Clinical assessment of computed tomography for detecting ingested blister packs: A single-center retrospective study

Objectives

Blister pack (BP) ingestion poses serious risks, such as gastrointestinal perforation, and accurate localization by computed tomography (CT) is a common practice. However, while it has been reported in vitro that CT visibility varies with the material type of BPs, there have been no reports on this variability in clinical settings. In this study, we investigated the CT detection rates of different BPs in clinical settings.

Methods

This single-center retrospective study from 2010 to 2022 included patients who underwent endoscopic foreign body removal for BP ingestion. The patients were categorized into two groups for BP components, the polypropylene (PP) and the polyvinyl chloride (PVC)/polyvinylidene chloride (PVDC) groups. The primary outcome was the comparison of CT detection rates between the groups. We also evaluated whether the BPs contained tablets and analyzed their locations.

Results

This study included 61 patients (15 in the PP group and 46 in the PVC/PVDC group). Detection rates were 97.8% for the PVC/PVDC group compared to 53.3% for the PP group, a significant difference (p < 0.01). No cases of BPs composed solely of PP were detected by CT. Blister packs were most commonly found in the upper thoracic esophagus.

Conclusions

Even in a clinical setting, the detection rates of PVC and PVDC were higher than that of PP alone. Identifying PP without tablets has proven challenging in clinical. Considering the risk of perforation, these findings suggest that esophagogastroduodenoscopy may be necessary, even if CT detection is negative.

Successful prehospital ECMO in drowning resuscitation after prolonged submersion

An 18-year-old drowning victim was successfully resuscitated using prehospital veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Despite 24 min of submersion in water with a surface temperature of 15 °C, the patient was cannulated on-scene and transported to a trauma center. After ICU admission on VA-ECMO, he was decannulated and extubated by day 5. He was transferred to a peripheral hospital on day 6 and discharged home after 3.5 weeks with favorable neurological outcome of a Cerebral Performance Categories (CPC) score of 1 out of 5. This case underscores the potential of prehospital ECMO in drowning cases within a well-equipped emergency response system.

The ABC (Age, Bystander, and Cardiogram) score for predicting neurological outcomes of cardiac arrests without pre-hospital return of spontaneous circulation: A nationwide population-based study

Aim

We previously proposed the ABC score to predict the neurological outcomes of cardiac arrest without prehospital return of spontaneous circulation (ROSC). Using nationwide population-based data, this study aimed to validate the ABC score through various resuscitation guideline periods.

Methods

We analysed cases with cardiac arrest due to internal causes and failure to achieve prehospital ROSC in the All-Japan Utstein Registry. Patients from the 2007-2009, 2012-2014, and 2017-2019 periods were classified into the 2005, 2010, and 2015 guideline groups, respectively. Neurological outcomes were assessed using cerebral performance categories (CPCs) one month after the cardiac arrest. We defined CPC 1-2 as a favourable outcome. We evaluated the test characteristics of the ABC score, which could range from 0 to 3.

Results

Among the 162,710, 186,228, and 190,794 patients in the 2005, 2010, and 2015 guideline groups, 0.7%, 0.8%, and 0.9% of the patients had CPC 1-2, respectively. The proportions of CPC 1-2 were 2.9%, 3.6%, and 4.6% in patients with ABC scores of 2 and were 9.5%, 13.3%, and 16.8% in patients with ABC scores of 3, respectively. Among patients with ABC scores of 0, 0.2%, 0.1%, and 0.2%, all had CPC 1-2, respectively. The areas under the receiver operating characteristic curves for the ABC score were 0.798, 0.822, and 0.828, respectively.

Conclusions

The ABC score had acceptable discrimination for neurological outcomes in patients without prehospital ROSC in the three guideline periods.

Changes of pulse wave transit time after haemodynamic manoeuvres in healthy adults: a prospective randomised observational trial (PWTT volunteer study)

Background

Pulse wave transit time (PWTT) shows promise for monitoring intravascular fluid status intraoperatively. Presently, it is unknown how PWTT mirrors haemodynamic variables representing preload, inotropy, or afterload.

Methods

PWTT was measured continuously in 24 adult volunteers. Stroke volume was assessed by transthoracic echocardiography. Volunteers underwent four randomly assigned manoeuvres: 'Stand-up' (decrease in preload), passive leg raise (increase in preload), a 'step-test' (adrenergic stimulation), and a 'Valsalva manoeuvre' (increase in intrathoracic pressure). Haemodynamic measurements were performed before and 1 and 5 min after completion of each manoeuvre. Correlations between PWTT and stroke volume were analysed using the Pearson correlation coefficient.

Results

'Stand-up' caused an immediate increase in PWTT (mean change +55.9 ms, P-value <0.0001, 95% confidence interval 46.0-65.7) along with an increase in mean arterial pressure and heart rate and a drop in stroke volume (P-values <0.0001). Passive leg raise caused an immediate drop in PWTT (mean change -15.4 ms, P-value=0.0024, 95% confidence interval -25.2 to -5.5) along with a decrease in mean arterial pressure (P-value=0.0052) and an increase in stroke volume (P-value=0.001). After 1 min, a 'step-test' caused no significant change in PWTT measurements (P-value=0.5716) but an increase in mean arterial pressure and heart rate (P-values <0.0001), without changes in stroke volume (P-value=0.1770). After 5 min, however, PWTT had increased significantly (P-value <0.0001). Measurements after the Valsalva manoeuvre caused heterogeneous results.

Conclusion

Noninvasive assessment of PWTT shows promise to register immediate preload changes in healthy adults. The clinical usefulness of PWTT may be hampered by late changes because of reasons different from fluid shifts.

Clinical trial registration

German clinical trial register (DRKS, ID: DRKS00031978, https://www.drks.de/DRKS00031978).

Association between signs of life and survival in traumatic cardiac arrest patients: A nationwide, retrospective cohort study

Background

The clinical impact of signs of life (SOLs) in traumatic cardiac arrest (TCA) remains to be elucidated. The aim of this study was to examine the association between SOLs and survival/neurological outcomes in TCA patients.

Methods

Retrospective data from the Japan Trauma Data Bank (2019-2021) was reviewed. TCA patients were assigned to one of two study groups based on the presence or absence of SOLs and compared. SOLs were defined as having at least one of following criteria: pulseless electrical activity >40 beats per minute, gasping, positive light reflex, or extremity/eye movement at hospital arrival. The primary outcome was survival at hospital discharge. The secondary outcome was favorable neurological status (Glasgow Outcome Scale score of 4 or 5) at hospital discharge.

Results

A total of 1,981 patients (114 with SOLs and 1,867 without SOLs) were included. Characteristics of patients were as follows: age (median age 60.0 years old [interquartile range: 41-80] years vs. 55.4 [38-75] years), gender (male: 76/114 (66.7%) vs. 1,207/1,867 (65.0%), blunt trauma (90/111 [81.1%] vs. 1,559/1,844 [84.5%]), Injury Severity Score (29.2 [22-41] vs. 27.9 [20-34]). Patients with SOLs showed higher survival (10/114 (8.8%) vs. 25/1,867 (1.3%), OR 1.96 [CI 1.20-2.72]) and higher favorable neurological outcomes (4/110 (3.5%) vs. 6/1,865 (0.3%), OR 2.42 [CI 1.14-3.70]) compared with patients without SOLs.

Conclusions

TCA patients with SOLs at hospital arrival showed higher survival and favorable neurological outcomes at hospital discharge compared with TCA patients without SOLs.

Extracorporeal cardiopulmonary resuscitation in hypothermic cardiac arrest: A secondary analysis of multicenter extracorporeal cardiopulmonary resuscitation registry data in Japan

Aim

Extracorporeal cardiopulmonary resuscitation (ECPR) is used to resuscitate patients with cardiac arrest; however, its effect in treating hypothermic cardiac arrest has not been well studied. Therefore, in this study, we aimed to examine the characteristics and outcomes of patients with hypothermic cardiac arrest who underwent ECPR, using a multicenter out-of-hospital cardiac arrest (OHCA) registry in Japan.

Methods

Baseline characteristics of patients with hypothermic OHCA and body temperature below 32 °C were assessed. Logistic regression analysis was performed to identify factors associated with in-hospital mortality and neurological outcomes in these patients. Outcomes of hypothermic and cardiogenic OHCA cases were compared using propensity-score matching to investigate differences among subgroups.

Results

We included 2,157 patients, with 102 and 1,646 in the hypothermic and cardiogenic groups, respectively. Higher age and longer low-flow time were independent risk factors for mortality, and higher age was an independent risk factor for unfavorable neurological outcomes in the hypothermic OHCA group.Eighty matched pairs were selected during propensity-score matching, and the mortality rate was lower in the hypothermic group than in the cardiogenic group (46.2% vs. 77.5%; p < 0.01). Unfavorable neurological outcome rate was lower in the hypothermic group than in the cardiogenic group (62.5% vs. 87.5%; p < 0.01).

Conclusions

Increased age and prolonged low-flow time were identified as negative prognostic factors in patients with hypothermic OHCA who underwent ECPR. These patients showed lower mortality and unfavorable neurological outcome rates than patients with cardiogenic OHCA, suggesting that ECPR is a promising strategy for treating hypothermic OHCA.

Accidental compression of the thoracic wall. Mechanical asphyxia rather than trauma is the main culprit

We present three cases of traumatic asphyxia after thoracic compression. All victims were Caucasian males aged 22-50 years. One man was crushed by a truck trailer, another was crushed by an overturned vehicle, and the last was crushed by a large heavy stone slab. None of the patients survived the accident. There was no evidence of trauma or only minor trauma from the bones or vital organs of the thoracic cavity and abdomen.

