSRI)s, particularly fluvoxamine, have been hypothesized to reduce clinical deterioration in patients with COVID-19 when administered early in the disease course. The objective of this analysis was to examine the effect of maintenance SSRI administration, including variation among different medications, on the outcomes of hospitalized patients with COVID-19. Methods Retrospective analysis of disease progression and mortality risk of over 230,000 patients hospitalized with COVID-19 at facilities associated with a large healthcare system in the United States. Key findings Receipt of SSRIs during the hospital encounter occurred in approximately 10.6% (n = 24,690) of COVID-19 patients. When matched for patient characteristics, disease severity and other treatments, receipt of any SSRI was associated with a 30% reduction in the relative risk of mortality (RR: 0.70, 95% confidence interval [CI]: 0.67–0.73; adjusted P-value &amp;lt;0.001). Similar reductions in the relative risk of mortality were seen with nearly every individual SSRI; for sertraline-treated patients, the most commonly used SSRI in the data set, there was a 29% reduction in the relative risk of mortality (RR: 0.71, 95% CI: 0.66–0.77; adjusted P-value &amp;lt;0.001). Conclusions In total, this retrospective analysis suggests that there is a significant association between SSRI antidepressants and reduced morality among patients hospitalized with COVID-19.

Exploring the nurses' experiences in recognising and managing clinical deterioration in emergency patients: A qualitative study

BackgroundEmergency Department (ED) patients are particularly at a high risk of deterioration. The frontline nurses are key players in identifying and responding to deterioration events; however, few studies have sought to explore the whole process of recognition and management of clinical deterioration by emergency nurses. ObjectivesThe aim of this study was to explore the experiences of emergency nurses and provide a whole picture of how they recognise and manage clinical deterioration. MethodsA qualitative descriptive study involving 11 senior nurses and seven junior nurses was conducted in the ED of a 3000-bed tertiary general hospital using semistructured interviews. The interviews were transcribed and thematically analysed. FindingsFour salient themes emerged from the data analysis. The first, 'early recognition and response', revealed the importance of vital signs assessment in recognising and responding to clinical deterioration. The second, 'information transfer', depicted the skills and difficulties of transferring information in escalations of care. The third, 'abilities, education, and training', presented the abilities that emergency nurses should have and their perspectives on training. The fourth, 'support culture', described the major role of senior nurses in collaboration with colleagues in the ED. ConclusionsThis study explored the experiences of emergency nurses in recognising and managing clinical deterioration. The findings illuminate the need to support the critical role of emergency nurses, with an emphasis on their abilities and continuous interprofessional collaboration training to improve the recognition and management of clinical deterioration.

Shocked to death: a case report of cardiogenic shock and death following electrocardioversion for atrial fibrillation

BackgroundAtrial fibrillation (AF) is prevalent, especially in patients with heart failure. Their prevalence increases with age and both conditions are interrelated. Electrocardioversion (ECV) is considered a safe and effective procedure and is among one of the recommended therapies to terminate AF back to normal sinus rhythm. Our study highlights one of the rare complications following ECV.Case summaryA 71-year-old female with a history of atrial fibrillation underwent electrocardioversion and developed sudden onset of ventricular stunning resulting in refractory cardiogenic shock. She was treated with mechanical cardiac support including IABP and Impella. Both provided minimal support then rapid clinical deterioration happened leading to imminent death.ConclusionPatients with atrial fibrillation and heart failure treated with electrocardioversion might develop refractory cardiogenic shock and death as a complication of this procedure.

Development and validation of a prediction model for mechanical ventilation based on comorbidities in hospitalized patients with COVID-19.

