Rapid Deterioration Of Patient Research Articles

Interleukin-6 and Biomarkers Predict Outcomes in People with Diabetes and COVID-19 Infection

Abstract Objective: The study aimed to evaluate the association between interleukin-(IL-6) and other inflammatory markers (ferritin, D-dimer, and C-reactive protein [CRP]) in severe and critical coronavirus disease 2019 (COVID-19) infection severing from diabetic mellitus (DM). Materials and Methods: A total of 130 patients confirmed with COVID-19 infection in a Laboratory of the Ministry of Health/Department of Public Health and Al-Amal Specialized Hospital for Communicable Diseases from January 1, 2022, to May 1, 2022, were included in the study. Demographic and clinical data, signs and symptoms, diabetics history, laboratory diagnosis (reverse-transcription polymerase chain reaction), as well chest computed tomography were collected and analyzed. The patients were divided according to the severity of the disease into three groups: mild cases (39%), severe cases (33%), and critical cases (28%). Results: The results revealed that 70 of the 130 severe acute respiratory syndrome coronavirus-2 infected patients had diabetes and were at a high risk of a severe and critical outcome. Furthermore, the level of proinflammatory biomarkers, such as IL-6 and other inflammatory biomarkers, such as CRP, serum ferritin, and D-dimer, were significantly higher (P < 0.01) in patients with diabetes compared with those without diabetes and the control group. Conclusion: This study concludes that according to COVID-19, DM must be a consideration of high-risk factor for the rapid progression of COVID-19 and an increased mortality rate. A recent study suggests that COVID-19 patients with diabetes are more susceptible to cytokine storms, eventually leading to rapid deterioration of patients’ health.

The clinical practice of palliative sedation in patients dying from COVID-19: a retrospective chart review

BackgroundClinical experts experienced challenges in the practice of palliative sedation (PS) during the COVID-19 pandemic. Rapid deterioration in patients’ situation was observed while the indications for starting PS seemed to differ compared to other terminal patients. It is unclear to which extent clinical trajectories of PS differ for these COVID patients compared to regular clinical practice of PS.ObjectivesTo describe the clinical practice of PS in patients with COVID versus non-COVID patients.MethodsA retrospective analysis of data from a Dutch tertiary medical centre was performed. Charts of adult patients who died with PS during hospitalisation between March ’20 and January ‘21 were included.ResultsDuring the study period, 73 patients received PS and of those 25 (34%) had a COVID infection. Refractory dyspnoea was reported as primary indication for starting PS in 84% of patients with COVID compared to 33% in the other group (p < 0.001). Median duration of PS was significantly shorter in the COVID group (5.8 vs. 17.1 h, p < 0.01). No differences were found for starting dosages, but median hourly dose of midazolam was higher in the COVID group (4.2 mg/hr vs. 2.4 mg/hr, p < 0.001). Time interval between start PS and first medication adjustments seemed to be shorter in COVID patients (1.5 vs. 2.9 h, p = 0.08).ConclusionPS in COVID patients is characterized by rapid clinical deterioration in all phases of the trajectory. What is manifested by earlier dose adjustments and higher hourly doses of midazolam. Timely evaluation of efficacy is recommended in those patients.

Bereavement outcomes of carers of patients with high grade glioma: Experiences of support before and after the death

Carers of people with High Grade Glioma (HGG) completed a survey assessing their anxiety, depression, and grief in addition to open-ended questions exploring their experiences of support pre- and post-death (N = 25). One-third reported borderline or clinical levels of anxiety, depression, and grief related distress. Given the poor prognosis and rapid deterioration of patients with HGG, the findings highlight the importance of sensitive communication about prognosis early in the disease trajectory, information tailored to disease stage, the initiation of a referral to psychological support services, and timely discussions about the preferred place of care and death.

Conducting Goals of Care Conversations: Lessons From the COVID-19 Pandemic.

