Federated Learning Survival Model and Potential Radiotherapy Decision Support Impact Assessment for Non-small Cell Lung Cancer Using Real-World Data

AIMS

The objective of this study was to develop a two-year overall survival model for inoperable stage I-III non-small cell lung cancer (NSCLC) patients using routine radiation oncology data over a federated (distributed) learning network and evaluate the potential of decision support for curative versus palliative radiotherapy.

METHODS

A federated infrastructure of data extraction, de-identification, standardisation, image analysis, and modelling was installed for seven clinics to obtain clinical and imaging features and survival information for patients treated in 2011-2019. A logistic regression model was trained for the 2011-2016 curative patient cohort and validated for the 2017-2019 cohort. Features were selected with univariate and model-based analysis and optimised using bootstrapping. System performance was assessed by the receiver operating characteristic (ROC) and corresponding area under curve (AUC), C-index, calibration metrics and Kaplan-Meier survival curves, with risk groups defined by model probability quartiles. Decision support was evaluated using a case-control analysis using propensity matching between treatment groups.

RESULTS

1655 patient datasets were included. The overall model AUC was 0.68. Fifty-eight percent of patients treated with palliative radiotherapy had a low-to-moderate risk prediction according to the model, with survival times not significantly different (p = 0.87 and 0.061) from patients treated with curative radiotherapy classified as high-risk by the model. When survival was simulated by risk group and model-indicated treatment, there was an estimated 11% increase in survival rate at two years (p < 0.01).

CONCLUSION

Federated learning over multiple institution data can be used to develop and validate decision support systems for lung cancer while quantifying the potential impact of their use in practice. This paves the way for personalised medicine, where decisions can be based more closely on individual patient details from routine care.

Impact of radiological surveillance for major blood vessels on complications of percutaneous dilatational tracheostomy: A retrospective cohort study

PURPOSE

Percutaneous dilatational tracheostomy (PDT) is the preferred method for managing long-term ventilator-dependent patients in ICUs. This study aimed to evaluate the association between preprocedural screening (ultrasound Doppler [USD] or computed tomography [CT]) for major neck blood vessels and complications in ICU patients undergoing PDT.

MATERIALS AND METHODS

This was a retrospective cohort study of patients who underwent PDT between 2012 and 2023 at a tertiary referral center. We performed a multivariable analysis and created a propensity-matched cohort. The primary outcome was bleeding within the first seven days after PDT. Secondary outcomes included early and late PDT complications and PTD-related mortality.

RESULTS

A total of 1766 consecutive critically ill patients hospitalized at a tertiary academic hospital were evaluated for PDT. Of these, 881 (49.9 %) underwent only physical examination before PDT, while 885 (50.1 %) underwent additional imaging (CT/USD). A higher proportion of patients in the imaging group were referred to open surgery due to suspected major blood vessels interfering with the procedure (6.2 % vs. 3.0 %, p = 0.001). Among the 1685 patients who underwent PDT, there was no significant difference in the rate of early bleeding between the physical examination group and the imaging group (4.6 % vs. 6.3 %, p = 0.12). Similarly, the overall early complication rates (5.5 % vs. 7.6 %, p = 0.08), late complication rates (1.6 % vs. 2.2 %, p = 0.42), and PDT-related mortality rates (0.7 % vs. 0.6 %, p = 0.73) did not exhibit significant differences between the two groups. In a propensity score-matched cohort, results remained consistent.

CONCLUSIONS

Physical examination can effectively identify major neck blood vessels without increasing the risk of bleeding during and after PDT.

When not hitting your sales target is 'the end of the world': Examining the effects of rational emotive behaviour therapy on the irrational beliefs and emotional reactivity of UK-based sales professionals

Against the backdrop of the COVID-19 pandemic, workplace wellbeing is a key priority for employers. Severe market and health conditions continue to bring inevitable problems that could be reduced with the application of psychological interventions to prevent mental and physical health issues, making this study a highly pertinent and valuable contribution to the field. This paper reports the effects of a rational emotive behaviour therapy (REBT) programme on the irrational beliefs and emotional reactivity of 56 office-based sales professionals located in the northwest region of the UK. A pre-test, post-test experimental design was utilised, and a mixed model ANOVA (repeated measures) was adopted to assess changes in mean differences concerning irrational beliefs and emotional reactivity at pre and post-test stages for the intervention group, in comparison to a control group. Results indicate that those in the REBT group reported significant reductions in irrational beliefs and emotional reactivity, whilst those in the control group reported no such changes. It is recommended that future research studies consider utilizing a mixed methods design and focus on a strategic collaboration of organisational and individual level interventions for improving the psychological wellbeing and performance of sales personnel.

