First-Response ABCDE Management of Status Epilepticus: A Prospective High-Fidelity Simulation Study

Respiratory infections following status epilepticus (SE) are frequent, and associated with higher mortality, prolonged ICU stay, and higher rates of refractory SE. Lack of airway protection may contribute to respiratory infectious complications. This study investigates the order and frequency of physicians treating a simulated SE following a systematic Airways-Breathing-Circulation-Disability-Exposure (ABCDE) approach, identifies risk factors for non-adherence, and analyzes the compliance of an ABCDE guided approach to SE with current guidelines. We conducted a prospective single-blinded high-fidelity trial at a Swiss academic simulator training center. Physicians of different affiliations were confronted with a simulated SE. Physicians (n = 74) recognized SE and performed a median of four of the five ABCDE checks (interquartile range 3–4). Thereof, 5% performed a complete assessment. Airways were checked within the recommended timeframe in 46%, breathing in 66%, circulation in 92%, and disability in 96%. Head-to-toe (exposure) examination was performed in 15%. Airways were protected in a timely manner in 14%, oxygen supplied in 69%, and antiseizure drugs (ASDs) administered in 99%. Participants’ neurologic affiliation was associated with performance of fewer checks (regression coefficient −0.49; p = 0.015). We conclude that adherence to the ABCDE approach in a simulated SE was infrequent, but, if followed, resulted in adherence to treatment steps and more frequent protection of airways.

Aluminium leaching in fluid warming devices – A Review

Current guidelines recommend the use of an intravenous fluid warmer to prevent perioperative hypothermia. Among the various methods of warming intravenous fluids, contact warmers are among the most effective and accurate, particularly in clinical conditions requiring rapid infusions of refrigerated blood or fluids. Contact warmers put the infusate in direct contact with a heating block. Some fluid warmers use heating blocks manufactured from aluminium. Several recent publications, however, have shown that uncoated aluminium blocks can leach potentially toxic amounts of aluminium into the body. In this review we performed a systematic literature review on aluminium leaching with contact fluid warmers and describe what manufacturer and competent authorities did in the past years to ensure patient safety. The search resulted in five articles describing the aluminium leaching. Four different devices (Level 1 Fluid Warmer from Smiths Medical, ThermaCor from Smisson-Cartledge Biomedical, Recirculator 8.0 from Eight Medical International BV, enFlow from Vyaire) were shown to leach high levels of aluminium when heating certain intravenous fluids. One manufacturer (Vyaire) voluntarily removed their product from the market, while three manufacturers (Eight Medical International BV, Smisson-Cartledge Biomedical, and Smiths Medical) revised the instructions for use for the affected devices. The enFlow fluid warmer was subsequently redesigned with a parylene coating over the heating block. The scientific literature shows that by using a thin parylene layer on the heating block, the leaching of aluminium can be nearly eliminated without affecting the heating performance of the device.

Development and validation of a prediction index for recent mortality in advanced COPD patients

The primary barrier to initiating palliative care for advanced COPD patients is the unpredictable course of the disease. We enroll 752 COPD patients into the study and validate the prediction tools for 1-year mortality using the current guidelines for palliative care. We also develop a composite prediction index for 1-year mortality and validate it in another cohort of 342 patients. Using the current prognostic models for recent mortality in palliative care, the best area under the curve (AUC) for predicting mortality is 0.68. Using the Modified Medical Research Council dyspnea score and oxygen saturation to define the combined dyspnea and oxygenation (DO) index, we find that the AUC of the DO index is 0.84 for predicting mortality in the validated cohort. Predictions of 1-year mortality based on the current palliative care guideline for COPD patients are poor. The DO index exhibits better predictive ability than other models in the study.

Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center

Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy—especially in austere or challenging environments—is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.

Migraine in the Emergency Department: A Prospective Multinational Study of Patient Characteristics, Management, and Outcomes

<b><i>Background and Aim:</i></b> Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. <b><i>Methods:</i></b> This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. <b><i>Results:</i></b> The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5; 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. <b><i>Conclusions:</i></b> This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required.

MEN1 Surveillance Guidelines: Time to (re)Think?

Clinical Practice Guidelines for patients with Multiple Endocrine Neoplasia type 1 (MEN1) recommend a variety of surveillance options. Given progress over the past decade in this area, it is timely to evaluate their ongoing utility. MEN1 is characterized by the development of synchronous or asynchronous tumors affecting a multitude of endocrine and non-endocrine tissues, resulting in premature morbidity and mortality, such that the rationale for undertaking surveillance screening in at-risk individuals appears robust. Current guidelines recommend an intensive regimen of clinical, biochemical and radiological surveillance commencing in early childhood for those with a clinical or genetic diagnosis of MEN1, with the aim of early tumor detection and treatment. Although it is tempting to assume that such screening results in patient benefits and improved outcomes, the lack of a strong evidence base for several aspects of MEN1 care, and the potential for iatrogenic harms related to screening tests or interventions of unproven benefit, make such assumptions potentially unsound. Furthermore, the psychological, as well as economic burdens of intensive screening remain largely unstudied. Although screening undoubtedly constitutes an important component of MEN1 patient care, this perspective aims to highlight some of the current uncertainties and challenges related to existing MEN1 guidelines with a particular focus on the role of screening for pre-symptomatic tumors. Looking forward, a screening approach that acknowledges these limitations and uncertainties and places the patient at the heart of the decision-making process, is advocated.