Objective: Internal medicine (IM) residents discuss a patient's goals of care (GOC) as part of their initial consultation. Residents have described inexperience, general discomfort, limited formal teaching, and prognostic uncertainty as barriers to effective GOC conversations. The early COVID-19 pandemic resulted in rapid changes to the healthcare system on the individual, patient, and systemic level that might exacerbate and/or introduce new barriers to IM residents' GOC conversations. This qualitative study examines how the early COVID-19 pandemic challenged IM residents' ability to have effective GOC conversations. Methods: Using a constructivist grounded theory approach, participants (n=11) completed a semi-structured interview. Data collection and analysis occurred simultaneously using an open coding, constant comparison process. Interviews were completed until no new themes were identified. Results: Residents self-described their GOC conversations in 5 steps: normalization of the conversation, introduction of expected clinical course, discussion of possible care plans, exploration of the patient's values, and occasionally providing a recommendation. Residents described limited structured teaching around GOC conversations and instead relied on observed role-modelling and self-practice to hone their skillset. Residents described an increased sense of urgency to have GOC conversations due to the uncertainty of clinical course and potential for rapid deterioration of patients with COVID-19. Residents identified restrictive visitor policies as a significant barrier that contributed to feelings of dehumanization. Residents felt that these limitations affected their GOC conversations and potentially resulted in discordant care plans which contributed to moral distress. Conclusion: The early COVID-19 pandemic resulted in several barriers that challenged residents' ability to conduct effective GOC conversations. This is on the background of previously reported discomfort and limited formal training in conducting GOC conversations. Based on our findings, we present a conceptual model involving teaching validated GOC frameworks, positive role-modelling, and experiential learning to support GOC conversation education in post-graduate medical education.

UNDERSTANDING THE NEED FOR A BROAD DIFFERENTIAL DIAGNOSIS: A CASE OF PNEUMONIC TULAREMIA

UNDERSTANDING THE NEED FOR A BROAD DIFFERENTIAL DIAGNOSIS: A CASE OF PNEUMONIC TULAREMIA

464 ESCALATION DURING COVID-19

Abstract Introduction During the first surge of COVID-19 it was well recognised that early identification of a plan for escalation in the event of deterioration for each patient was vital. If no decision is documented it results in junior staff frequently making decisions regarding escalation in the out of hours period. This leads to patients, or family members, having these conversations with a doctor they may never have met before. My aim was to improve the documentation of escalation plans in all patients within the first 24 hrs of admission. Method Baseline data was collected in September 2019 with further samples in April 2020 and August 2020. Patient medical notes were reviewed to identify if an escalation plan had been made during the period from admission to post take ward round. A COVID admission pathway document was introduced with a specific section on Clinical Frailty Score and Escalation plan between the baseline and April 2020 data. Results Baseline data showed that only 12.8% of medical patients had a documented escalation plan within the first 24 hrs of admission to hospital. During the first surge in April 2020 this number had improved to 47% following introduction of the COVID-19 admission pathway. This included 100% of patients admitted to respiratory wards. Unfortunately when reassessed in August 2020, this number had fallen to 16%. Conclusion Introduction of clinical frailty scoring and an area specifically to document escalation discussions resulted in a marked improvement. Heightened awareness of rapid deterioration of patients during the first surge almost certainly played a role in this. Unfortunately this was not sustained once staff discontinued the use of COVID-19 admission document. Moving forward we will incorporate these sections into the medical and surgical admissions pathways in the hope it produces similar results.

Musculoskeletal Changes in Hemophilia Patients Subsequent to COVID-19 Lockdown.

