Clinical Predictors of Mortality in Prehospital Distress Calls by Emergency Medical Service Subscribers

(1) Introduction: Most studies rely on in-hospital data to predict cardiovascular risk and do not include prehospital information that is substantially important for early decision making. The aim of the study was to define clinical parameters in the prehospital setting, which may affect clinical outcomes. (2) Methods: In this population-based study, we performed a retrospective analysis of emergency calls that were made by patients to the largest private emergency medical services (EMS) in Israel, SHL Telemedicine Ltd., who were treated on-site by the EMS team. Demographics, clinical characteristics, and clinical outcomes were analyzed. Mortality was evaluated at three time points: 1, 3, and 12 months’ follow-up. The first EMS prehospital measurements of the systolic blood pressure (SBP) were recorded and analyzed. Logistic regression analyses were performed. (3) Results: A total of 64,320 emergency calls were included with a follow-up of 12 months post index EMS call. Fifty-five percent of patients were men and the mean age was 70.2 ± 13.1 years. During follow-up of 12 months, 7.6% of patients died. Age above 80 years (OR 3.34; 95% CI 3.03–3.69, p < 0.005), first EMS SBP ≤ 130 mm Hg (OR 2.61; 95% CI 2.36–2.88, p < 0.005), dyspnea at presentation (OR 2.55; 95% CI 2.29–2.83, p < 0001), and chest pain with ischemic ECG changes (OR 1.95; 95% CI 1.71–2.23, p < 0.001) were the highest predictors of 1 month mortality and remained so for mortality at 3 and 12 months. In contrast, history of hypertension and first EMS prehospital SBP ≥ 160 mm Hg were significantly associated with decreased mortality at 1, 3 and 12 months. (4) Conclusions: We identified risk predictors for all-cause mortality in a large cohort of patients during prehospital EMS calls. Age over 80 years, first EMS-documented prehospital SBP < 130 mm Hg, and dyspnea at presentation were the most profound risk predictors for short- and long-term mortality. The current study demonstrates that in prehospital EMS call settings, several parameters can be used to improve prioritization and management of high-risk patients.

A common neural currency account for social and non-social decisions

To date, social and non-social decisions have been studied in isolation. Consequently, the extent to which social and non-social forms of decision uncertainty are integrated using shared neurocomputational resources remains elusive. Here, we address this question using simultaneous EEG-fMRI and a task in which decision evidence in social and non-social contexts varies along comparable scales. First, we identify comparable time-resolved build-up of activity in the EEG, akin to a process of evidence accumulation. We then use the endogenous trial-by-trial variability in the slopes of these accumulating signals to construct parametric fMRI predictors. We show that a region of the posterior-medial frontal cortex (pMFC) uniquely explains trial-wise variability in the process of evidence accumulation in both the social and non-social contexts. We further demonstrate a task-dependent coupling between the pMFC and regions of the human valuation system in dorso- and ventro-medial prefrontal cortex (dmPFC/vmPFC) across both contexts. Finally, we report domain-specific representations in regions known to encode the early decision evidence for each context. These results are suggestive of a domain-general decision-making architecture, whereupon domain-specific information is likely converted into a "common currency" in the dmPFC/vmPFC and accumulated for the decision in the pMFC.

Maintenance Strategies for Industrial Multi-Stage Machines: The Study of a Thermoforming Machine

The study of reliability, availability and control of industrial manufacturing machines is a constant challenge in the industrial environment. This paper compares the results offered by several maintenance strategies for multi-stage industrial manufacturing machines by analysing a real case of a multi-stage thermoforming machine. Specifically, two strategies based on preventive maintenance, Preventive Programming Maintenance (PPM) and Improve Preventive Programming Maintenance (IPPM) are compared with two new strategies based on predictive maintenance, namely Algorithm Life Optimisation Programming (ALOP) and Digital Behaviour Twin (DBT). The condition of machine components can be assessed with the latter two proposals (ALOP and DBT) using sensors and algorithms, thus providing a warning value for early decision-making before unexpected faults occur. The study shows that the ALOP and DBT models detect unexpected failures early enough, while the PPM and IPPM strategies warn of scheduled component replacement at the end of their life cycle. The ALOP and DBT strategies algorithms can also be valid for managing the maintenance of other multi-stage industrial manufacturing machines. The authors consider that the combination of preventive and predictive maintenance strategies may be an ideal approach because operating conditions affect the mechanical, electrical, electronic and pneumatic components of multi-stage industrial manufacturing machines differently.