High-flow nasal cannula oxygen versus noninvasive ventilation for the management of acute cardiogenic pulmonary edema: a randomized controlled pilot study

BACKGROUND

Whether high-flow nasal oxygen can improve clinical signs of acute respiratory failure in acute heart failure (AHF) is uncertain.

OBJECTIVE

To compare the effect of high-flow oxygen with noninvasive ventilation (NIV) on respiratory rate in patients admitted to an emergency department (ED) for AHF-related acute respiratory failure.

DESIGN, SETTINGS AND PARTICIPANTS

Multicenter, randomized pilot study in three French EDs. Adult patients with acute respiratory failure due to suspected AHF were included. Key exclusion criteria were urgent need for intubation, Glasgow Coma Scale <13 points or hemodynamic instability.

INTERVENTION

Patients were randomly assigned to receive high-flow oxygen (minimum 50 l/min) or noninvasive bilevel positive pressure ventilation.

OUTCOMES MEASURE

The primary outcome was change in respiratory rate within the first hour of treatment and was analyzed with a linear mixed model. Secondary outcomes included changes in pulse oximetry, heart rate, blood pressure, blood gas samples, comfort, treatment failure and mortality.

MAIN RESULTS

Among the 145 eligible patients in the three participating centers, 60 patients were included in the analysis [median age 86 (interquartile range (IQR), 90; 92) years]. There was a median respiratory rate of 30.5 (IQR, 28; 33) and 29.5 (IQR, 27; 35) breaths/min in the high-flow oxygen and NIV groups respectively, with a median change of -10 (IQR, -12; -8) with high-flow nasal oxygen and -7 (IQR, -11; -5) breaths/min with NIV [estimated difference -2.6 breaths/min (95% confidence interval (CI), -0.5-5.7), P  = 0.052] at 60 min. There was a median SpO 2 of 95 (IQR, 92; 97) and 96 (IQR, 93; 97) in the high-flow oxygen and NIV groups respectively, with a median change at 60 min of 2 (IQR, 0; 5) with high-flow nasal oxygen and 2 (IQR, -1; 5) % with NIV [estimated difference 0.8% (95% CI, -1.1-2.8), P  = 0.60]. PaO 2 , PaCO 2 and pH did not differ at 1 h between groups, nor did treatment failure, intubation and mortality rates.

CONCLUSION

In this pilot study, we did not observe a statistically significant difference in changes in respiratory rate among patients with acute respiratory failure due to AHF and managed with high-flow oxygen or NIV. However, the point estimate and its large confidence interval may suggest a benefit of high-flow oxygen.

TRIAL REGISTRATION

NCT04971213 ( https://clinicaltrials.gov ).

Nursing diagnoses as factors associated with delirium among intensive care unit patients with sepsis: A retrospective correlational study

AIMS

To examine whether nursing diagnoses were associated with delirium in patients with sepsis.

BACKGROUND

Nursing diagnosis is a nurse's clinical judgement about clients' current or potential health conditions. Delirium is regarded as an important nurse-sensitive outcome. Nonetheless, nursing diagnoses associated with delirium have not yet been identified.

DESIGN

Retrospective correlational study.

METHODS

This study was carried out from December 2021 to January 2023. We analysed electronic health records of patients with sepsis admitted to the intensive care units (ICUs) of a tertiary hospital in Seoul, South Korea. Delirium was defined based on the Intensive Care Delirium Screening Checklist score. Nursing diagnoses established within 24 h of admission to the ICU were included and were based on the North American Nursing Diagnosis Association diagnostic classification. The data were analysed using logistic regression. Demographics, comorbidities, procedures and physiological measures were adjusted. Regression model was evaluated via receiver operating characteristic curve, Nagelkerke R2, accuracy and F1 score.

RESULTS

The prevalence of delirium in patients with sepsis was 51.8%. Ineffective breathing patterns, decreased cardiac output and impaired skin integrity were significant nursing diagnoses related to delirium. Age ≥ 65 years, Acute Physiology and Chronic Health Evaluation II score, mechanical ventilation, continuous renal replacement therapy, physical restraint and comatose state were also associated with delirium in patients with sepsis. The area under the receiver operating characteristic curve was 0.806.

CONCLUSION

Ineffective breathing patterns, decreased cardiac output and impaired skin integrity could manifest as prodromal symptoms of delirium among patients with sepsis.

IMPACT

The prodromal symptoms of delirium revealed through nursing diagnoses can be efficiently used to identify high-risk groups for delirium. The use of nursing diagnosis system should be recommended in clinical practice caring for sepsis patients.

REPORTING METHODS

STROBE checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Effect of timing of advanced life support on out-of-hospital cardiac arrests at home

AIM

In cases of out-of-hospital cardiac arrests (OHCA) occurring at home, Japanese emergency medical services personnel decide whether to provide treatment on the scene or during transport based on their judgment. This study aimed to evaluate the association between the timing of advanced life support (ALS) (i.e., endotracheal intubation [ETI] or adrenaline administration) for OHCA at home and prognosis.

METHOD

This retrospective cohort study used data from the Japan Utstein Registry and emergency transport data collected from patients who underwent pre-hospital ETI (n = 6806) and received adrenaline (n = 22,636) between 2016 and 2019. The timing of ETI or adrenaline administration was determined as "on the scene" or "in the ambulance." Multiple logistic regression analysis was used to estimate the association among the timing of ALS implementation, pre-hospital return of spontaneous circulation (ROSC), and survival at 1 month.

RESULT

ETI on the scene was significantly positively associated with pre-hospital ROSC (adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.57-2.09) and survival at 1 month (AOR, 1.81; 95% CI, 1.47-2.23). Adrenaline administration on the scene was significantly positively associated with pre-hospital ROSC (AOR, 2.51; 95% CI, 2.33-2.70) and survival at 1 month (AOR, 2.13; 95% CI, 1.89-2.40).

CONCLUSION

Our analysis suggests performing ALS on the scene was associated with pre-hospital ROSC and survival at 1 month. Further efforts are needed to increase the rate of ALS implementation on the scene by emergency life-saving technicians.

Structural and functional imaging of psoriasis for severity assessment and quantitative monitoring of treatment response using high-resolution optoacoustic imaging

Psoriasis is a chronic inflammatory skin disease, characterized by thick scaly plaques. It imposes a notable disease burden with varying levels of severity affecting the quality of life significantly. Current disease severity assessment relies on semi-objective visual inspection based on the Psoriasis Area and Severity index (PASI) score that might not be sensitive to sub-clinical changes. Histology of psoriasis skin lesions necessitate invasive skin biopsies. This indicates an unmet need for a non-invasive, objective and quantitative approach to assess disease severity serially. Herein, we employ multispectral Raster-Scanning Optoacoustic Mesoscopy (ms-RSOM) derived structural and microvascular functional imaging metrics to examine the lesional and non-lesional skin in psoriasis subjects across different severities and also evaluate the treatment outcome in a subject with topical steroids and biologics, such as adalimumab. ms-RSOM derived structural metrics like epidermal thickness and total blood volume (TBV) and microvascular functional information such as oxygen saturation (sO2) are evaluated by spectrally resolving the endogenous chromophores like melanin, oxy-, and deoxy-hemoglobin. Initial findings reveal an elevated sO2 and TBV with severity in lesional and non-lesional psoriasis skin, thus representing increasing inflammation. An increase in epidermal thickness is also noted with the degree of severity, corresponding to the inflammation and increased abnormal cell growth. As a marker to evaluate the treatment response, we observed a decrease in epidermal thickness, sO2, and TBV in a psoriasis patient post-treatment, which is consistent with the decrease in the PASI score from 4.1 to 1.9. We envision that ms-RSOM has a huge potential to be translated into routine clinical setting for the diagnosis of severity and assessment of treatment monitoring in psoriasis subjects.

Systematic Lymphatic Repair for Reduction of Postoperative Lymphatic Leak Following Neuroblastoma Resection

BACKGROUND

Gross total resection of neuroblastoma is associated with lymphatic leaks that can delay postoperative resumption of treatment. To prevent postoperative lymphatic leak, we introduced systematic lymphatic repair (SLR), which involved oversewing the entire edge of the disrupted lymphatic plane after neuroblastoma resection. We sought to study the impact of SLR on postoperative lymphatic leak and time to return to treatment.

METHODS

We reviewed 60 neuroblastoma patients who underwent gross total resection at KK Women's and Children's Hospital. Patient, disease, and operative factors were correlated with surgical drainage, treatment delay and length of stay (LOS). Among patients with sufficient records, the interaction between variables associated with drainage, delay and LOS outcomes were compared in 14 patients who had SLR versus 35 historical controls who had targeted lymphatic repair (TLR).

RESULTS

Postoperative drain duration and volume were significantly higher in tumors with ≥2 image-derived risk factors (IDRFs, P = 0.005 and P = 0.013, respectively) or vessel encasement (P = 0.031 and P = 0.024, respectively). Longer LOS was significantly associated with ≥2 IDRFs (P = 0.006). All forms of suture repair of lymphatics and use of Tachosil™ were associated with significantly longer postoperative drain duration (P < 0.05); the former was also associated with significantly higher total drain volume (P < 0.05) - indicating appropriate use of these adjuncts in patients at risk of chyle leak. In patients who had suture repair of lymphatics, SLR was significantly associated with reduced postoperative interval to chemotherapy resumption (P = 0.014, two-way ANOVA).