(1) Background. The lockdown period due to the COVID−19 pandemic has drastically decreased levels of physical activity in the population. Hemophilia is characterized by hemarthrosis that leads to chronic, progressive and degenerative joint deterioration. (2) Methods. This observational study recruited 27 patients with hemophilia and arthropathy. Knee, ankle and elbow joints were assessed. The frequency of clinical hemarthrosis, pain intensity, pressure pain threshold, and joint ROM were evaluated. (3) Results. Following lockdown, a significant deterioration of joint condition, perceived joint pain and range of motion was noted in all joints. There were no changes in the frequency of knee hemarthrosis, while the frequency of ankle hemarthrosis significantly reduced. However, the frequency of elbow hemarthrosis increased. Depending on the degree of hemophilia severity, there were changes in pressure pain threshold in the elbow and in pain intensity and range of motion of the ankle joint. According to the type of treatment, i.e., prophylaxis vs. on-demand treatment, there were differences in the joint condition in elbows and the plantar flexion movement of the ankle. There were no differences in the knee joint based on the severity of the disease, the type of treatment or the development of inhibitors (4). Conclusions. Because of the COVID−19 lockdown, the musculoskeletal status of patients with hemophilia deteriorated. Joint condition, perceived pain, and range of motion were significantly affected. The frequency of clinical hemarthrosis did not increase during this period. A more active therapeutic model could prevent rapid deterioration in patients with hemophilic arthropathy during prolonged sedentary periods.

Personal Protective Equipment and Donning and Doffing Techniques in the Cardiac Catheterization Laboratory During the COVID-19 Pandemic: Insights From an Internet Search for Protocols.

Background: Due to the ongoing coronavirus disease 2019 (COVID-19) pandemic, a need for precise donning and doffing protocols for personal protective equipment (PPE) among healthcare infrastructures is paramount. Procedures involving the cardiac catheterization laboratory (CCL) are routinely non-aerosolizing but have the potential for rapid patient deterioration, creating the need for aerosolizing generating procedures. Multiple societal and governmental guidelines on the use of PPE during medical procedures are available on Internet websites; however, there is limited literature available in peer-reviewed formats in this context. This study aims to provide an overview of current PPE donning and doffing protocols specific to the catheterization laboratory.Methods: A series of internet searches regarding donning and doffing of PPE in the CCL including published articles and internet protocols were compiled and compared using Pubmed.gov, Google.com, www.twitter.com, and www.youtube.com.Results: Most institutions used N95 masks, shoe covers, at least one head covering, face shield or goggles, two pairs of gloves, and inner and outer gowns. Doffing variation was greater than donning. Doffing has the potential to contaminate the healthcare worker (HCW), and therefore, this step of PPE management requires further study. Common steps in temporal priority included cleaning of gloved hands, removal of outer (or only) gown, removal of outer gloves, repeat gloved hand cleaning, removal of facial PPE last, and a final non-gloved hand cleaning.Conclusions: This analysis provides a summary of commonly used practices that may be considered when designing CCL-specific PPE protocols. Analysis of consistent steps from the literature led the authors to formulate a suggested protocol for CCL HCWs when performing procedures on patients with confirmed or suspected/unknown COVID-19.

