Video-consultation in the Emergency Department: An Assessment of the Potential Benefit for a UK District General Hospital (Preprint)

BACKGROUND DGH Emergency department referrals to a tertiary centre depend on information available from a ‘generalist’ clinician in discussion with a specialist team. If there is uncertainty, the lowest risk strategy is often to transfer the patient. Video consultation allowing the specialist team to see and talk to the patient whilst still in the Emergency department could improve decision making about patient transfer. OBJECTIVE This study assessed the potential benefit of real time video consultation between remote specialist and Emergency department patient across all specialities. METHODS Detailed patient data was collected prospectively for 6 months on all patients presenting to a DGH Emergency department who required input from a specialist team in the nearest tertiary centre. These patients were discussed retrospectively with the specialist teams to determine whether video conferencing could have benefited the patient’s management. The logistics for use of videoconferencing were explored. RESULTS 18,799 patients were seen in the Emergency department during the study period. 413 referrals were made to the tertiary centre specialist teams. Review of patients transferred indicated 193 might have benefited from video consultation. If the specialist team could be accessed via video conferencing only whilst a senior member was available in hospital (0800-2200hr) then a maximum of only 5 patients per week across all specialities would use the equipment. If 24hr specialist access was available this would increase to 7 patients per week. CONCLUSIONS Video consultation between emergency department patient and specialist has limited potential to improve patient management.

Friedreich's Ataxia Frequency in a Large Cohort of Genetically Undetermined Ataxia Patients

Background: Patients with suspected genetic ataxia are often tested for Friedreich's ataxia (FRDA) and/or a variety of spinocerebellar ataxias (SCAs). FRDA can present with atypical, late-onset forms and so may be missed in the diagnostic process. We aimed to determine FRDA-positive subjects among two cohorts of patients referred to a specialist ataxia centre either for FRDA or SCA testing to determine the proportion of FRDA cases missed in the diagnostic screening process.Methods: 2000 SCA-negative ataxia patients, not previously referred for FRDA testing (group A), were tested for FRDA expansions and mutations. This group was compared with 1768 ataxia patients who had been previously referred for FRDA testing (group B) and were therefore more likely to have a typical presentation. The phenotypes of positive cases were assessed through review of the clinical case notes.Results: Three patients (0.2%) in group A had the FRDA expansion on both alleles, compared with 207 patients (11.7%) in group B. The heterozygous carrier rate across both cohorts was of 41 out of 3,768 cases (1.1%). The size of the expansions in the three FRDA-positive cases in group A was small, and their presentation atypical with late-onset.Conclusions: This study demonstrates that FRDA is very rare among patients who were referred purely for SCA testing without the clinical suspicion of FRDA. Such cases should be referred to specialist ataxia centres for more extensive testing to improve patient management and outcomes.

A Mobile App to Improve Patient Management in Emergency Departments: Caregiver Needs Analysis, Design and Early Technology Acceptance Assessment

Emergency care is very complex in that it requires patient-centered care in a coordinated manner among multiple providers in a highly distractible, unpredictable and stressful environment. Sharing information efficiently between providers in this context is difficult. Connecting emergency providers with each other through a digital communication channel could improve the efficiency of information sharing and emergency care. This study describes the development process of PIMPmyHospital, a mobile app dedicated to emergency department physicians and nurses to collaboratively manage their patients. We relied on a user-centered design process involving caregivers from a pediatric emergency department. The process started with semi-structured interviews that informed the specifications of the app, followed by an iterative design and development approach. The resulting prototype was evaluated by end-users using the perceived usefulness dimension of the technology acceptance model questionnaire. Early user engagement during the design and development of a dedicated mobile app must be taken into account to improve its perceived usefulness and future adoption.

