Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study

BACKGROUND: There is controversy regarding whether saddle main pulmonary artery (MPA) embolism represents a high risk of deterioration in non-high-risk acute pulmonary embolism (PE) patients. This study aims to address this issue by conducting a propensity score matching (PSM) study. METHODS: A total of 727 non-high-risk acute PE patients were retrospectively evaluated. We evaluated the Bova score and risk stratification to examine the risk of deterioration. Deterioration defined as any adverse event within 30 days after admission. Computed tomographic pulmonary angiography was used to identify the embolism type. All patients were matched into four subgroups by PSM according to age, sex, Bova score, and risk stratification: (1) MPA and non-MPA embolism; (2) non-saddle MPA and non-MPA embolism; (3) saddle MPA and non-saddle MPA embolism; (4) saddle MPA and non-MPA embolism. Correlations were analyzed using Cox regression analysis, and deterioration risk was compared between subgroups using Kaplan-Meier analysis. RESULTS: Cox regression analysis revealed that MPA embolism was correlated with deterioration, regardless of whether saddle MPA embolism was included or excluded. Saddle MPA embolism was not correlated with deterioration, regardless of comparison with non-saddle MPA embolism or non-MPA embolism. Patients with MPA and non-saddle MPA embolism presented a high risk for deterioration (log-rank test=5.23 and 4.70, P=0.022 and 0.030, respetively), while patients with saddle MPA embolism were not at a high risk of deterioration (log-rank test=1.20 and 3.17, P=0.729 and 0.077, respetively). CONCLUSIONS: Saddle MPA embolism is not indicative of a high risk of deterioration in non-high-risk acute PE patients.     

1470 nm/980 nm dual-wavelength laser is safe and efficient for the en-bloc resection of non-muscle invasive bladder cancer: A propensity score-matched analysis

ObjectiveTo evaluate the efficacy and safety of a 1470 nm/980 nm dual-wavelength laser system used for the en-bloc resection of non-muscle invasive bladder cancer (NMIBC) compared with transurethral resection of bladder tumour (TURBT).MethodsThis retrospective study analysed the demographic and clinical data from patients diagnosed with NMIBC that were treated by either dual laser or TURBT. Intraoperative characteristics, postoperative characteristics and outcomes between the two groups were compared.ResultsThis study analysed 64 patients, 32 in each group. No severe complications were identified in either group. After propensity score-matching, there were no significant differences between the two groups in terms of the demographics, clinical and tumour characteristics. There was no significant difference between the two groups in terms of specimen quality. In the laser group, intraoperative blood loss was significantly lower and significantly fewer patients required continuous bladder irrigation after surgery, compared with the TURBT group. No significant differences were observed in the catheterization time, gross haematuria time and hospitalization time. Operation time in the laser group was significantly longer compared with the TURBT group. No significant difference was found in the recurrence and progression rates between the two groups.ConclusionsThe 1470 nm/980 nm dual-wavelength laser provides a safe and effective surgical treatment option for patients with NMIBC.     

三联药物背肌注射治疗支气管哮喘急性发作临床研究--附600例病例报告

目的:探讨选择背部肌肉注射药物治疗支气管哮喘急性发作的治疗效果,皆在寻求一种方便、快捷、高效、安全的平喘治疗途径.方法:将确诊为支气管哮喘急性发作的963例患者中资料完整的600例随机分为A、B、C 3组.A组:在患者的背部注射本院配制的三联药物(决明茶碱,薯芋皂甙,莨菪碱);B组:常规肌肉注射上述三联药物;C组:质量分数为5%的葡萄糖20 ml 氨茶碱0.25 g 地塞米松10 mg静脉注射.治疗前及治疗20 min后3组均行肺功能测定,治疗20 min后评价疗效.结果:A组:显效时间1～10 min,明显改善率为49.0%,中度改善率为37.5%,轻度改善率为12.0%,无改善率为1.5%;B组:显效时间30～45 min,明显改善率为14.0%,中度改善率为11.5%,轻度改善率为42.5%,无改善率为32.0%;C组:显效时间5～15 min,明显改善率为46.0% ,中度改善率为36.5%,轻度改善率为13.0%,无改善率为4.5%;A、B两组疗效有显著性差异(P<0.01),A、C两组间无显著性差异(P>0.05).A组和C组治疗后用力肺活量(FVC)、第1秒呼出气量(FEV1)、呼气中段流量(MMEF)3项肺功能指标改善明显,B组治疗后无明显改善.结论:背肌注射药物方便易行、快捷、高效、安全,疗效可靠,同时避免了静脉用氨茶碱及激素带来的不良反应,临床值得推广.     

