Low Level Of Consciousness Research Articles

Multicentric Pediatric Stroke Code: Insight to the first years after implementation

BackgroundThe development of unicentric pediatric acute stroke protocols has improved stroke diagnosis and treatment. The impact of the implementation of a multicentric Pediatric Stroke Code (PSC) remains unknown. Aimto describe the characteristics of the PSC activations and identify clinical features associated with stroke compared to stroke mimics in children in whom a multicentric PSC had been activated and compare them to reported monocentric PSC results. MethodsObservational, retrospective, case and control multicentric study, performed in the Pediatric Emergency Department (PED) of the three Primary Pediatric Stroke Centers (PPSCs) in Madrid (Spain). Study population corresponded to children between 28 days and 16 years old in whom PSC was activated that consulted or were referred to any of the PPSC PED between March 2019 and June 2022. The main outcome was to compare the characteristics of patients with final diagnosis of stroke versus stroke mimics, among all patients for which PSC had been activated. Logistic regression modeling was used to investigate associations between independent variables and stroke diagnosis. Odds ratio (ORs) and 95 % confidence intervals (95%CIs) were estimated. ResultsPSC was activated in 196 patients. Stroke was confirmed in 39 patients (19.9 %): 20 (10.2 %) had an ischemic stroke and 19 (9.7 %) a hemorrhagic stroke. Stroke mimics represented 80.1 % of the PSC activations. Migraine was the most frequent stroke mimic (38.3 %). Time from symptom onset to brain imaging was 233.00 min (IQR 153.00–373.00) when patients self-presented at the PPSC compared to 231.00 min (IQR 129.00–400.00) when PSC was triggered at other settings (p0.580). Five patients (25.3 %) were eligible for hyperacute recanalization treatment. Low level of consciousness (OR4.373, 95%IC 0.247–0.652, p < 0.001), sensory disruption/motor disability of face/limbs (OR3.633, 95%IC 0.103–0.349, p < 0.001), aphasia (OR2.311, 95%IC 0.023–0.284, p0.022) and altered mental status (OR2.517, 95%IC 0.043–0.357, p0.013) were associated with an increased probability of stroke. Conclusionmulticentric PSC achieved similar results to previously reported unicentric PSCs, showing the feasibility of such an organization.

Assessment of the diagnostic utility of the electroencephalogram in pediatric emergencies

IntroductionWe analyze the diagnostic utility of urgent EEG (electroencephalogram) performed in children under 16 years of age in our center. Material and methodsDescriptive, retrospective, observational study of consecutive patients from 0 to 16 years of age, who underwent an urgent EEG for any reason, from January to December 2022. ResultsOf the 388 patients, 70 were children: 37 (52.85%) women, and 33 (47.14%) men. Average age: 6.27 ± 4.809. Of the 70 patients, 6 (8.57%) had previous epilepsy. Reasons for consultation: 17 febrile seizures, 10 first focal seizures, 10 first TCG seizures, 6 paroxysmal episodes, 6 absences, 3 myoclonus of extremities, 3 syncope, 2 SE, 2 visual alterations, 2 low level of consciousness, 2 cyanosis, 2 suspected meningitis or encephalitis, 1 choking, 1 atypical headache, 1 chorea, 1 presyncope, 1 language delay. Of the 70 patients, 47 had a normal EEG (67.14%). Of the 47 patients with a normal EEG, 10 were diagnosed with epilepsy, and 3 of them began receiving antiepileptic treatment upon discharge. None of the patients with suspected syncope or paroxysmal disorder (17 patients, 24.28%) had EEG abnormalities. Of the 17 patients with atypical febrile seizures, 3 had EEG abnormalities. ConclusionsA third of the EEG records performed in the Emergency Department showed alterations, probably due to the time taken. Almost half of the patients with suspected epilepsy or EE showed EEG abnormalities, which confirmed the diagnosis in these cases and encouraged the clinician to start drug treatment. No case with a high suspicion of epilepsy was dismissed due to the normality of the EEG recording in our series. No patient diagnosed with syncope or paroxysmal disorder had EEG abnormalities. Nearly a quarter of patients with atypical febrile seizures showed EEG abnormalities. We barely register cases of status epilepticus, probably due to the degree of complexity of our center.