Timely recognition of respiratory failure and the need for mechanical ventilation is crucial in managing patients with coronavirus disease 2019 (COVID-19) and reducing hospital mortality rate. A risk stratification tool could assist to avoid clinical deterioration of patients with COVID-19 and optimize allocation of scarce resources. Therefore, we aimed to develop a prediction model for early identification of patients with COVID-19 who may require mechanical ventilation. We included patients with COVID-19 hospitalized in United States. Demographic and clinical data were extracted from the records of the Healthcare Cost and Utilization Project State Inpatient Database in 2020. Model construction involved the use of the least absolute shrinkage and selection operator and multivariable logistic regression. The model's performance was evaluated based on discrimination, calibration, and clinical utility. The training set comprised 73,957 patients (5,971 requiring mechanical ventilation), whereas the validation set included 10,428 (887 requiring mechanical ventilation). The prediction model incorporating age, sex, and 11 other comorbidities (deficiency anemias, congestive heart failure, coagulopathy, dementia, diabetes with chronic complications, complicated hypertension, neurological disorders unaffecting movement, obesity, pulmonary circulation disease, severe renal failure, and weight loss) demonstrated moderate discrimination (area under the curve, 0.715; 95% confidence interval, 0.709-0.722), good calibration (Brier score = 0.070, slope = 1, intercept = 0) and a clinical net benefit with a threshold probability ranged from 2 to 34% in the training set. Similar model's performances were observed in the validation set. A robust prognostic model utilizing readily available predictors at hospital admission was developed for the early identification of patients with COVID-19 who may require mechanical ventilation. Application of this model could support clinical decision-making to optimize patient management and resource allocation.

New care pathway to enable ambulances transfer patients to a model 2 hospital medical assessment unit.

Reconfiguration of the Irish acute hospital sector resulted in the establishment of a Medical Assessment Unit (MAU) in Mallow General Hospital (MGH). We developed a protocol whereby certain patients deemed to be low risk for clinical deterioration could be brought by the National Ambulance Service (NAS) to the MAU following a 999 or 112 call. The aim of this paper is to report on the initial experience of this quality improvement initiative. The Plan-Do-Study-Act (PDSA) Cycle for quality improvement was implemented when undertaking this project. A pathway was established whereby, following discussion between paramedic and physician, patients for whom a 999 or 112 call had been made could be brought directly to the MAU in MGH. Strict inclusion and exclusion criteria were agreed. The protocol was implemented from the 1st of September 2022 for a 3-month pilot period. Of 39 patients discussed, 29 were accepted for review in the MAU. One of the 29 accepted patients declined transfer to MAU. Of 28 patients reviewed in the MAU, 7 were discharged home. One patient required same day transfer to a model 4 centre. Twenty patients were admitted to MGH with an average length of stay of 8days. Frailty and falls accounted for 7 of the admissions and the mean length of stay for these patients was 12days. Our results have demonstrated the safety, feasibility and effectiveness of this pathway. With increased resourcing, upscaling of this initiative is possible and should be considered.

Emphysematous pyelonephritis and sepsis in a diabetic female patient caused by extended-spectrum beta-lactamase-producing Escherichia coli – case report

Emphysematous pyelonephritis (EPN) is a rare, severe, spontaneous gas-forming infection of renal parenchyma and its surrounding areas. EPN was detected in diabetic patients. A 49-year-old female with type I diabetes mellitus presented with severe thrombocytopenia, acute kidney injury (AKI) and was in need of haemodialysis treatment. She had impaired liver function tests, with active urine sediment, indicating severe upper urinary tract infection with suspected sepsis. The contrast enhanced CT scan of the abdomen showed multiple areas of air density in renal parenchyma and perirenal regions, suggestive of left-side EPN. The blood and urine cultures reported growth of extended-spectrum beta-lactamase (ESBL) producing Escherichia coli. The final diagnosis of emphysematous pyelonephritis complicated with severe sepsis and AKI was established. The patient was managed conservatively with wide-spectrum antibiotics, fluid resuscitation, consistent blood sugar control, and haemodialysis treatment. Percutaneous drainage techniques (PCD) and nephrectomy were postponed because of the initial clinical response to the antibiotics treatment. However, the patient experienced sudden clinical deterioration and died only a few hours after the established diagnosis. An autopsy was not performed upon the patient’s family’s request. EPN should be highly suspected in poorly controlled diabetic patients with urinary tract infection and should be promptly recognized and aggressively treated. The patients with multiple risk factors had high mortality, even with timely diagnosis and combined (conservative and surgical) treatment.

