Circulating miR-147b as a diagnostic marker for patients with bacterial sepsis and septic shock

Background Early diagnosis, precise antimicrobial treatment and subsequent patient stratification can improve sepsis outcomes. Circulating biomarkers such as plasma microRNAs (miRNAs) have proven to be surrogates for diagnosis, severity and case management of infections. The expression of four selected miRNAs (miR-146-3p, miR-147b, miR-155 and miR-223) was validated for their prognostic and diagnostic potential in a clinically defined cohort of patients with sepsis and septic shock. Methods The expression of plasma miRNAs was quantified by quantitative PCR (qPCR) in patients with bacterial sepsis (n = 78), in patients with septic shock (n = 52) and in patients with dengue haemorrhagic fever (DHF; n = 69) and in healthy controls (n = 82). Results The expression of studied miRNA was significantly increased in patients with bacterial sepsis and septic shock. The plasma miR-147b was able to differentiate bacterial sepsis from non-sepsis and septic shock (AUC = 0.77 and 0.8, respectively, p≤ 0.05), while the combination of plasma miR-147b and procalcitonin (PCT) predicted septic shock (AUC = 0.86, p≤ 0.05). Conclusions The plasma miR-147b may be an useful biomarker independently or in combination with PCT to support clinical diagnosis of sepsis and equally prognosis of patients with septic shock.

Improving recording and reporting of dementia and frailty via electronic patient record by ambulance staff in a single service (IDEAS)

Background: Dementia is common in older adults assessed by ambulance services. However, inconsistent reporting via the patient record may result in this diagnosis being overlooked by healthcare staff further down the care pathway. This can have a deleterious effect on subsequent patient care, increasing morbidity and mortality. We sought to understand how and where ambulance staff would like to record this finding on the electronic patient record (ePR).Methods: We designed and implemented a survey of ambulance staff in a single service to understand how they identify patients with dementia, how they record dementia on the ePR and how the ePR could be improved to better capture dementia. Scoping questions on frailty were included. The survey was tested using cognitive interviewing. Analysis was conducted using descriptive statistics for closed questions and thematic analysis for open questions as appropriate.Results: 131 surveys were completed; 60% of participants were paramedics and 40% were other grades of front line staff. Participants reported consulting electronic/paper sources, and individuals such as carers involved in the patients’ care, to establish whether dementia had been diagnosed. Frailty assessments were prompted by social context, reduced mobility, a fall or diagnosis of dementia. Staff reported documenting dementia in 20 different areas on the ePR and 46% of participants stated a preference for a designated area to record the information. However, 15% indicated it was not necessary to record dementia or that no ePR changes were required.Conclusions: We have highlighted the variation in ambulance staff practice in recording of dementia. Alterations to the ePR are required to ensure that dementia is recorded consistently and is easily retrievable. Clearer guidance on when to assess frailty may also enhance information provision to care staff in other sectors, resulting in more appropriate clinical and social care.

Automated Detection of Ischemic Stroke and Subsequent Patient Triage in Routinely Acquired Head CT

Purpose Advanced machine-learning (ML) techniques can potentially detect the entire spectrum of pathology through deviations from a learned norm. We investigated the utility of a weakly supervised ML tool to detect characteristic findings related to ischemic stroke in head CT and provide subsequent patient triage. Methods Patients having undergone non-enhanced head CT at a tertiary care hospital in April 2020 with either no anomalies, subacute or chronic ischemia, lacunar infarcts of the deep white matter or hyperdense vessel signs were retrospectively analyzed. Anomaly detection was performed using a weakly supervised ML classifier. Findings were displayed on a voxel-level (heatmap) and pooled to an anomaly score. Thresholds for this score classified patients into i) normal, ii) inconclusive, iii) pathological. Expert-validated radiological reports were considered as ground truth. Test assessment was performed with ROC analysis; inconclusive results were pooled to pathological predictions for accuracy measurements. Results During the investigation period 208 patients were referred for head CT of which 111 could be included. Definite ratings into normal/pathological were feasible in 77 (69.4%) patients. Based on anomaly scores, the AUC to differentiate normal from pathological scans was 0.98 (95% CI 0.97–1.00). The sensitivity, specificity, positive and negative predictive values were 100%, 40.6%, 80.6% and 100%, respectively. Conclusion Our study demonstrates the potential of a weakly supervised anomaly-detection tool to detect stroke findings in head CT. Definite classification into normal/pathological was made with high accuracy in > 2/3 of patients. Anomaly heatmaps further provide guidance towards pathologies, also in cases with inconclusive ratings.

