Stepwise Algorithm Research Articles

Screening high-risk Veterans for cirrhosis: taking a stepwise population health approach

BackgroundBecause cirrhosis is often unrecognized, we aimed to develop a stepwise screening algorithm for cirrhosis in the Veterans Health Administration (VHA) and assess this approach’s feasibility and acceptability.MethodsVHA hepatology clinicians (“champions”) were invited to participate in a pilot program from June 2020 to October 2022. The VHA Corporate Data Warehouse was queried to identify Veterans with possible undiagnosed cirrhosis using Fibrosis-4 (FIB-4) ≥ 3.25 and at least one risk factor for liver disease (e.g., obesity), and generate an age-stratified sample. Champions at four sites reviewed charts to confirm eligibility and contacted Veterans to offer further evaluation with elastography. Feasibility was defined as protocol implementation with completion of at least one elastography test and acceptability was defined based on Veteran- and clinician-reported surveys. Participation in the program, patient outcomes, adaptations to the protocol, and implementation barriers were also assessed.ResultsFour sites were able to implement the screening protocol. Adaptations included type of outreach (primary care vs. hepatology, phone vs. mail) and type of elastography used. One site chose to refer patients with clear evidence of cirrhosis directly to hepatology (n = 12) rather than to elastography. Key implementation barriers included staffing, primary care provider (PCP) comfort with interpreting and communicating results, and appointment availability during the COVID-19 pandemic. Of 488 patients whose charts were reviewed, 230 were excluded from outreach based on predefined criteria (e.g., advanced cancer, prior or current referral to hepatology). Champions and PCPs attempted to contact 165 of 246 Veterans who were deemed eligible for evaluation with elastography. Among 53 Veterans who completed elastography, 22 (42%) had findings consistent with significant fibrosis and were referred to hepatology. Clinicians and Veterans reported high acceptability of the program on surveys (80% of Veterans who completed survey).ConclusionsThis pilot demonstrated the feasibility, acceptability, and challenges of a multisite approach to cirrhosis screening.

Single-cell sequencing uncovers the mechanistic role of DAPK1 in glioma and its diagnostic and prognostic implications

BackgroundWe conducted an investigation into the characteristics of single-cell differentiation data in gliomas, with a focus on developing DAPK1-based prognostic markers to predict patient outcomes. Dysregulated expression of DAPK1 has been associated with the invasive behavior of various malignancies, including gliomas. However, the precise role and underlying mechanisms of DAPK1 in gliomas remain inadequately understood.MethodsWe performed analyses on RNA-seq and microarray datasets from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO), in addition to single-cell RNA sequencing (scRNA-seq) data from glioma patients available in GEO. Utilizing the Seurat R package, we identified gene clusters associated with survival from the scRNA-seq data. Prognostic models were developed using LASSO and stepwise regression algorithms. Furthermore, we assessed the predictive potential of these genes within the immune microenvironment and their relevance in immunotherapy contexts.ResultsOur scRNA-seq data analysis revealed 32 distinct cell clusters corresponding to 10 cell types. Through dimensionality reduction and clustering, we identified three glial cell subpopulations based on their differentiation trajectories. DAPK1, serving as a marker gene for the terminal subpopulation, exhibited an association with poor prognosis.ConclusionsDAPK1-based prognostic models show promise for accurately predicting outcomes in glioblastoma and glioma. An in-depth examination of DAPK1’s specific mechanisms in glioblastoma could elucidate its role in immunotherapy response. Targeting the DAPK1 gene may offer therapeutic benefits for glioma patients.

An algorithm for identifying causes of reoperations after orthopedic fracture surgery in health administrative data: a diagnostic accuracy study using the Danish National Patient Register.