Frequency-Dependent Squeezed Vacuum Source for the Advanced Virgo Gravitational-Wave Detector

In this Letter, we present the design and performance of the frequency-dependent squeezed vacuum source that will be used for the broadband quantum noise reduction of the Advanced Virgo Plus gravitational-wave detector in the upcoming observation run. The frequency-dependent squeezed field is generated by a phase rotation of a frequency-independent squeezed state through a 285 m long, high-finesse, near-detuned optical resonator. With about 8.5 dB of generated squeezing, up to 5.6 dB of quantum noise suppression has been measured at high frequency while close to the filter cavity resonance frequency, the intracavity losses limit this value to about 2 dB. Frequency-dependent squeezing is produced with a rotation frequency stability of about 6 Hz rms, which is maintained over the long term. The achieved results fulfill the frequency dependent squeezed vacuum source requirements for Advanced Virgo Plus. With the current squeezing source, considering also the estimated squeezing degradation induced by the interferometer, we expect a reduction of the quantum shot noise and radiation pressure noise of up to 4.5 dB and 2 dB, respectively.

An outbreak of severe coagulopathy in northern Israel among users of illicit synthetic cannabinoids adulterated with brodifacoum

INTRODUCTION

Adulteration of illicit drugs is a well-known phenomenon that may expose consumers to unexpected adverse effects. We report a large outbreak of severe coagulopathy in northern Israel during nine months in 2021-2022 among users of synthetic cannabinoids adulterated with a long-acting anticoagulant, brodifacoum.

METHODS

We performed a retrospective cohort study based on data extracted from the Israeli National Poison Information Center database and from electronic medical patient records at three participating hospitals. Confiscated drug samples and blood samples obtained at admission in a subgroup of patients were tested for the presence of long-acting anticoagulants.

RESULTS

We identified 98 patients affected by the outbreak. All patients had a prolonged international normalized ratio on admission, and in 69%, the blood was non-coagulating. For patients treated in the three participating centers (n = 72), the presenting complaint was overt bleeding in 79% of patients, most commonly in the urinary (53%) and gastrointestinal tracts (50%). The most severe complications were intracranial bleeding (4%), hemothorax (3%), pericardial bleeding (1%), and four patients died. Brodifacoum was detected in all available blood samples (median concentration 207 µg/L, interquartile range 112-349 μg/L, range 45-1,118 µg/L), and the drug samples contained both brodifacoum and the synthetic cannabinoid ADB-BUTINACA. All patients were treated with high-dose phytomenadione (vitamin K₁) and additionally by packed red blood cell transfusions, fresh frozen plasma, and/or 4-factor prothrombin complex concentrate when indicated. The most frequent phytomenadione (vitamin K₁) dose regimen was initially 20 mg intravenously every eight hours, and at discharge, 20 mg orally three times daily.

CONCLUSIONS

Outbreaks of severe coagulopathies in users of synthetic cannabinoids adulterated with a long-acting anticoagulant continue to erupt in different regions of the world. Rapid recognition of an outbreak requires a high index of suspicion when confronting young, otherwise healthy subjects with otherwise unexplained severe coagulopathy.

The role of single positron emission computed tomography imaging in the diagnosis of brain death whenever Trans-cranial Doppler fails to support it: A retrospective cohort study

OBJECTIVE

Although there is widespread acceptance of the concept of brain death/death by neurologic criteria (BD/DNC), there is marked variability in the use of ancillary tests worldwide. Transcranial Doppler (TCD) is a useful ancillary test for brain death confirmation because it is safe, noninvasive, and done at the bedside. However, it is considered less sensitive than Single Photon Emission Computed Tomography (SPECT) Tc-HMPAO (99 m). This study aims to test the yield of brain perfusion SPECT testing after a TCD has demonstrated some level of intracranial blood flow among patients fulfilling clinical criteria for BD/DNC.

METHODS

This was a single-center retrospective cohort study of all the patients fulfilling clinical criteria for BD/DNC who underwent brain perfusion SPECT after an intracerebral circulatory arrest was not confirmed by TCD between July 2016 and January 2022.

RESULTS

TCD was an initial ancillary test performed in 252 patients (99.6%) fulfilling clinical criteria for BD/DNC. A complete circulatory arrest was demonstrated in 228 (90.5%) patients. Brain perfusion SPECT was performed in the remaining 24 patients. The absence of cerebral perfusion consistent with BD/DNC was found in 21 cases (87.5%). BD/DN could not be confirmed in three patients (12.5%).

CONCLUSIONS

SPECT testing has a high diagnostic yield when TCD fails to confirm a suspected diagnosis of BD/DNC. Combining these two modalities may be an optimal strategy for BD/DNC diagnosis when this is required by local regulations or when confounding factors interfere with the performance of a complete clinical assessment.