A before and after study assessing the impact of a new model for recognizing and responding to early signs of deterioration in an acute hospital

Aim. To evaluate the impact of a new model for the detection and management of deteriorating patients on knowledge and confidence of nursing staff in an acute hospital. Background. International evidence shows that clinical deterioration is not always recognized or acted on by nurses. The use of physiological track and trigger scoring systems accompanied by a graded response strategy has been recommended to monitor all adult patients in acute UK hospitals. However, little is known about the impact of these new systems in practice. Design. A single centre, mixed methods before‐and‐after study. Methods. A mixed methods before‐and‐after study, set in a district general hospital in England, in 2009, including a survey (n = 213) and qualitative interviews (n = 15) with nursing staff. The questionnaire examined knowledge and confidence in recognition and management of deteriorating patients 6 weeks before and after an intervention which included training, new observation charts and a new track and trigger system. Interviews further explored participants’ perspectives. Comparisons were made between registered and unregistered nurses. Results. Following the intervention, knowledge, and confidence to recognize and manage deteriorating patients increased; the number of concerns were reduced. Scores were higher for registered than unregistered nurses before and after the intervention. Interviews confirmed these findings and provided detail on how nurses felt the new system had improved practice. Conclusion. The new model had a positive impact on the self‐assessed knowledge and confidence of registered and unregistered nurses. Similar initiatives should take into account the clinical context and tailor training packages accordingly.     

Forensic mental health nurses' experiences of rebuilding the therapeutic relationship after an episode of physical restraint in forensic services in Ireland: A qualitative study

Few studies have explored how forensic mental health nurses can rebuild the therapeutic relationship following an episode of physical restraint in the acute forensic setting. In this study, we aimed to redress this gap in the literature by exploring with forensic mental health nurses the factors that enable or hinder the rebuilding of the therapeutic relationship following an episode of physical restraint. A qualitative study design was used to capture participants' experiences, views and perceptions of the therapeutic relationship following an episode of physical restraint in the acute forensic setting. Data were collected through individual interviews with forensic mental health nurses (n = 10) working in an acute forensic setting. Interviews were audio recorded, and transcribed verbatim and accounts were analysed using thematic analysis. Four themes were identified: ‘Building a Recovery Focused Therapeutic Relationship’; ‘Authoritarian Role’; ‘Inevitable Imbalance’; ‘Rebuilding the Therapeutic Relationship’; plus two sub-themes ‘Facilitators to rebuilding’ and ‘Barriers to rebuilding’. Findings suggest that an inevitable imbalance exists in building a recovery-focused therapeutic relationship and at times, is hindered by the authoritarian role of the forensic mental health nurse. Recommendations for changes in clinical practice and in upcoming policies should incorporate a dedicated debrief room and protected time for staff to debrief effectively following restraint. Routine post-restraint-focused clinical supervision would also be beneficial to mental health nursing staff.     

Increased body weight in men after the age of 55 is a risk factor for internal carotid artery stenosis: an epidemiological study of men aged 69

Summary. A population-based cohort of 393 men born in 1914and residing in the city of Malmö, Sweden, was examined at ages 55 and 69 years, respectively, with regard to risk factors for arteriosclerotic vascular and coronary disease. At age 69 an examination of the carotid arteries with Doppler ultrasound was carried out also, to establish the prevalence and degree of stenosis in the carotid vessels. The material was analysed for the following risk factors for internal carotid artery stenosis: systolic and diastolic blood pressure, cholesterol, triglycerides, haematocrit, gamma glutamyl transferase (GT), blood glucose, body mass index (BMI), body weight change (BWC), and smoking. Stepwise multiple regression analysis showed that only increased body weight between 55 and 69 years of age and the earlier known risk factor, smoking, remained as independent risk factors for developing carotid artery disease.     

