The Role of Predictive Models in the Assessment of the Poor Outcomes in Pediatric Acute Liver Failure

Objectives: In children, acute liver failure (ALF) is a severe condition with high mortality. As some patients need liver transplantation (LT), it is essential to predict the fatal evolution and to refer them early for LT if needed. Our study aimed to evaluate the prognostic criteria and scores for assessing the outcome in children with ALF. Methods: Data of 161 children with ALF (54.66% female, mean age 7.66 ± 6.18 years) were analyzed based on final evolution (32.91% with fatal evolution or LT) and etiology. We calculated on the first day of hospitalization the PELD score (109 children), MELD, and MELD-Na score (52 children), and King’s College Criteria (KCC) for all patients. The Nazer prognostic index and Wilson index for predicting mortality were calculated for nine patients with ALF in Wilson’s disease (WD). Results: PELD, MELD, and MELD-Na scores were significantly higher in patients with fatal evolution (21.04 ± 13.28 vs. 13.99 ± 10.07, p = 0.0023; 36.20 ± 19.51 vs. 20.08 ± 8.57, p < 0.0001; and 33.07 ± 8.29 vs. 20.08 ± 8.47, p < 0.0001, respectively). Moreover, age, bilirubin, albumin, INR, and hemoglobin significantly differed in children with fatal evolution. Function to etiology, PELD, MELD, MELD-Na, and KCC accurately predicted fatal evolution in toxic ALF (25.33 vs. 9.90, p = 0.0032; 37.29 vs. 18.79, p < 0.0001; 34.29 vs. 19.24, p = 0.0002, respectively; with positive predicting value 100%, negative predicting value 88.52%, and accuracy 89.23% for King’s College criteria). The Wilson index for predicting mortality had an excellent predictive strength (100% sensibility and specificity), better than the Nazer prognostic index. Conclusions: Prognostic scores may be used to predict the fatal evolution of ALF in children in correlation with other parameters or criteria. Early estimation of the outcome of ALF is essential, mainly in countries where emergency LT is problematic, as the transfer to a specialized center could be delayed, affecting survival chances.

Efficient Breast Cancer Classification Using Histopathological Images and a Simple VGG

Breast cancer is the second most deadly disease worldwide. This severe condition led to 627,000 people dying in 2018. Thus, early detection is critical for improving the patients' lifetime or even curing them. In this context, we can appeal to Medicine 4.0, which exploits machine learning capabilities to obtain a faster and more efficient diagnosis. Therefore, this work aims to apply a simpler convolutional neural network, called VGG-7, for classifying breast cancer in histopathological images. Results have shown that VGG-7 overcomes the performance of VGG-16 and VGG-19, showing an accuracy of 98%, a precision of 99%, a recall of 98%, and an F1 score of 98%.

Life-Threatening Necrotizing Pneumonia with Panton–Valentine Leukocidin-Producing, Methicillin-Sensitive Staphylococcus aureus in a Healthy Male Co-Infected with Influenza B

A previously healthy male was rushed into a hospital critically ill with confusion, sepsis, and acute respiratory distress syndrome only 43 h after having a normal chest X-ray and with blood samples showing only minimally elevated C-reactive protein. Two days earlier, the patient had returned to his home country, the Faroe Islands, from a 10-day work trip aboard a Scandinavian ship in Colombia. The diagnosis turned out to be an influenza B infection and necrotizing pneumonia with Panton–Valentine leukocidin (PVL)-producing methicillin-sensitive Staphylococcus aureus (MSSA). It was influenza season in Colombia but not in the Faroe Islands. The frequency of MSSA with PVL-encoding genes among pediatric infection patients is very low in the Kingdom of Denmark and Faroe Islands and very high in Colombia, and the frequency generally varies highly by region. The patient in this case now suffers severe sequelae from the infection. With this case, we would like to remind clinicians of this rare but severe condition. PVL-producing S. aureus pneumonia should be considered in critically ill, previously healthy patients, especially during influenza season and if the patient has been traveling in countries with high frequencies of PVL-producing S. aureus.