Pituitary Lymphoma Presenting as Diabetes Insipidus

Introduction: Primary CNS lymphomas are rare accounting for 1-3% of CNS neoplasms. They lack specific clinical or radiological features and are diagnosed histologically. We describe a case of Primary CNS lymphoma involving pituitary gland presenting with confusion and diabetes insipidus. Case: 74-year-old presented with anorexia, weight loss, visual hallucinations and acute confusion. Initial evaluation revealed hypernatremia (148 mmol/L), an old cerebral infarct and new extensive thrombus in aorta and lower limb deep vein thrombosis. During hospital stay, he sustained a fall and a CT head showed a new high attenuation change around the temporal horn and left temporal lobe. MRI head was done to characterize the lesion but because of confusion and irritability, this was inconclusive. Patient continued to have hypernatremia with serum sodium ranging from 148 - 154 mmol/L (135-145 mmol/L) that failed to improve after rehydration. He continued to have negative fluid balance and urine output >2.5 litres a day with dilute urine and urine osmolarity of 134 mosm/L. Due to confusion, we were unable to conduct a water deprivation test. Anterior pituitary profile was consistent with secondary hypothyroidism (TSH was 0.09 (0.02-6.00), Free T4 8.2 (8.0-18.0) and (Free T3 was 2.8 (3.0- 4.8)), and secondary hypogonadism (Testosterone 0.9 nmol/L (6.1-27.1), FSH 1.0 IU/L and LH was <0.2 IU/L). Hypothalamic- adrenal axis was intact as cortisol showed adequate increment after corticotropin stimulation (Cortisol at 0 min 386 nmol/L, 30 minutes 584 nmol/L and 60 minutes 640 nmol/L). Further CT Head with contrast was carried out in view of new findings of hypopituitarism that showed smooth hyperattenuating pituitary gland that was consistent with diabetes insipidus and intense contrast enhancement seen in the periventricular regions and the caudate and dentate nuclei bilaterally. Based on clinical and radiological picture, diagnosis of CNS lymphoma and diabetes insipidus was made and commenced on desmopressin nasal spray. We were unable to perform brain biopsy or quantify the response to desmopressin due to rapid deterioration of patient who died 9 weeks after his initial presentation. An autopsy was carried out and histopathology of pituitary yielded normal anterior pituitary but posterior pituitary was completely infiltrated by Non-Hodgkin’s Lymphoma of Diffuse large B cell type that was also infiltrating parts of the cerebellum, temporal cortex and the basal ganglia hence proving diagnosis of Primary CNS lymphoma. Conclusion: Sudden onset of DI with pathological appearance of posterior pituitary and equivocal/non diagnostic CNS imaging should raise the suspicion of CNS lymphoma. Although diagnosis is histopathological, early detection with high index of suspicion and treatment and lead to better outcomes.

Effective management of patients with electrical storm – networking and VT unit as essential parts for a successful outcome

Ventricular tachycardias (VT) represents worldwide one of the leading causes of sudden cardiac death. The increasing number of implanted ICDs have reduced signifi cantly the number of sudden cardiac deaths SCDs); however recurrent VTs episodes might lead to a rapid deterioration of patient’s clinical status and systolic function. An early intervention after a successful patient stabilization in a dedicated VT unit is mandatory for the mid- and long term prognosis of the patient. Nevertheless, a tight collaboration between general hospitals and highly specialized centers in treatment of patients with electrical storm is essential for an effi cient and successful outcome.

Association Between Average Plasma Potassium Levels and 30-day Mortality During Hospitalization in Patients with COVID-19 in Wuhan, China.

Background: Coronavirus disease 2019 (COVID-19) has resulted in more than 610,000 deaths worldwide since December 2019. Given the rapid deterioration of patients' condition before death, markers with efficient prognostic values are urgently required. During the treatment process, notable changes in plasma potassium levels have been observed among severely ill patients. We aimed to evaluate the association between average plasma potassium (Ka+) levels during hospitalization and 30-day mortality in patients with COVID-19.Methods: Consecutive patients with COVID-19 hospitalized in the Zhongfaxincheng branch of Tongji Hospital in Wuhan, China from February 8 to 28, 2020 were enrolled in this study. We followed patients up to 30 days after admission.Results: A total of 136 patients were included in the study. The average age was 62.1±14.6 years and 51.5% of patients were male. The median baseline potassium level was 4.3 (3.9-4.6) mmol/L and Ka+ level during hospitalization was 4.4 (4.2-4.7) mmol/L; the median number of times that we measured potassium was 4 (3-5). The 30-day mortality was 19.1%. A J-shaped association was observed between Ka+ and 30-day mortality. Multivariate Cox regression showed that compared with the reference group (Ka+ 4.0 to <4.5 mmol/L), 30-day mortality was 1.99 (95% confidence interval [CI]=0.54-7.35, P=0.300), 1.14 (95% CI=0.39-3.32, P=0.810), and 4.14 (95% CI=1.29-13.29, P=0.017) times higher in patients with COVID-19 who had Ka+ <4.0, 4.5 to <5.0, and ≥5.0 mmol/L, respectively.Conclusion: Patients with COVID-19 who had a Ka+ level ≥5.0 mmol/L had a significantly increased 30-day mortality compared with those who had a Ka+ level 4.0 to <4.5 mmol/L. Plasma potassium levels should be monitored routinely and maintained within appropriate ranges in patients with COVID-19.