Disease- or procedure-specific registers offer valuable information but are costly and often inaccurate regarding outcome measures. Alternatively, automatically collected data from administrative systems could be a solution, given their high completeness. Our primary aim was to validate a method for identifying secondary surgical procedures (reoperations) in the Danish National Patient Register (DNPR) within the first year following primary fracture surgery. The secondary aim was to evaluate the accuracy of the diagnosis and procedure codes used to determine the causes of these reoperations. Finally, we developed algorithms to enhance precision in identifying the reasons for reoperations. In a national cohort of 11,551 patients with primary fracture surgery, reoperations were identified through subsequent surgical procedure codes in the DNPR. Each patient record was reviewed to confirm the reoperations and causes. To improve accuracy, a stepwise algorithm was developed for each cause. We identified 2,347 possible reoperations; 2,212 were validated as true reoperations by review of patient record, i.e., a 94% positive predictive value (PPV). However, the coding for the causes of these reoperations was inaccurate. Our algorithm identified major reoperations with a sensitivity/PPV of 89/77%, minor reoperations 99%/89%, infections 77/85%, nonunion 82/56%, early re-osteosynthesis 90/75%, and secondary arthroplasties 95/87%. While the overall reported reoperations in the DNPR had a high PPV, the predefined diagnosis and procedure codes alone were not sufficient to accurately determine the causes of these reoperations. An algorithm was developed for this purpose, yielding acceptable results for all causes except nonunion.

Multistep Algorithm to Predict RVOT PVC Site of Origin for Successful Ablation Using Available Criteria: A Two-Center Cross-Validation Study.

Predicting premature ventricular contraction (PVC) origin pre-ablation is a fundamental step, as right ventricular outflow tract (RVOT) PVC often leads to higher success rates. To compare nine published ECG criteria to differentiate between RVOT and non-RVOT origins of PVCs and develop a stepwise algorithm using those criteria to better determine PVC origin to predict ablation success. Two centers were involved in this study, the derivation group and the validation group. The derivation group included 65 patients with PVC left bundle branch block (LBBB) pattern morphology (predominantly negative in lead V1) and inferior axis (predominantly positive in leads II and III), who underwent ablation at Cipto Mangunkusumo Hospital (RSCM) (2017-2022). The validation group included 291 patients who underwent ablation at the Taipei Veteran General Hospital (2020-2023). We calculated and compared six diagnostic accuracy measures from nine previously published ECG morphology criteria to develop an algorithm to enhance the accuracy of predicting RVOT PVC origin for successful ablation. Our multistep algorithm using Criteria 5, 8, and 1 enhanced diagnostic performance compared to using each criterion alone. The accuracy, sensitivity, and specificity in the derivation group were 86.2%, 93.6%, and 66.7%, respectively; those in the validation group were 85.9%, 90.8%, and 64.7%, respectively. The ROC curve AUCs were 0.802 and 0.775, respectively. In cases of inferior axis and LBBB pattern PVCs, a multistep algorithm using multiple criteria increases the accuracy of predicting RVOT PVC origin instead of using a single criterion.

Correlation between triglyceride-glucose index and atrial fibrillation in acute coronary syndrome patients: a retrospective cohort study and the establishment of a LASSO-Logistic regression model