Osteonecrosis of the jaw and antiresorptive agents in benign and malignant diseases: a critical review organized by ECTS

Context Antiresorptive therapy significantly reduces fracture risk in patients with benign bone disease and skeletal-related events (SREs) in patients with bone metastases. Osteonecrosis of the jaw (ONJ) is a rare, but severe condition, manifested as necrotic bone lesion(-s) of the jaws. ONJ has been linked to the use of potent antiresorptive agents, termed as Medication Related ONJ (MRONJ). Methods A working group of the European Calcified Tissue Society (ECTS) and two experts performed an updated detailed review of existing literature on MRONJ incidence, characteristics, and treatment applied in bone diseases with variable severity of skeletal insult, ranging from osteoporosis to prevention of cancer treatment-induced bone loss and SREs in cancer patients with bone metastases. We aimed to identify the differences in various aspects of MRONJ among these distinct patient categories and provide recommendations on how to mitigate the risk and optimally manage MRONJ in each one of them. Results The risk for MRONJ is much higher in patients with advanced malignancies compared to those with benign bone diseases, because of the higher doses and more frequent administration of antiresorptive agents in individuals with compromised general health, along with co-administration of other medications that predispose to MRONJ. The overall risk for MRONJ is considerably lower than the benefits in all categories of patients. Conclusions The risk for MRONJ largely depends on the underlying bone disease and the relevant antiresorptive regimen applied. Physicians and dentists should keep in mind that the benefits of antiresorptive therapy far outweigh the risk for MRONJ development.

Clinical features, diagnosis, and types of optic neuritis

Establishing a proper diagnosis and identifying the underlying etiology of optic neuritis can be challenging in clinical settings. This is due to the various subtypes and etiologies that were reported for the condition. However, conducting a thorough examination and the laboratory and imaging modalities can significantly enhance the diagnosis. Therefore, it is essential to be adequately aware of the different subtypes of optic neuritis and distinguish between the different clinical features and diagnostic findings of each subtype to conduct a proper diagnosis and enhance management of the affected cases. Optic neuritis is a severe condition that can lead to permanent vision loss. In the present literature review, we have discussed the potential clinical features and diagnostic findings of the different types of optic neuritis. More severe cases of optic neuritis are usually associated with NMOSD and IgG-MOG cases with a worsened prognosis. Painless and chronic vision loss might occur secondary to infections and granulomatous diseases. On the other hand, optic neuritis secondary to multiple sclerosis is usually self-limited. Many of the cases of optic neuritis are characterized by being responsive to steroid therapy. However, acute vision loss was also reported in some cases. Therefore, clinicians must be knowledgeable enough to conduct the most appropriate diagnostic and management modalities to enhance the prognosis of the affected patients. Further research is needed for optimizing the treatment plan and drawing better interventions.

Polypharmacy: definition, risks, management

A search was performed in the Scopus, Web of Science, MedLine, The Cochrane Library databases. The term “polypharmacy”, in contrast to the term “polypragmasia”, does not always has a negative meaning and is often used to describe the simultaneous use of five or more drugs, and polypharmacy is considered intensive, when the patient takes 10 or more drugs at the same time. One of the main causes of polypharmacy is polymorbidity. Severe condition of the patient, self-medication and inappropriate recommendations can also cause polypharmacy, as well as some demographic factors (age, gender, level of education) and the level of the health care system development. Polypharmacy can be appropriate when the prescription of a large number of drugs is justified, and inappropriate (problematic) when the number of prescribed drugs is incorrect and/or unbalanced. Problematic polypharmacy is a manifestation of polypragmasia, with several drugs prescribed improperly that does not allow realizing the expected advantage of these drugs. The risk of harm from treatment outweighs the benefits due to drug interactions, adverse reactions, increasing economic burden of treatment. Problematic polypharmacy is especially dangerous for critically ill patients. The management of problematic polypharmacy should be based on its transition into an appropriate form. The combination of drugs is substantiated, which allows treating the patient effectively, safely and economically expediently through the prevention of drug interaction and adverse effects. Deprescribing of certain drugs can be used as a therapeutic intervention, it should be performed in each individual patient through the assessment of benefits and risks. Beers criteria, ARMOR, STOPP-START criteria are offered for prevention and correction of problematic polypharmacy in the elderly.

Behcet’s disease: a review

Behcet's disease (BD) is a complex systemic vasculitis with an etiopathogenesis that remains unclear. It has a strong geographic association as well as a genetic propensity linked to the HLA-B51 factor and interactions between genetic and environmental factors. The typical age of onset is 25 to 40 years old and it is more common in men, who also have a more severe condition. Occlusive vasculitis is the hallmark of this condition, which can affect vessels of all diameters. Oral ulcers, genital ulcers, skin lesions, pathergy reaction as well as involvement of other systems and organs such as ophthalmic, neurological and vascular lesions, among others, are used to make the diagnosis. Uncontrolled neutrophil activation, activation of the humoral and cell immune systems, toxic proteins and infectious agents such as herpes simplex and streptococci are all involved in their pathophysiology. Due to the heterogeneity and several systems affected, the treatment is individualized and focused on treating each clinical manifestation.