HIT-Heparin Induced Thrombocytopenia Simulation Case.

The aim of this simulation is to educate emergency medicine interns, residents and advanced providers on the recognition, diagnosis, and management of heparin-induced thrombocytopenia (HIT). Communication, teamwork, and crisis resource management are incorporated into the case. Heparin-induced thrombocytopenia is a life-threatening complication of heparin exposure (eg, unfractionated heparin, low molecular weight [LMW] heparin) that occurs in a small percentage of patients exposed.1 It results in a consumptive coagulopathy in which the clotting cascade is inappropriately activated, leading to a low platelet count yet hypercoagulable state. HIT is associated with mortality rates of 20-30%, with a similar percentage of patients becoming subsequently disabled due to severe complications including limb amputation, multi-system organ failure, stroke or other causes of morbidity.2 Heparin-induced thrombocytopenia often presents 5 to 15 days after starting heparin treatment, and with more outpatients being treated with heparin products, it is likely that a first-line provider, such as an emergency medicine physician, would be the first clinician to encounter these patients. The combination of thrombocytopenia and hypercoagulability, along with the rarity of the disease, can make this difficult to diagnose and puts the first line clinician at risk for mismanagement. It is important to be familiar with the signs and symptoms of HIT and to refrain from starting heparin or platelets upon discovery of thrombosis or thrombocytopenia because it will lead to severe and rapid patient deterioration. Therefore, the ability to quickly recognize and treat this condition properly is an essential skill for emergency medicine physicians. Our goal is to create a simulated case that familiarizes emergency providers to this condition so they can be comfortable diagnosing and managing it in a real clinical scenario. After completing this simulated case, participants will be able to: Obtain a detailed history that includes recent medications, medical, surgical, and social history to evaluate for HIT risk factors.Perform an adequate neurovascular exam including evaluation of motor function, sensation, skin color, pulses, and capillary refill.Order appropriate laboratory testing and imaging for diagnosis of thrombocytopenia and arterial occlusion, including bed side doppler or ultrasound.Discuss and recognize the symptoms of HIT and the contraindications of platelet and heparin administration in the emergency department.Avoid administration of heparin in the emergency department setting and recognize that platelets may worsen thrombus formation and lead to limb amputation.2Select appropriate medications for treatment and determine appropriate disposition for a patient presenting with HIT.Demonstrate interpersonal communication with patient and family.Recognize that HIT with thrombosis is a potential complication in hospitalized patients and outpatient settings and is associated with high mortality rates. This is a high-fidelity simulation case that allows participants to diagnose and treat HIT in a safe environment. The case is followed by a debriefing and small group discussion to review patient care skills, medical knowledge, interpersonal communication, and practice-based learning and improvement. The educational content and efficacy were evaluated by oral feedback and a debriefing session immediately after completion of the simulation. Participants were provided with an evaluation at the completion of the debriefing session to provide qualitative feedback on the simulation case. A quality Likert Scale was used for the evaluation. Post-simulation feedback resulted in positive reception, and learners found it useful to run through a high-risk case potentially seen in the emergency department. Out of the 21 participants, 14 responded to the evaluation. Feedback was overwhelmingly positive with the majority rating the simulation as excellent or good.Discussion: The simulation improved awareness of the symptoms of HIT and contraindications of immediate platelet and/or heparin initiation upon vessel occlusion and thrombocytopenia discovery.Topics: Heparin-induced thrombocytopenia, pain control, resuscitation efforts, coagulation disorders, history taking, undifferentiated patient, arterial occlusion, hematology, emergency medicine simulation.

