Dopamine Use and Its Consequences in The Intensive Care Unit: a Cohort Study Utilizing the Japanese Intensive care Patient Database

Background: Dopamine is used to treat patients with shock in intensive care units (ICU) throughout the world, despite recent evidence against its use. Current practice patterns for the use of dopamine have not been reported.Methods: The Japanese Intensive Care PAtient Database (JIPAD), the largest intensive care database in Japan, was utilized. Inclusion criteria included: 1) age 18 years or older, 2) admitted to the ICU for reasons other than procedures, 3) ICU length of stay of 24 hours or more, and 4) treatment with either dopamine or noradrenaline within 24 hours of admission. The primary outcome was in-hospital mortality. Multivariable regression analysis was performed, followed by a pre-planned propensity score-matched analysis.Results: Of the 132,354 case records, 14594 records from 56 facilities were included in this analysis. Dopamine was administered to 4653 patients and noradrenaline to 11844. There was no statistically significant difference in facility characteristics between frequent dopamine users (N = 28) and infrequent users (N = 28). Patients receiving dopamine had more cardiovascular diagnosis codes (70% vs. 42%; p<0.01), more post-elective surgery status (60% vs. 31%), and lower APACHE III scores compared to patients given noradrenaline alone (70.7 vs. 83.0; p<0.01). Multivariable analysis showed an odds ratio for in-hospital mortality of 0.86 [95% CI: 0.71-1.04] in the dopamine <=5 μg/kg/min group, 1.50 [95% CI: 1.18-1.82] in the 5-15 μg/kg/min group, and 3.30 [95% CI: 1.19-9.20] in the >15 μg/kg/min group. In 1:1 propensity score matching for dopamine use (3322 pairs), there was no statistically significant difference for in-hospital mortality between the dopamine group and no dopamine group (13.0% vs. 12.0%, p=0.21), but ICU length of stay was significantly longer in the dopamine group (mean 7.4 days vs. 6.6 days, p<0.01).Conclusion: Dopamine is still widely used in Japan. The results of this study suggest detrimental effects of dopamine use specifically at a high dose, although there is no significant association with increased in-hospital mortality.Trial registration: Retrospectively registered upon approval of the Institutional Review Board and the administration office of JIPAD.

Clinical Implications of Airway Anomalies and Stenosis in Patients with Heterotaxy Syndrome

In heterotaxy syndrome, bronchopulmonary situs usually reflects atrial situs, resulting in either right (RAI) or left atrial isomerism (LAI). This study determines airway anomalies and its implications in patients with heterotaxy. This retrospective study included 223 patients with heterotaxy syndrome who received an integrated cardiac computed tomography evaluation. Patient database from 1995 to 2020 was reviewed. The patients were examined by a congenital heart disease team comprising pediatric cardiologists, radiologists, pulmonologists, and cardiovascular surgeons. Among the 223 patients, 189 (84.8%, M/F=1.66) had RAI and 29 had LAI (13.0%, M/F=0.71). Five patients had indeterminate isomerism (2.2%, M/F=1.5). Discordant bronchopulmonary and atrial situs occurred in 4% patients, while discordant bronchopulmonary, atrial, and splenic situs occurred in 23.2% patients. Lower airway stenosis was observed in 61 patients (27.4%), including 27.5%, 20.7%, and 60% RAI, LAI, and indeterminate isomerism patients, respectively (p=0.189). One patient had an intrinsic long segment lower tracheal stenosis and received slide tracheoplasty. Initial cardiac operation was performed in 213 patients. Higher surgical mortality occurred in patients with RAI (19.5% vs. none for LAI and indeterminate isomerism, p=0.038). In patients with RAI, lower airway anomaly/stenosis increased the duration of ventilator usage (p=0.030) but did not affect surgical mortality. Total anomalous pulmonary venous return to systemic veins and pulmonary venous stenosis were major surgical risk factors. Bronchopulmonary isomerism shares a similar isomeric pattern to cardiac atrial appendage. Lower airway anomalies/stenosis was common in patients with heterotaxy, resulting in prolonged ventilator therapy in patients with RAI.