Risk Factors Associated with Mortality in Hospitalized COVID-19 Patients: A Case Study from Southeast Iran

Background: This study aimed to identify mortality risk factors among hospitalized COVID-19 patients in southeast Iran. Methods: This cross-sectional study used data from the COVID-19 patients admitted to Afzalipour teaching hospital in Kerman, Iran, from February 2020 to September 2021. The demographic and clinical data of 6,057 patients were analyzed using Bayesian network and logistic regression models. Results: Out of 6,057 patients, 333 (5.5%) died. The most important risk factors for COVID-19 mortality were age, gender, fever, headache, decreased level of consciousness (LoC), chronic liver disease, blood oxygen level (BOL), admission season, and length of stay (LoS). Fever, headache, and longer LoS were protective and mortality-reducing variables. Conclusion: Following model estimation results, it is recommended that older male patients with low oxygen levels and a lower LoC, as well as patients with chronic liver disease, receive additional medical care and not be discharged prematurely. Early medical interventions for high-risk patients may reduce COVID-19 mortality risk.

Geo-demographics and source of information as determinants of climate change consciousness among citizens in African countries

Climate change constitutes one of the greatest threats to human health globally and there have been increasing interests in understanding the dynamics of climate change consciousness particularly in less industrialised countries of Africa. Research on cross-country, sub-regional and continent differences in climate change consciousness are rare especially in sub-Saharan Africa. Thus, to complement the existing body of literature, this study was conducted on cross-national predictors of public climate change consciousness. Data from the Afrobarometer round 7 for thirty-four [34] African countries, collected between 2017 and 2020, were used to investigate the influence of geographical, socio-demographics, and source of information on public consciousness of climate change. Statistical analyses of t-test, ANOVA and multiple regression were conducted to test the formulated hypotheses. Results showed a low level of climate change consciousness (CCC) among participants. Radio news was the major source of information for the sampled African citizens. There were significant differences in the CCC of male and female as well as between urban and rural respondents. Significant differences were also found among the sub-regions, educational levels, age groups and occupations. Sources of information and demographic variables significantly influenced the level of CCC among participating citizens. Educational attainment was the single most potent predictor of climate change consciousness. The study recommends that African citizens need capacity building on climate change awareness and initiatives which would assist in mitigating the effects of climate change.

Predicting early complications in patients with spinal gunshot wounds: A multicenter study

IntroductionThere is a wide variation in the clinical presentation of spinal gunshot wounds ranging from isolated minor stable fractures to extremely severe injuries with catastrophic neurological damage. Research questionwe aim to analyze the risk factors for early complications and impact of surgical treatment in patients with spinal gunshot wounds. Material and methodsThis is a multicentre retrospective case-control study to compare patients with spinal gunshot wounds who had early complications with those who did not. The following matching criteria were used: sex (1:1), injury level (1:1) and age (±5 years). Univariate and multivariate analyses were performed using logistic regression. ResultsResults: Among 387 patients, 36.9 % registered early complications, being persistent pain (n = 32; 15 %), sepsis/septic shock (n = 28; 13 %), pneumonia (n = 27; 13 %) and neurogenic bladder (n = 27; 12 %) the most frequently reported. After case-control matched analysis, we obtained 133 patients who suffered early complications (cases) and 133 patients who did not as control group, not differing significantly in sex (p = 1000), age (p = 0,535) and injury level (p = 1000), while the 35 % of complications group required surgical treatment versus 15 % of the non-complication group (p < 0.001). On multivariable analysis, significant predictors of complications were surgical treatment for spinal injury (OR = 3.50, 95 % CI = 1.68–7.30), dirty wound (3.32, 1.50–7.34), GCS ≤8 (3.56, 1.17–10.79), hemodynamic instability (2.29, 1.07–4.88), and multiple bullets (1.97, 1.05–3.67). Discussion and conclusionSpinal gunshot wounds are associated with a high risk of early complications, especially when spinal surgery is required, and among patients with dirty wound, low level of consciousness, hemodynamic instability, and multiple bullets.

Structural Modeling of Early Ambulation Progression in Patients with Acute Stroke: A Covariance Structure Analysis Approach.