Transcranial Doppler Sonography is Useful for the Decision-Making at the Point of Care in Patients with Acute Hepatic Failure: A Single Centre’s Experience

Acute hepatic failure (ALF) is an uncommon disease characterized by a rapid deterioration of the hepatic function with severe derangements of the mental status in previously healthy subjects due to massive hepatocytes necrosis. Neurological impairment, due to intracranial hypertension and cerebral ischemia, is a key factor because it is a main criterion to decide when to proceed to liver transplantation, which is only treatment for these patients. Therefore, neurological monitoring holds an essential role in the clinical management of ALF patients but it needs to be performed at the point-of-care in the majority of the cases as such critically ill patients cannot be moved away from the ICU because they frequently need continuous hemodynamic, ventilatory and renal support. We herein report and discuss our experience relating to the use of transcranial sonography as a neuro-monitoring tool in ALF patients. In our series this technique allowed a repeatable and reliable non-invasive assessment of cerebral blood flow changes at the bedside thus avoiding the complications associated with the use of an intracranial probe to measure intra-cranial pressure and making it possible to correctly evaluate the timing and feasibility of liver transplantation. Bindi ML, Biancofiore G, Esposito M, Meacci L, Bisà M, Mozzo R, Urbani L, Catalano G, Montin U, Filipponi F. Transcranial Doppler sonography is useful for the decision-making at the point of care in patients with acute hepatic failure: a single centre’s experience.     

Respiratory rate at intensive care unit discharge after liver transplant is an independent risk factor for intensive care unit readmission within the same hospital stay: A nested case-control study

Purpose

Intensive care unit (ICU) readmission negatively impacts patients’ outcomes. We aimed to characterize and determine risk factors for ICU readmission within the initial hospital stay after liver transplant (LT).

Materials and methods

The reference cohort included 369 LT recipients from a Canadian center between 2005 and 2012. One control was randomly selected per each case of ICU readmission within the initial hospital stay after LT. Survival analysis used the Kaplan-Meier method. Associations were studied by conditional logistic regression.

Results

Fifty-two (14%) LT recipients were readmitted to the ICU within the initial hospital stay after LT; they had longer first hospital stay (P < .001) and lower 1-month to 2-year cumulative survival (P < .001). Respiratory failure was the major cause of ICU readmission (61%). Respiratory rate at discharge from the first ICU stay after LT was an independent risk factor for ICU readmission (odds ratio = 1.24). The cutoff point more than 20 breaths per minute prognosticated ICU readmission with a specificity of 90% and a positive predictive value of 80%.

Conclusions

Intensive care unit readmission within the initial hospital stay after LT negatively impacts LT recipients’ outcomes. Monitoring respiratory rate at discharge from the first ICU stay after LT is important to prevent readmission.     

Hematological characteristics of COVID‐19 patients with fever infected by the Omicron variant in Shanghai: A retrospective cohort study in China

BackgroundA wave of the Omicron variant of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection has rapidly spread in Shanghai, China. Hematological abnormalities have been reported in coronavirus disease 2019 (COVID‐19) patients; however, the difference in hematological parameters between COVID‐19 patients with fever and patients who are febrile from other causes remains unexplored.MethodsThis retrospective cohort study enrolled 663 SARS‐CoV‐2 positive patients identified by RT‐PCR. Clinical parameters, including age, sex, and threshold cycle values of all COVID‐19 patients, and hematological parameters of COVID‐19 patients in the fever clinic were abstracted for analysis.ResultsOverall, 60.8% of COVID‐19 patients were male, and the median age was 45 years. Most of COVID‐19 patients were asymptomatic, while 25.8% of patients showed fever and 10.9% of patients had other emergencies. COVID‐19 patients with fever had significantly lower white blood cells (WBCs), neutrophils, lymphocytes, platelets and C‐reactive protein (CRP), and significantly higher monocyte‐to‐lymphocyte ratio (MLR), platelet‐to‐lymphocyte ratio (PLR), mean platelet volume (MPV), and mean platelet volume‐to‐platelet ratio (MPR) levels, compared with those in SARS‐CoV‐2 negative patients with fever from other causes (p < 0.05). Neutrophil‐to‐lymphocyte ratio (NLR), PLR, and systemic inflammatory index (SII) levels were significantly higher in COVID‐19 patients with emergencies (p < 0.05). WBCs showed the best performance with an area under the curve (0.756), followed by neutrophils (0.730) and lymphocytes (0.694) in the diagnosis of COVID‐19 in the fever clinic.ConclusionWBCs, neutrophils, lymphocytes, platelets, CRP and MLR, PLR, and MPR may be useful in early diagnosis of COVID‐19 in the fever clinic.     