Descriptive characteristics of continuous oximetry measurement in moderate to severe covid-19 patients

Non-invasive oxygen saturation (SpO2) is a central vital sign used to shape the management of COVID-19 patients. Yet, there have been no report quantitatively describing SpO2 dynamics and patterns in COVID-19 patients using continuous SpO2 recordings. We performed a retrospective observational analysis of the clinical information and 27 K hours of continuous SpO2 high-resolution (1 Hz) recordings of 367 critical and non-critical COVID-19 patients hospitalised at the Rambam Health Care Campus, Haifa, Israel. An absolute SpO2 threshold of 93% most efficiently discriminated between critical and non-critical patients, regardless of oxygen support. Oximetry-derived digital biomarker (OBMs) computed per 1 h monitoring window showed significant differences between groups, notably the cumulative time below 93% SpO2 (CT93). Patients with CT93 above 60% during the first hour of monitoring, were more likely to require oxygen support. Mechanical ventilation exhibited a strong effect on SpO2 dynamics by significantly reducing the frequency and depth of desaturations. OBMs related to periodicity and hypoxic burden were markedly affected, up to several hours before the initiation of the mechanical ventilation. In summary, OBMs, traditionally used in the field of sleep medicine research, are informative for continuous assessment of disease severity and response to respiratory support of hospitalised COVID-19 patients. In conclusion, OBMs may improve risk stratification and therapy management of critical care patients with respiratory impairment.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

P-728 Prevalence of Infertility among women with Multiple Sclerosis compared to the general population of women matched for age

Study question

Is the prevalence of infertility among multiple sclerosis female patients higher compared to the general population?

Summary answer

The prevalence of infertility among women with multiple sclerosis is similar to the matched general population

What is known already

Multiple sclerosis (MS) is an autoimmune disease predominant in women (1:3 ratio) during childbearing years. Studies addressing the question of infertility among multiple sclerosis patients are inconclusive and whether fertility is impaired in this population is debatable.

Study design, size, duration

Data regarding multiple sclerosis diagnosis and treatment and data about infertility and ART treatments was collected for patients during childbearing years (18-45) between the years 2005 to 2020 from the health service computerized database.

Participants/materials, setting, methods

The prevalence of infertility among women with MS was analyzed and compared to healthy controls (1:5) matched for age. Association between multiple sclerosis and the different ART treatments: in vitro fertilization (IVF) versus controlled ovarian hyperstimulation (COH) were analyzed.

Main results and the role of chance

1,570 women with multiple sclerosis were compared to 7,851 healthy women matched for age. Mean age of both groups was 32 years old. The prevalence of infertility was 34.1% (534) in the MS population compared to 33.3% (2,601) in the matched general population (p = 0.4). 299 of the 536 MS patients were diagnosed with infertility after they were diagnosed with multiple sclerosis. The prevalence of the different ART treatments was similar between MS patients and healthy women matched for age: (IVF: 7.1% vs 7% p = 0.813 and COH: 5.7% vs 6% p = 0.6; respectively).

Limitations, reasons for caution

The major limitation of our study is its retrospective nature. Furthermore, we were not able to evaluate for confounding factors possibly contributing to postponed family planning.

Wider implications of the findings

To date this is the largest study evaluating the prevalence of infertility and ART treatment among MS patients during childbearing years. Our findings may reassure patients with MS that their risk for infertility and need for ART treatments is comparable to the health general population.

Trial registration number

not applicable

AB0209 PHYSICIAN TRUST RATHER THAN RHEUMATOID ARTHRITIS KNOWLEDGE RELEVANT IN DISEASE OUTCOMES IN ETHNIC MINORITY PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Ethnic minority (EM) patients with Rheumatoid Arthritis (RA) have more severe disease, more disability, and less use of biologic disease modifying anti-rheumatic drugs (bDMARDs). A Treat to target (T2T) strategy has been recommended to improve clinical outcomes but barriers include patient preference, access to specialty care and increased administrative effort. Additionally, EM patients in the US often have low health literacy, express greater reluctance to accept physician recommendations, in part due to sociocultural preference and mistrust of a historically biased healthcare system. It is unknown whether improving knowledge of RA would improve T2T outcomes in EM active RA patients.

Objectives

To assess the proportion of EM RA patients who achieve low disease activity or remission following implementation of a coordinator-based education program highlighting T2T RA strategy.

Methods

Adult participants with active RA (RAPID3>6 or CDAI > 10) were invited to participate in a series of five one-on-one 20-minute educational sessions, co-occurring with scheduled routine clinic visits (6 -12-week intervals). Sessions were facilitated by a rheumatology care coordinator, a non-healthcare professional with intensive training over 4 weeks to conduct RA patient education. Sociodemographic data was collected, and disease activity measures (TJC, SJC, RAPID3, CDAI) and validated patient questionnaires on RA Knowledge (ACREU), compliance (CQR5), and physician trust (Trust in Physician Scale) were recorded at baseline and after the final educational session. Descriptive statistics were applied and medians and ranges for instrument scores are reported. Paired T-test was used to test for significant differences in scores after the education sessions. Correlations between the ACREU scores and clinical-demographic variables were measured using Pearson’s correlation coefficient.