Risk assessment in patients with pulmonary arterial hypertension in the era of COVID 19 pandemic and the telehealth revolution: State of the art review

Patients affected by pulmonary arterial hypertension (PAH) benefit from intensive, continuous clinical monitoring to guide escalation of treatments that carry the potential to improve survival and quality of life. During the coronavirus disease 2019 pandemic, the need for physical distancing has fueled the expeditious expansion of various telehealth modalities, which may apply in a unique manner to individuals with PAH. Performance of objective risk assessments in patients with PAH remotely via telemedical visits and other telehealth mechanisms is unprecedented and not yet rigorously validated. The uniquely high risk for rapid deterioration in patients with PAH demands a high degree of sensitivity to detect changes in functional assessments. In this review, several telehealth modalities for potential utilization in risk assessment and treatment titration in patients with PAH are explored, yet additional study is needed for their validation with the pre-pandemic care paradigm.

Non-Invasive Ventilation in COVID-19 Patients: A Debate to Continue

The use of Non-Invasive Ventilation (NIV) in patients with acute hypoxemic respiratory failure and specifically in Corona Virus Disease 2019 (COVID-19) that causes by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a matter for discussion since the current COVID 19 pandemic started. The limited available data led to conflicting opinions and variable recommendations and suggestions by the different health care professional bodies. Trends toward early intubation and avoiding NIV justified by the rapid deterioration of patients and the risk of disease transmission to the health care workers were prevalent mainly in the early stages of the pandemic. The limited available medical resources to provide invasive ventilation and subsequent anecdotal evidence suggestive of NIV success in patients with COVID 19 respiratory failure led to a change in the practice in different medical institutions around the world. Despite the absence of strong evidence, NIV probably has a role in the management of COVID 19 respiratory failure in a selected group of patients especially in the early stages of the disease via Continuous Positive Airway Pressure. Close monitoring and strict infection control precautions are required whilst providing NIV to avoid any possible complications.

Transformacja i zasady działania psychiatrycznego oddziału jednoimiennego w trakcie pandemii COVID-19

Celem niniejszego artykułu jest prezentacja doświadczeń Oddziału Klinicznego Psychiatrii Dorosłych Dzieci i Młodzieży Szpitala Uniwersyteckiego w Krakowie (OKPDDiM) w podejmowaniu roli psychiatrycznego oddziału jednoimiennego dla Województwa Małopolskiego dla osób dorosłych oraz dla Polski południowej w wypadku dzieci i młodzieży w trakcie pandemii COVID-19. W pracy zaprezentowane zostały etapy transformacji, przyjęte rozwiązania praktyczne oraz trudności, na jakie napotkał zespół w trakcie tego procesu. W okresie od 9.04-29.05.2020 roku w warunkach stacjonarnych budynku OKPDDiM leczonych było 9 pacjentów zakażonych SARS-CoV-2, natomiast w dniach 23.03-23.05.2020 roku w głównej siedzibie Szpitala Uniwersyteckiego w Krakowie konsultujący psychiatrzy zaopatrywali 97 chorych zakażonych SARS-CoV-2. Nasze doświadczenia wskazały, że placówki opieki medycznej w Polsce, zwłaszcza te dedykowane pacjentom ze schorzeniami psychicznymi oraz domy opieki długoterminowej, nie były przygotowane do pracy w warunkach kryzysu pandemii. Sytuacja ta uwydatniła też brak rozwiązań systemowych na wypadek kryzysu na szczeblu ogólnokrajowym, w tym zwłaszcza dotyczących psychiatrii dzieci i młodzieży oraz psychiatrii sądowej. Funkcjonowanie w ramach kryzysu sanitarno-epidemiologicznego związanego z możliwością szybkiego pogarszania się stanu somatycznego pacjentów psychiatrycznych wskazuje dobitnie na konieczność powstawania oddziałów psychiatrycznych w szpitalach ogólnych. Wymóg posiadania w ramach oddziałów różnych stref dla pacjentów z wykluczoną infekcją SARS-CoV-2 oraz bez wykluczonej infekcji powinien być uwzględniony w ramach reformy psychiatrii zakładającej regionalną odpowiedzialność ośrodków stacjonarnych.