This study used structural equation modeling (SEM) to elucidate the causal relationships between Functional Independence Measure (FIM) items and consciousness levels in patients with stroke and low consciousness levels 2 weeks after initiating occupational therapy (OT). This modeling sought to identify the factors influencing the number of days required to get out of bed. SEM was used for multifactorial simultaneous analysis in a study of 22 patients with a Japan Coma Scale score of 20 after stroke. The Glasgow Coma Scale was used to evaluate patients' consciousness level; FIMs were used to evaluate activities of daily living in the ward. Influencing factors, including "bed/chair transfers" and "toilet transfers," were defined as "transfer functions," while factors involving "social interactions," "comprehension," "memory," "problem solving," and "expression" were defined as "cognitive decline." After 2 weeks, standardized coefficients showed that "transfer functions" and "cognitive decline" had effects of -0.33 and -0.25, respectively, on "early ambulation days." Further analysis revealed that improvements in "consciousness level" impacted "early ambulation days," with coefficients of -0.35 for "transfer functions" and 0.14 for "cognitive decline." Through the "consciousness level" observation variable, the coefficients of indirect effects were -0.27 for "transfer function" on "days to get out of bed," 0.38 for "cognitive decline," and -0.06 for "self-care" on "early ambulation days." Improvement in transfer movements and cognitive decline influenced the number of days required to get out of bed without improving consciousness or affecting early ambulation.

Prognostic Value of Serum Biomarkers in Patients With Moderate-Severe Traumatic Brain Injury, Differentiated by Marshall Computer Tomography Classification.

Prognostication is challenging in patients with traumatic brain injury (TBI) in whom computed tomography (CT) fails to fully explain a low level of consciousness. Serum biomarkers reflect the extent of structural damage in a different way than CT does, but it is unclear whether biomarkers provide additional prognostic value across the range of CT abnormalities. This study aimed to determine the added predictive value of biomarkers, differentiated by imaging severity. This prognostic study used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study (2014-2017). The analysis included patients aged ≥16 years with a moderate-severe TBI (Glasgow Coma Scale [GCS] <13) who had an acute CT and serum biomarkers obtained ≤24h of injury. Of six protein biomarkers (GFAP, NFL, NSE, S100B, Tau, UCH-L1), the most prognostic panel was selected using lasso regression. The performance of established prognostic models (CRASH and IMPACT) was assessed before and after the addition of the biomarker panel and compared between patients with different CT Marshall scores (Marshall score <3 vs. Marshall score ≥3). Outcome was assessed at six months post-injury using the extended Glasgow Outcome Scale (GOSE), and dichotomized into favorable and unfavorable (GOSE <5). We included 872 patients with moderate-severe TBI. The mean age was 47 years (range 16-95); 647 (74%) were male and 438 (50%) had a Marshall CT score <3. The serum biomarkers GFAP, NFL, S100B and UCH-L1 provided complementary prognostic information; NSE and Tau showed no added value. The addition of the biomarker panel to established prognostic models increased the area under the curve (AUC) by 0.08 and 0.03, and the explained variation in outcome by 13-14% and 7-8%, for patients with a Marshall score of <3 and ≥3, respectively. The incremental AUC of biomarkers for individual models was significantly greater when the Marshall score was <3 compared with ≥3 (p < 0.001). Serum biomarkers improve outcome prediction after moderate-severe TBI across the range of imaging severities and especially in patients with a Marshall score <3.

Effectiveness of supervised implementation of an oral health care protocol on ventilator-associated pneumonia patients in intensive care units: a double-blind multicenter randomized controlled trial

The available scientific evidence suggests a significant association between oral bacteria and the incidence of ventilator-associated pneumonia (VAP). The aim of this study was to determine the effectiveness of an oral health protocol in the prevention of ventilator-associated pneumonia. In this multi-center RCT, conducted in the intensive care units of neurological patients in three general teaching hospitals of two provinces located in the west of the Iran, a consecutive sample of 200 intubated patients were initially recruited. Patients were randomly allocated to the intervention (received oral health care based on evidence-based oral health protocol) or control (routine oral health care) groups. Both groups received their prescribed treatment regimen for seven consecutive days. The percentage of VAP diagnoses as main outcome assessed using clinical pulmonary infection score (CPIS). The rate of VAP in the intervention and control groups was 5% and 64%, respectively. The intervention reduced the risk of VAP by 97% and this difference was statistically significant (P <0.001). The chance of VAP occurrence in patients with lower levels of consciousness in univariate and multivariate analysis was significantly higher (OR: 2.38; 95%CI: 1.11-5.26) P <0.05). The results of our study suggest that the use of a dynamic supervised oral health care guideline is more effective than the routinely used protocols in the intensive care units of hospitals.