Results

20 EM patients (75% Female, mean age, 58.8 years (12.2) seen by EM physicians were enrolled, with mean RA disease duration of 7 years and poor prognosticators (75% double seropositivity). ACREU scores were low at baseline (mean 0.45 (0.16)), with no significant improvement on completion of educational sessions, and no correlation with years of education or duration of RA. There was a positive correlation between ACREU and compliance scores at baseline (r=0.3). Average duration of the education period was 9.72 months, with a 33% decrease in average RAPID3 over time, and 42% of patients achieving a target of remission or LDA. Trust in Physician scores were high at baseline and persisted with >50% of patients completing at least one medication change during study period.

Conclusion

RA knowledge did not impact RA patient outcomes in this cohort of EM patients. However, patients had high trust in their providers and achieved clinical remission or LDA despite risk for poor outcomes highlighting the importance of the provider- patient relationship in achieving targeted goals of therapy. Limitations include the small sample size from a single institution, and the lengthy time between initial and final assessment of RA knowledge.

References

[1]Lineker SC, Badley EM, Hughes EA, Bell MJ. Development of an instrument to measure knowledge in individuals with rheumatoid arthritis: the ACREU rheumatoid arthritis knowledge questionnaire. The Journal of rheumatology. 1997/04// 1997;24(4):647-653.

[2]Hughes LD, Done J, Young A. A 5 item version of the Compliance Questionnaire for Rheumatology (CQR5) successfully identifies low adherence to DMARDs. BMC Musculoskeletal Disorders. 2013-12-01 2013;14(1):286. doi:10.1186/1471-2474-14-286

[3]Anderson LA, Dedrick RF. Development of the Trust in Physician Scale: A Measure to Assess Interpersonal Trust in Patient-Physician Relationships. Psychological Reports. 1990-12-01 1990;67(3_suppl):1091-1100. doi:10.2466/pr0.1990.67.3f.1091

Acknowledgements

Sincere gratitude to our patients for their participation, and to the team at Bristol Myers Squibb for supporting this research initiative.

Disclosure of Interests

Sharon Dowell Speakers bureau: Horizon Pharma, Aurinia Pharmaceuticals Inc, Abbvie, Grant/research support from: Pfizer, Bristol Myers Squibb, Mercedes Quinones Speakers bureau: Abbvie, Sanofi Genzyme, Grant/research support from: Bristol Myers Squibb, Pfizer, Alani Miller: None declared, Oshoze Kadiri: None declared, Tahereh Jamshidi: None declared, Gail Kerr Speakers bureau: Aurinia Pharmaceuticals Inc, Consultant of: CSL Behring, Janssen, Pfizer, Samumed, UCB, Viela Bio/Horizon, Grant/research support from: Novartis

Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness

OBJECTIVE

Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason.

METHODS

Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma.

RESULTS

In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively.

CONCLUSION

Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.

The association between the degree of fever as measured in the emergency department and clinical outcomes of hospitalized adult patients

BACKGROUND

Fever is a physiologic response to a wide range of pathologies and one of the most common complaints and clinical signs in the emergency medicine department (ED). The association between fever magnitude and clinical outcomes has been evaluated in specific populations with inconsistent results.

OBJECTIVES

In this study we aimed to investigate the association between the degree of fever in the ED and clinical outcomes of hospitalized febrile adult patients.

METHODS

This was a retrospective single-center cohort study of all the patients with maximal body temperature (BT) ≥ 38.0 °C, as recorded during the ED evaluation, who were hospitalized between January 2015 and December 2020. Patients with heatstroke were excluded. The primary outcome was 30-day all-cause mortality and secondary outcomes were intensive care unit (ICU) admission and development of acute kidney injury (AKI).

RESULTS

Fever was recorded among 8.1% of patients evaluated in the ED. Elevated BT was associated with increased risk of hospital admission (70.3% vs. 49.4%, p < 0.001), 30-day mortality (12.3% vs. 2.6%, p < 0.001), ICU admission (5.7% vs. 2.8%, p < 0.001), and AKI 11.7% vs. 3.8%, p < 0.001). After exclusion of nine patients with heatstroke, 21,252 hospitalized febrile patients were included in the final analysis. BT > 39.7 °C was progressively associated with increased mortality (OR 1.64-2.22, 95% CI 1.16-2.81, p < 0.005) as compared to BT 38.0-38.1 °C. More AKI events were observed in patients with BT > 39.5 °C (OR 1.48-2.91, 95% CI 1.11-3.66, p < 0.007). Temperature between 39.2 and 39.5 °C was associated with lower mortality (OR 0.62-0.71, 95% CI 0.51-0.87, p < 0.001). In a multiple logistic regression analysis BT > 39.9 °C was independently associated with increased mortality and AKI. BT > 39.7 °C was progressively associated with an increased risk of ICU admission.

CONCLUSION

Among febrile patients admitted to the hospital, BT > 39.5 °C was associated with adverse clinical course, as compared to patients with lower-grade fever (38.0-38.1 °C). These patients should be flagged on arrival to the ED and likely warrant more aggressive evaluation and treatment.