A Practical Approach to the Patient with Obesity

The prevalence of obesity and obesity-related comorbidities is rising. Primary care physicians are the frontline of healthcare and play a central role in the management of obesity. In this article, we discuss the 5As framework (Ask, Assess, Advise, Agree, and Assist) as a practical framework for obesity counselling, focusing on initiating the conversation and assessing the person with obesity. The assessment includes taking a weight history, excluding secondary causes, understanding lifestyle factors contributing to weight gain and assessing for complications of obesity. This assessment then makes it possible for subsequent patient engagement, including advising, agreeing (goal setting), and assisting the patient on an individualised care plan.

Evaluasi Penerapan Early Warning Score di Ruang Rawat Inap Dewasa

Early Warning Score (EWS) is one of the instruments used to assess the patient's physiological deterioration and is one of the assessments in hospital accreditation. The application of the EWS can predict patient outcomes in the form of mortality, length of stay, and re-hospitalization. The purpose of this study was to evaluate the application of EWS in the inpatient room. This study was a prospective observational cohort study of patients in adult wards (≥16 years) over a while (1 month). The number of samples was 256 patients. The instruments used in this study were a demographic data questionnaire and an EWS observation sheet. Descriptive statistics were used for patient characteristics, and EWS monitoring documents. The results showed that 100% of the EWS sheet documentation was incomplete, if this examination sheet was not carried out correctly it would affect the subsequent patient handling and patient outcomes both related to illness and death. Monitoring and evaluation related to the implementation of the EWS are very much needed in the future for the improvement of hospital services as a whole. Keywords: Early Warning Score, Evaluation

Outcomes After Tracheostomy for Patients With Respiratory Failure due to COVID-19

Objective: To evaluate the utility and safety of tracheostomy for patients with respiratory failure from COIVD-19 and describe patient clinical characteristics and process of management. Methods: Case series of the first 24 COVID-19 patients who underwent tracheostomy at our institution, a single-center tertiary care community hospital intensive care/ventilator weaning unit. The patients all had respiratory failure from COVID-19 and required endotracheal intubation and mechanical ventilation. Outcomes reviewed include mortality, percent discharged, percent liberated from mechanical ventilation, percent decannulated, time from tracheostomy to ventilator liberation and discharge, and number of staff infected with COVID-19 during tracheostomy and management. Results: Of the 24 patients who underwent tracheostomy, 21 (88%) of 24 survived. Twenty (83%) were liberated from mechanical ventilation, and 19 (79%) were discharged. Fourteen (74%) of the discharged had been decannulated. The average (± SD) time from tracheostomy to ventilator liberation was 9 ± 4.3 days and from tracheostomy to discharge 21 ± 9 days. All discharged patients had been liberated from mechanical ventilation. No health care workers became infected with COVID-19 during the procedure or subsequent patient management. Conclusion: Patients with respiratory failure from COVID-19 who underwent tracheostomy had a high likelihood of being liberated from mechanical ventilation and discharged. Tracheostomy and subsequent ventilator weaning management can be performed safely. Tracheostomy allowed for decompression of higher acuity medical units in a safe and effective manner.