The predictive value of the modified early warning score for admission to the intensive care unit in patients with a hematologic malignancy – A multicenter observational study

ObjectivesThe modified early warning score (MEWS) is used to detect clinical deterioration of hospitalized patients. We aimed to investigate the predictive value of MEWS and derived quick Sequential Organ Failure Assessment (qSOFA) scores for intensive care unit admission in patients with a hematologic malignancy admitted to the ward. DesignRetrospective, observational study in two Dutch university hospitals. SettingData from adult patients with a hematologic malignancy, admitted to the ward over a 2-year period, were extracted from electronic patient files. Main outcome measuresIntensive care admission. ResultsWe included 395 patients with 736 hospital admissions; 2% (n = 15) of admissions resulted in admission to the intensive care unit. A higher MEWS (OR 1.5; 95 %CI 1.3–1.80) and qSOFA (OR 4.4; 95 %CI 2.1–9.3) were associated with admission. Using restricted cubic splines, a rise in the probability of admission for a MEWS ≥ 6 was observed. The AUC of MEWS for predicting admission was 0.830, the AUC of qSOFA was 0.752. MEWS was indicative for intensive care unit admission two days before admission. ConclusionsMEWS was a sensitive predictor of ICU admission in patients with a hematologic malignancy, superior to qSOFA. Future studies should confirm cut-off values and identify potential additional characteristics, to further enhance identification of critically ill hemato-oncology patients. Implications for Clinical PracticeThe Modified Early Warning Score (MEWS) can be used as a tool for healthcare providers to monitor clinical deterioration and predict the need for intensive care unit admission in patients with a hematologic malignancy. Yet, consistent application and potential reevaluation of current thresholds is crucial. This will enable bedside nurses to more effectively identify patients needing adjunctive care, facilitating timely interventions and improved outcome.

Ceftazidime-Avibactam Treatment for Klebsiella pneumoniae Bacteremia in Preterm Infants in NICU: A Clinical Experience.

Ceftazidime/avibactam (CAZ/AVI) is an antibiotic combination approved for the treatment of several infections caused by multi-drug resistant (MDR) Gram-negative bacteria. Neonates admitted to the Neonatal Intensive Care Unit (NICU) are at high risk of developing bacterial infections, and the choice of appropriate antibiotics is crucial. However, the use of antibiotics in neonates carries risks such as antibiotic resistance and disruption of gut microbiota. This study aimed to assess the safety and efficacy of CAZ/AVI in preterm infants admitted to the NICU. Retrospective data from preterm infants with Klebsiella pneumoniae bacteremia who received CAZ/AVI were analyzed. Clinical and microbiological responses, adverse events, and outcomes were evaluated. Eight patients were included in the study, all of whom showed clinical improvement and achieved microbiological cure with CAZ/AVI treatment. No adverse drug reactions were reported. Previous antibiotic therapies failed to improve the neonates' condition, and CAZ/AVI was initiated based on clinical deterioration and epidemiological considerations. The median duration of CAZ/AVI treatment was 14 days, and combination therapy with fosfomycin or amikacin was administered. Previous case reports have also shown positive outcomes with CAZ/AVI in neonates. However, larger trials are needed to further investigate the safety and efficacy of CAZ/AVI in this population.

Effect of paediatric early warning systems (PEWS) implementation on clinical deterioration event mortality among children with cancer in resource-limited hospitals in Latin America: a prospective, multicentre cohort study