1411 Amoebic Colitis: Inaccurate Diagnosis; Inappropriate Surgery

Global prevalence of symptomatic Amoebiasis (pathogen Entamoeba histolytica) is approximately 50 million cases per year, with an annual mortality of up to 100,000. Despite this, a diagnosis of amoebiasis is rarely considered in the UK. Transmission is via the faeco-oral route, person-to-person contact or oral-anal sexual contact. The majority of cases diagnosed in the UK are in international travellers or immigrants.

Symptoms of amoebiasis can closely mirror those of Inflammatory Bowel Disease (IBD) resulting in diagnostic uncertainty. A misdiagnosis could result in treatment with corticosteroids, immunosuppressant or biological agents when standard treatment for amoebiasis is actually Metronidazole. In exceptional circumstances, a misdiagnosis of IBD may lead to a patient requiring colectomy and formation of end ileostomy due to an apparent failure of medical management. Emergency colonic surgery is associated with a risk of complications such as wound infections and collections, together with the psychological consequences of major illness and surgery.

We report on two patients who have undergone emergency subtotal colectomy and end ileostomy in whom a diagnosis of amoebic colitis was made on histology. Both British Asian patients were under 55 years of age, had a travel history to India and presented with diarrhoea.

The diagnosis of amoebiasis must be considered in the differential diagnosis for all returning travellers and immigrants who present with GI symptoms, consistent with IBD. A correct diagnosis allows appropriate, simple, curative treatment and avoids unnecessary surgery with its attendant morbidity. Polymerase chain reaction is the gold standard diagnostic test and is currently significantly under-utilised.

Hypocalcemia is associated with adverse clinical course in patients with upper gastrointestinal bleeding

Acute non-variceal upper gastrointestinal bleeding (NV-UGIB) is associated with significant morbidity and mortality. Early and efficient risk stratification can facilitate management and improve outcomes. We aimed to determine whether the level of ionized calcium (Ca⁺⁺), an essential co-factor in the coagulation cascade, is associated with the severity of bleeding and the need for advanced interventions among these patients. This was a retrospective single-center cohort study of all patients admitted due to NV-UGIB. The primary outcome was transfusion of ≥ 2 packed red blood cells, arterial embolization, or emergency surgery. Secondary outcomes included (1) transfusion of ≥ 2 packed red blood cells, (2) arterial embolization, or emergency surgery, and (3) all-cause in-hospital mortality. Multivariable logistic regression was performed to determine whether Ca⁺⁺ was an independent predictor of these adverse outcomes. 1345 patients were included. Hypocalcemia was recorded in 604 (44.9%) patients. The rates of primary adverse outcome were significantly higher in the hypocalcemic group, 14.4% vs. 5.1%, p < 0.001. Secondary outcomes-multiple transfusions, need for angiography or surgery, and mortality were also increased (9.9% vs. 2.3%, p < 0.001, 5.3% vs. 2.8%, p = 0.03, and 33.3% vs. 24.7%, p < 0.001, respectively). Hypocalcemia was an independent predictor of primary and all the secondary outcomes, except mortality. Hypocalcemia in high-risk hospitalized patients with NV-UGIB is common and independently associated with adverse outcomes. Ca⁺⁺ monitoring in this population may facilitate the rapid identification of high-risk patients. Trials are needed to assess whether correction of hypocalcemia will lead to improved outcomes.

Association of Low Alanine Aminotransferase Values with Extubation Failure in Adult Critically Ill Patients: A Retrospective Cohort Study

Background: Liberation from mechanical ventilation is a cardinal landmark during hospitalization of ventilated patients. Decreased muscle mass and sarcopenia are associated with a high risk of extubation failure. A low level of alanine aminotransferase (ALT) is a known biomarker of sarcopenia. This study aimed to determine whether low levels of ALT are associated with increased risk of extubation failure among critically ill patients. Methods: This was a retrospective single-center cohort study of mechanically ventilated patients undergoing their first extubation. The study’s outcome was extubation failure within 48 h and 7 days. Multivariable logistic and Cox regression were performed to determine whether ALT was an independent predictor of these outcomes. Results: The study included 329 patients with a median age of 62.4 years (IQR 48.1–71.2); 210 (63.8%) patients were at high risk for extubation failure. 66 (20.1%) and 83 (25.2%) failed the extubation attempt after 48 h and 7 days, respectively. Low ALT values were more common among patients requiring reintubation (80.3–61.5% vs. 58.6–58.9%, p < 0.002). Multivariable logistic regression analysis identified ALT as an independent predictor of extubation failure at 48 h and 7 days. ALT ≤ 21 IU/L had an adjusted hazard ratio (HR) of 2.41 (95% CI 1.31–4.42, p < 0.001) for extubation failure at 48 h and ALT ≤ 16 IU/L had adjusted HR of 1.94 (95% CI 1.25–3.02, p < 0.001) for failure after 7 days. Conclusions: Low ALT, an established biomarker of sarcopenia and frailty, is an independent risk factor for extubation failure among hospitalized patients. This simple laboratory parameter can be used as an effective adjunct predictor, along with other weaning parameters, and thereby facilitate the identification of high-risk patients.