Update on endothelial dysfunction in COVID-19: severe disease, long COVID-19 and pediatric characteristics

Objectives To review current literature on the role of endothelial dysfunction in coronavirus disease-2019 (COVID-19) infection in terms of pathophysiology, laboratory features and markers, clinical phenotype in adults and children, as well as long COVID-19. Content We conducted a thorough assessment of the literature and critically analyzed current data, mostly utilizing the PubMed and Medline search engines to find original studies published in the previous decade. Summary and Outlook Accumulating evidence suggests that endothelial dysfunction may be a common denominator of severe COVID-19 in adults and children, as well as long COVID-19, implicating mutual pathophysiological pathways. This narrative review summarizes the up-to-date knowledge of endothelial dysfunction caused by COVID-19, including novel aspects of long COVID-19 and pediatric disease. This knowledge is important in order not only to understand the multisystemic attack of COVID-19, but also to improve patient management and prognosis.

Editorial: State of the Art CT and Image Quality, Radiation and Contrast Dose

A special issue of the journal Dose-Response entitled “State of the Art CT and Image Quality, Radiation and Contrast Dose” is proposed. Technological improvements on CT scanners have the potentiality to reduce the issues related to ionizing radiation administration, opening new insights toward innovative applications also thanks to the contamination of other research fields like artificial intelligence algorithms and additive manufacturing technologies. In order to approach these new research directions, a multidisciplinary team becomes needed, overcoming the clinical and radiological point of view and enriching the workflow with different contributes. The real weight of these afferents on patient’s management remains to be assessed and characterized. The main topics will be related to innovative CT applications able to improve patient management and treatment assessment and reduce patients risks due to radiation exposure and iodinated contrast injection.

Mortality Prediction Utilizing Blood Biomarkers to Predict the Severity of COVID-19 Using Machine Learning Technique

Healthcare researchers have been working on mortality prediction for COVID-19 patients with differing levels of severity. A rapid and reliable clinical evaluation of disease intensity will assist in the allocation and prioritization of mortality mitigation resources. The novelty of the work proposed in this paper is an early prediction model of high mortality risk for both COVID-19 and non-COVID-19 patients, which provides state-of-the-art performance, in an external validation cohort from a different population. Retrospective research was performed on two separate hospital datasets from two different countries for model development and validation. In the first dataset, COVID-19 and non-COVID-19 patients were admitted to the emergency department in Boston (24 March 2020 to 30 April 2020), and in the second dataset, 375 COVID-19 patients were admitted to Tongji Hospital in China (10 January 2020 to 18 February 2020). The key parameters to predict the risk of mortality for COVID-19 and non-COVID-19 patients were identified and a nomogram-based scoring technique was developed using the top-ranked five parameters. Age, Lymphocyte count, D-dimer, CRP, and Creatinine (ALDCC), information acquired at hospital admission, were identified by the logistic regression model as the primary predictors of hospital death. For the development cohort, and internal and external validation cohorts, the area under the curves (AUCs) were 0.987, 0.999, and 0.992, respectively. All the patients are categorized into three groups using ALDCC score and death probability: Low (probability < 5%), Moderate (5% < probability < 50%), and High (probability > 50%) risk groups. The prognostic model, nomogram, and ALDCC score will be able to assist in the early identification of both COVID-19 and non-COVID-19 patients with high mortality risk, helping physicians to improve patient management.

Refining Adjuvant Therapy for Endometrial Cancer: New Standards and Perspectives

Endometrial carcinoma is the most frequent cancer of the reproductive female organs. Most endometrial cancers are diagnosed at early stage (75%). Treatment options depend on pathogenetic, histopathologic and clinical characteristic at the diagnosis. To improve patient management in the near future, recent research has focused on new molecular features; evidence has shown that these give a better definition of patient prognosis and can help in tailoring adjuvant treatments by identifying specific subgroups of patients whose tumors may benefit from specific therapeutic approaches. In this review, we will focus on current knowledge of adjuvant treatment of endometrial carcinoma, using a prognostic-risk group stratification based on pathogenetic, clinical and molecular features, and will take a look at the ongoing trials that will further change the therapeutic approach in coming years.