CONCLUSION

A systematic approach to repair of lymphatic channels following neuroblastoma resection can significantly reduce time to postoperative resumption of treatment.

TYPE OF STUDY

Clinical Research.

LEVEL OF EVIDENCE

III.

Environmental Hypothermia

Although a rare diagnosis in the Emergency Department, hypothermia affects patients in all environments, from urban to mountainous settings. Classic signs of death cannot be interpreted in the hypothermic patient, thus resulting in the mantra, "No one is dead until they're warm and dead." This comprehensive review of environmental hypothermia covers the clinical significance and pathophysiology of hypothermia, pearls and pitfalls in the prehospital management of hypothermia (including temperature measurement techniques and advanced cardiac life support deviations), necessary Emergency Department diagnostics, available rewarming modalities including extracorporeal life support, and criteria for termination of resuscitation.

Multivariate modeling and prediction of cerebral physiology in acute traumatic neural injury: A scoping review

Traumatic brain injury (TBI) poses a significant global public health challenge necessitating a profound understanding of cerebral physiology. The dynamic nature of TBI demands sophisticated methodologies for modeling and predicting cerebral signals to unravel intricate pathophysiology and predict secondary injury mechanisms prior to their occurrence. In this comprehensive scoping review, we focus specifically on multivariate cerebral physiologic signal analysis in the context of multi-modal monitoring (MMM) in TBI, exploring a range of techniques including multivariate statistical time-series models and machine learning algorithms. Conducting a comprehensive search across databases yielded 7 studies for evaluation, encompassing diverse cerebral physiologic signals and parameters from TBI patients. Among these, five studies concentrated on modeling cerebral physiologic signals using statistical time-series models, while the remaining two studies primarily delved into intracranial pressure (ICP) prediction through machine learning models. Autoregressive models were predominantly utilized in the modeling studies. In the context of prediction studies, logistic regression and Gaussian processes (GP) emerged as the predominant choice in both research endeavors, with their performance being evaluated against each other in one study and other models such as random forest, and decision tree in the other study. Notably among these models, random forest model, an ensemble learning approach, demonstrated superior performance across various metrics. Additionally, a notable gap was identified concerning the absence of studies focusing on prediction for multivariate outcomes. This review addresses existing knowledge gaps and sets the stage for future research in advancing cerebral physiologic signal analysis for neurocritical care improvement.

Risk factors for neurological disability outcomes in patients under extracorporeal membrane oxygenation following cardiac arrest: An observational study

OBJECTIVES

This study aimed to identify factors associated with neurological and disability outcomes in patients who underwent ECMO following cardiac arrest.

METHODS

This retrospective, single-center, observational study included adult patients who received ECMO treatment for in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) between February 2016 and March 2020. Factors associated with neurological and disability outcomes in these patients who underwent ECMO were assessed.

SETTING

Hamad General Hospital, Qatar.

MAIN OUTCOME MEASURES

Neurological disability outcomes were assessed using the Modified Rankin Scale (mRS) and the Cerebral Performance Category (CPC) scale.

RESULTS

Among the 48 patients included, 37 (77 %) experienced OHCA, and 11 (23 %) had IHCA. The 28-day survival rate was 14 (29.2 %). Of the survivors, 9 (64.3 %) achieved a good neurological outcome, while 5 (35.7 %) experienced poor neurological outcomes. Regarding disability, 5 (35.7 %) of survivors had no disability, while 9 (64.3 %) had some form of disability. The results showed significantly shorter median time intervals in minutes, including collapse to cardiopulmonary resuscitation (CPR) (3 vs. 6, P = 0.001), CPR duration (12 vs. 35, P = 0.001), CPR to extracorporeal cardiopulmonary resuscitation (ECPR) (20 vs. 40, P = 0.001), and collapse-to-ECPR (23 vs. 45, P = 0.001), in the good outcome group compared to the poor outcome group.

CONCLUSION

This study emphasizes the importance of minimizing the time between collapse and CPR/ECMO initiation to improve neurological outcomes and reduce disability in cardiac arrest patients. However, no significant associations were found between outcomes and other demographic or clinical variables in this study. Further research with a larger sample size is needed to validate these findings.

IMPLICATIONS FOR CLINICAL PRACTICE

The study underscores the significance of reducing the time between collapse and the initiation of CPR and ECMO. Shorter time intervals were associated with improved neurological outcomes and reduced disability in cardiac arrest patients.

Implementation considerations for the adoption of artificial intelligence in the emergency department

OBJECTIVE

Artificial intelligence (AI) has emerged as a potentially transformative force, particularly in the realm of emergency medicine (EM). The implementation of AI in emergency departments (ED) has the potential to improve patient care through various modalities. However, the implementation of AI in the ED presents unique challenges that influence its clinical adoption. This scoping review summarizes the current literature exploring the barriers and facilitators of the clinical implementation of AI in the ED.

METHODS

We systematically searched Embase (Ovid), MEDLINE (Ovid), Web of Science, and Engineering Village. All articles were published in English through November 20th, 2023. Two reviewers screened the search results, with disagreements resolved through third-party adjudication.

RESULTS

A total of 8172 studies were included in the preliminary search, with 22 selected for the final data extraction. 10 studies were reviews and the remaining 12 were primary quantitative, qualitative, and mixed-methods studies. Out of the 22, 13 studies investigated a specific AI tool or application. Common barriers to implementation included a lack of model interpretability and explainability, encroachment on physician autonomy, and medicolegal considerations. Common facilitators to implementation included educating staff on the model, efficient integration into existing workflows, and sound external validation.

CONCLUSION

There is increasing literature on AI implementation in the ED. Our research suggests that the most common barrier facing AI implementation in the ED is model interpretability and explainability. More primary research investigating the implementation of specific AI tools should be undertaken to help facilitate their successful clinical adoption in the ED.

Prevalence and clinical significance of incidental findings in chest and abdominopelvic CT scans of trauma patients; A cross-sectional study

BACKGROUND

Imaging may inadvertently reveal pathologies unrelated to their performing purpose, known as incidental findings (IF). This study aimed to assess the prevalence, clinical significance, and documentation of IFs in chest and abdominopelvic computed tomography (CT) scans of trauma patients.

METHODS

This observational study was conducted at two urban level-1 trauma centers from March 2019 through April 2022. Official radiology reports of trauma patients who underwent chest and/or abdominopelvic CT scans at the emergency department (ED) were explored, and IF were extracted. Predictive factors of the presence of IFs and their documenting were investigated.

RESULTS

Out of 656 chest and 658 abdominopelvic CT scans, 167 (25.37%) and 212 (32.31%) scans harbored at least one IF, respectively. Patients with IFs tended to be of higher age and female in both chest (age: 48 [IQR: 35-62] vs. 34 [IQR: 25-42.5]; female: 31.14% vs 14.66%, p < 0.001 for both) and abdominopelvic CT scans (age: 41 [IQR: 30-57.5] vs 33 [IQR: 25-43], female: 26.42% vs. 13.96%, p < 0.001 for both). As for documentation of significant IFs, only 49 of 112 chest IFs (43.8%) and 55 of 176 abdominopelvic IFs (31.3%) were documented. Investigating factors associated with documentation of clinically significant IFs, shorter length of hospital stay (1.5 (IQR: 0-4) vs. 3 (IQR: 2-8), p = 0.003), and discharging by ED physicians (documentation rate: 13.2% vs 42.6%, p < 0.001) were associated with poorer documentation of IFs only in abdominopelvic scans.

CONCLUSION

CT imaging in ED trauma patients often reveals incidental findings, especially in older patients. Over 50% of these findings are clinically significant, yet they are frequently ignored and not documented. Physicians need to be more vigilant in recognizing and documenting these incidental findings and informing patients of the need for further evaluation.

When rare meets common: Treatable genetic diseases are enriched in the general psychiatric population

Mental illnesses are one of the biggest contributors to the global disease burden. Despite the increased recognition, diagnosis and ongoing research of mental health disorders, the etiology and underlying molecular mechanisms of these disorders are yet to be fully elucidated. Moreover, despite many treatment options available, a large subset of the psychiatric patient population is nonresponsive to standard medications and therapies. There has not been a comprehensive study to date examining the burden and impact of treatable genetic disorders (TGDs) that can present with neuropsychiatric features in psychiatric patient populations. In this study, we test the hypothesis that TGDs that present with psychiatric symptoms are more prevalent within psychiatric patient populations compared to the general population by performing targeted next-generation sequencing of 129 genes associated with 108 TGDs in a cohort of 2301 psychiatric patients. In total, 48 putative affected and 180 putative carriers for TGDs were identified, with known or likely pathogenic variants in 79 genes. Despite screening for only 108 genetic disorders, this study showed a two-fold (2.09%) enrichment for genetic disorders within the psychiatric population relative to the estimated 1% cumulative prevalence of all single gene disorders globally. This strongly suggests that the prevalence of these, and most likely all, genetic diseases is greatly underestimated in psychiatric populations. Increasing awareness and ensuring accurate diagnosis of TGDs will open new avenues to targeted treatment for a subset of psychiatric patients.

Retroperitoneum revisited: a review of radiological literature and updated concept of retroperitoneal fascial anatomy with imaging features and correlating anatomy

PURPOSE

Spread of disease in the retroperitoneum is dictated by the complex anatomy of retroperitoneal fasciae and is still incompletely understood. Conflicting reports have led to insufficient and incorrect anatomical concepts in radiological literature.

METHODS

This review will discuss previous concepts prevalent in radiological literature and their shortcomings will be highlighted. New insights from recent anatomical and embryological research, together with imaging examples, will be used to clarify patterns of disease spread in the retroperitoneum that remain unexplained by these concepts.

