A Scoring Tool to Predict Pulmonary Complications in Severe Leptospirosis with Kidney Failure

Rapid identification of patients likely to develop pulmonary complications in severe leptospirosis is crucial to prompt aggressive management and improve survival. The following article is a cohort study of leptospirosis patients admitted at the National Kidney and Transplant Institute (NKTI). Logistic regression was used to predict pulmonary complications and obtain a scoring tool. The Kaplan–Meir method was used to describe survival rates. Among 380 patients with severe leptospirosis and kidney failure, the overall mortality was 14%, with pulmonary hemorrhage as the most common cause. In total, there were 85 (22.4%) individuals who developed pulmonary complications, the majority (95.3%) were observed within three days of admission. Among the patients with pulmonary complications, 56.5% died. Patients placed on mechanical ventilation had an 82.1% mortality rate. Multivariate analyses showed that dyspnea (OR = 28.76, p < 0.0001), hemoptysis (OR = 20.73, p < 0.0001), diabetes (OR = 10.21, p < 0.0001), renal replacement therapy (RRT) requirement (OR = 6.25, p < 0.0001), thrombocytopenia (OR = 3.54, p < 0.0029), and oliguria/anuria (OR = 3.15, p < 0.0108) were significantly associated with pulmonary complications. A scoring index was developed termed THe-RADS score (Thrombocytopenia, Hemoptysis, RRT, Anuria, Diabetes, Shortness of breath). The odds of developing pulmonary complications were 13.90 times higher among patients with a score >2 (63% sensitivity, 88% specificity). Pulmonary complications in severe leptospirosis with kidney failure have high mortality and warrant timely and aggressive management.

Introduction of a new scoring tool to identify clinically stable heart failure patients

Introduction Heart failure (HF) poses a burden on specialist care, making referral of clinically stable HF patients to primary care a desirable goal. However, a structured approach to guide patient referral is lacking. Methods The Maastricht Instability Score—Heart Failure (MIS-HF) questionnaire was developed to objectively stratify the clinical status of HF patients: patients with a low MIS-HF (0–2 points, indicating a stable clinical condition) were considered for treatment in primary care, whereas high scores (> 2 points) indicated the need for specialised care. The MIS-HF was evaluated in 637 consecutive HF patients presenting between 2015 and 2018 at Maastricht University Medical Centre. Results Of the 637 patients, 329 (52%) had a low score and 205 of these 329 (62%) patients were referred to primary care. The remaining 124 (38%) patients remained in secondary care. Of the 308 (48%) patients with a high score (> 2 points), 265 (86%) remained in secondary care and 41 (14%) were referred to primary care. The primary composite endpoint (mortality, cardiac hospital admissions) occurred more frequently in patients with a high compared to those with a low MIS-HF after 1 year of follow-up (29.2% vs 10.9%; odds ratio (OR) 3.36, 95% confidence interval (CI) 2.20–5.14). No significant difference in the composite endpoint (9.8% vs 12.9%; OR 0.73, 95% CI 0.36–1.47) was found between patients with a low MIS-HF treated in primary versus secondary care. Conclusion The MIS-HF questionnaire may improve referral policies, as it helps to identify HF patients that can safely be referred to primary care.

Effect of Replacing Vendor QTc Alerts with a Custom QTc Risk Alert in Inpatients

Objective The aim of the study is to implement a customized QTc interval clinical decision support (CDS) alert strategy in our electronic health record for hospitalized patients and aimed at providers with the following objectives: minimize QTc prolongation, minimize exposure to QTc prolonging medications, and decrease overall QTc-related alerts. A strategy that was based on the validated QTc risk scoring tool and replacing medication knowledge vendor alerts with custom QTc prolongation alerts was implemented. Methods This is a retrospective quasi-experimental study with a pre-intervention period (August 2019 to October 2019) and post-intervention period (December 2019 to February 2020). The custom alert was implemented in November 2019. Results In the pre-implementation group, 361 (19.3%) patients developed QTc prolongation, and in the post-implementation group, 357 (19.6%) patients developed QTc prolongation (OR: 1.02, 95% CI: 0.87–1.20, p = 0.81). The odds ratio of an action taken post-implementation compared with pre-implementation was 18.90 (95% CI: 14.03–25.47, p <0. 001). There was also a decrease in total orders for QTc prolonging medications from 7,921 (5.5%) to 7,566 (5.3%) with an odds ratio of 0.96 (95% CI: 0.93–0.99, p = 0.01). Conclusion We were able to decrease patient exposure to QTc prolonging medications while not increasing the rate of QTc prolongation as well as improving alert action rate. Additionally, there was a decrease in QTc prolonging medication orders which illustrates the benefit of using a validated risk score with a customized CDS approach compared with a traditional vendor-based strategy. Further research is needed to confirm if an approach implemented at our organization can reduce QTc prolongation rates.