Simultaneous orthogonal bipole mapping compared to conventional electrode configurations and impact on ablation strategies: results from a real world observational study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott

Background

3D mapping systems are pivotal to identify low voltage areas and to define ablation strategies. In this context, high-density multipolar mapping catheters with varying electrode configurations are used for accurate myocardial substrate definition. High density mapping using a grid shaped catheter allows for use of simultaneous analysis of adjacent orthogonal bipolar signals that may assist in more accurate substrate characterization and ablation strategy decisions.

Purpose

This was a prospective, multicenter observational study to characterize the utility of electroanatomical mapping with a high density grid-style mapping catheter (HD Grid) in subjects undergoing catheter ablation for persistent atrial fibrillation (PersAF) or ventricular tachycardia (VT) in real-world clinical settings.

Methods

Mapping was performed with the HD Grid catheter to generate high-density maps of cardiac chambers in order to assess the potential influence of the simultaneous orthogonal bipole configuration on PersAF and VT ablation strategies. Differences in substrate identification between simultaneous orthogonal bipole configuration and standard along-the-spline electrode configuration, and potential effects on ablation strategies were investigated.

Results

During the study period (January 2019 through April 2020), 367 subjects underwent catheter ablation for PersAF (N = 333, average age 64.1yr, 75% male) or VT (N = 34, average age = 64.3yr, 85.3% male).

In total, 494 maps were generated to treat patients undergoing PersAF ablation and 57 to treat patients undergoing VT ablation. Compared to standard along-the-spline configuration, mapping with the simultaneous orthogonal bipole configuration showed differences in 57.8% (178/308) of maps generated, with the greatest difference noticed in surface area of low voltage (62.9%) and location of low voltage (55.6%).

In comparisons performed live during the procedure (n = 50), simultaneous orthogonal bipole configuration assisted in identification of ablation targets in 70.0% of cases, changing the ablation strategy compared to that identified with along-the-spline configuration in 34.3%.

In comparisons performed retrospectively after the procedure (n = 258), the ablation strategy identified with simultaneous orthogonal bipole configuration differed from along-the-spline configuration in 21.7% of maps. Even compared to a higher-density electrode configuration using all-bipoles rather than along-the-spline bipoles, simultaneous orthogonal bipole configuration identified differences in 57.1% of maps.

Conclusion

The HD grid catheter combined with simultaneous orthogonal bipole configuration can define myocardial substrate more accurately compared to standard along-the-spline configuration. The difference in substrate identification has potential impact on ablation strategy. Further clinical trials are needed to elucidate the role of orthogonal bipole configuration mapping and improved ablation success rates.

Impact of high density mapping using a grid shaped catheter with orthogonal signal analysis on ventricular tachycardia ablation strategy

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Abbott

Background

Ventricular tachycardia (VT) in patients with structural heart disease (SHD) is related to scar and slow conduction areas. Substrate-based ablation has become the gold standard treatment in patients with SHD-related refractory VT. A new high-density grid shaped catheter that allows simultaneous analysis of adjacent orthogonal bipolar signals can allow better understanding of these slow conduction areas with the potential to improve ablation results.

Purpose

This was a prospective, multicenter observational study to characterize the utility of electroanatomical mapping with a high density grid-style mapping catheter (HD Grid) in subjects undergoing catheter ablation for ventricular tachycardia (VT) in real-world clinical settings.

Methods

During the study period, patients who underwent VT ablation using the HD Grid catheter as the primary mapping catheter were included. Comparisons both during the procedure and retrospectively were performed between conventional electrode configuration maps and simultaneous orthogonal bipole electrode configuration maps. The influence of these different configurations on ablation strategy was analyzed.

Results

  During study period (January 2019 – April 2020) 57 maps were performed in 34 VT subjects (average age: 64.3yr, male: 85.3%, ischemic cardiomyopathy: 70.6%). The left ventricle was mapped in 94.1% of subjects, including left ventricular outflow tract and papillary muscles in 20.6% and 8.8% respectively, reporting minimal or no ectopic beats in 97.1% of the subjects. The total number of mapping points collected was 14172.0 ± 15174.8 in 24.3 ± 17.9 min per map.

Simultaneous orthogonal bipole mapping identified differences in 67.6% of maps compared to linear along-the-spline electrode configurations. The differences consisted mainly in the surface area (92%) and location of low voltage (40%). When compared during the procedure, simultaneous orthogonal bipole mapping was used to identify ablation strategy in 100% of cases. When compared to a standard along-the-spline configuration retrospectively, the ablation strategy identified with simultaneous orthogonal bipoles was different in 30.1% of cases.  The ablation strategy used in these subjects was mainly substrate ablation (late potentials and low voltage areas in scar regions) with an acute success rate of 97.1%.

Conclusions

The use of the HD Grid catheter with the ability to analyze orthogonal signals is feasible and has the potential to change the ablation strategy in one third of VT patients with a high acute success rate.