BackgroundInsulin resistance (IR) is an independent predictor of atrial fibrillation (AF), but the specific utility of the triglyceride-glucose (TyG) index as a predictive marker for the incidence of AF in the acute coronary syndrome (ACS) population has not yet been explored.ObjectiveTo explore the correlation between TyG index and the risk of AF in ACS patients and to establish a predictive model.MethodsA retrospective study was conducted on 613 ACS patients admitted to the Department of Cardiovascular Medicine at the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine from January 2022 to September 2024. Patients were divided into four groups based on quartiles of TyG index. Patients were further divided into two groups based on the occurrence of AF: the AF group and the non-AF group. Patient information was collected through the hospital's HIS system. Variable selection was completed using LASSO regression algorithms. Multivariate logistic bidirectional stepwise regression analysis was used to explore the correlation between the TyG index and the risk of AF in ACS patients and to construct a regression model. Three different models were constructed by adjusting for confounding factors and restricted cubic spline plots were drawn to validate the significance of the TyG index combined with AF further. The predictive value of the LASSO-multivariate logistic bidirectional stepwise regression model and the TyG index alone for predicting AF in ACS patients was analyzed using the receiver operating characteristic curve.ResultsThe LASSO-multivariate logistic bidirectional stepwise regression algorithm showed that coronary heart disease (CHD), valvular heart disease (VHD), TyG, age (AGE), and diastolic blood pressure (DBP) were risk factors for AF in ACS. The restricted cubic spline model demonstrated a significant linear relationship between a higher TyG index and an increased risk of AF in the ACS patient population. The area under the curve (AUC) for predicting AF in ACS patients using the TyG index and the LASSO-multivariate logistic bidirectional stepwise regression model was 0.65(95%CI = 0.58 ~ 0.73) and 0.71(95%CI = 0.65 ~ 0.77) respectively. Additionally, the correlation between the TyG index and AF was consistent across different subgroups.ConclusionIn ACS patients, the TyG index is a stable and independent predictor of AF, with specific clinical value in identifying the occurrence of AF in this population.

Effects of alcohol-related problems on the costs of frequent emergency department use: an economic analysis of a case-control study in Spain.

Alcohol-related problems increase the probability of frequent emergency department (ED) use. In this study, we compared the direct healthcare expenses incurred during a single visit among frequent and non-frequent ED users and analyzed the impact of alcohol-related issues in healthcare costs arising from ED usage. The study relied on secondary analyses of economic data from a 1:1 matched case-control study with the primary aim of identifying the clinical characteristics of hospital ED frequent users in a Mediterranean European environment with a public, universal, and tax-funded health system. The participants ranged in age from 18 to 65 years and underwent ED visits at a high-complexity Spanish hospital (cases ≥5 times, controls <5) from December 2018 to November 2019. Each case was matched to a control with the same age, gender, and date of attendance at the ED. Clinical data and direct healthcare costs for a single ED visit were obtained by a retrospective review of the first electronic medical register. Costs and duration of stay were compared between cases and controls using paired-samples t-tests, and ED users with and without alcohol-related problems were compared using bivariate (independent-samples t-tests, one-way analysis of variance, Chi square tests, and multiple linear regression) and multivariate analyses (multiple linear regression models with backward stepwise selection algorithm, and dependent variable: total mean direct costs). Among 609 case-control pairs (total n = 1218), mean total healthcare direct costs per ED visit were 22.2% higher among frequent compared with non-frequent users [mean difference 44.44 euros; 95% confidence interval (CI) 13.4-75.5; t(608) = 2.811; p = 0.005]. Multiple linear regression identified length of stay, triage level, ambulance arrival, and the specialty discharging the patient as associated with total healthcare costs for frequent users. In bivariate analyses, a history of alcohol-related problems was associated with a 32.5% higher mean total healthcare costs among frequent users [mean difference 72.61 euros; 95% confidence interval 25.24-119.97; t(320.016) = 3.015; p = 0.003]. The findings confirm the high cost of frequent ED use among people with alcohol-related problems, suggesting that costs could be reduced through implementation of intervention protocols.

Geographical variation in quality-adjusted life expectancy in the North Denmark Region.