Graph Neural Network Modelling as a potentially effective Method for predicting and analyzing Procedures based on Patient Diagnoses

BackgroundCurrently, the healthcare sector strives to increase the quality of patient management and improve the economic performance of healthcare providers. The data contained in electronic health records (EHRs) offer the potential to discover relevant patterns that aim to relate diseases and therapies, and thus discover patterns that could help identify empirical medical guidelines that reflect best practices in the healthcare system. Based on this pattern identification, it is then possible to implement recommendation systems based on the idea that a higher volume of procedures is associated with high-quality models.MethodsAlthough there are several applications that use machine learning methods to identify these patterns, this identification is still a challenge, in part because these methods often ignore the basic structure of the population, considering the similarity of diagnoses and patient typology. To this end, we have developed graph methods that aim to cluster similar patients. In such models, patients are linked when the same or similar patterns can be observed for these patients, a concept that enables the construction of a network-like structure. This structure can then be analyzed with Graph Neural Networks (GNN) to identify relevant labels, in this case the appropriate medical procedures.ResultsWe report the construction of a patient Graph structure based on basic patient’s information like age and gender as well as the diagnoses and trained GNNs models to identify the corresponding patient’s therapies using a synthetic patient database. We compared our GNN models against different baseline models (using the SCIKIT-learn library of python) and compared the performance of the different model methods. We have found that GNNs are superior, with an average improvement of the f1 score of 6.48% respect to the baseline models. In addition, the GNNs are useful for performing additional clustering analyses that allow specific identification of specific therapeutic clusters related to a particular combination of diagnoses.ConclusionsWe found that GNNs are a promising way to model the distribution of diagnoses in a patient population and thus better model how similar patients can be identified based on the combination of morbidities and comorbidities. Nevertheless, network building is still challenging and prone to prejudice, as it depends on how ICD distribution affects the patient network embedding space. This network setup requires not only a high quality of the underlying diagnostic ecosystem, but also a good understanding of how to identify related patients by disease. For this reason, additional work is needed to improve and better standardize patient embedding in graph structures for future investigations and applications of services based on this technology, and therefore is not yet an interventional study.

Assessing the use of antibiotics and the burden of varicella in Belgium using a retrospective GP database analysis

Background Varicella is a highly contagious infection that typically occurs in childhood. While most cases have a generally benign outcome, infection results in a considerable healthcare burden and serious complications may occur. Objectives The objective of this study was to characterize the burden of varicella in a real-world primary care setting in Belgium, including the rate of varicella-related complications, medication management and general practitioner (GP) visits. Methods The study was a retrospective observational study using data from a longitudinal patient database in a primary care setting in Belgium. Patients with a GP visit and a varicella diagnosis between January 2016 and June 2019 were eligible and data one month prior and three months after the diagnosis were included. Outcomes included varicella-related complications, antibiotic use, antiviral use, and GP follow-up visits. Antibiotic use could be specified by class of antibiotic and linked to a diagnosis. Complications were identified based on concomitant diagnosis with varicella during the study period. Results 3,847 patients with diagnosis of varicella were included, with a mean age of 8.4 years and a comparable distribution of gender. 12.6% of patients with varicella had a concomitant diagnosis of a varicella-related complication. During the follow-up period, 27.3% of patients with varicella were prescribed antibiotics, either systemic (19.8%) and/or topical (10.3%). The highest rate of antibiotic prescriptions was observed in patients with complications (63.5%) and in patients younger than 1 year (41.8%). Nevertheless, 5.3% of the patients were prescribed antibiotics without a concomitant diagnosis of another infection. The most commonly prescribed systemic antibiotics were amoxicillin alone or combined with beta-lactamase inhibitor, and thiamphenicol. Fusidic acid and tobramycin were the most prescribed topical antibiotics. Antivirals were prescribed for 2.7% of the study population. 4.7% of the patients needed a follow-up visit with their GP. Conclusions This study reports a substantial burden of varicella in a primary care setting in Belgium, with high rates of complications and antibiotic use.

Outcome of ECMO and CRRT, experience of Hospital University MED VI, Oujda, Morocco.