Features of postoperative pain relief in patients with a low level of consciousness: a prospective randomised study

AIM: To determine the possibility of using analgonociception monitoring (analgesia nociception index, ANI) to assess the need for postoperative analgesia in patients with prolonged impairment of consciousness.&#x0D; MATERIAL AND METHODS: This pilot prospective randomized study enrolled 34 consecutive patients with chronic impairment of consciousness (vegetative state/minimal state of consciousness) who underwent neurosurgical interventions. Randomization was made by the envelope method for the grouping of the patients: study group (SG, n=17), received anesthesia with intravenous paracetamol 1000 mg according to ANI in the postoperative period; control group (CG, n=17), without additional anesthesia in the postoperative period. Patients with arrhythmias were excluded. The groups are comparable in terms of the main clinical parameters (all parameters p 0.05). The ANI (MetroDoloris device, France) was recorded at 1, 4, 8, 12, and 24 h after surgery. The valuation was based on the revised scale for assessing pain in a coma, i.e., Nociception Coma ScaleRevised (NCS-R) [7], after 4, 12, and 24 h.&#x0D; RESULTS: An intragroup comparison of the changes in ANI during postoperative day 1 showed an adequate level of pain relief (60.1 [55.362.5]), whereas in the group without postoperative analgesia with paracetamol, by 4 h after the operation, ANI dropped to the lower limit (46.3 [40.251.9]). In an intergroup comparison in the first 8 h after surgery, ANI was significantly higher than in the group without anesthesia (p=0.04) and had values of 55, which indicates the absence of pronounced vegetative reactions indicating the presence of pain. From 12 oclock, the values are leveled out, not going beyond the limits of indicators of inadequate anesthesia (p=0.69). When assessing nociception on the NCR-R scale during the postoperative day in both groups, a tendency to the appearance of weak autonomic responses was observed (6 [5; 8] in SG and 6 [5; 7] in CS, respectively), which did not differ significantly. The presence of pain 4 h after surgery was confirmed by increased levels of cortisol and salivary alpha-amylase in patients without postoperative analgesia (p=0.03).&#x0D; CONCLUSION: No generally recognized and available evidence-based instrumental methods are available for the assessment of pain intensity in patients with chronic impairment of consciousness. There is no single position of the professional community on the need for postoperative analgesia in such patients. Further studies to evaluate the effectiveness of using the ANI Metro Doloris monitoring system with a significant number of observations will lead to the determination of adequate perioperative analgesia regimens in patients with various forms of prolonged impairment of consciousness.

Pre-hospital Prognostic Factors of 30-Day Survival in Sepsis Patients; a Retrospective Cohort Study.

According to excising findings, if the emergency management system (EMS) operation will be developed, the survival outcome of sepsis patients might improve. This study aimed to evaluate the pre-hospital associated factors of survival in sepsis patients. This retrospective cohort study was conducted on patients diagnosed with sepsis, coded with the Thailand emergency medical triage protocol and criteria-based dispatch symptom group 17. Information on the 30-day survival rate of patients was obtained from the electronic medical records. Pre-hospital factors associated with 30-day survival were analyzed using univariate and multivariate logistic regression analyses and were reported using odds ratio (OR) with 95% confidence interval (CI). 300 patients diagnosed with sepsis were enrolled. Among them, 232 (77.3%) survived within 30 days. Non-survived cases had significantly older age (p = 0.019), lower oxygen saturations (92.5% vs. 95.0%; p = 0.003), higher heart rate (p = 0.001), higher respiratory rate (p < 0.001), lower level of consciousness (p < 0.001), higher disease severity based on qSOFA score (p = 0.001), and higher need for invasive airway management (p = 0.001) and supplementary oxygen (p = 0.001). The survival rate improved by 3.5% with every 1% increase in pre-hospital oxygen saturation (adjusted OR = 1.035, 95% CI: 1.005-1.066, p = 0.020) and the survival probabilities of patients who responded to voice (adjusted OR = 0.170, 95% CI: 0.050-0.579, p = 0.005), those who responded to pain (adjusted OR = 0.130, 95% CI: 0.036-0.475, p = 0.002), and those who were unresponsive (adjusted OR = 0.086, 95% CI: 0.026-0.278, p-value < 0.001) were lower than patients who were alert. The 30-day survival rate of patients with sepsis managed by the EMS team was 77.3%. Pre-hospital oxygen saturation and level of consciousness were associated with the survival of patients with sepsis who were managed in the pre-hospital setting.