This study examined the geographical variations in quality-adjusted life expectancy (QALE) in the North Denmark Region. QALE was used to measure health expectancy within each municipality of the North Denmark Region. Measures of health-related quality of life (HRQoL) were obtained from a representative sample of 19,598 responses to the EQ-5D-5L questionnaire in the 2021 regional health survey. Abridged periodic life tables were constructed using mortality data from Statistics Denmark stratified by age, sex, and municipality. The stepwise replacement algorithm developed by Andreev et al. was applied to decompose QALE into its mortality and HRQoL components and investigate the main drivers of the QALE variations between municipalities. The regional average QALE at 16 years of age was 52.6 quality-adjusted life years (QALYs) (95% CI: 52.1-53.0) for men and 53.1 QALYs (95% CI: 52.7-53.5) for women. No statistically significant variations in QALE were found between municipalities. Comparing the highest and lowest scoring municipalities for males, Rebild had 54.5 QALY (95% CI: 51.7-57.2) while Hjørring had 51.9 QALY (95% CI: 49.9-54.1), showing a variation of 2.57 QALE driven by higher HRQoL scores and lower mortality rates. For females, Rebild had 54.3 QALY (95% CI: 52.1-56.5) and Vesthimmerland had 51.3 QALY (95% CI: 49.1-53.4), showing a variation of 3.03 QALE, mostly driven by increased HRQoL scores and to some extent lower mortality rates. Variations in QALE, although not statistically significant, existed between the municipalities in the North Denmark Region. Further research should explore the reasons for these variations to inspire future policy development.

Acceptability and feasibility of a chronic breathlessness diagnostic clinical algorithm in Australian primary care.

Chronic breathlessness is a frequent diagnostic challenge in primary care. Our aim is to evaluate the feasibility of a stepwise breathlessness diagnostic algorithm for primary care. This mixed-methods study included: (1) a general practitioner (GP) nominal group technique study; (2) focus groups on GPs' views on the algorithm; and (3) analysis of algorithm alignment against patterns of diagnostic referrals and diagnoses of breathlessness presentations (2014-19) from the MedicineInsight primary care electronic health record (EHR) dataset of 1,961,264 patients (405 general practice sites). All the tests in our algorithm, except for echocardiography, were ranked in the top 10 tests used by most GPs for patients presenting with chronic breathlessness. Themes from the focus group include similarity with current practice and test accessibility. Analysis of EHR diagnostic referrals revealed that all tests in the algorithm are regularly utilised and covered the major tests needed for breathlessness diagnoses recorded. The results of the three studies support the acceptability and feasibility of the clinical algorithm in primary care.

Congenital Curly Toes in the Pediatric Population: A Management Algorithm and Systematic Review

Purpose: This study aims to formulate a systematic management algorithm for pediatric congenital curly toes (CCTs), addressing the lack of standardized guidelines. By synthesizing the existing literature, the study evaluates CCT presentation, evaluation, treatment options, and outcomes. Methods: A systematic review on PubMed identified nine articles, involving 346 patients younger than 18 years with CCTs. Data extraction included presentation, evaluation, treatment modalities, and outcomes. Results: The analysis revealed that pediatric CCTs predominantly present in younger children. Clinical presentation often involves family concerns or referrals from primary care physicians, emphasizing the aesthetic nature of the condition. The most affected toes are the fourth (43.8%) and fifth (25%). Evaluation methods vary, with the Hamer grading scale and Satake imaging system being prominent. Nonsurgical treatments, including taping and observation, are favored for mild cases (grade 0 to 1), whereas surgical interventions, such as tendon transfer and flexor tenotomy, are reserved for moderate to severe cases (grade 2 to 3). Results indicate that conservative treatments yield varied outcomes, with surgical interventions demonstrating more favorable and permanent results, especially for Grades 2 to 3 deformities. Conclusion: This study proposes a stepwise management algorithm integrating clinical presentation, severity grading, and age-specific considerations for pediatric CCTs. The aim is to guide both nonsurgical and surgical interventions, enhancing clinical decision making for improved patient outcomes. Further research is recommended for algorithm validation.