Paediatric early warning systems (PEWS) aid in the early identification of clinical deterioration events in children admitted to hospital. We aimed to investigate the effect of PEWS implementation on mortality due to clinical deterioration in children with cancer in 32 resource-limited hospitals across Latin America. Proyecto Escala de Valoración de Alerta Temprana (Proyecto EVAT) is a quality improvement collaborative to implement PEWS in hospitals providing childhood cancer care. In this prospective, multicentre cohort study, centres joining Proyecto EVAT and completing PEWS implementation between April 1, 2017, and May 31, 2021, prospectively tracked clinical deterioration events and monthly inpatient-days in children admitted to hospital with cancer. De-identified registry data reported between April 17, 2017, and Nov 30, 2021, from all hospitals were included in analyses; children with limitations on escalation of care were excluded. The primary outcome was clinical deterioration event mortality. Incidence rate ratios (IRRs) were used to compare clinical deterioration event mortality before and after PEWS implementation; multivariable analyses assessed the correlation between clinical deterioration event mortality and centre characteristics. Between April 1, 2017, and May 31, 2021, 32 paediatric oncology centres from 11 countries in Latin America successfully implemented PEWS through Proyecto EVAT; these centres documented 2020 clinical deterioration events in 1651 patients over 556 400 inpatient-days. Overall clinical deterioration event mortality was 32·9% (664 of 2020 events). The median age of patients with clinical deterioration events was 8·5 years (IQR 3·9-13·2), and 1095 (54·2%) of 2020 clinical deterioration events were reported in male patients; data on race or ethnicity were not collected. Data were reported per centre for a median of 12 months (IQR 10-13) before PEWS implementation and 18 months (16-18) after PEWS implementation. The mortality rate due to a clinical deterioration event was 1·33 events per 1000 patient-days before PEWS implementation and 1·09 events per 1000 patient-days after PEWS implementation (IRR 0·82 [95% CI 0·69-0·97]; p=0·021). In the multivariable analysis of centre characteristics, higher clinical deterioration event mortality rates before PEWS implementation (IRR 1·32 [95% CI 1·22-1·43]; p<0·0001), being a teaching hospital (1·18 [1·09-1·27]; p<0·0001), not having a separate paediatric haematology-oncology unit (1·38 [1·21-1·57]; p<0·0001), and having fewer PEWS omissions (0·95 [0·92-0·99]; p=0·0091) were associated with a greater reduction in clinical deterioration event mortality after PEWS implementation; no association was found with country income level (IRR 0·86 [95% CI 0·68-1·09]; p=0·22) or clinical deterioration event rates before PEWS implementation (1·04 [0·97-1·12]; p=0·29). PEWS implementation was associated with reduced clinical deterioration event mortality in paediatric patients with cancer across 32 resource-limited hospitals in Latin America. These data support the use of PEWS as an effective evidence-based intervention to reduce disparities in global survival for children with cancer. American Lebanese Syrian Associated Charities, US National Institutes of Health, and Conquer Cancer Foundation. For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Nocturnal hypoxemia and prognosis in patients with acute symptomatic pulmonary embolism

BackgroundNocturnal hypoxemia has been associated with cardiovascular and non-cardiovascular morbidity and mortality. This study aimed to investigate the prognostic value of nocturnal hypoxemia among patients with hemodynamically stable acute symptomatic pulmonary embolism (PE). MethodsWe performed an ad hoc secondary analysis of clinical data from a prospective cohort study. Nocturnal hypoxemia was measured by the percent sleep registry with oxygen saturation <90% [TSat90]). Outcomes assessed over the 30-days after the diagnosis of PE included PE-related death, other cardiovascular deaths, clinical deterioration requiring an escalation of treatment, recurrent venous thromboembolism (VTE), acute myocardial infarction [AMI], or stroke. ResultsOf the 221 hemodynamically stable patients with acute PE from which the TSat90 could be calculated and did not receive supplemental oxygen, the primary outcome occurred in 11 (5.0%; 95% confidence interval [CI], 2.5% to 8.7%) within 30-days after the diagnosis of PE. When categorized by quartiles, TSat90 was not significantly associated with the occurrence of the primary outcome in unadjusted Cox regression analysis (hazard ratio, 0.96; 95% CI, 0.57 to 1.63; P = 0.88), or after adjustment for body mass index (adjusted hazard ratio, 0.97; 95% CI, 0.57 to 1.65; P = 0.92). When examined as a completely continuous variable (between 0 and 100), TSat90 was not associated with a significant increase in the adjusted hazard of 30-day primary outcome rates (hazard ratio, 0.97; 95% CI, 0.86 to 1.10; P = 0.66). ConclusionsIn this study, nocturnal hypoxemia did not identify stable patients with acute symptomatic PE at increased risk for adverse cardiovascular events.