Case Report: Organophosphorus Section Poisoning-Induced Intermediate Extrapyramidal Syndrome

Organophosphate (OP) compounds are one of the most common agents used for deliberate self-harm in developing countries, including India. OP compounds inhibit the enzyme acetylcholinesterase, which is responsible for hydrolysing the neurotransmitter acetylcholine in both the central and peripheral nervous systems (PNS). Acute cholinergic crises are the most common clinical presentation of OP poisoning. While physicians mostly encounter acute and delayed complications, there have been rare documented cases in the litreature of an intermediate syndrome presenting with extrapyramidal symptoms such as tremors, rigidity, and dystonia. In this report, the authors present a case of a 64-year-old male patient who presented to the Emergency Department (ED) with a history of consuming an unknown quantity of OP-Phorate (11.2%). The initial manifestations included vomiting, sweating, difficulty in breathing, and a low level of consciousness. The patient was managed with atropine, pralidoxime, and mechanical ventilation. He was extubated but later reintubated due to respiratory failure. Eventually, a neurological examination revealed rigidity in all four limbs. The patient was diagnosed with an extrapyramidal type of intermediate syndrome and treated with oral amantadine and trihexyphenidyl. After further hospital monitoring, the patient was extubated and discharged with intact neurological function.

What is the nutritional status of patients with prolonged disorders of consciousness? A retrospective cross-sectional study

ABSTRACT Background Nutritional status of patients with disorders of consciousness (DoC) is poorly studied. Objectives To evaluate the relationship between nutritional status (body mass index, daily calories intake) and clinical variables (level of consciousness, time since injury, diagnosis, etiology and spastic muscle overactivity; SMO,) in patients with prolonged DoCor emerging. Our main hypotheses are i) patients with lower level of consciousness (UWS) have worse nutritional status compared to patients in minimally conscious state (MCS) and ii) SMO could influence nutritional status. Methods and results Among the 80 patients included in the study (19 UWS, 47 MCS, 14 emerging MCS; 43 ± 15 yo; 3 ± 4 years post-injury, 35 traumatic etiology, 34 females), 9% were at risk to be undernourished, with no differences between UWS and MCS. Patients without SMO had a higher BMI compared to patients with severe SMO. Compared to the recommended daily calories intake, patients with the highest BMI received less calories and patients with the lowest BMI received more calories. We observed a negative correlation between SMO (in lower limbs) and BMI. Conclusion Our study shows that most patients are well nourished, independently from the level of consciousness. SMO may require additional calories in patients’ daily needs; however, longitudinal studies are needed to explore the causal relationship between these variables.

Long-Term Functional Outcome and Quality of Life After Surgical Evacuation of Spontaneous Supratentorial Intracerebral Hemorrhage: Results from a Swedish Nationwide Cohort

To investigate long-term survival, neurologic outcome, and quality of life in patients with spontaneous supratentorial intracerebral hemorrhage (ICH) treated with craniotomy and hematoma evacuation. A nationwide multicenter retrospective analysis of 341 patients who underwent craniotomy and evacuation of supratentorial ICH between January 1, 2011, and December 31, 2015, was performed. Baseline characteristics associated with 6-month mortality and long-term mortality were investigated. Survivors received a questionnaire about their state of health from which EuroQol 5D (EQ-5D) and modified Rankin scale (mRS) were obtained. Predictors of mortality, unfavorable outcome, and life quality were analyzed. The mean follow-up time was 55.2 months. Predictors of 6-month mortality in multiple regression analysis were age ≥75 years, previous myocardial infarction, lower level of consciousness, and mechanical ventilation. Predictors of long-term mortality were higher age and mechanical ventilation. At follow-up, 49.5% of survivors had a favorable neurologic outcome (mRS ≤3). Predictors of an unfavorable functional outcome were higher age and ICH volume ≥50 mL. The mean EQ-5D health index was 0.719, and the mean EQ-5D visual analog scale score was 53.9. In multiple regression, only a higher mRS score was significantly associated with worse life quality. Knowledge about survival, functional outcome, and life quality as well as their predictors in this specific patient group is previously primarily described in short-term follow-up. This multicenter study provides novel information in the long-term perspective, which is important for improved surgical decision-making and prognostication.