Development of an artificial intelligence-based assessment model for prediction of embryo viability using static images captured by optical light microscopy during IVF

STUDY QUESTION

Can an artificial intelligence (AI)-based model predict human embryo viability using images captured by optical light microscopy?

SUMMARY ANSWER

We have combined computer vision image processing methods and deep learning techniques to create the non-invasive Life Whisperer AI model for robust prediction of embryo viability, as measured by clinical pregnancy outcome, using single static images of Day 5 blastocysts obtained from standard optical light microscope systems.

WHAT IS KNOWN ALREADY

Embryo selection following IVF is a critical factor in determining the success of ensuing pregnancy. Traditional morphokinetic grading by trained embryologists can be subjective and variable, and other complementary techniques, such as time-lapse imaging, require costly equipment and have not reliably demonstrated predictive ability for the endpoint of clinical pregnancy. AI methods are being investigated as a promising means for improving embryo selection and predicting implantation and pregnancy outcomes.

STUDY DESIGN, SIZE, DURATION

These studies involved analysis of retrospectively collected data including standard optical light microscope images and clinical outcomes of 8886 embryos from 11 different IVF clinics, across three different countries, between 2011 and 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The AI-based model was trained using static two-dimensional optical light microscope images with known clinical pregnancy outcome as measured by fetal heartbeat to provide a confidence score for prediction of pregnancy. Predictive accuracy was determined by evaluating sensitivity, specificity and overall weighted accuracy, and was visualized using histograms of the distributions of predictions. Comparison to embryologists’ predictive accuracy was performed using a binary classification approach and a 5-band ranking comparison.

MAIN RESULTS AND THE ROLE OF CHANCE

The Life Whisperer AI model showed a sensitivity of 70.1% for viable embryos while maintaining a specificity of 60.5% for non-viable embryos across three independent blind test sets from different clinics. The weighted overall accuracy in each blind test set was >63%, with a combined accuracy of 64.3% across both viable and non-viable embryos, demonstrating model robustness and generalizability beyond the result expected from chance. Distributions of predictions showed clear separation of correctly and incorrectly classified embryos. Binary comparison of viable/non-viable embryo classification demonstrated an improvement of 24.7% over embryologists’ accuracy (P = 0.047, n = 2, Student’s t test), and 5-band ranking comparison demonstrated an improvement of 42.0% over embryologists (P = 0.028, n = 2, Student’s t test).

LIMITATIONS, REASONS FOR CAUTION

The AI model developed here is limited to analysis of Day 5 embryos; therefore, further evaluation or modification of the model is needed to incorporate information from different time points. The endpoint described is clinical pregnancy as measured by fetal heartbeat, and this does not indicate the probability of live birth. The current investigation was performed with retrospectively collected data, and hence it will be of importance to collect data prospectively to assess real-world use of the AI model.

WIDER IMPLICATIONS OF THE FINDINGS

These studies demonstrated an improved predictive ability for evaluation of embryo viability when compared with embryologists’ traditional morphokinetic grading methods. The superior accuracy of the Life Whisperer AI model could lead to improved pregnancy success rates in IVF when used in a clinical setting. It could also potentially assist in standardization of embryo selection methods across multiple clinical environments, while eliminating the need for complex time-lapse imaging equipment. Finally, the cloud-based software application used to apply the Life Whisperer AI model in clinical practice makes it broadly applicable and globally scalable to IVF clinics worldwide.

STUDY FUNDING/COMPETING INTEREST(S)

Life Whisperer Diagnostics, Pty Ltd is a wholly owned subsidiary of the parent company, Presagen Pty Ltd. Funding for the study was provided by Presagen with grant funding received from the South Australian Government: Research, Commercialisation and Startup Fund (RCSF). ‘In kind’ support and embryology expertise to guide algorithm development were provided by Ovation Fertility. J.M.M.H., D.P. and M.P. are co-owners of Life Whisperer and Presagen. Presagen has filed a provisional patent for the technology described in this manuscript (52985P pending). A.P.M. owns stock in Life Whisperer, and S.M.D., A.J., T.N. and A.P.M. are employees of Life Whisperer.

Association Between Ionized Calcium Level and Neurological Outcome in Endovascularly Treated Patients with Spontaneous Subarachnoid Hemorrhage: A Retrospective Cohort Study

BACKGROUND

Spontaneous subarachnoid hemorrhage (SSAH) is associated with significant morbidity and mortality. Pathophysiological processes following initial bleeding are complex and not fully understood. In this study, we aimed to determine whether a low level of ionized calcium (Ca⁺⁺), an essential cofactor in the coagulation cascade and other cellular processes, is associated with adverse neurological outcome, development of early hydrocephalus, and symptomatic vasospasm among patients with SSAH.

METHODS

This was a retrospective single-center cohort study of all patients admitted for SSAH between January 1, 2009, and April 31, 2020. The primary outcome was an unfavorable neurological status at discharge, defined as a modified Rankin Scale score greater than or equal to 3. Secondary outcomes were the development of early hydrocephalus and symptomatic vasospasm. Multivariable logistic regression was performed to determine whether Ca⁺⁺ was an independent predictor of these outcomes.