RESULTS

The fusion fascia and the renal fascia in particular give rise to planes and spaces that act as vectors for spread of disease in the retroperitoneum. Some of these planes and structures, such as the caudal extension of the renal fascia, have previously not been described in radiological literature.

CONCLUSION

New insights, including the various fasciae, potential spaces and planes, are incorporated into an updated combined retroperitoneal fascial concept.

Association of prehospital lactate levels with base excess in various emergencies - a retrospective study

OBJECTIVES

Blood gas analysis, including parameters like lactate and base excess (BE), is crucial in emergency medicine but less commonly utilized prehospital. This study aims to elucidate the relationship between lactate and BE in various emergencies in a prehospital setting and their prognostic implications.

METHODS

We conducted a retrospective analysis of prehospital emergency patients in Graz, Austria, from October 2015 to November 2020. Our primary aim was to assess the association between BE and lactate. This was assessed using Spearman's rank correlation and fitting a multiple linear regression model with lactate as the outcome, BE as the primary covariate of interest and age, sex, and medical emergency type as confounders.

RESULTS

In our analysis population (n=312), lactate and BE levels were inversely correlated (Spearman's ρ, -0.75; p<0.001). From the adjusted multiple linear regression model (n=302), we estimated that a 1 mEq/L increase in BE levels was associated with an average change of -0.35 (95 % CI: -0.39, -0.30; p<0.001) mmol/L in lactate levels. Lactate levels were moderately useful for predicting mortality with notable variations across different emergency types.

CONCLUSIONS

Our study highlights a significant inverse association between lactate levels and BE in the prehospital setting, underscoring their importance in early assessment and prognosis in emergency care. Additionally, the findings from our secondary aims emphasize the value of lactate in diagnosing acid-base disorders and predicting patient outcomes. Recognizing the nuances in lactate physiology is essential for effective prehospital care in various emergency scenarios.

Video Versus Nonvideo in a Rabbit Training Model for Establishing an Emergency Front of Neck Airway in Children: A Prospective Trial

OBJECTIVES

Simulating a realistic "cannot intubate, cannot oxygenate" (CICO) situation to train an "emergency front of neck airway" is difficult. It further remains unclear if provision of regular technical refreshers improves performance in the setting of a real CICO situation. The purpose of this prospective study on an established surgical rabbit cadaver tracheostomy model was to evaluate the benefit of viewing training material shortly before performing "emergency front of neck airway."

METHODS

Previously trained participants were randomized into 2 groups. The control group (video) was allowed to watch an instructional video before performing a tracheotomy on the training model, while the study group (nonvideo) was not. Queried outcomes included success rate, performance time, and severe secondary airway injuries between the 2 groups.

RESULTS

In 29 tracheotomies performed by 29 participants, the overall success rate was 86% (92% video; 81% nonvideo, P = 0.4). Performance time was not different between the 2 groups (video: 80 s [IQR25-75: 53-86], nonvideo 64 s [IQR25-75: 47-102]; P = 0.93). Only in the nonvideo group, the performance time and the time between the workshops correlated positively (P = 0.048). Severe secondary injuries were noted in 4 of 29 rabbit cadavers, 2 in each group. Watching a refresher video before performing an emergency surgical tracheostomy in an infant training model did not influence the success rate and the performance time in previously trained anesthetists.

CONCLUSIONS

These results highlight the ease of learning, memorization, and recall of this emergency surgical tracheostomy technique and may demonstrate its applicability in a real infant CICO situation.

Inside-out, antimicrobial resistance mediated by efflux pumps in clinical strains of Acinetobacter baumannii isolated from burn wound infections

Acinetobacter baumannii belongs to the ESKAPE group. It is classified as a critical priority group by the World Health Organization and a global concern on account of its capacity to acquire and develop resistance mechanisms to multiple antibiotics. Data from the United States indicates 500 deaths annually. Resistance mechanisms of this bacterium include enzymatic pathways such as ß-lactamases, carbapenemases, and aminoglycoside-modifying enzymes, decreased permeability, and overexpression of efflux pumps. A. baumannii has been demonstrated to possess efflux pumps, which are classified as members of the MATE family, RND and MFS superfamilies, and SMR transporters. The aim of our work was to assess the distribution of efflux pumps and their regulatory gene expression in clinical strains of A. baumannii isolated from burned patients. METHODS: From the Clinical Microbiology Laboratory at the Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra collection in Mexico, 199 strains were selected. Antibiotics susceptibilities were performed by broth microdilutions to determine minimal inhibitory concentrations. Phenotypic assays with efflux pump inhibitors were conducted using carbonyl cyanide 3-chlorophenylhydrazone (CCCP) and phenylalanine-arginine ß-naphthylamide (PAßN) in conjunction with amikacin, ceftazidime, imipenem, meropenem and levofloxacin. A search was conducted for structural genes that are linked to efflux pumps, and the relative expression of the adeR, adeS, and adeL genes was analyzed. RESULTS: Among a total of 199 strains, 186 exhibited multidrug resistance (MDR). Fluoroquinolones demonstrated the highest resistance rates, while minocycline and amikacin displayed comparatively reduced resistance rates (1.5 and 28.1, respectively). The efflux activity of fluorquinolones exhibited the highest phenotypic detection (from 85 to 100%), while IMP demonstrated the lowest activity of 27% with PAßN and 43.3% with CCCP. Overexpression was observed in adeS and adeL, with adeR exhibiting overexpression. Concluding that clinical strains of A. baumannii from our institution exhibited efflux pumps as one of the resistance mechanisms.

Intentional Insulin Overdose and Depression in Subjects with and Without Diabetes Mellitus: A Commentary

Insulin is an essential medication for people with type 1 diabetes mellitus and for some people with type 2 diabetes. Interestingly, insulin abuse has been reported as a mode of suicide, not only among people with diabetes, but also among their relatives, and among medical and paramedical personnel who have access to insulin. The aim of the present commentary was to raise awareness of potential depression-related intentional insulin overdose and its complications, as well as of the diagnosis and treatment of this entity. Insulin overdose may lead to severe and prolonged hypoglycemia, hypoglycemic coma, and death. Moreover, hypokalemia, hypomagnesemia, hypophosphatemia, and elevated liver enzymes are common. Insulin overdose should be suspected among people with diabetes in case of unexplained prolonged hypoglycemia and among people without diabetes who exhibit hypoglycemia and may have access to diabetic medications. The ratio of insulin to C-peptide helps distinguish exogenous insulin administration from endogenous secretion. The cornerstone of therapy is prompt administration of concentrated glucose infusions for days with simultaneous oral intake, when possible, and intense glucose monitoring to prevent hypoglycemia. Moreover, monitoring of serum electrolyte levels is recommended. Finally, psychiatric evaluation aiming at early identification of depression and suicidality is of paramount importance.

A novel AVPR2 gene mutation in a Chinese pedigree with nephrogenic diabetes insipidus

Nephrogenic diabetes insipidus (NDI) is a rare genetic disorder primarily associated with mutations in the arginine vasopressin receptor 2 (AVPR2) gene or the aquaporin 2 (AQP2) gene, resulting in impaired water reabsorption in the renal tubules. This report describes a case of a young male patient with NDI from China with a history of polydipsia and polyuria for over 15 years. Laboratory examinations of the proband indicated low urine-specific gravity and osmolality. Urologic ultrasound revealed severe bilateral hydronephrosis in both kidneys, bilateral dilatation of the ureters, roughness of the bladder wall, and the formation of muscle trabeculae. The diagnosis of diabetes insipidus was confirmed by water deprivation tests. The administration of posterior pituitary hormone did not alter urine-specific gravity, and osmolality remained at a low level (<300 mOsm/kg). Based on these findings, and the genetic tests of the proband and his parents were performed. A missense mutation (c.616 G>C) in exon 3 of the AVPR2 gene of the proband was found, caused by the substitution of amino acid valine to leucine at position 206 [p.Val206Leu], which was a hemizygous mutation and consistent with X-chromosome recessive inheritance. The administration of oral hydrochlorothiazide improves the symptoms of polydipsia and polyuria in the proband. This novel AVPR2 gene mutation may be the main cause of NDI in this family, which induces a functional defect in AVPR2, and leads to reduced tubular reabsorption of water.

Differences in outcomes of patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation between day-time and night-time

Although patients who underwent night-time resuscitation for out-of-hospital cardiac arrest (OHCA) had worse clinical outcomes than those who underwent day-time resuscitation, the differences between the outcomes of patients with OHCA who underwent extracorporeal cardiopulmonary resuscitation (ECPR) in the day-time and night-time remain unclear. We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan. Patients were categorized according to whether they received treatment during the day-time or night-time. The primary outcomes were survival to hospital discharge and favorable neurological outcome at discharge, and the secondary outcomes were estimated low-flow time, implementation time of ECPR, and complications due to ECPR. A multivariate logistic regression model adjusted for confounders was used for comparison. Among the 1644 patients, the night-time patients had a significantly longer ECMO implementation time and estimated low-flow time than the day-time patients, along with a significantly higher number of complications than the day-time patients. However, the survival and neurologically favorable survival rates did not differ significantly between the groups. Thus, although patients who underwent ECPR at night had an increased risk of longer implementation time and complications, their clinical outcomes did not differ from those who underwent day-time ECPR.