Hospital to Hospital Transfers of Cerebral Hemorrhage: Characteristics of Early Withdrawal of Life-Sustaining Treatment.

Large intracerebral hemorrhages (ICHs) are associated with significant morbidity and mortality. Patient transfer to higher level centers is common, but care in these centers rarely demonstrably improves morbidity or reduces mortality. Patients may rapidly progress to brain death, but a large number die shortly after transferring because of withdrawal of life-sustaining treatment (WOLST). This outcome may result in poor resource use and unnecessary cost to patients, families, and institutions. We sought to determine clinical and radiographic predictors of early death or WOLST that may alter potential transfer. We performed a retrospective review of patients admitted from outside medical centers to the neurosciences intensive care unit at Saint Marys Mayo Clinic Hospital in Rochester, MN, from January 2014 to December 2019. Patients ≥ 18years old with a spontaneous ICH were included. Exclusion criteria included trauma, subarachnoid hemorrhage, and subdural hematoma. We identified patients who died or underwent WOLST within 24h of transfer. Descriptive characteristics of patients and ICH were collected. Data were analyzed with univariable, multivariable, and logistic regression. Predictive modeling was performed. An additional case-matched study was completed to evaluate for characteristics further. A total of 317 consecutive patients were identified. Forty-two patients were found with early death or WOLST within 24h of transfer. Do not resuscitate/do not intubate (DNR/DNI) code status (odds ratio [OR] 5.23, confidence interval [CI] 3.31-8.28), anticoagulation use (OR 2.11, CI 1.09-4.09), and lower level of consciousness at presentation based on Glasgow Coma Score (OR 1.41, CI 1.29-1.54) and Full Outline of Unresponsiveness (FOUR) score (OR 1.34, CI 1.26-1.46) were associated with WOLST. Associated characteristics on the computed tomography scan included midline shift (OR 4.64, CI 2.32-9.29), hydrocephalus (OR 9.30, CI 4.56-18.96), and intraventricular extension (OR 5.27, CI 2.60-10.68). Case matching restricted to midline shift demonstrated similarity between patients with aggressive care and WOLST. DNR/DNI code status, warfarin use, ICH score, and composite FOUR score were the best predictive characteristics (area under the curve 0.942). Early death or WOLST after ICH within 24h of presentation was most associated with DNR/DNI code status, warfarin use, ICH score, and lower level of consciousness at presentation. These characteristics may be used by clinicians to guide conversations prior to transfer to tertiary care centers.

Study and validation of an explainable machine learning-based mortality prediction following emergency surgery in the elderly: A prospective observational study

IntroductionThe heterogeneity of procedures and the variety of comorbidities of the patients undergoing surgery in an emergency setting makes perioperative risk stratification, planning, and risk mitigation crucial. In this optic, Machine Learning has the capability of deriving data-driven predictions based on multivariate interactions of thousands of instances. Our aim was to cross-validate and test interpretable models for the prediction of post-operative mortality after any surgery in an emergency setting on elderly patients. MethodsThis study is a secondary analysis derived from the FRAILESEL study, a multi-center (N = 29 emergency care units), nationwide, observational prospective study with data collected between 06-2017 and 06–2018 investigating perioperative outcomes of elderly patients (age≥65 years) undergoing emergency surgery. Demographic and clinical data, medical and surgical history, preoperative risk factors, frailty, biochemical blood examination, vital parameters, and operative details were collected and the primary outcome was set to the 30-day mortality. ResultsOf the 2570 included patients (50.66% males, median age 77 [IQR = 13] years) 238 (9.26%) were in the non-survivors group. The best performing solution (MultiLayer Perceptron) resulted in a test accuracy of 94.9% (sensitivity = 92.0%, specificity = 95.2%). Model explanations showed how non-chronic cardiac-related comorbidities reduced activities of daily living, low consciousness levels, high creatinine and low saturation increase the risk of death following surgery. ConclusionsIn this prospective observational study, a robustly cross-validated model resulted in better predictive performance than existing tools and scores in literature. By using only preoperative features and by deriving patient-specific explanations, the model provides crucial information during shared decision-making processes required for risk mitigation procedures.