Nutrition in neonatal and pediatric patients on extracorporeal membrane oxygenation: A survey of current practice in the US and Canada

Abstract Background: Patients requiring extracorporeal membrane oxygenation (ECMO) are at increased risk of malnutrition due to high rates of protein catabolism, unclear metabolic needs, and safety risks with both parenteral and enteral nutrition (EN). Malnourishment is associated with increased morbidity and mortality, and improved EN and protein intake are associated with decreased 60-day mortality. A standardized practice for nutrition therapy in this population is unestablished. We aim to provide an update on current nutritional practices in pediatric and neonatal patients receiving ECMO support. Subjects and Methods: An online survey was distributed to ECMO medical directors in the US and Canada who had previously participated in survey-based research and those who requested participation during a pediatric ECMO presentation of this study. Each medical director was asked to forward the survey to their center’s registered dietitians (RDs). Results: Of 100 institutions surveyed, 36 physicians and 19 RDs responded yielding a physician response rate of 36% and an RD response rate of 19%. Physicians report “always” providing nutrition parenterally 28% and enterally 17% of the time with 11% of institutions using a protocolized approach. Nutrition therapy aids reduction of morbidity and mortality; however, there is variability in its delivery. Conclusions: Compared to 2015, EN is reported to be less utilized (47% vs. 55%) with less protocol use (11% vs. 38%). These data support the need for the development of a stepwise nutritional support algorithm, which is congruent with the recommendations in the Extracorporeal Life Support Organization Nutrition Guidelines.

South African Rheumatism and Arthritis Association 2024 guidelines for the management of axial spondyloarthritis.

Early diagnosis and prompt treatment initiation are essential in the management of axial spondyloarthritis (axSpA), also known as ankylosing spondylitis, remembering that underdiagnosis and overdiagnosis of axSpA are common. These South African guidelines offer screening tools and details of useful investigations, including imaging. Care of the axSpA patient requires a multidisciplinary holistic approach emphasising lifestyle interventions, particularly exercise, smoking cessation and psychosocial support. The ankylosing spondylitis disease activity score is recommended as a measure of disease activity, and a stepwise algorithm for therapy is provided. Screening for comorbidities and vaccination is advised.

Comprehensive Codified Algorithms to Identify the Underestimated Burden of Hidradenitis Suppurativa in the United States.

Hidradenitis suppurativa (HS) is a painful, inflammatory skin disease associated with a high disease burden and long diagnostic delay. Prevalence estimates of HS vary widely in the literature owing to differing estimation methodologies. This study aimed to apply stepwise algorithms to estimate the prevalence of possible/diagnosed cases of HS in the US. This was a retrospective cohort study in adult and pediatric patients with HS which utilized data from four US databases (MarketScan [Medicare and Medicaid] andOptum [electronichealth record (EHR) andClinformatics Data Mart (CDM)]). Patients withpossible/diagnosed HS were identified using two algorithms (termed Algorithm 1 and Algorithm 2), which assessed symptoms such as multiple skin boils in site-specific areas based on international classification of disease (ICD) codes. Patients with diagnosed HS were defined as having ≥ 2 outpatient or ≥ 1 inpatient diagnosis codes of HS. In each database, patients with continuous medical and pharmacy benefits in the 365days pre-index and 0-365days post-index periods were eligible for inclusion. Across all databases, Algorithm 2 (MarketScan Medicare [N = 309,916]; MarketScan Medicaid [N = 188,783]; Optum EHR [N = 366,158]; Optum CDM [N = 173,812]) identified more patients with possible/diagnosed HS than Algorithm 1 (MarketScan Medicare [N = 194,353]; MarketScan Medicaid [N = 99,276]; Optum EHR [N = 177,957]; Optum CDM [N = 112,244]). Based on ICD-9/10 codes, the 5-year period prevalence of HS ranged from 0.06% to 0.12% across all databases, while for Algorithm 1 and Algorithm 2, this ranged from 0.27% to 0.41% and 0.49% to 0.78%, respectively. Adults and females generally had a higher 5-year period prevalence versus pediatric patients and males, respectively. This real-world study highlights that HS diagnosis codes alone may be insufficient to estimate the prevalence of HS, demonstrating the value of employing algorithms in practice which assess for parameters such as multiple skin boils in site-specific areas. Integrating robust methods to identify the prevalence of HS may improve the diagnostic delay observed in HS and improve treatment outcomes.