Imaging Findings in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Coronavirus Disease (COVID-19).

BACKGROUND. A multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) has recently been described. OBJECTIVE. The purpose of our study was to evaluate the imaging findings of MIS-C associated with COVID-19. METHODS. Imaging studies and medical records of patients (age range, 0-20 years) admitted with MIS-C between April 22 and May 21, 2020, were retrospectively reviewed. Thoracic imaging studies were evaluated for parenchymal, mediastinal and hilar, and cardiovascular abnormalities. Abdominal imaging studies were evaluated for abnormalities of solid viscera, hollow viscera, and the peritoneum as well as the mesentery and retroperitoneum. Studies were reviewed independently by two radiologists, and disagreements were resolved by a third senior radiologist. RESULTS. Sixteen patients (10 male and six female patients; age range, 20 months-20 years) were included in this study. All 16 patients presented with fever. Other presenting signs and symptoms included the following: vomiting (12/16, 75%), abdominal pain (11/16, 69%), rash (10/16, 63%), conjunctivitis (8/16, 50%), diarrhea (7/16, 44%), headache (6/16, 38%), and sore throat (5/16, 31%). Shortness of breath and cough were each present in one patient. Chest radiography showed cardiomegaly (10/16, 63%), congestive heart failure or cardiogenic pulmonary edema (9/16, 56%), atelectasis (9/16, 56%), pleural effusions (7/16, 44%), acute respiratory distress syndrome (2/16, 13%), and pneumonia (1/16, 6%). Eight patients (50%) were evaluated for pulmonary embolism (PE) (six [75%] by CT angiography [CTA] and two [25%] by ventilation-perfusion scintigraphy). In two of the eight patients (25%), CTA showed a segmental PE. Abdominal imaging findings (ultrasound, CT, and radiography) included small-volume ascites (6/16, 38%), hepatomegaly (6/16, 38%), echogenic kidneys (5/16, 31%), bowel wall thickening (3/16, 19%), gallbladder wall thickening (3/16, 19%), mesenteric lymphadenopathy (2/16, 13%), splenomegaly (1/16, 6%), and bladder wall thickening (1/16, 6%). The frequencies of findings based on all the reviewed modalities were as follows: cardiomegaly (12/16, 75%), pleural effusion (10/16, 63%), and atelectasis (10/16, 63%). Absolute interobserver agreement was 0.69-1 for thoracic findings and 0.17-1 for abdominal findings. Fifteen patients (94%) were discharged from the hospital (length of hospital stay: range, 3-20 days), and one patient remained in the hospital at the end of the study period. There were no mortalities. CONCLUSION. MIS-C associated with COVID-19 is characterized predominantly by cardiovascular abnormalities, although solid visceral organ, gallbladder, and bowel abnormalities as well as ascites are also seen, reflecting a multisystemic inflammatory process. CLINICAL IMPACT. The constellation of imaging findings in the setting of COVID-19 may alert radiologists to the diagnosis of MIS-C before rapid deterioration of patients.