Pneumococcal meningitis secondary to otitis media in two patients with COVID-19 omicron variant

BackgroundThe SARS-CoV-2 omicron variant produces more symptoms in the upper respiratory tract than in the lower respiratory tract. This form of “common cold” can cause inflammation of the oropharynx and the Eustachian tube, leading to the multiplication of bacteria such as Streptococcus pneumoniae in the oropharynx. Eustachian tube dysfunction facilitates migration of these bacteria to the middle ear, causing inflammation and infection (otitis media), which in turn could lead to further complications such as acute mastoiditis and meningitis.Case presentationIn January 2022, during the rapid spread of the omicron variant of the SARS-CoV-2 virus, two patients presented to the emergency room at our hospital complaining of headache and a low level of consciousness. A few days prior to admission, the patients had been diagnosed with COVID-19 based on clinical manifestations of a cold virus, without respiratory failure. Cranial computed tomography revealed signs of bilateral invasion of the middle ear in both cases. Lumbar puncture was compatible with acute bacterial meningitis, and S. pneumoniae was isolated in cerebrospinal fluid in both patients. RT-PCR tests for SARS-CoV-2 were repeated, confirming the presence of the omicron variant in one of the patients. We were unable to confirm the variant in the second patient due to the low viral load in the nasopharyngeal sample obtained at admission. However, the time of diagnosis (i.e., during the peak spread of the omicron variant), strongly suggest the presence of the omicron variant. Both patients were admitted to the intensive care unit and both showed rapid clinical improvement after initiation of antibiotic treatment.ConclusionsThe omicron variant of the SARS-CoV-2 virus can promote the development of otitis media and secondary acute bacterial meningitis. S. pneumoniae is one of the main bacteria involved in this process.

Pain Behaviors Analyzed by Videorecording in Brain-Injured Patients Admitted to the Intensive Care Unit

AimTo describe and classify pain behaviors (facial and body) in brain-injured patients with a low level of consciousness before, during, and after the performance of painful and non-painful care procedures. MethodsFacial behaviors and body movements in brain-injured patients were videotaped at rest, during the application of three care procedures (two painful and one non-painful), and 15 minutes after completion of these procedures. Each video recording was evaluated by expert evaluators blinded to each other. For each of the behaviors observed, all possible combinations between the three procedures and/or time were compared using the McNemar test. Effect size was measured by the difference in proportions using the Wilson score 95% confidence intervals. ResultsTwenty-seven patients were included. The mean (standard deviation) Glasgow Coma Score was 5.4 (1.9). A total of 33 behaviors (29 active, four neutral) were registered. Expression of behaviors was more common during the painful procedures compared with the other time points (non-painful procedures, baseline, and final evaluation). Inter-evaluator agreement was substantial (Kappa index >0.7) in more than 50% of the observed behaviors. ConclusionsIn this study involving brain-injured patients with a low level of consciousness, facial, body, and ventilation-related behaviors were more common during painful procedures. Agreement between evaluators to detect the presence or absence of these behaviors was substantial. These findings underscore the need to develop pain assessment measures specific to this patient population.