Prolonged Fatigue and Mental Health Challenges in Critical COVID-19 Survivors

Background: The aim of this study was to investigate the development of fatigue and mental illness between 3 and 12 months after critical COVID-19 and explore risk factors for long-lasting symptoms. Study Design and Methods: A prospective, multicenter COVID-19 study in southern Sweden, including adult patients (≥18 years) with rtPCR-confirmed COVID-19 requiring intensive care. Survivors were invited to a follow-up at 3 and 12 months, where patient-reported symptoms were assessed using the Modified Fatigue Impact Scale (MFIS), the Hospital Anxiety and Depression Scale (HADS) and the Posttraumatic Stress Disorder Checklist version 5 (PCL-5). The development between 3 and 12 months was described by changes in relation to statistical significance and suggested values for a minimally important difference (MID). Potential risk factors for long-lasting symptoms were analyzed by multivariable logistic regression. Results: At the 3-month follow-up, 262 survivors (87%) participated, 215 (72%) returned at 12 months. Fatigue was reported by 50% versus 40%, with a significant improvement at 12 months (MFIS; median 38 vs. 33, P < .001, MID ≥4). There were no significant differences in symptoms of mental illness between 3 and 12 months, with anxiety present in 33% versus 28%, depression in 30% versus 22%, and posttraumatic stress disorder in 17% versus 13%. A worse functional outcome and less sleep compared to before COVID-19 were risk factors for fatigue and mental illness at 12 months. Conclusions: Fatigue improved between 3 and 12 months but was still common. Symptoms of mental illness remained unchanged with anxiety being the most reported. A worse functional outcome and less sleep compared to before COVID-19 were identified as risk factors for reporting long-lasting symptoms.

Performance of 21 Early Warning System scores in predicting in-hospital deterioration among undifferentiated admitted patients managed by ambulance services

BACKGROUND

The optimal Early Warning System (EWS) scores for identifying patients at risk of clinical deterioration among those transported by ambulance services remain uncertain. This retrospective study compared the performance of 21 EWS scores to predict clinical deterioration using vital signs (VS) measured in the prehospital or emergency department (ED) setting.

METHODS

Adult patients transported to a single ED by ambulances and subsequently admitted to the hospital between 1 January 2019 and 18 April 2019 were eligible for inclusion. The primary outcome was 30-day mortality; secondary outcomes included 3-day mortality, admission to intensive care or coronary care units, length of hospital stay and emergency call activations. The discriminative ability of the EWS scores was assessed using the area under the receiver operating characteristic curve (AUROC). Subanalyses compared the performance of EWS scores between surgical and medical patient types.

RESULTS

Of 1414 patients, 995 (70.4%) (53.1% male, mean age 68.7±17.5 years) were included. In the ED setting, 30-day mortality was best predicted by VitalPAC EWS (AUROC 0.71, 95% CI (0.65 to 0.77)) and National Early Warning Score (0.709 (0.65 to 0.77)). All EWS scores calculated in the prehospital setting had AUROC <0.70. Rapid Emergency Medicine Score (0.83 (0.73 to 0.92)) and New Zealand EWS (0.88 (0.81 to 0.95)) best predicted 3-day mortality in the prehospital and ED settings, respectively. EWS scores calculated using either prehospital or ED VS were more effective in predicting 3-day mortality in surgical patients, whereas 30-day mortality was best predicted in medical patients. Among the EWS scores that achieved AUROC ≥0.70, no statistically significant differences were detected in their discriminatory abilities to identify patients at risk of clinical deterioration.

CONCLUSIONS

EWS scores better predict 3-day as opposed to 30-day mortality and are more accurate when estimated using VS measured in the ED. The discriminatory performance of EWS scores in identifying patients at higher risk of clinical deterioration may vary by patient type.

Practical approach to thrombocytopenia in patients with sepsis: a narrative review

Thrombocytopenia frequently occurs in patients with sepsis. Disseminated intravascular coagulation (DIC) may be a possible cause of thrombocytopenia owing to its high prevalence and association with poor outcomes; however, it is important to keep the presence of other diseases in mind in sepsis practice. Thrombotic microangiopathy (TMA), which is characterized by thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (HUS), and complement-mediated HUS, is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ damage. TMA has become widely recognized in recent years because of the development of specific treatments. Previous studies have reported a remarkably lower prevalence of TMA than DIC; however, its epidemiology is not well defined, and there may be cases in which TMA is not correctly diagnosed, resulting in poor outcomes. Therefore, it is important to differentiate DIC from TMA. Nevertheless, differentiating between DIC and TMA remains a challenge as indicated by previous reports that most patients with TMA can be diagnosed as DIC using the universal coagulation scoring system. Several algorithms to differentiate sepsis-related DIC from TMA have been suggested, contributing to improving the care of septic patients with thrombocytopenia; however, it may be difficult to apply these algorithms to patients with coexisting DIC and TMA, which has recently been reported. This review describes the disease characteristics, including epidemiology, pathophysiology, and treatment, of DIC, TMA, and other diseases with thrombocytopenia and proposes a novel practical approach flow, which is characterized by the initiation of the diagnosis of TMA in parallel with the diagnosis of DIC. This practical flow also refers to the longitudinal diagnosis and treatment flow with TMA in mind and real clinical timeframes. In conclusion, we aim to widely disseminate the results of this review that emphasize the importance of incorporating consideration of TMA in the management of septic DIC. We anticipate that this practical new approach for the diagnostic and treatment flow will lead to the appropriate diagnosis and treatment of complex cases, improve patient outcomes, and generate new epidemiological evidence regarding TMA.

Viscolin-mediated antiapoptotic and neuroprotective effects in cortical neurons exposed to oxygen-glucose deprivation and rats subjected to transient focal cerebral ischemia

OBJECTIVE

Previously, we have successfully purified and synthesized viscolin, an agent derived from Viscum coloratum extract, which has shown significant potential in the treatment of stroke. Our study aimed to evaluate the neuroprotective effects of viscolin.

METHODS

We first assessed the cytotoxicity of viscolin on primary neuronal cultures and determined its antioxidant and radical scavenging properties. Subsequently, we identified the optimal dose-response of viscolin in protecting against glutamate-induced neurotoxicity.

RESULTS

Our results demonstrated that viscolin at a concentration of 10 μM effectively reduced neuronal cell death up to 6 hours after glutamate-induced neurotoxicity. Additionally, we investigated the therapeutic window of opportunity and the potential of viscolin in preventing necrotic and apoptotic damage in cultured neurons exposed to oxygen glucose deprivation-induced neurotoxicity. Our findings showed that viscolin treatment significantly reduced DNA breakage, prevented the release of cytochrome c from mitochondria to cytosol, increased the expression of anti-apoptotic protein Bcl-2, decreased the expression of pro-apoptotic protein Bax, and reduced the number of TUNEL-positive cells. Additionally, our in vivo investigation demonstrated a reduction in brain infarction following middle cerebral artery occlusion.

CONCLUSION

Viscolin has potential utility as a therapeutic agent in the treatment of stroke.

Correlation of preoperative inflammatory factors and emotional disorders with postoperative delirium in patients with craniocerebral trauma

BACKGROUND

Traumatic brain injury (TBI) imposes a substantial societal and familial burden due to its high disability and fatality rates, rendering it a serious public health problem. Some patients with TBI have poor treatment outcomes and are prone to postoperative delirium (POD), which affects their quality of life. Anxiety has been linked to increased POD incidence in some studies, while others have found no correlation.

AIM

To investigate the correlation of POD risk factors, preoperative inflammatory factors, and mood disorders in patients with TBI.

METHODS

We retrospectively collected data on the treatment of 80 patients with TBI from November 2021 to September 2023. Patients were grouped as POD and non-POD, according to their POD status, and the general data of the two groups were compared. Inflammatory factor levels were detected preoperatively, and the Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA) were used to investigate the risk factors associated with POD in these patients. Logistic regression was used to identify the independent risk factors.

RESULTS

Twenty-one patients (26.25%) developed POD, including 7, 10, and 4 cases of the excitatory, inhibitory, and mixed types, respectively. There were 59 cases (73.75%) in the non-POD group. Compared with the non-POD group, the POD group had a significantly higher proportion of patients with low Glasgow Coma Scale (GCS) scores before admission, unilateral mydriasis, preoperative hemorrhagic shock, intraventricular hemorrhage (IVH), and postoperative hyperglycemic hyperosmolar disease (P < 0.05). In the POD group, interleukin-6 (IL-6), human tumor necrosis factor-α (TNF-α), myeloperoxidase levels, HAMA, and HAMD scores were higher than those in the non-POD group (all P < 0.05). Logistic multivariate analysis showed that GCS score at admission, IVH, IL-6, TNF-α, HAMA, and HAMD were independent risk factors for POD in patients with TBI (P < 0.05).

CONCLUSION

Low GCS score at admission, IVH, elevated IL-6 and TNF-α, other inflammatory indicators, anxiety, and depression, can increase the risk of POD in patients with TBI after surgery.

Analysis of high-risk factors and mortality prediction of ruptured abdominal aortic aneurysm

INTRODUCTION

Ruptured abdominal aortic aneurysms (RAAAs) are among the most dangerous emergencies in vascular surgery, with a high death rate and numerous risk factors influencing perioperative death. Therefore, identifying the critical risk factors for RAAAs is crucial to increasing their survival rate. Our aim was to identify those risk factors from a wide range of parameters.

METHODS

Retrospective analysis of hospitalised RAAA patients treated at this center between May 2004 and January 2023. After comparing the preoperative data of patients who survived and those who died, high-risk characteristics influencing the perioperative care of RAAA patients were identified, and logistic regression analysis was carried out. The mean follow-up time was 45.34 months.