High Burden of Cryptococcal Meningitis Among ART-Experienced HIV-infected Patients in Northern Uganda in the era of “Test and Treat”: Implications for Cryptococcal Screening Programs

Background The impact of the "test-and-treat" program for HIV treatment in rural areas of Uganda on cryptococcal antigen (CrAg) screening or cryptococcal meningitis (CM) is poorly understood. Methods We retrospectively evaluated clinical factors in 212 HIV-infected patients diagnosed with CM from February of 2017 to November of 2019 at Lira Regional Referral Hospital (LRRH) in northern Uganda. Results Among 212 patients diagnosed with CM, 58.5% were male. Median age, CD4 count, and HIV viral load were 35 years, 86 cells/μL, and 9,463 copies/mL respectively. Only 10% of patients had a previous history of CM. We found that 190 of 209 (90.9%) patients were ART-experienced, and 19 (9.1%) were ART-naïve. Overall, 90 of 212 (42.5%) patients died while hospitalized with a median time to death of 14 days. Increased risk of death was associated with altered mental status (HR 6.6, 95% CI 2.411-18.219, p =&lt;0.0001), and seizures (HR 5.23, 95% CI 1.245-21.991, p=0.024). Conclusion Current guidelines recommend CrAg screening based on low CD4 counts for ART-naïve patients and VL or clinical failure for ART-experienced patients. Using current guidelines for CrAg screening, some ART- experienced patients miss CrAg screening in resource limited settings, when CD4 or VL tests are unavailable. We found that the majority of HIV- infected patients with CM were ART- experienced (90.9%) at presentation. The high burden of CM in ART-experienced patients supports a need for improved CrAg screening of ART-exposed patients.

Men’s health and osteoporosis: modern treatment and prevention options

Osteoporosis (OP) has traditionally been seen as a pathology that mainly occurs in postmenopausal women and elderly men, and until recently, the problem of this disease among males has not been given sufficient priority. At the moment, however, OP in men is widely acknowledged to be an important issue of modern health care. Given the etiological and pathogenetic characteristics, two categories of OP have been identified: primary and secondary. In the structure of male OP, the secondary category of OP accounts for up to 40-60 % of all cases. Hypogonadism is one of the common causes of bone loss in men. Initially, males develop a larger bone mass compared to women and, accordingly, greater bone strength. Men over the age of 50 do not undergo rapid bone mass loss, as women do after menopause, and the bone mass decreases more gradually, in a linear manner. With ageing, the trabecular number (Tb.N) in men are relatively maintained with underlying more pronounced thinning of Tb. N associated with decreased osteoblast-forming activity. Although the prevalence of OP among men is significantly lower than among women, the clinical consequences of OP in men are of a great importance. The primary strategy of the anti-osteoporotic therapy is to prevent OP and low-traumatic fractures. According to the current guidelines for the treatment of OP in men, bisphosphonates (BP) are the drugs of choice. Zoledronic acid is a highly effective nitrogen-containing BP, the first drug to be injected once a year. Intravenous injection of zoledronic acid is as effective in reducing the risk of fractures in men as in women.

Echocardiographic probability of pulmonary hypertension: a validation study

BackgroundAccording to current guidelines, the diagnosis of pulmonary hypertension (PH) relies on echocardiographic probability followed by right heart catheterization. How echocardiography predicts PH recently re-defined by a mean pulmonary artery pressure (mPAP) >20 mmHg instead of ≥25 mmHg and pulmonary vascular disease defined by a pulmonary vascular resistance (PVR) >3 or >2 Wood units has not been established.MethodsA total of 278 patients referred for PH underwent a comprehensive echocardiography followed by a right heart catheterization. Fifteen patients (5.4%) were excluded because of insufficient quality echocardiography.ResultsWith PH defined by a mPAP >20 mmHg, 23 patients had no PH, 146 had pre-capillary and 94 post-capillary PH. At univariate analysis, maximum velocity of tricuspid regurgitation (TRV) ≥2.9 and ≤3.4 m s−1, left ventricle (LV) eccentricity index >1.1, right ventricle (RV) outflow tract (OT) notching or acceleration time <105 ms, RV-LV basal diameter >1 and PA diameter predicted PH, whereas inferior vena cava diameter and right atrial area did not. At multivariable analysis, only TRV ≥2.9 m s−1 independently predicted PH. Additional independent prediction of PVR >3 Wood units was offered by LV eccentricity index >1.1 and RVOT acceleration time <105 ms and/or notching, but with no improvement of optimal combination of specificity and sensibility or positive prediction.ConclusionsEchocardiography as recommended in current guidelines can be used to assess the probability of re-defined PH in a referral center. However, the added value of indirect signs is modest and sufficient quality echocardiographic signals may not be recovered in some patients.