Background: Although acute kidney injury (AKI) is a frequent complication in patients receiving extracorporeal membrane oxygenation (ECMO), and the CRRT impact is widely studied. The incidence of simultaneous use of ECMO and CRRT remain unclear. Objective: We conducted this retrospective study to define the incidence of concomitant CRRT with ECMO therapy and to determine the overall impact of this strategy on patient outcomes such as mortality and renal recovery. Methods: We retrospectively analyzed data of patients of all ages, genders and ethnicities, admitted in the intensive care unit of Mohammed VI University Hospital, Oujda, Morocco, on a cumulative period of 2 years (January 2019 – December 2020). Were enrolled in the study patients who benefited from ECMO, and presented an acute kidney injury afterwards, using ‘Microsoft Excel’ as a software to utilize the information collected from the computerized patient database. 30 patients were included in the final study. Results: 30 patients with ECMO were enrolled. The mean age was 59.8 ± 12.7 years, with a male predominance (sex ratio (M/F) of 3.28). Over one third of the patients had comorbidities, Diabetes mellitus was the most common (30%), followed by hypertension (17%). 83.3% of our patients benefitted from a veno-venous type of ECMO; and ARDS was the most frequent cause for using ECMO comparing to cardiac failure (90% vs 16.6%). 63.3% of our ECMO-using patients developed an AKI, with a mean creatinine peak of 28.74mg/L. 36.6% of our ECMO-using patients required the use of a continuous renal replacement therapy (CRRT). Unfortunately, all our ECMO-using patients complicated with AKI died, with a mortality rate of 100%. Conclusion: Among patients receiving ECMO, the incidence rates of AKI and severe AKI requiring CRRT are high, regardless of their prior medical conditions and the technique used to connect ECMO and CRRT.

Better late than never: initial experience of intra-arterial pulsed-urokinase-injection as a salvage therapy for refractory sudden sensorineural hearing loss

Background and Purpose Cochlear vascular micro-thrombosis has been hypothesized as one of the pathogenic mechanisms for sudden sensorineural hearing loss (SSNHL) refractory to regular management. This study aimed to evaluate the feasibility and safety of intra-arterial pulsed-injection urokinase (IAPU) as a salvage therapy for SSNHL after the failure of conventional therapy. Methods We retrospectively reviewed our patient database to identify refractory SSNHL patients between November 2017 and July 2020. Study outcomes before and after the IAPU therapy were compared between IAPU and conventional therapy groups. Results Sixty-seven moderate-profound SSNHL patients (29 in IAUP group, 38 in control group) were included in this study. Compared to the control group, patients in the IAPU group showed more significant improvement in pure tone average (PTA) (34.2 ± 23.5 vs. 10.7 ± 13.1, p < 0.001) and degree of hearing recovery (total: 20.7% vs. 5.3%, partial: 24.1% vs. 10.5%, mild: 27.6% vs. 13.2% and non: 27.6% vs. 71.1%) 2 weeks after admission. In the IAPU group, a significant improvement of PTA (86.6 ± 11.5 vs. 54.6 ± 20.1 dB, p < 0.005) was observed on the first day after IAPU treatment. Conclusion In carefully selected SSNHL cases with a highly suspected vascular origin, IAPU is a safe and effective therapy when conventional treatments have failed. Despite the encouraging findings of our work, large studies are needed to better investigate the strengths and limitations of this salvage therapy.

Role of MRI in diagnosing the primary site of origin in indeterminate cases of uterocervical carcinomas: a systematic review and meta-analysis

Objective: To perform a literature review assessing role of MRI in predicting origin of indeterminate uterocervical carcinomas with emphasis on sequences and imaging parameters. Methods: Electronic literature search of PubMed was performed from its inception until May 2020 and PICO model used for study selection; population was female patients with known/clinical suspicion of uterocervical cancer, intervention was MRI, comparison was by histopathology and outcome was differentiation between primary endometrial and cervical cancers. Results: Eight out of 9 reviewed articles reinforced role of MRI in uterocervical primary determination. T2 and Dynamic contrast were the most popular sequences determining tumor location, morphology, enhancement, and invasion patterns. Role of DWI and MR spectroscopy has been evaluated by even fewer studies with significant differences found in both apparent diffusion coefficient values and metabolite spectra. The four studies eligible for meta-analysis showed a pooled sensitivity of 88.4% (95% confidence interval 70.6 to 96.1%) and a pooled specificity of 39.5% (95% confidence interval 4.2 to 90.6%). Conclusions: MRI plays a pivotal role in uterocervical primary determination with both conventional and newer sequences assessing important morphometric and functional parameters. Socioeconomic impact of both primaries, different management guidelines and paucity of existing studies warrants further research. Prospective multicenter trials will help bridge this gap. Meanwhile, individual patient database meta-analysis can help corroborate existing data. Advances in knowledge: MRI with its classical and functional sequences helps in differentiation of the uterine ‘cancer gray zone’ which is imperative as both primary endometrial and cervical tumors have different management protocols.