South African Rheumatism and Arthritis Association 2024 updated guidelines for the management of rheumatoid arthritis.

The management of rheumatoid arthritis (RA) requires early diagnosis and prompt initiation of therapy, together with lifestyle interventions, particularly smoking cessation. These guidelines recommend a treat-to-target strategy using a composite disease activity score at each visit, with frequent follow-up and escalation or switching of disease-modifying antirheumatic drug (DMARD) therapy until the goal of low disease activity is achieved. A stepwise algorithm for DMARD therapy is provided. Screening for comorbidities and vaccination is advised.

Life expectancy at birth and life disparity: an assessment of sex differentials in mortality in India

This study aims to examine the sex differentials in life expectancy at birth and life disparity, and to estimate the age-specific contribution of the differences for India and its major states. Life dispari-ty measures the variation in the distribution of deaths, and life expectancy at birth measures the average length of life. Complete life tables generated from death rates and abridged life tables of the Sample Reg-istration System in India from 1970&amp;ndash;1975 to 2006&amp;ndash;2010 were used to fulfill the research goals. Stepwise replacement algorithm was used for the decomposition of sex differences in life expectancy at birth and in life disparity. The results indicate that the increase in life expectancy at birth and decline in life disparity was higher for females. The sex differential was more prominent in urban areas than in rural areas. A ma-jority of the states in India experienced changes in the direction and magnitude of sex differentials in life expectancy at birth and life disparity from 1970&amp;ndash;1975 to 2006&amp;ndash;2010. The sex differentials in life expec-tancy at birth and life disparity in 1970&amp;ndash;1975 were primarily attributed to child mortality, whereas the sex differentials in recent decades were attributed to adult mortality.&amp;nbsp; &amp;nbsp; &amp;nbsp; &amp;nbsp;&amp;nbsp;

Does vegetation greening have a positive effect on global vegetation carbon and water use efficiency?

Terrestrial ecosystems have undergone significant changes as a result of climate change, profoundly affecting global carbon and water cycling processes. Notably, the synergistic changes in vegetation carbon use efficiency (CUE) and water use efficiency (WUE) and their response to patterns of climate change over the last 40 years are unknown. Therefore, in this study, global vegetation WUE and CUE were inverted using Gross primary productivity (GPP), Net primary productivity (NPP) and total evaporation (ET) data from 1981 to 2019 to reveal their temporal and spatial patterns of change through trend analysis and stability analysis. A stepwise regression algorithm was used to reveal the potential driving law of environmental factors on vegetation WUE and CUE. The results shows that (1) From 1981 to 2019, the global vegetation WUE and CUE showed in a relatively stable state, and the trends of WUE and CUE were -0.00004/year and 0.006 g C m−2 mm−1/year, respectively; (2) the greening of vegetation was the most important cause of the changes in WUE and CUE, and the driving force of rain and heat conditions on the CUE of vegetation was smaller than that of solar radiation and soil water, the regions where CO2 is the dominant factor affecting CUE and WUE are mainly in the north temperate zone; (3) the region of synergistic growth of WUE and CUE accounts for about 31.38 % of the global terrestrial area, and this pattern of change suggests that the global vegetation carbon sink potential is huge, and the popularization of vegetation planting patterns under the synergistic growth of CUE and WUE should be strengthened. The research has shown that vegetation greening is a key factor influencing changes in the WUE and CUE of vegetation, therefore, the implementation of ecological engineering will be an important step in combating climate change.