Staff perspectives on the influence of patient characteristics on alarm management in the intensive care unit: a cross-sectional survey study

BackgroundHigh rates of clinical alarms in the intensive care unit can result in alarm fatigue among staff. Individualization of alarm thresholds is regarded as one measure to reduce non-actionable alarms. The aim of this study was to investigate staff’s perceptions of alarm threshold individualization according to patient characteristics and disease status.MethodsThis is a cross-sectional survey study (February-July 2020). Intensive care nurses and physicians were sampled by convenience. Data was collected using an online questionnaire.ResultsStaff view the individualization of alarm thresholds in the monitoring of vital signs as important. The extent to which alarm thresholds are adapted from the normal range varies depending on the vital sign monitored, the reason for clinical deterioration, and the professional group asked. Vital signs used for hemodynamic monitoring (heart rate and blood pressure) were most subject to alarm individualizations. Staff are ambivalent regarding the integration of novel technological features into alarm management.ConclusionsAll relevant stakeholders, including clinicians, hospital management, and industry, must collaborate to establish a “standard for individualization,” moving away from ad hoc alarm management to an intelligent, data-driven alarm management. Making alarms meaningful and trustworthy again has the potential to mitigate alarm fatigue – a major cause of stress in clinical staff and considerable hazard to patient safety.Trial registrationThe study was registered at ClinicalTrials.gov (NCT03514173) on 02/05/2018.

Multimodal deep learning for COVID-19 prognosis prediction in the emergency department: a bi-centric study

Predicting clinical deterioration in COVID-19 patients remains a challenging task in the Emergency Department (ED). To address this aim, we developed an artificial neural network using textual (e.g. patient history) and tabular (e.g. laboratory values) data from ED electronic medical reports. The predicted outcomes were 30-day mortality and ICU admission. We included consecutive patients from Humanitas Research Hospital and San Raffaele Hospital in the Milan area between February 20 and May 5, 2020. We included 1296 COVID-19 patients. Textual predictors consisted of patient history, physical exam, and radiological reports. Tabular predictors included age, creatinine, C-reactive protein, hemoglobin, and platelet count. TensorFlow tabular-textual model performance indices were compared to those of models implementing only tabular data. For 30-day mortality, the combined model yielded slightly better performances than the tabular fastai and XGBoost models, with AUC 0.87 ± 0.02, F1 score 0.62 ± 0.10 and an MCC 0.52 ± 0.04 (p < 0.32). As for ICU admission, the combined model MCC was superior (p < 0.024) to the tabular models. Our results suggest that a combined textual and tabular model can effectively predict COVID-19 prognosis which may assist ED physicians in their decision-making process.

Antibiotics and Antivirals in COVID-19: Clinical Outcomes

The clinical manifestations of COVID-19 disease are mainly caused by an irregular host response associated with excessive expression of inflammatory markers. Patients with mild, moderate, and severe symptoms of COVID-19 with or without comorbidities use a combination of antiviral drugs and antibiotics. This study aimed to determine the relationship between the use of antiviral drugs and antibiotics on the clinical outcomes of COVID-19 patients. The research design used a cross-sectional study with retrospective data collection. The inclusion criteria were COVID-19 patients hospitalized at Panti Waluya Sawahan Malang Hospital with or without comorbidities, positive RT-PCR results, and receiving antibiotic and antiviral therapy. The clinical outcome is a patient improvement if the length of stay is 14 days, and the patient worsens if it is &gt;14 days. There is no relationship between antibiotics and antiviral drugs on the clinical outcomes of COVID-19 patients (p&gt;0,05).&#x0D; Highlights:&#x0D; &#x0D; Excessive expression of inflammatory markers contributes to the clinical manifestations of COVID-19.&#x0D; Combination therapy of antiviral drugs and antibiotics is commonly used for COVID-19 patients.&#x0D; The study found no significant relationship between the use of antibiotics and antiviral drugs and the clinical outcomes of COVID-19 patients&#x0D; &#x0D; Keywords: antibiotics, antiviruses, COVID-19, clinical improvement, clinical deterioration