Pulse oximetry and supplemental oxygen use in nationwide Veterans Health Administration hospitals, 2013–2017: a Veterans Affairs Patient Database validation study

ObjectiveExtraction and standardisation of pulse oximetry and supplemental oxygen data from electronic health records has the potential to improve risk-adjustment, quality assessment and prognostication. We develop an approach to standardisation and report on its use for benchmarking purposes.Materials and methodsUsing electronic health record data from the nationwide Veteran’s Affairs healthcare system (2013–2017), we extracted, standardised and validated pulse oximetry and supplemental oxygen data for 2 765 446 hospitalisations in the Veteran’s Affairs Patient Database (VAPD) cohort study. We assessed face, concurrent and predictive validities using the following approaches, respectively: (1) evaluating the stability of patients’ pulse oximetry values during a 24-hour period, (2) testing for greater amounts of supplemental oxygen use in patients likely to need oxygen therapy and (3) examining the association between supplemental oxygen and subsequent mortality.ResultsWe found that 2 700 922 (98%) hospitalisations had at least one pulse oximetry reading, and 864 605 (31%) hospitalisations received oxygen therapy. Patients monitored by pulse oximetry had a reading on average every 6 hours (median 4; IQR 3–7). Patients on supplemental oxygen were older, white and male compared with patients not receiving oxygen therapy (p<0.001) and were more likely to have diagnoses of heart failure and chronic pulmonary diseases (p<0.001). The amount of supplemental oxygen for patients with at least three consecutive values recorded during a 24-hour period fluctuated by median 2 L/min (IQR: 2–3), and 81% of such triplets showed the same level of oxygen receipt.ConclusionOur approach to standardising pulse oximetry and supplemental oxygen data shows face, concurrent and predictive validities as the following: supplemental oxygen clusters in the range consistent with hospital wall-dispensed oxygen supplies (face validity); there are greater amounts of supplemental oxygen for certain clinical conditions (concurrent validity) and there is an association of supplemental oxygen with in-hospital and postdischarge mortality (predictive validity).

EP.FRI.472Building the ‘LIEGS’ way – Establishing an ambulatory Rapid Access Theatre Service for those patients with acute surgical pathology requiring operative management

Aim LTHT is the largest acute surgical unit in the UK and has seen an annual 11% increase in attendances with often 90 patients assessed daily. 40% patients present with acute biliary pathology but despite this there has been no dedicated operating list for this cohort of patients. Rapid Access Theatre (RAT) lists were created to manage these patients. We report our early results. Method In October 2020 the trust appointed four EGS Consultants forming a dedicated acute general surgical service. Emphasis was placed on creating ambulatory pathways and those patients safe to be managed at home but requiring surgical intervention are placed on a day case RAT list. COVID-19 has restricted the broad use of this service for all emergency admissions but biliary pathology continues to be amenable to these pathways. Data was collected retrospectively using in-house coding and electronic patient database systems. Results 34 day case laparoscopic cholecystectomies were performed in the first 10 weeks. Mean age was 44(17-67) with a male:female ratio of 1:1. Mean wait time from clinical review to theatre was 11(3-23) days. 1 patient required overnight admission but there were no readmissions and no reported complications at 30 days. Conclusion Despite isolation restrictions resulting from COVID-19, the service has allowed patients to be assessed and treated in a timely, safe fashion. The new service has resulted in significant reductions in bed stays and improved patient experiences. Financial savings have been clearly delineated and as such expansion of the model is underway.

A proof of concept study for machine learning application to stenosis detection

This proof of concept (PoC) assesses the ability of machine learning (ML) classifiers to predict the presence of a stenosis in a three vessel arterial system consisting of the abdominal aorta bifurcating into the two common iliacs. A virtual patient database (VPD) is created using one-dimensional pulse wave propagation model of haemodynamics. Four different machine learning (ML) methods are used to train and test a series of classifiers—both binary and multiclass—to distinguish between healthy and unhealthy virtual patients (VPs) using different combinations of pressure and flow-rate measurements. It is found that the ML classifiers achieve specificities larger than 80% and sensitivities ranging from 50 to 75%. The most balanced classifier also achieves an area under the receiver operative characteristic curve of 0.75, outperforming approximately 20 methods used in clinical practice, and thus placing the method as moderately accurate. Other important observations from this study are that (i) few measurements can provide similar classification accuracies compared to the case when more/all the measurements are used; (ii) some measurements are more informative than others for classification; and (iii) a modification of standard methods can result in detection of not only the presence of stenosis, but also the stenosed vessel.