The duration of cardiopulmonary resuscitation in emergency departments after out-of-hospital cardiac arrest is associated with the outcome: A nationwide observational study

Aim of the studyThe appropriate duration of cardiopulmonary resuscitation (CPR) for patients who experience out-of-hospital cardiac arrest (OHCA) remains unknown. This study aimed to evaluate the duration of CPR in emergency departments (EDs) and to determine whether the institutions’ median duration of CPR was associated with survival-to-discharge rate.MethodsA cohort of adult patients from a nationwide OHCA registry was retrospectively evaluated. The main variable was the median duration of CPR for each ED (institutional duration), and the main outcome was survival to discharge. Multivariable logistic regression analysis was performed to adjust for individual and aggregated confounders.ResultsAmong the 107,736 patients who experienced OHCA between 2006 and 2010, 30,716 (28.5%) were selected for analysis. The median age was 65 years, and 67.1% were men. The median duration of CPR for all EDs was 28 min, ranging from 11 to 45 min. EDs were categorized into 3 groups according to their institutional duration of CPR: groups A (<20 min), B (20–29 min), C (≥30 min). The observed survival rates of the 3 groups were 2.11%, 5.20%, and 5.62%, respectively. Compared with group B, the adjusted difference (95% confidence interval) for survival to discharge was 3.01% (1.90–4.11, P < 0.001) for group A, and 0.33% (−0.64 to 1.30, P = 0.51) for group C.ConclusionThe duration of CPR varied widely among hospitals. The institutional duration of CPR less than 20 min was significantly associated with lower survival-to-discharge rate.     

Advocacy for use of the modified Iowa Level of Assistance Scale for clinical use in patients after hip replacement: an observational study

Objectives

To test the internal consistency and item difficulty of the modified Iowa Level of Assistance Scale (mILAS).

A bicortical pedicle screw in the caudad trajectory is the best option for the fixation of an osteoporotic vertebra: An in-vitro experimental study using synthetic lumbar osteoporotic bone models

BackgroundIn pedicle screw fixation, the optimal depth and trajectory of insertion are controversial, and this might be because of the wide variations in specimens. The present study aimed to investigate the biomechanically optimal depth and trajectory of screw insertion using synthetic lumbar osteoporotic vertebrae.MethodsA total of 27 synthetic osteoporotic lumbar vertebrae (L3) were used to ensure standard vertebral quality and shape. Pedicle screws having two different lengths (unicortical: to the center of the vertebra; bicortical: to the anterior cortex of the vertebra) were inserted in the following three different trajectories: 1) straight-forward (parallel to the superior endplate), 2) cephalad (toward the anterosuperior corner), and 3) caudad (toward the anteroinferior corner). Maximum insertional torque and pull-out strength were measured.FindingsFor the straight-forward, cephalad, and caudad trajectories, the maximum insertional torque (Ncm) values of unicortical screws were 144.4, 143.1, and 148.9, respectively, and those of bicortical screws were 205.5, 156.2, and 207.8, respectively. The maximum insertional torque values were significantly higher for bicortical screws than unicortical screws (p < 0.001). Additionally, regarding bicortical screws, the maximum insertional torque values were significantly lower for the cephalad trajectory than other trajectories (p = 0.002). The pull-out strength (N) values of bicortical screws for the straight-forward, cephalad, and caudad trajectories were 703.3, 783.9, and 981.3, respectively. The pull-out strength values were significantly lower for the straight-forward trajectory than other trajectories (p = 0.034).InterpretationA bicortical pedicle screw in the caudad trajectory might be the best option to improve fixation in an osteoporotic lumbar vertebra.