Diffusion mechanism of quick-setting slurry in water-rich fractured rock mass based on circle-outburst diffusion model

Grouting is the most commonly used methods in dealing with water inrush issue in mine and tunnel engineering. In order to better predict the grouting effect, research on slurry diffusion mechanism became a hotspot for scholars. At present, the mainstream theoretical model used to study the slurry diffusion mechanism are the circle diffusion model and the modified ones in plane plate fracture. However, these models cannot explain the “contradiction” between the rapid setting characteristics of quick-setting slurry and the continuous long-term injection of slurry in grouting engineering, which cannot accurately predict the grouting pressure or grouting diffusion range. Therefore, a “circle-outburst diffusion model” which can explain the above “contradiction” was proposed in this paper. Based on the new model, stepwise algorithms were developed to predict the grouting pressure and slurry diffusion range. By means of conducting fracture grouting simulation test and collecting grouting pressure data in an actual grouting project, the new model was verified and the slurry diffusion mechanism was studied. Comparison results indicate that the new model can reveal the intrinsic reason for the irregular diffusion phenomenon of the slurry and forecast the outburst moment accurately. The circle diffusion stage and outburst diffusion stage elaborated in the new “circle-outburst diffusion model” were consistent with the staged characteristics of the grouting process presented in the grouting simulating test. Differences between theoretical and experimental pressure value were within 10 %, indicating a high degree of consistency. The number and distribution of outburst diffusion points determine slurry diffusion form and significantly influence the diffusion range. The grouting pressure and the length of slurry flow path increase nonlinearly with time in each diffusion stage. It is hoped that the new model can provide a theoretical basis for the study of diffusion mechanism of quick-setting slurry.

Identification of MDA in seized ecstasy-like samples using atmospheric solids analysis probe mass spectrometry and machine learning

In this study, a total of 64 samples of ecstasy tablets seized during operations conducted within the State of Rio Grande do Sul – Brazil in 2021–2022 were analyzed. The instrumental analysis was performed using the Radian ASAP MS instrument with a single quadrupole mass spectrometer and an Atmospheric Solids Analysis Probe (ASAP) interface. Data preprocessing was conducted using MATLAB to improve data quality for subsequent chemometric analyses. Classification models seeking to identify samples containing MDA (3,4-methylenedioxyamphetamine) were developed using Linear Discriminant Analysis (LDA) with variable selection through the genetic algorithm (GA), stepwise (SW), and successive projections algorithm (SPA). Additionally, Partial Least Squares Discriminant Analysis (PLS-DA) models were explored. The GA-LDA model achieved an accuracy of approximately 95% for both training and testing sets, demonstrating its effectiveness in distinguishing between sample classes. It selected only five variables during model building. The SW-LDA model displayed exceptional performance in the training set, achieving 100% for all metrics. However, its accuracy for the testing set was slightly lower at 84.7%, suggesting potential overfitting due to the inclusion of numerous variables. The SPA-LDA model, while not the best performer in the testing set, selected variables that were more easily attributed to specific ions/fragments, aiding in the interpretation of results. Interpretation of selected variables revealed key m/z values associated with different compounds found in the samples, such as MDMA, cocaine, and amphetamine-related fragments. Notably, the SPA method selected six variables that played a crucial role in distinguishing between sample groups. These findings contribute to the advancement of forensic drug analysis and quality control processes.

Acute diarrhea in the hospitalized immunocompromised patient: what is new on diagnostic and treatment?

This article aims to provide an intuitive framework for diagnosing and managing healthcare-associated diarrhea (HCAD) in the immunocompromised (IC) host. Our understanding of diarrhea in hospitalized IC patients has significantly evolved. However, the challenge lies in distinguishing between these patients' numerous causes of diarrhea. The incorporation of gastrointestinal (GI) multiplex polymerase chain reaction (PCR) panels has led to a paradigm shift in our approach to diarrhea. However, using these panels judiciously is of utmost importance, as their misuse can lead to over-testing, overtreatment, and increased hospital costs. We propose a stepwise diagnostic algorithm that ensures diagnostic stewardship, optimal patient care, and resource utilization. Diarrhea is a common complication in hospitalized IC patients and is associated with significant morbidity and rare mortality. The advent of new diagnostics, such as GI multiplex PCR panels, holds promise in facilitating the detection of recognized pathogens and may allow for improved outcomes using pathogen-targeted therapy.