Comparing burnout and work-life balance among specialists in internal medicine: the role of inpatient vs. outpatient workplace

Background Compared to the general population, physicians are more likely to experience increased burnout and lowered work-life balance. In our article, we want to analyze whether the workplace of a physician is associated with these outcomes. Methods In September 2019, physicians from various specialties answered a comprehensive questionnaire. We analyzed a subsample of 183 internists that were working full time, 51.4% were female. Results Multivariate analysis showed that internists working in an outpatient setting exhibit significantly higher WLB and more favorable scores on all three burnout dimensions. In the regression analysis, hospital-based physicians exhibited higher exhaustion, cynicism and total burnout score as well as lower WLB. Conclusions Physician working at hospitals exhibit less favorable outcomes compared to their colleagues in outpatient settings. This could be a consequence of workplace-specific factors that could be targeted by interventions to improve physician mental health and subsequent patient care.

Effectiveness of barrier precautions for prevention of patient-to-patient transfer of a viral DNA surrogate marker

Background: Gloves and gowns are used during patient care to reduce contamination of personnel and prevent pathogen transmission. Objective: To determine whether the use of gowns adds a substantial benefit over gloves alone in preventing patient-to-patient transfer of a viral DNA surrogate marker. Methods: In total, 30 source patients had 1 cauliflower mosaic virus surrogate marker applied to their skin and clothing and a second to their bed rail and bedside table. Personnel caring for the source patients were randomized to wear gloves, gloves plus cover gowns, or no barrier. Interactions with up to 7 subsequent patients were observed, and the percentages of transfer of the DNA markers were compared among the 3 groups. Results: In comparison to the no-barrier group (57.8% transfer of 1 or both markers), there were significant reductions in transfer of the DNA markers in the gloves group (31.1% transfer; odds ratio [OR], 0.16; 95% confidence interval [CI], 0.02-0.73) and the gloves-plus-gown group (25.9% transfer; OR, 0.11; 95% CI, 0.01–0.51). The addition of a cover gown to gloves during the interaction with the source patient did not significantly reduce the transfer of the DNA marker (P = .53). During subsequent patient interactions, transfer of the DNA markers was significantly reduced if gloves plus gowns were worn and if hand hygiene was performed (P < .05). Conclusions: Wearing gloves or gloves plus gowns reduced the frequency of patient-to-patient transfer of a viral DNA surrogate marker. The use of gloves plus gowns during interactions with the source patient did not reduce transfer in comparison to gloves alone.

Comparative assessment of the frequency and risk factors of purulent-septic infections in adult patients after various types of open and closed heart surgery

BACKGROUND: The widespread increase in the number and types of cardiac surgery necessitate the study of frequency and risk factors of postoperative purulent-septic infections (PSIs). AIM: to provide a comparative assessment of the PSI frequency and risk factors in adult patients after various types of cardiac surgery. MATERIALS AND METHODS: Based on the cardiac surgery hospital materials, medical records of 4.815 patients over 18 years of age, who underwent open (n = 1.540) and closed (n = 3.275) heart surgeries within 1 year, were analyzed. The typical and prenosological forms of PSIs were taken into account in accordance with the epidemiological standard of case definition. RESULTS: The incidence rates for typical and prenosological PSI forms amounted to 39.6 and 72.7 per 1000 surgeries after open heart surgery, respectively, and 3.1 and 3.9 after minimally invasive endovascular surgical interventions, respectively. The main clinical forms of PSI after open and closed heart surgeries were surgical site infections, nosocomial pneumonia, urinary tract infection, and bloodstream infection. In an open heart surgery, the maximum incidence rates for typical and prenosological forms of PSIs were recorded after surgeries on the aorta and less often after heart valve replacement or coronary artery bypass grafting. The increased incidence rate after aortic surgery was mainly due to urinary tract infection and nosocomial pneumonia. In the case of closed heart surgery, no statistically significant differences were detected between the incidence rates of PSIs after coronary artery stenting, cardiac arrhythmia and carotid artery stenosis surgery, and other interventions. The duration of both the surgery itself and the subsequent patient stay in the intensive care unit was found to be important as risk factors for PSIs after cardiac surgery. CONCLUSION: The incidence rate of PSIs after open heart surgery is significantly higher than after closed heart surgery, which is mostly associated with the duration of surgical intervention and the subsequent patient stay in the intensive care unit.