Hemorrhagic transformation of ischemic stroke in a patient with Fahr’s disease

BackgroundFahr’s disease is a very rare inherited neurodegenerative disorder characterized by diffuse and symetric intracranial calcification of the bilateral basal ganglia and cerebellum. Although the disease is slowly progressive, several acute forms have been described. We would like to present a very rare case of Fahr’s disease with an ischemic stroke and its hemorrhagic transformation.Case presentationA 70-year-old woman presented to our emergency department with rapid cognitive decline, dysarthria and right limb weakness. Cranial computed tomography showed diffuse and symmetric hyperdense areas at the level of the bilateral dentate nuclei of cerebellar hemispheres and basal ganglia, suggestive of calcification consistent with Fahr's disease on a background of thyroidectomy history, and effacement in the left caudate region. The patient was admitted to the intensive care unit with suspected left cerebral ischemic stroke. Because of clinical deterioration with increasing drowsiness and right hemiplegia, a control computed tomography scan was performed. Upon detection of a 6 * 8 cm lesion corresponding to an intracerebral hematoma in the left temporoparietal area with intraventricular component, she underwent surgery. The patient did not become hemodynamically stable and died on post-operative day 3.ConclusionsThe calcium deposits in the walls of the cerebral vessels in Fahr’s disease may exacerbate inflammatory processes leading to disruption of the blood-brain barrier. In addition, peripheral blood extravasation into the disrupted blood brain barrier due to ischemic stroke may lead to hemorrhagic transformation.

Original Research: Can a Palliative Care Lay Health Advisor–Nurse Partnership Improve Health Equity for Latinos with Cancer?

ABSTRACT Purpose: A palliative care infrastructure is lacking for Latinos with life-threatening illness, especially in rural regions of the United States. The purpose of this study was to develop and evaluate a community-based palliative care lay health advisor (LHA) intervention for rural-dwelling Latino adults with cancer. Methods: An exploratory mixed-methods participatory action research design was carried out by an interprofessional research team that included community and academic members. Fifteen Latino community leaders completed a 10-hour palliative care training program and then served as palliative care LHAs. Although 45 Latinos with cancer initially agreed to participate, four withdrew or died and six were not reachable by the LHAs, for a final total of 35 patient participants. The trained palliative care LHAs delivered information on home symptom management and advance care planning to assigned participants. Palliative care nurses led the training and were available to the LHAs for consultation throughout the study. The LHAs made an average of three telephone calls to each participant. The Edmonton Symptom Assessment System–Revised (ESAS-r) and the four-item Advance Care Planning Engagement Survey (ACPES-4) were administered pre- and postintervention to determine the intervention's effectiveness. Encounter forms were transcribed, coded, and analyzed using case comparison. Results: The major finding was that significant improvements were shown for all four items of the ACPES-4 among both the LHAs (posttraining) and the participants (postintervention). Information on advance care planning was shared with 74.3% of the 35 participants. Participants showed clinical improvement in physical symptom scores and clinical deterioration in emotional symptom scores following the intervention, although these changes did not reach statistical significance. The advisors noted that participants were anxious about how to explain cancer to children, the uncertainty of their prognosis, and medical expenses. This sample was younger than those of other cancer studies; 51.4% were under age 50 and 73.1% had at least one child in the home. Conclusions: A community-based palliative care LHA–nurse partnership was shown to be a feasible way to engage in conversations and deliver information about advance care planning to rural-dwelling Latino adults with cancer. The positive results led to the regional cancer center's decision to select “cultural care” as its 2022 goal for maintaining its accreditation with the Commission on Cancer.