RESULTS

During the study period, a total of 155 patients (average age 67.4±71.93 years, 123 (78.85%)males, 32 (20.51%)females) were enrolled. The patients participating in the group were divided into survival group (n = 123) and death group (n = 27). The main differences included hemodynamic instability (51.9% vs 28.5%; P=0.019), sudden cardiac arrest (14.8% vs 1.6%; P=0.010), deterioration of consciousness (40.7% vs 17.1%; P=0.007), renal impairment (22.2% vs 2.4%; P=0.001), chronic kidney disease (18.5% vs3.2%; P=0.010). There is also a history of cancer (Ca) (18.5% vs 4.1%; P=0.021). Risk factors for Endovascular aneurysm repair (EVAR) include diastolic blood pressure ≤ 50 mmHg (36.4% vs 8.0%; P=0.025), renal function impairment (18.2% vs 0; P=0.015), and chronic kidney disease (27.3% vs 4.0%; P=0.028). Risk factors for open surgical repair (OSR) include diastolic blood pressure ≤ 50 mmHg (40.0% vs 6.3%; P=0.014). Finally, the above statistically significant factors were analyzed by Logistic regression analysis, and it was found that diastolic blood pressure ≤ 50mmHg, cardiac arrest, renal function damage and Ca history were independent risk factors. We followed 123 individuals and 14 were lost to follow-up, with an overall survival rate of 43.8%.

CONCLUSION

Hemodynamics, which includes shock, blood pressure, cardiac arrest, deterioration of consciousness, and other conditions, are the primary risk factors for the perioperative death of a ruptured abdominal aortic aneurysm. Simultaneously, diastolic blood pressure ≤50mmHg was found to be associated with risk factors for OSR, whereas renal function impairment, chronic renal illness, and diastolic blood pressure ≤50mmHg were associated with risk for EVAR.

Case report of pharmacokinetic analysis of continuous intravenous infusion of fentanyl in a patient with severe burn: burn shock stage complicates pain management

BACKGROUND

Fentanyl is widely used as an analgesic and sedative for patients with severe burn injuries in intensive care units. However, pharmacokinetic (PK) data for fentanyl, particularly for continuous intravenous infusion during the acute phase of burn injuries, are limited. Here, we report the clinical course and changes in blood fentanyl concentrations during the acute phase in a patient with severe burns treated with continuous intravenous infusion of fentanyl.

CASE PRESENTATION

A woman in her 40s, with burns caused by a gas cylinder explosion, was transported to our hospital. The patient had burn wounds on face, neck, shoulders, and all four extremities, with a total burn area of 39.0%. For pain relief, the patient received a continuous infusion of 0.01 mg/mL fentanyl (20-30 µg/h) with a target blood concentration of 1.0-1.5 ng/mL, but continued to suffer from pain due to burning during the acute phase. We measured the blood fentanyl concentrations and found that all concentrations obtained during the acute phase were subtherapeutic. Notably, during the burn shock stage, blood concentrations of fentanyl were 0.50 ng/mL on day 1 and 0.66 ng/mL on day 2, indicating that the blood concentration did not rise sufficiently for the dosage. From days 0 to 2, the patient was administered a massive fluid load for burn shock. After the burn shock stage resolved, fentanyl concentrations gradually approached the target range, and the pain rating scale improved, even though the fentanyl administration rate remained unchanged (30 µg/h).

CONCLUSIONS

Major changes in the fluid volumes of body compartments that occur with large burns might increase the volume of fentanyl distribution, thereby lowering its concentration when a standard dose is administered. Our findings indicate that the PK of fentanyl in patients with severe burns can be substantially affected, especially during the shock phase, implying the importance of titrating analgesics for clinical efficacy in the acute phase.

Quantification of treprostinil concentration in rat and human using a novel validated and rapid liquid chromatography-tandem mass spectrometry method: Experimental and clinical applications in ischemia-reperfusion injury

Treprostinil (Remodulin®) is a Food and Drug Administration (FDA) approved prostacyclin analog to treat pulmonary arterial hypertension. Recently, treprostinil has been investigated to reduce ischemia-reperfusion injury (IRI) during transplantation, which currently has no approved treatment. A validated analytical method is necessary to measure treprostinil concentrations in biological specimens. Here, a novel, sensitive, and specific method to measure treprostinil concentrations in rat serum, human serum, and human plasma has been developed using liquid chromatography with tandem mass spectrometry (LC-MS/MS). Biological samples were processed by protein precipitation before chromatography and 6-keto Prostaglandin F1α-d4 was used as an internal standard. A gradient method was established with a total run time of 4 min. The assay was linear over the range of 0.25-75.0 ng/ml with accuracy (92.97-107.87 %), intra-assay precision (1.16-3.34 %), and inter-assay precision (1.11-4.58 %) in all biological matrices, which are within FDA acceptance criteria. No significant variation in treprostinil or 6-keto Prostaglandin F1α-d4 concentrations were observed under the investigated storage conditions. This novel, sensitive, and specific LC/MS-MS method is cost-effective and suitable for measuring treprostinil concentrations in animal studies and human biological samples for clinical applications.

Linoleic acid-derived diol 12,13-DiHOME enhances NLRP3 inflammasome activation in macrophages

12,13-dihydroxy-9z-octadecenoic acid (12,13-DiHOME) is a linoleic acid diol derived from cytochrome P-450 (CYP) epoxygenase and epoxide hydrolase (EH) metabolism. 12,13-DiHOME is associated with inflammation and mitochondrial damage in the innate immune response, but how 12,13-DiHOME contributes to these effects is unclear. We hypothesized that 12,13-DiHOME enhances macrophage inflammation through effects on NOD-like receptor protein 3 (NLRP3) inflammasome activation. To test this hypothesis, we utilized human monocytic THP1 cells differentiated into macrophage-like cells with phorbol myristate acetate (PMA). 12,13-DiHOME present during lipopolysaccharide (LPS)-priming of THP1 macrophages exacerbated nigericin-induced NLRP3 inflammasome activation. Using high-resolution respirometry, we observed that priming with LPS+12,13-DiHOME altered mitochondrial respiratory function. Mitophagy, measured using mito-Keima, was also modulated by 12,13-DiHOME present during priming. These mitochondrial effects were associated with increased sensitivity to nigericin-induced mitochondrial depolarization and reactive oxygen species production in LPS+12,13-DiHOME-primed macrophages. Nigericin-induced mitochondrial damage and NLRP3 inflammasome activation in LPS+12,13-DiHOME-primed macrophages were ablated by the mitochondrial calcium uniporter (MCU) inhibitor, Ru265. 12,13-DiHOME present during LPS-priming also enhanced nigericin-induced NLRP3 inflammasome activation in primary murine bone marrow-derived macrophages. In summary, these data demonstrate a pro-inflammatory role for 12,13-DiHOME by enhancing NLRP3 inflammasome activation in macrophages.

Effect of polypharmacy on the outcomes of older patients with advanced non-small-cell lung cancer treated with PD-1/PD-L1 inhibitors: A retrospective cohort study

INTRODUCTION

The effect of polypharmacy on older patients with cancer is unclear. This study aimed to explore the effect of polypharmacy on the outcomes of treatment in older patients with advanced non-small cell lung cancer (NSCLC) treated with PD-1/PD-L1 inhibitors.

MATERIALS AND METHODS

We retrospectively reviewed the records of older patients (aged ≥65 years) with advanced NSCLC who received PD-1/PD-L1 inhibitors with or without platinum-based chemotherapy as first-line treatment from March 2016 to December 2020. Patients with driver oncogenes or Eastern Cooperative Oncology Group performance status (PS) ≥2 were excluded. Polypharmacy was defined as receiving five or more oral or inhaled medications at baseline. We compared the progression-free survival (PFS), overall survival (OS), and mean cumulative length of hospital stays between the polypharmacy and non-polypharmacy groups.

RESULTS

A total of 122 patients, with a median age of 72 years (range, 65-89 years), were included in the analysis. Of the patients, 34 (27.8%) had a PS of 0 and 68 (55.7%) had a PD-L1 tumor proportion score (TPS) of ≥50%. The median number of oral or inhaled medications was 4 (range, 0-12), and 60 (49.1%) patients were taking ≥5 medications (polypharmacy). Age and Charlson Comorbidity Index score were significantly higher in the polypharmacy group (P = 0.01 and P < 0.001, respectively). Compared with the non-polypharmacy group, the polypharmacy group had a similar median PFS (6.7 vs. 8.5 months, P = 0.94) and a shorter median OS (17.3 vs. 26.0 months, P = 0.04). In the polypharmacy group, the adjusted hazard ratio for OS (adjusted for age, PS, and PD-L1 TPS) was 1.65 (95% confidence interval, 1.04-2.86, P = 0.03). Patients in the polypharmacy group had longer hospital stays (46.3 ± 7.5 vs. 27.7 ± 4.1 days/person, P < 0.05) and more emergency hospitalizations (1.6 ± 0.3 vs. 0.8 ± 0.1 times/person, P < 0.05) during the first year.

DISCUSSION

Polypharmacy was associated with shorter survival time and longer hospitalization in older patients with advanced NSCLC receiving first-line immunotherapy with or without chemotherapy.