Optimizing diuretic management in acute decompensated heart failure: the impact of diuretic algorithm in real-world setting

Abstract Background/Introduction Achieving euvolaemia is an important prognostic factor in acutely decompensated heart failure (ADHF). The European Society of Cardiology (ESC) guidelines suggest that a stepwise diuretic treatment algorithm based on regular reassessment of urinary output and natriuresis may be superior compared to current standard of care. We studied the implementation and effectiveness of such a pre-specified algorithm in a real-word cohort for realizing euvolaemia. Methods In 2020 we implemented the stepped diuretic strategy from the Heart Failure Association position statement, now stated in the 2021 ESC guidelines, in a peripheral hospital. Afterwards we conducted a retrospective cohort study, including patients with ADHF (with hospitalization duration &amp;gt; 3 days for decongestive treatment). Patients admitted between 10-Jan-2021 and 04-Dec-2021, who were treated according to the diuretic algorithm (protocol cohort), were compared to patients who were treated between 04-Jan-2018 and 19-jan-2019 (before implementation of this algorithm). Our primary outcomes were length of hospital stay (days), complications during hospitalization, such as electrolyte disturbance, kidney function, arrhythmias, infections and mortality during hospitalization. Results The study comprised 221 patients, with 107 in the pre-protocol cohort and 114 in the protocol cohort. Baseline characteristics were similar between the cohorts, expect for the kidney function and NT-proBNP levels at admission. Mean eGFR was slightly better in the protocol cohort (53 [36-71] vs 43 [29-63] ml/min/1.73m2, p .016), were as NT-proBNP was higher in the pre-protocol cohort (990 vs 480 pmol/l) (Table 1). The mean length of stay was shorter in the protocol cohort (7.0 [5.1-10.3] vs 7.5 [5.9-10.9] days). The incidence of complications, such as electrolyte disturbances and arrhythmias, were comparable. Notably, the mean eGFR on third day of hospitalization was higher in the protocol cohort (50 ± 21 vs. 42 ± 19 ml/min/1.73m2). There was a difference in the median weight lost during the admission between the two cohorts (Figure 1). Conclusion Our data suggest that a pre-specified stepwise diuretic treatment algorithm, based on urinary output is feasible and effective in achieving euvolaemia in a real-world cohort. Furthermore, it reduces length of hospital stay without increasing the risk of complications.

Establishment and validation of a predictive nomogram for polyuria during general anesthesia in thoracic surgery

BackgroundTo develop and evaluate a predictive nomogram for polyuria during general anesthesia in thoracic surgery.MethodsA retrospective study was designed and performed. The whole dataset was used to develop the predictive nomogram and used a stepwise algorithm to screen variables. The stepwise algorithm was based on Akaike’s information criterion (AIC). Multivariable logistic regression analysis was used to develop the nomogram. The receiver operating characteristic (ROC) curve was used to evaluate the model’s discrimination ability. The Hosmer–Lemeshow (HL) test was performed to check if the model was well calibrated. Decision curve analysis (DCA) was performed to measure the nomogram’s clinical usefulness and net benefits. P < 0.05 was considered to indicate statistical significance.ResultsThe sample included 529 subjects who had undergone thoracic surgery. Fentanyl use, gender, the difference between mean arterial pressure at admission and before the operation, operation type, total amount of fluids and blood products transfused, blood loss, vasopressor, and cisatracurium use were identified as predictors and incorporated into the nomogram. The nomogram showed good discrimination ability on the receiver operating characteristic curve (0.6937) and is well calibrated using the Hosmer–Lemeshow test. Decision curve analysis demonstrated that the nomogram was clinically useful.ConclusionsIndividualized and precise prediction of intraoperative polyuria allows for better anesthesia management and early prevention optimization.