Nodding Syndrome: A Scoping Review

Nodding syndrome (NS) is a debilitating yet often neglected neurological disease affecting thousands of children in several sub-Saharan African countries. The cause of NS remains unknown, and effective treatment options are lacking. Moreover, knowledge regarding NS is scarce and is based on a limited number of publications, with no comprehensive overview published to date. Therefore, the aim of this scoping review was to summarise the current evidence and identify existing knowledge gaps in order to help clinicians, scientists, and policymakers develop guidelines for prioritising this severe condition. We searched the Medline (Ovid), Embase (Ovid), Scopus, and Global Health Library databases in accordance with the PRISMA extension for scoping review guidance and in accordance with the Joanna Briggs Institute guidelines and methodology for a scoping review, using keywords describing NS. We then extracted and presented the original data regarding the epidemiology, aetiology, pathophysiology, clinical features, diagnosis, management, and outcomes of NS, as well as community perceptions and the psychosocial and economic impact of NS. Out of 1470 identified articles, a total of 69 were included in this scoping review. Major gaps exist in understanding the aetiology and pathogenesis of NS. Future research is urgently needed not only to address these gaps, but also to study the treatment options, epidemiology, and psychosocial and economic impacts of NS. Innovative interventions and rehabilitation programmes designed to address the psychosocial and economic burdens associated with NS are also urgently needed.

A Condition of Uncertainty: A Qualitative Study Exploring Women´s Experiences of Preeclampsia

Background Preeclampsia is a severe condition that annually affects about 3-8% of pregnancies worldwide. Preeclampsia is thereby one of the most common pregnancy complications for both mother and child. Despite that, there is limited research exploring the women´s perspective of experiencing preeclampsia. Aim The aim of this study was to describe women´s experiences of preeclampsia to improve the support and care given during and after pregnancy. Methods A qualitative descriptive interview study was undertaken. Nine women, who were diagnosed with preeclampsia, were recruited from a maternity unit in southern Sweden. The descriptive phenomenological method according to Amadeo Giorgi was used to analyse the data. Results The essence of women’s experiences of PE were expressed as A condition of uncertainty, meaning that it was an unexpected and unknown situation. The five constituents forming the essence were incomprehensible diagnosis message, ambivalent feelings when the unexpected happens, confusing contradictory messages, appreciated support from the midwife, and need for continuous information. The nature of preeclampsia can sometimes deteriorate rapidly both for the mother and/or the child, often resulting in conversion from a planned vaginal spontaneous delivery to an emergency Caesarean section. The women narrated diffuse symptoms, and they experienced that they got contradictory information from different health care professionals regarding the severity of their disease. Detailed and continuous information is requested throughout the course of the disease, and the postpartum period. Conclusion Health care professionals must be aware that women and their partners need detailed, consistent and repeated information about severity and prognosis to diminish the condition of uncertainty, confusion and fearful experience. The clinical implication would be a standardized preeclampsia education for pregnant women early on in the pregnancy, to raise awareness of preeclamptic symptoms. Furthermore, there is a need for harmonized guidelines both at the antenatal care and the maternity ward and inpatient care at the hospital.

Clinical Features and Predictors for Mortality in Neurolisteriosis: An Administrative Data-Based Study

Listeriosis is an uncommon and potentially severe zoonotic bacterial infection that usually occurs in outbreaks instead of isolated cases. In recent years, there has been an increase in the incidence of this disease. One of the most severe of its complications involves the central nervous system (CNS) in a condition known as neurolisteriosis. Here, we describe the demographic and clinical features of patients presenting with neurolisteriosis between 2001 and 2015 using administrative data and attempt to identify potential predictors for mortality. We used the Spanish Minimum Basic Data Set at Hospitalization, a compulsory registry that collects data from clinical discharge reports. Up to 2015, data were coded based on the International Classification of Diseases, 9th Revision, so we used diagnoses and clinical conditions based on these codes. Age, sex, clinical presentation, mortality, and involvement of the CNS were identified. Using algorithms to aggregate data, variables such as immunosuppression and malignant disease were obtained. We analyzed correlations among clinical features and identified risk factors for morbidity and mortality. Between 2001 and 2015 we identified 5180 individuals, with a hospitalization rate of 0.76 per 100,000 population. Most (94%) were adults, and only 5.4% were pregnant women. The average age was 66 years. Neurological involvement was present in 2313 patients (44.7%), mostly meningitis (90.4%). Global mortality was 17%, but mortality in CNS infections was 19.2%. Age, severe sepsis, chronic liver disease, chronic kidney disease, and malignancy were the main risk factors for mortality in patients with CNS infections by Listeria monocytogenes. Although it is uncommon, neurolisteriosis can be a severe condition, associated with a high rate of mortality. Health care providers should be aware of potential sources of infection so that appropriate measures can be taken to prevent it.