The spectrum of anti-GQ1B antibody syndrome: beyond Miller Fisher syndrome and Bickerstaff brainstem encephalitis

INTRODUCTION

Since the initial identification of Miller Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis (BBE),significant milestones have been achieved in understanding these diseases.Discoveries of common serum antibodies (IgG anti-GQ1b), antecedent infections, neurophysiological data, andneuroimaging suggested a shared autoimmune pathogenetic mechanism rather than distinct pathogenesis, leadingto the hypothesis that both diseases are part of a unified syndrome, termed "Fisher-Bickerstaff syndrome". The subsequent identification of atypical anti-GQ1b-positive forms expanded the classification to a broader condition known as "Anti-GQ1b-Antibody syndrome".

METHODS

An exhaustive literature review was conducted, analyzing a substantial body of research spanning from the initialdescriptions of the syndrome's components to recent developments in diagnostic classification and researchperspectives.

RESULTS

Anti-GQ1b syndrome encompasses a continuous spectrum of conditions defined by a common serological profilewith varying degrees of peripheral (PNS) and central nervous system (CNS) involvement. MFS and BBE represent theopposite ends of this spectrum, with MFS primarily affecting the PNS and BBE predominantly involving the CNS.Recently identified atypical forms, such as acute ophthalmoparesis, acute ataxic neuropathy withoutophthalmoparesis, Guillain-Barré syndrome (GBS) with ophthalmoparesis, MFS-GBS and BBE-GBS overlap syndromes,have broadened this spectrum.

CONCLUSION

This work aims to provide an extensive, detailed, and updated overview of all aspects of the anti-GQ1b syndromewith the intention of serving as a stepping stone for further shaping thereof. Special attention was given to therecently identified atypical forms, underscoring their significance in redefining the boundaries of the syndrome.

Emergency Patient Triage Improvement through a Retrieval-Augmented Generation Enhanced Large-Scale Language Model

OBJECTIVES

Emergency medical triage is crucial for prioritizing patient care in emergency situations, yet its effectiveness can vary significantly based on the experience and training of the personnel involved. This study aims to evaluate the efficacy of integrating Retrieval Augmented Generation (RAG) with Large Language Models (LLMs), specifically OpenAI's GPT models, to standardize triage procedures and reduce variability in emergency care.

METHODS

We created 100 simulated triage scenarios based on modified cases from the Japanese National Examination for Emergency Medical Technicians. These scenarios were processed by the RAG-enhanced LLMs, and the models were given patient vital signs, symptoms, and observations from emergency medical services (EMS) teams as inputs. The primary outcome was the accuracy of triage classifications, which was used to compare the performance of the RAG-enhanced LLMs with that of emergency medical technicians and emergency physicians. Secondary outcomes included the rates of under-triage and over-triage.

RESULTS

The Generative Pre-trained Transformer 3.5 (GPT-3.5) with RAG model achieved a correct triage rate of 70%, significantly outperforming Emergency Medical Technicians (EMTs) with 35% and 38% correct rates, and emergency physicians with 50% and 47% correct rates (p < 0.05). Additionally, this model demonstrated a substantial reduction in under-triage rates to 8%, compared with 33% for GPT-3.5 without RAG, and 39% for GPT-4 without RAG.

CONCLUSIONS

The integration of RAG with LLMs shows promise in improving the accuracy and consistency of medical assessments in emergency settings. Further validation in diverse medical settings with broader datasets is necessary to confirm the effectiveness and adaptability of these technologies in live environments.

Systemic capillary leak syndrome in a patient treated with nivolumab/ipilimumab immunotherapy for metastatic melanoma with concurrent COVID-19 vaccination

Systemic capillary leak syndrome (SCLS) is a rare and life-threatening disorder characterised by leaking of intravascular fluid to extravascular tissues. An association with immunotherapy and COVID-19 vaccination has been reported as potential triggers. A case of a patient in her 70s developing SCLS after the BNT162b2 (Pfizer-BioNTech) COVID-19 vaccination with a history of metastatic melanoma treated with nivolumab (PD-1 monoclonal antibody) and ipilimumab (anti-CTLA4 monoclonal antibody) is reported. The aetiology and management of SCLS are also reviewed in this case context.

Clinical characteristics of extracorporeal cardiopulmonary resuscitation in China: a multicenter retrospective study

PURPOSE

Extracorporeal cardiopulmonary resuscitation (ECPR) might markedly increase the survival of selected patients with refractory cardiac arrest. But the application situation and indications remained unclear.

MATERIALS AND METHODS

We respectively reviwed all adult patients who underwent ECPR from January 2017 to March 2021. Patient characteristics, initiation and management of ECMO, complications, and outcomes were collected and compared between the survivors and nonsurvivors. LASSO regression was used to screen risk factors. Multivariate logistic regression was performed with several parameters screened by LASSO regression.

RESULTS

Data were reported from 42 ECMO centers covering 19 provinces of China. A total of 648 patients were included in the study, including 491 (75.8%) males. There were 11 ECPR centers in 2017, and the number increased to 42 in 2020. The number of patients received ECPR increased from 33 in 2017 to 274 in 2020, and the survival rate increased from 24.2% to 33.6%. Neurological complications, renal replacement therapy, epinephrine dosage after ECMO, recovery of spontaneous circulation before ECMO, lactate clearance and shockable rhythm were risk factors independently associated with outcomes of whole process. Sex, recovery of spontaneous circulation before ECMO, lactate, shockable rhythm and causes of arrest were pre-ECMO risk factors independently affecting outcomes.

CONCLUSIONS

From January 2017 to March 2021, the numbers of ECPR centers and cases in mainland China increased gradually over time, as well as the survival rate. Pre-ECMO risk factors, especially recovery of spontaneous circulation before ECMO, shockable rhythm and lactate, are as important as post-ECMO management,. Neurological complications are vital risk factors after ECMO that deserved close attention.

TRIAL REGISTRATION

NCT04158479, registered on 2019/11/08. https://clinicaltrials.gov/NCT04158479.

Development of a risk prediction nomogram for delayed neuropsychiatric sequelae in patients with acute carbon monoxide poisoning

OBJECTIVES

Delayed neuropsychiatric sequelae (DNS) are critical complications following acute carbon monoxide (CO) poisoning that can substantially affect the patient's life. Identifying high-risk patients for developing DNS may improve the quality of follow-up care. To date, the predictive DNS determinants are still controversial. Consequently, this study aimed to construct a practical nomogram for predicting DNS in acute CO-poisoned patients.

METHODS

This retrospective study was conducted on patients with acute CO poisoning admitted to the Tanta University Poison Control Center (TUPCC) from December 2018 to December 2022. Demographic, toxicological, and initial clinical characteristics data, as well as laboratory investigation results, were recorded for the included patients. After acute recovery, patients were followed up for six months and categorized into patients with and without DNS.

RESULTS

Out of 174 enrolled patients, 38 (21.8%) developed DNS. The initial Glasgow Coma Scale (GCS), carboxyhemoglobin (COHb) level, CO exposure duration, oxygen saturation, PaCO2, and pulse rate were significantly associated with DNS development by univariate analysis. However, the constructed nomogram based on the multivariable regression analysis included three parameters: duration of CO exposure, COHb level, and GCS with adjusted odd ratios of 1.453 (95% CI: 1.116-1.892), 1.262 (95% CI: 1.126-1.415), and 0.619 (95% CI: 0.486-0.787), respectively. The internal validation of the nomogram exhibited excellent discrimination (area under the curve [AUC] = 0.962), good calibration, and satisfactory decision curve analysis for predicting the DNS probability.

CONCLUSIONS

The proposed nomogram could be considered a simple, precise, and applicable tool to predict DNS development in acute CO-poisoned patients.

Effect of cardiopulmonary resuscitation training for layperson bystanders on outcomes of out-of-hospital cardiac arrest: A prospective multicenter observational study

BACKGROUND

Effective bystander cardiopulmonary resuscitation (CPR) improves outcomes in out-of-hospital cardiac arrest (OHCA) patients. However, the effect of CPR training on the rate of return of spontaneous circulation (ROSC) among laypersons has yet to be thoroughly evaluated.

METHODS

This prospective, multicenter observational study was conducted across 42 centers in Japan. We assessed OHCA patients who received bystander CPR from a layperson, excluding those performed by healthcare staff. The primary outcome was the ROSC rate. Secondary outcomes included pre-hospital ROSC, ROSC after hospital arrival, favorable neurological outcomes, and 30-day survival. Propensity score with inverse probability treatment weighting (IPTW) was used to adjust for confounders, including age, sex, presence or absence of witnesses, and past medical history.

RESULTS

A total of 969 OHCA patients were included, divided into CPR-trained (n = 322) and control (n = 647). Before adjustment, the ROSC rate was higher in the trained group than the control (40.1% vs. 30.1%, P < 0.01). After IPTW adjustment, the trained group showed a significantly higher ROSC rate (36.7% vs. 30.6%; P = 0.02). All secondary outcomes in the trained group were significantly improved before adjustment. After IPTW adjustment, the trained group showed improved rates of pre-hospital ROSC and ROSC after hospital arrival (30.7% vs. 24.0%; P < 0.01, 23.9% vs. 20.7%; P = 0.04). There were no differences in neurological outcomes and 30-day survival.

CONCLUSION

This study demonstrated that CPR training for laypersons was associated with increased ROSC rates in OHCA patients, indicating potential advantages of CPR training for non-healthcare professionals.