P242 When there is no time for further imaging

Abstract Introduction Cardiac tamponade (CT) is a clinical syndrome characterized by hemodynamic abnormalities resulting from an increase in pericardial pressure due to accumulation of fluid. Tamponade is one of the cardiac emergencies where urgent management steps are crucial and life saving. Absolute goal of treatment in Cardiac tamponade is to relieve the intra-pericardial pressure and to reverse the hemodynamic shutdown, by removal of the pericardial fluid via pericardiocentesis or surgical drainage. As much inevitable as it is, pericardiocentesis is relatively contraindicated when the effusion is associated with aortic dissection or myocardial rupture due to the potential risk of aggravating the dissection or rupture via rapid pericardial decompression and restoration of systemic arterial pressure. Case description A 44-year-Old transit passenger was admitted after she developed sudden onset of palpitations, vomiting and epigastric pain. She was in sinus tachycardia when brought to the Emergency department, within minutes’ patient went into cardiac shock with severe metabolic acidosis. She was admitted to ICU and subsequently intubated. Chest X-ray showed evidence of Pleural effusion with enlarged cardiac shadow, which prompted an urgent transthoracic echocardiogram. Echo findings were consistent with clinical cardiac tamponade with a large left pericardial mass compressing the lateral LV wall and aortic root, with a color flow from the mass toward the left coronary system. Mean while the patient was rapidly deteriorating, with and patient was not stable to undergo further imaging (CT or MRI), urgent contrast echo was done to rule out vascular connection between the mass and pericardial fluid, The Echo contrast study showed no vascular connection from the mass to the pericardial space ,however there was a connection from the mass to the left coronary system as shown in the figure, based on these findings a pericardial drainage was done successfully. These findings were confirmed by contrast CT scan after patient is stabilized. Patient gradually improved clinically, was extubated successfully, the provisional diagnosis was suspicious of pheochromocytoma,however the final diagnosis not established as the patient travelled to home country for further management. Conclusion Some times, it may become clinically challenging to effectively rule out contraindications to a procedure by the gold standard modalities, specially when a patient is collapsing on the table and the clock is ticking. In such scenarios, immediate alternate approaches resulting in safe outcomes are indispensable. Likewise, in our case of emergent cardiac tamponade and a suspicious pericardial mass in a crashing patient, Transthoracic echo with Optison proved to be life saving to rule out vascular connections between cardiac mass and coronaries or pericardial fluid, when there was no time for definitive imaging modalities due to rapid deterioration of patient’s clinical status. Abstract P242 Figure.

Overcoming Barriers Impeding Nurse Activation of Rapid Response Teams

Management of rapid patient deterioration requires prompt recognition and swift response by bedside nurses and specially trained personnel, who successfully intervene to improve patient outcomes. Timely recognition and activation of rapid response mechanisms requires prudent nursing care. When patient needs and nurse competencies are unbalanced, patient outcomes decline and nurse confidence diminishes. This article offers a brief background of rapid response, including the supporting theoretical framework. Also discussed are barriers to nursing action that result in synergistic imbalance, including: bedside nurse competence to recognize patient deterioration and activate rapid response systems; bedside nurse clinical judgment, interdisciplinary teamwork; and organizational culture. The article includes implications for practice aims to address identified barriers and improve patient outcomes.

Classification of Alzheimer’s Disease in PET Scans using MFCC and SVM

Unlike age related dementia, Alzheimer’s disease is more progressive and causes rapid deterioration in patient’s cognitive functions. Prior to its first clinical manifestation, it is evident that the brain damaging process has already been commenced much earlier in life. This asymptomatic period could have spanned as long as a decade or more. Although there is not yet ultimate cure for the disease, the sooner it is diagnosed, the more chance that available therapeutic measures could improve patient’s quality of life. Standard medical questionnaire and medical imaging are the most prevailing means of identifying early Alzheimer’s disease. Despite a great effort having been made in analyzing structural atrophy in human brain by using CT and MRI, the recent attempts have reached high accuracy and precision but relatively poor sensitivity. Functional imaging such as PET is of much lower spatial resolution but promising modality taken to elevate this limitation. This paper presents a classification method for early detection of the disease from PET scans drawn from Thai population. However, instead of conventional structural analysis, this study performed clustering on unwrapped signals, transformed from imaging data by using Mel-Frequency Cepstral Coefficients (MFCC), by a generic Support Vector Machine (SVM) classifier. The experimental results reported herein indicates that, with optimal MFCC order, the proposed method could identify subjects with Alzheimer’s from controls, with high accuracy, precision and specificity. With a cross-validation ratio of 8:2 and a linear SVM kernel, the classification accuracy, sensitivity and specificity were 96.51, 93.98, and 97.77, respectively, and increased as the MFCC orders.

Thoracic ultrasound: it’s not all about the pleura

As clinicians who deal with acutely and critically unwell adult and paediatric patients we welcome the recently published guidelines aspiring to provide a 24/7 service to deliver safe pleural procedures...