EP.TU.411Thinking Ahead: Improving Documentation of Treatment Escalation Plans for Surgical Patients

Aims The GMC recommends early decision making on CPR status for all acutely unwell patients admitted to hospital. An audit was undertaken of documentation of treatment escalation plans (TEPs) for general surgical patients at a District General Hospital. Method A retrospective study looking at documentation of TEPs in patients (n = 55) admitted under the care of the general surgical team over a one month period. Documentation from the surgical admission clerking and the first consultant ward round were reviewed for evidence of a TEP. Results Of 55 patients admitted only 24% had a TEP documented within 48 hours of admission under the general surgeons. Of those that had a TEP recorded (n = 13), twelve were in the admission surgical clerking and one was completed on the post-take consultant ward round. Conclusions This project highlighted the lack of TEP documentation for surgical patients within 48 hours of admission to hospital. Our recommendation is to develop a specific ‘post-take ward round’ proforma with mandatory TEP, to be filled out within 24 hours of patient admission. This updated process will then be reassessed for improved compliance with TEP documentation. We anticipate this will improve early decision making regarding escalation status and facilitate TEP discussions with patients. Overall this process should help ensure a more patient-centered approach to care planning.

Endoscopic features for early decision to evaluate superior mesenteric artery syndrome in children

Background Diagnostic delay of superior mesenteric artery syndrome (SMAS) is common due to its rarity and lack of index of clinical suspicion. Early diagnosis under suspicion is pivotal for adequate treatment. Present study aims to explore the endoscopic features for early decision to evaluate SMAS in children. Methods In case controlled observation study, the recruitment was limited to patients who had endoscopic finding I or finding 1 plus more as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s (finding I), a marked dilation of the duodenal first and second part during air insufflation at the third part of the duodenum (finding II), a bile mixed fluid collection (bile lake) in the stomach (finding III). SMAS was confirmed with UGI series or hypotonic duodenography in enrolled patients. We analyzed positive endoscopic findings related with SMAS. Results The enrolled 29 patients consisted of 18 (62.1%) with SMAS and 11 (37.9%) without SMAS. The three most common presenting symptoms were abdominal pain, postprandial discomfort, and early satiety. The clinical impressions based on history and physical examination before endoscopy were functional dyspepsia (34.6%), gastritis or gastric ulcer (31.0%), and SMAS (17.3%). The constellation of three endoscopic findings (finding I + II + III, feature D) observed in 13 (72.2%) patients of SMAS group and 3 (27.3%) patients of non SMAS group (P = 0.027). Of 16 patients with features D, SMAS was diagnosed in 13 patients (81.2%) and not detected in 3 patients (18.8%) on UGI series or hypotonic duodenography. Conclusions Endoscopic examination to the third part of the duodenum can provide a clue making a decision to evaluate SMAS, which consists of features of three endoscopic findings as follows: a pulsating vertical or oblique band or slit like luminal narrowing of the third part of the duodenum without no expansion over one third during air insufflation for at least 15 s, a marked dilation of the first and second part of the duodenum, and a bile lake in the stomach.

Simulation Methodology Based on Wind and Thermal Performance for Early Building Optimization Design in Taiwan

In a subtropical climate like that of Taiwan, the high temperature and humid environmental conditions often result in discomfort and health effects for building occupants. With regard to building geometry, the wind environment and thermal comfort assessment, which can enhance energy efficiency and the comfort and health of occupants, both ought to be considered as soon as possible in the design process. In view of the limited comprehensive design evaluation methods and design workflows regarding wind and thermal performance currently available, this research aims to develop an early decision support workflow that includes suggested performance evaluation methods and design optimization processes. The results of our case study show that the building had clear performance results using the proposed evaluation methods, making it easier for architects to understand and compare alternatives. Appropriate analysis and visualization of the results also effectively assisted architects in determining design solutions and making relevant decisions. The methods and results in this article can facilitate performance-based buildings for healthy and energy-efficient built environments.

The Influence of the Characteristics of Online Itinerary on Purchasing Behavior

This study presents insights into the influence of the characteristics of tourism itineraries on tourist purchasing behavior. We adopted data between 1 August 2019 and 30 November 2019 from the Qunar, the biggest online tourism platform in China and 4366 samples on travel itineraries were obtained. The ordinary least square regression (OLS) method was used. Controlling for product-related and channel-related factors, we demonstrate that in terms of tourism destination choice, outbound tourism products attract an increased number of tourists; in terms of the types of travel, private travel has replaced group travel to become the majority of the tourism market; in terms of the length of travel, mid-term travel (4–6 days) is the first choice, outnumbering short-term and long-term ones; price promotions such as discount for early decision, multi-person price reduction and membership prices significantly lead to increased sales; online reviews also have great impact on tourist purchasing behavior. In sum, this study uses a unique data set to reveal the influence of online tourism product characteristics on sales and provide potential guidance of the marketing strategy in response to consumer behavior for the online tourism industry.