Quantitative photogrammetric methodology for measuring mammalian belly score in the painted dog

The use of “belly scoring” can offer a novel, non-invasive objective management tool to gauge food intake between individuals, groups, and populations, and thus, population fitness. As food availability is increasingly affected by predation, ecological competition, climate change, habitat modification, and other human activities, an accurate belly scoring tool can facilitate comparisons among wildlife populations, serving as an early warning indicator of threats to wildlife population health and potential population collapse. In social species, belly scores can also be a tool to understand social behavior and ranking. We developed and applied the first rigorous quantitative photogrammetric methodology to measure belly scores of wild painted dogs (Lycaon pictus). Our methodology involves: (1) Rigorous selection of photographs of the dorso/lateral profile of individuals at a right angle to the camera, (2) photogrammetrically measuring belly chord length and “belly drop” in pixels, (3) adjusting belly chord length as a departure from a standardized leg angle, and (4) converting pixel measurements to ratios to eliminate the need to introduce distance from the camera. To highlight a practical application, this belly score method was applied to 631 suitable photographs of 15 painted dog packs that included 186 individuals, all collected between 2004–2015 from allopatric painted dog populations in and around Hwange (n = 462) and Mana Pools National Parks (n = 169) in Zimbabwe. Variation in mean belly scores exhibited a cyclical pattern throughout the year, corresponding to biologically significant patterns to include denning demand and prey availability. Our results show significant differences between belly scores of the two different populations we assessed, thus highlighting food stress in the Hwange population. In the face of growing direct and indirect anthropogenic disturbances, this standardised methodology can provide a rapid, species-specific non-invasive management tool that can be applied across studies to rapidly detect emergent threats.

Paroxysmal Hypothermia With Prominent Parkinsonian Features After Suprachiasmatic Tumor Resection

Paroxysmal hypothermia (PH) is a rare syndrome of stereotyped episodes of hypothermia, bradycardia, and altered mental status occurring in patients with hypothalamic lesions. Prior cases have mentioned bradykinesia, ataxia, and dysarthria, but parkinsonism has not been described as a specific feature of PH. We report two patients, an adult and a child, who developed PH after suprachiasmatic tumor resection, both with clinical presentations notable for prominent parkinsonian features despite no evidence of parkinsonism during the intervening months and years. We propose a diagnostic algorithm and scoring tool to aid in the clinical diagnosis of PH presenting as parkinsonism.

P-P16 Management of acute pancreatitis in a busy district general hospital

Background Pancreatitis is a common surgical presentation and can be life threatening, with complications such as acute respiratory distress syndrome and necrosis occurring. Due to high hospital incidence, it is important to ensure patients are managed appropriately using available guidelines. This audit aims to assess the management of acute pancreatitis in a busy district general hospital and identify areas for improvement to better patient safety. Methods Only cases of acute pancreatitis were used in this audit. Case notes for the period between October and December 2020 were collected respectively. A data collection proforma was created using guidelines from the British society of gastroenterology for the management of acute pancreatitis. Data was then analysed using Excel. Results 23% of cases had documented scoring, with Glasgow-Imrie the only scoring tool used. 41% had documented oxygen saturation. 33% had been reviewed by alcohol liaison team for pancreatitis secondary to high alcohol consumption. No patients were given the guideline’s recommended rate of fluid resuscitation (5-10ml/kg/hr). All patients had amylase/lipase in their blood profile. 80% of patients had antiemetics prescribed should they require them, whilst 95% of patients had opioids prescribed for analgesia. 50% of patients were given antibiotics despite them not being indicated. 18% were kept nil by mouth (NBM) whilst having abdominal pain. Conclusions Our results suggest that guidelines for acute pancreatitis are not adequately adhered to. Many aspects of the guidance were not followed including documentation of oxygen saturation, antibiotic use, IV fluid resuscitation and alcohol liaison review for patients who required review. We have developed a proforma to use for the management of acute pancreatitis to ensure that cases are managed in accordance with evidence-based literature and to make the management of these cases easier. We will reaudit to analyse the effects of our intervention and determine whether there has been an improvement in the management of acute pancreatitis.