Evaluation of diagnosis and treatment practices of Brazilian neurologists among patients with multiple sclerosis

ABSTRACT Background: Recent changes to the diagnostic criteria for multiple sclerosis (MS) and new medications have had a major impact on the way in which specialists manage the disease. Objective: To investigate factors considered by Brazilian neurologists in managing MS, and to identify how these contribute to diagnosis and treatment. Methods: Potential participants were selected by a steering committee (MS experts who developed this survey). Only MS specialists were included in the study (neurologists who had completed a neuroimmunology fellowship or who were treating more than 30 MS patients). Links to the online questionnaire were distributed between March 2019 and January 2020. This questionnaire was composed of sections with hypothetical MS scenarios. Results: Neurologists from 13 Brazilian states responded to the survey (n = 94). In the clinically isolated syndrome (CIS) scenario, the respondents agreed to treat patients with a high risk of MS diagnosis, whereas in the radiologically isolated syndrome (RIS) half of the respondents opted not to treat, even among high-risk patients. In cases of low-activity relapsing-remitting MS (RRMS), the choice of treatment was distributed among interferon beta, glatiramer acetate and teriflunomide, which were changed to fingolimod and natalizumab, as RRMS severity increased. The topics in which disagreement was found included practices regarding use of disease-modifying therapy (DMT) for pregnant patients and the washout period required for some DMTs. Conclusions: This study enabled identification of areas of agreement and disagreement about MS treatment among Brazilian neurologists, which can be used to update future protocols and improve patient management.

Anesthesia for Transoral Endoscopic Parathyroidectomy by Vestibular Approach (TOEPVA)

Background After thyroid diseases, hyperparathyroidism is one of the most common endocrine surgical diseases. The increasing diagnosis of thyroid pathologies in early stages and a societal emphasis on physical appearances, especially in young women, have led to the development of new surgical techniques alternative to conventional transcervical incision consistently. Here, we describe our anesthesia experience for parathyroidectomy with Transoral Endoscopic Parathyroidectomy by Vestibular Approach (TOEPVA). Patients who undergo TOEPVA at our institution between November 2018 and April 2019 were reviewed. Demographic data and hemodynamic parameters were reported. Results Seven patients were operated successfully by this technique, none of which required conversion to conventional open surgery. Two patients required atropine and one patient required ephedrine during insufflation. Conclusion After induction of anesthesia with propofol, remifentanil, and rocuronium and anesthesia managed by desflurane co-administered with continuous infusion of remifentanil provide feasible and safe anesthesia for TOEPVA. However, especially during hydrodissection and insufflation, a close cooperation between surgeon and anesthetist has a great value to improve patient management.

Spadework for Establishing Integrative Enhanced Recovery Program after Spine Surgery: Web-based Survey Assessing Korean Medical Doctors’Perspectives (Preprint)

BACKGROUND Enhanced recovery after surgery (ERAS) is the object of numerous publications within the growing integrative medical domain. However, its value in spine surgery is not as recognized as it is in other surgical domains or in integrative medical fields. OBJECTIVE Our aim was to report the opinions of Korean medical doctors regarding integrative enhanced recovery after spine surgery. METHODS From December 2020 to January 2021, members of the Korean Medical Association were asked to complete an online questionnaire regarding an integrative enhanced recovery program after spine surgery. RESULTS A total of 726 participants responded to the survey. Approximately half of the respondents had more than 10 years of medical experience in the Korean health care system and 58.29% were affiliated with primary Korean medical clinics. The majority of respondents were not aware of the ERAS program (N= 412, 79.08%), but said that patient management would benefit from the establishment of a postoperative medical program that reflected an integrated medical perspective (N=505, 96.92%). Furthermore, according to our results Korean medical professionals believe that Korean medical interventions should play a major role in the pain management and digestive improvement sections of the upcoming postoperative program. Moreover, respondents claimed that Korean medical modalities such as acupuncture, moxibustion, cupping, and herbal decoction should be included in the program and should play a significant role. CONCLUSIONS Efforts are necessary to promote postoperative workflow, improve patient management and reduce complications or side effects, particularly those adapted to spinal surgery. Based on our results, a study on the development of a comprehensive postoperative program that reflects the perspectives of patients and conventional medical doctors should be conducted.