Food labelling and safety consciousness of consumers in Ghana: the case of tinned tomatoes

PurposeWith the empirical evidence on the purchase behaviour of tinned tomatoes, food labelling and the safety consciousness of consumers in Ghana were examined.Design/methodology/approachPrimary data were obtained from 130 consumers. Descriptive statistics, factor analysis and multinomial probit analysis were applied.FindingsConsumers use tinned tomatoes for cooking because of its easy accessibility in nearby shops, guaranteed constant supply, attractive package, it being affordable/cheaper, its better colour, advertisement/promotion, and longer shelf life. There is a low level of food safety consciousness among consumers since only one-fifth read labels on tinned tomatoes very often, and one-fifth do not read labels at all. Consumers frequently check on tinned tomatoes' most essential information: brand/type, manufacturing and expiry dates, and weight/volume. Age, residential status, contact information, nutritional benefits and affordability influence the choice of retail brand of tinned tomatoes. The health label consumer segment and conventional label consumer segment were identified, with the majority being the former.Research limitations/implicationsThe sample size used for the study could be improved in terms of number and geographical coverage. This is because the study was limited to only one main urbanised area in Ghana. Therefore, it will be worthwhile for a further study to be conducted by comparing urban and rural consumers in Ghana and other countries within Africa, to either validate or reveal a different trajectory of consumer behaviour relevant to marketing, policy and practice.Originality/valueTomato paste (tinned tomatoes) is consumed in almost all homes in Africa, but there are food scare concerns about tinned tomatoes due to reported cases of adulteration with unhealthy materials such as starch and food colour, leading to negative health implications on consumers. This makes the reading of tinned tomato labels very crucial. Thus, it is of policy relevance to investigate consumers' reading behaviour of label information on tinned tomatoes in Ghana. However, previous studies on food labelling focussed on food and nutrition labelling and implications of food labelling on consumers' purchase behaviour, with most of them outside Africa.

Epidemiology, microbiological and clinical characteristics of Enterococcus species bloodstream infections: A 10-year retrospective cohort study from Qatar

Background and objectiveEnterococcus species is one of the leading causes of community and healthcare-associated infections resulting in significant morbidity and mortality. In this study, we aim to evaluate the epidemiology, microbiological and clinical characteristics of Enterococcus Blood Stream Infections (BSIs) over 10 years period in a national secondary care setting. MethodsA retrospective cohort study was conducted on verified cases of enterococcal BSIs in adults from January 2009–December 2018 from specialized care hospitals at Hamad Medical Corporation, Qatar. Epidemiological, microbiological and clinical data were reported and analyzed. ResultsA total of 263 enterococcus BSIs cases were identified, predominant were males (65%) with a median age of 63 (IQR 48–74). E. faecalis and E. faecium were predominate at 93.5% (73.38% and 20.15% respectively). Diabetes was the commonest premorbid condition (54.3%) followed by chronic kidney disease (36.5%). Central lines and genitourinary were the most common sources (18.25%, 14.83% respectively) while no identified source was reported in 45.25% of cases. Ampicillin susceptibility was 82.51% while vancomycin resistance was reported in 10.6% of isolates. Successful bacteremia clearance was achieved in 81.37% of cases at a mean of 4 days (Range 2–5 days) while metastatic complications occurred in 5.3% of cases. Univariate mortality risk analysis was associated with ICU admission, low level of consciousness, high bacteremia scores, and presence of catheters. The 30 days mortality was high at 66.54% with CKD and cancer patients at the highest mortality risks (OR 16.334 (CI 4.2–62.4) and 16 (CI 3–84) respectively. ConclusionSignificant mortality was associated with enterococcus BSI despite low rates for ampicillin and vancomycin resistance necessitating early identification of susceptible patients to instigate suitable preventive measures.

How anticipated pride and guilt influence green consumption in the Middle East: The moderating role of environmental consciousness

This research empirically tests the combined effect of anticipated pride, anticipated guilt, and environmental consciousness in parallel to the Theory of Planned Behavior's main components on green purchase intention. For the first time, it also explores the interaction of environmental consciousness, anticipated pride, anticipated guilt, and attitude, respectively, on green purchase intention. Analysis of 304 responses collected from consumers in the United Arab Emirates revealed that environmental consciousness, attitude towards green products, anticipated pride, and anticipated guilt positively influence the intention to purchase green products, but not perceived behavioral control and subjective norms. Interestingly, anticipated pride increases green purchase intention under low level of environmental consciousness, while anticipated guilt decreases purchase intention. In contrast, anticipated guilt positively influences green purchase intention under high environmental consciousness, while anticipated pride does not. This study extends current knowledge related to green purchase behavior and provides a nuanced understanding of the influence of anticipated emotions. It also provides practical implications for marketers in the Middle East to formulate effective strategies to stimulate green products consumption.