Association between physiotherapist sleep duration and working environment during the coronavirus disease 2019 pandemic in Japan: A secondary retrospective analysis study

Studies have reported that health care professionals experienced a lack of sleep during the coronavirus disease 2019 (COVID-19) pandemic and that such lack of sleep and working environment affect their performance. However, to the authors' knowledge, no study has yet investigated the relationship between sleep duration and working environment among Japanese physiotherapists during the COVID-19 pandemic. This study retrospectively investigated the sleep duration of physiotherapists directly providing physiotherapy to patients with COVID-19 within the red zone and analyzed the association between sleep duration and working environment using logistic regression analysis. Among the 565 physiotherapists studied, the average sleep duration was 6 (6-7) h, and 381 (67.4%) had an average sleep duration of ≤6 h. Less experienced physiotherapists were 1.03 times more likely to sleep ≤6 h, and those in charge of patients with COVID-19 as the supervisor ordered were 0.64 times more likely to sleep ≤6 h. Moreover, physiotherapists with a significant increase in the frequency of internal online meetings and those who had been providing physiotherapy to patients with COVID-19 for >6 months were 2.34 and 2.05 times more likely to sleep ≤6 h, respectively. During the COVID-19 pandemic in Japan, two-thirds of the physiotherapists directly providing physiotherapy to patients with COVID-19 slept less than the recommended duration. This study highlights the need for appropriate workload and work hour management for physiotherapists according to their experience and workload, as well as establishing a medical care system that includes work rotation to ensure that the recommended sleep duration is satisfied.

Clinical investigation for the mechanisms of anaphylactic symptoms in osteoarthritis patients after diclofenac etalhyaluronate administration

OBJECTIVE

This study was conducted to investigate the mechanisms of anaphylaxis in patients with osteoarthritis of the knee and hip after diclofenac etalhyaluronate [product name: JOYCLU® (JCL)] intra-articular injection and to determine the utility of tests to investigate the mechanism involved.

METHODS

In this observational study in Japan, patients aged ≥20 years with knee or hip osteoarthritis who received JCL intra-articular injection experienced anaphylactic symptoms considered related to JCL ('experienced patients') or did not experience allergic symptoms considered related to JCL ('non-experienced patients'). Basophil activation tests (BATs), specific immunoglobulin E (IgE) antibody testing by enzyme-linked immunosorbent assays (ELISAs) or immunochromatographic kit, and genome-wide association studies (GWASs) were conducted using patient blood and saliva.

RESULTS

Thirteen experienced patients and 14 non-experienced patients were tested. Seven experienced patients tested positive by BAT using diclofenac etalhyaluronate-containing test substances. Diclofenac-specific IgE antibodies were detected in four of seven BAT-positive patients but not in the non-experienced patients. Specific IgE antibody testing by immunochromatographic kit and genome-wide association study showed no clear results.

CONCLUSIONS

These findings suggest that anaphylaxis occurs after JCL administration via an IgE-mediated mechanism and that diclofenac etalhyaluronate may be involved in this mechanism. BAT and diclofenac -specific IgE enzyme-linked immunosorbent assay may be useful tests for investigating the mechanisms of anaphylactic reactions after JCL administration.

Consequences of a stay in the intensive care unit and outpatient follow-up care for chronic critically ill patients: A retrospective data analysis

BACKGROUND

Patients with chronic critical illness (CCI) represent a particularly vulnerable patient population with significant quality-of-life consequences and a need for follow-up care. Existing research on their quality-of-life trajectory and outpatient follow-up care is limited.

OBJECTIVES

The aim of this study was to (i) describe a quality improvement project focussing on patients with CCI in the Swiss setting; (ii) explain the consequences of an intensive care unit (ICU) stay for patients with CCI; and (iii) evaluate outpatient follow-up care for patients with CCI.

METHODS

This retrospective descriptive mixed-methods longitudinal study used routine data from outpatient follow-up care between October 2018 and June 2022. The pre-ICU data were collected retrospectively for the week before ICU admission (baseline); prospectively at 3, 6, and 12 months after ICU discharge; and during an outpatient follow-up care at 6 months. Its main outcomes were health-related quality of life (HRQOL). Patients with CCI were defined as those having a ICU stay longer than 7 days.

RESULTS

This study enrolled 227 patients with outpatient follow-up care, but only 77 were analysed at all four timepoints. Their EuroQol five-dimension five-level questionnaire-Visual Analogue Scale scores ranged from 0 to 100, with a median of 85 (interquartile range = 0-100) and a mean of 77.2 (standard deviation ± 23.52) before their ICU stay. Their scores had almost returned to the baseline 12 months after their ICU stay. While some reported existing restrictions in the individual HRQOL dimensions before their ICU stay, patients and their families appreciated the outpatient follow-up care including an ICU visit.

CONCLUSION

Patients with CCI have different HRQOL trajectories over time. Patients with CCI can have a good HRQOL despite their impairments; however, the HRQOL trajectories of many patients remain unclear. The focus must be on identifying the illness trajectories and on measuring and maintaining their long-term HRQOL.

Heat stress-induced platelet dysfunction is associated with loss of fibrinogen and is improved by fibrinogen supplementation

INTRODUCTION

Heatstroke is a critical heat-related condition characterized by coagulopathy and multiple organ dysfunction. One of the most severe complications of heatstroke is disseminated intravascular coagulation. This condition manifests as excessive clot formation and bleeding that are primarily due to platelet depletion and dysfunction. Fibrinogen plays a crucial role in hemostasis because it links integrin αIIbβ3 on adjacent platelets, thereby promoting the platelet activation and aggregation necessary for clot formation. However, reduced fibrinogen levels may impair the formation of the initial platelet plug and increase the risk of bleeding. The current study explored the effect of fibrinogen on platelet dysfunction in a heatstroke model.

MATERIALS AND METHODS

Male Wistar rats were subjected to heat stress, and subsequent changes in hemodynamic, biochemical, and coagulation parameters were analyzed. Platelet viability, aggregation, adhesion, spreading and fibrin clot retraction were assessed.

RESULTS

The rats with heatstroke exhibited a variety of clinical symptoms, including hypotension, tachycardia, multiple organ dysfunction, and coagulopathy. Platelet viability in the heatstroke group was comparable to that in the healthy control group. However, the heatstroke group exhibited significant reductions in plasma fibrinogen levels and platelet aggregation, adhesion, spreading, and fibrin clot retraction. Notably, fibrinogen supplementation markedly augmented the aggregation responses of platelets in the heatstroke group. The impairment of platelet adhesion, spreading, and fibrin clot retraction in the rats with heatstroke was partially ameliorated by fibrinogen supplementation.

CONCLUSIONS

An early use of fibrinogen replacement may serve as a therapeutic intervention to alleviate platelet hyporeactivity and prevent the complications in patients with heatstroke.

Effectiveness of a hybrid emergency room system in the management of acute ischemic stroke: a single-center experience

Introduction

Hybrid emergency room systems (HERSs) have shown promise for the management of severe trauma by reducing mortality. However, the effectiveness of HERSs in the treatment of acute ischemic stroke (AIS) remains unclear. This study aimed to evaluate the impact of HERSs on treatment duration and neurological outcomes in patients with AIS undergoing endovascular therapy.

Materials and methods

This single-center retrospective study included 83 patients with AIS who were directly transported to our emergency department and underwent endovascular treatment between June 2017 and December 2023. Patients were divided into the HERS and conventional groups based on the utilization of HERSs. The primary outcome was the proportion of patients achieving a favorable neurological outcome (modified Rankin Scale score 0-2) at 30 days. The secondary outcomes included door-to-puncture and door-to-recanalization times. Univariate analysis was performed using the Mann-Whitney U test for continuous variables and the chi-squared test or Fisher's exact test for categorical variables, as appropriate.

Results

Of the 83 eligible patients, 50 (60.2%) were assigned to the HERS group and 33 (39.8%) to the conventional group. The median door-to-puncture time was significantly shorter in the HERS group than in the conventional group (99.5 vs. 131 min; p = 0.001). Similarly, the median door-to-recanalization time was significantly shorter in the HERS group (162.5 vs. 201.5 min, p = 0.018). Favorable neurological outcomes were achieved in 16/50 (32.0%) patients in the HERS group and 6/33 (18.2%) in the conventional group. The HERS and conventional groups showed no significant difference in the proportion of patients achieving favorable neurological outcomes (p = 0.21).

Conclusion

Implementation of the HERS significantly reduced the door-to-puncture and door-to-recanalization times in patients with AIS undergoing endovascular therapy. Despite these reductions in treatment duration, no significant improvement in neurological outcomes was observed. Further research is required to optimize patient selection and treatment strategies to maximize the benefits of the HERS in AIS management.

Evaluation of the Pedagogical Impact of "Traum'Cast" Podcast: A Pilot Study Based on Metacognition

INTRODUCTION

With the evolution of educational tools, the French Military medical service has created a podcast program, Traum'Cast, about the principles of war medicine, accessible online for free.

METHOD

Our objective was to measure the learning effect of the Traum'Cast program's first episode. A non-randomized pilot trial between July and December 2021 included 80 health care providers: 40 in the video podcast group compared to 40 in a group reading a pdf file providing the same information. Using a 10 MCQs, we evaluated knowledge acquisition before, just after, and 2 weeks after the intervention. It was measured using metacognition tools based on confidence marking (number of correct answers, score weighted by certainty level, and realism).

RESULTS

Knowledge acquisition was better in the podcast group than in the pdf file group immediately after the intervention (correct answers: 9.0 [9.0-10.0] vs 9.0 [7.8-9.0], P = 0.015; weighted score: 177.0 [159.0-198.0] vs 160.0 [129.5-176.5], P = 0.020). This difference was persistent 2 weeks after (weighted score: 127.5 [101.8-145.2] vs 105.5 [74.2-128.5], P = 0.023).

CONCLUSION

This podcast is an innovative teaching tool which has proven to strengthen the knowledge of the principles of war medicine.