1334 Improving Patient Flow Through the Hand Trauma Pathway

Aim A full-cycle audit was conducted at our plastic surgery unit, assessing adherence to hand trauma standards by the British Society for Surgery of the Hand. These stipulate that time from referral to clinic for open injuries and closed fractures should be within 24 hours and 72 hours respectively and time to theatre from date of injury (DOI) within 4 and 7 days, respectively. Method Data for the initial audit was collected from Nov 2019-Feb 2020 and for the re-audit from Aug-Dec 2020. Lists were generated of 50 patients with open injuries including flexor tendon, extensor tendon and nerve injuries and 50 hand fractures in both cycles. Data was collected on DOI, date of referral, clinic review and surgery. Results The initial audit results showed poor DOI documentation (open injuries 30%, fractures 54%). For open injuries, 44% met standards for clinical review within 24 hours and 94% for time to theatre. For fractures, 94% met the standard for time to clinic and 90% for time to theatre. The interventions included adding the standards to the clinic booking form and creating a mandatory DOI field on the referral system. The re-audit showed improvement of DOI documentation (open injuries 95%, fractures 100%) and the proportion of open injuries seen within 24 hours to 60%. Conclusions The interventions had a positive impact on our hand trauma pathway. Areas for improvement include reducing the number of patient visits to the service and encouraging early decision-making, particularly for patients reviewed in the emergency department.

Principles for Selection of the Quality, Health, Safety and Environmental Digital Solution

A digital solution for the Quality, Health, Safety and Environmental (QHSE) management system has lately become almost a must for any progressive company, especially the one that strives to take on, pass and maintain third-party certifications (such as ISO 9001, 14001 and 45001). However, its selection may be a complicated process balancing interests of field workers, executives, procurement, IT, safety/environmental/risk managers and training personnel. The process of selection of the QHSE digital solution starts with defining the scope of the project and its sponsors, stakeholders, resources and budget (most likely estimated, at initial stage). The next step is building of a list of requirements of a desired solution based on feedback from business. It will be followed by research of available solutions on the market and/or in-house capabilities to develop one. Three to five vendors with solutions best conforming to the defined requirements will be requested to do presentations of their capabilities, followed by proof-of-concept for 2-3 top candidates, leading to a selection of a winner. Despite the process described here being very straightforward, there may be pitfalls caused by complex interplay of interests of different disciplines and divisions within the company. The most important conclusions addressing these pitfalls are: It is unlikely that you will find one vendor, whose solution will become the best fit for all disciplines comprised by your management system (quality, occupational health, safety and environmental). An early decision needs to be made (most likely at the executive level) if you would go with a One Solution (Best-of-Suite) or different specialized software (Best-of-Breed) approaches. You need to get a very good idea of various QHSE-related software currently being used in your company at local or division levels. If the decision is made to switch to a new comprehensive digital solution on a global level, you will need to get a buy-in from local/division users before making this switch. Finally, you need to ensure that all stakeholders and interested parties are involved in (or at least informed of) the selection process and agree on its scope.

Can we predict the severe course of COVID-19 - a systematic review and meta-analysis of indicators of clinical outcome?

Background COVID-19 has been reported in over 40million people globally with variable clinical outcomes. In this systematic review and meta-analysis, we assessed demographic, laboratory and clinical indicators as predictors for severe courses of COVID-19. Methods This systematic review was registered at PROSPERO under CRD42020177154. We systematically searched multiple databases (PubMed, Web of Science Core Collection, MedRvix and bioRvix) for publications from December 2019 to May 31st 2020. Random-effects meta-analyses were used to calculate pooled odds ratios and differences of medians between (1) patients admitted to ICU versus non-ICU patients and (2) patients who died versus those who survived. We adapted an existing Cochrane risk-of-bias assessment tool for outcome studies. Results Of 6,702 unique citations, we included 88 articles with 69,762 patients. There was concern for bias across all articles included. Age was strongly associated with mortality with a difference of medians (DoM) of 13.15 years (95% confidence interval (CI) 11.37 to 14.94) between those who died and those who survived. We found a clinically relevant difference between non-survivors and survivors for C-reactive protein (CRP; DoM 69.10 mg/L, CI 50.43 to 87.77), lactate dehydrogenase (LDH; DoM 189.49 U/L, CI 155.00 to 223.98), cardiac troponin I (cTnI; DoM 21.88 pg/mL, CI 9.78 to 33.99) and D-Dimer (DoM 1.29mg/L, CI 0.9 to 1.69). Furthermore, cerebrovascular disease was the co-morbidity most strongly associated with mortality (Odds Ratio 3.45, CI 2.42 to 4.91) and ICU admission (Odds Ratio 5.88, CI 2.35 to 14.73). Discussion This comprehensive meta-analysis found age, cerebrovascular disease, CRP, LDH and cTnI to be the most important risk-factors that predict severe COVID-19 outcomes and will inform clinical scores to support early decision-making.