RESULTS

A total of 255 patients were included in the final analysis. Hypocalcemia, older age, admission Glasgow Coma Scale (GCS) score, and admission Hunt-Hess classification scale (H&H) grades IV and V were independently associated with unfavorable neurological outcome, with adjusted odds ratios (ORs) of 1.93 (95% confidence interval [CI] 1.1-3.4; p = 0.02) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level, 1.04 (95% CI 1.01-1.08; p = 0.02) for each year increase, 0.82 (95% CI 0.68-0.99; p = 0.04), and 6.29 (95% CI 1.14-34.6; p = 0.03), respectively. Risk factors for the development of hydrocephalus were hypocalcemia and GCS score, with ORs of 1.85 (95% CI 1.26-2.71; p = 0.002) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level and 0.83 (95% CI 0.73-0.94; p = 0.005), respectively. Ca⁺⁺ was not associated with symptomatic vasospasm (OR 1.04 [95% CI 0.76-1.41]; p = 0.81). Among patients with admission H&H grade I-III bleeding, hypocalcemia was independently associated with unfavorable neurological outcome at discharge, with an adjusted OR of 1.99 (95% CI 1.03-3.84; p = 0.04) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level. Hypocalcemia was also an independent risk factor for the development of early hydrocephalus, with an adjusted OR of 2.95 (95% CI 1.49-5.84; p = 0.002) for each 0.1 mmol L^-1 decrease in the Ca⁺⁺ level. Ca⁺⁺ was not associated with symptomatic vasospasm. No association was found between Ca⁺⁺ and predefined outcomes among patients with admission H&H grade IV and V bleeding.

CONCLUSIONS

Our study shows that hypocalcemia is associated with worse neurological outcome at discharge and development of early hydrocephalus in endovascularly treated patients with SSAH. Potential mechanisms include calcium-induced coagulopathy and higher blood pressure. Trials are needed to assess whether correction of hypocalcemia will lead to improved outcomes.

Community-acquired versus nosocomial Legionella pneumonia: factors associated with Legionella-related mortality

Over the past decade, changes in the diagnosis and management of Legionella pneumonia occurred and risk factors for severe infection and increased mortality were identified. Previous reports found that nosocomial infection is associated with higher mortality while others showed no differences. We aimed to evaluate the differences in the clinical course and mortality rates between hospital-acquired pneumonia (HAP) and community-acquired pneumonia (CAP) caused by Legionella pneumophila. A retrospective cohort study of patients admitted due to Legionella pneumonia between January 2012 through November 2019 was conducted in a tertiary referral center (Rambam Health Care Campus, Haifa, Israel). The primary outcome was 30-day Legionella pneumonia-related mortality. A multivariable logistic regression was performed to determine whether a nosocomial infection is an independent predictor of mortality. One hundred nine patients were included. Seventy (64.2%) had CAP and 39 (35.8%) had HAP. The groups were comparable regarding age, gender, and comorbidities. Time to diagnosis was longer and the number of patients receiving initial empiric anti-Legionella spp. treatment was smaller in the HAP group (8 days [IQR 5.5-12.5] vs. 5 days [IQR 3-8], p < 0.001 and 65.5% vs. 78.6%, p = 0.003, respectively). Patients with HAP had higher 30-day mortality, 41% vs. 18.6%, p = 0.02. In a multivariable logistic regression model, only pneumonia severity index and nosocomial source were independently associated with increased mortality. HAP caused by Legionella spp. is independently associated with increased mortality when compared to CAP caused by the same pathogen. The possible reasons for this increased mortality include late diagnosis and delayed initiation of appropriate treatment.

Association between ionised calcium and severity of postpartum haemorrhage: a retrospective cohort study

BACKGROUND

Postpartum haemorrhage (PPH) is often complicated by impaired coagulation. We aimed to determine whether the level of ionised calcium (Ca²⁺), an essential coagulation co-factor, at diagnosis of PPH is associated with bleeding severity.

METHODS

This was a retrospective cohort study of women diagnosed with PPH during vaginal delivery between January 2009 and April 2020. Ca²⁺ levels at PPH diagnosis were compared between women who progressed to severe PPH (primary outcome) and those with less severe bleeding. Severe PPH was defined by transfusion of ≥2 blood units, arterial embolisation or emergency surgery, admission to ICU, or death. Associations between other variables (e.g. fibrinogen concentration) and bleeding severity were also assessed.

RESULTS

For 436 patients included in the analysis, hypocalcaemia was more common among patients with severe PPH (51.5% vs 10.6%, P<0.001). In a multivariable logistic regression model, Ca²⁺ and fibrinogen were the only parameters independently associated with PPH severity with odds ratios of 1.14 for each 10 mg dl^-1 decrease in fibrinogen (95% confidence interval [CI], 1.05-1.24; P=0.002) and 1.97 for each 0.1 mmol L^-1 decrease in Ca²⁺ (95% CI, 1.25-3.1; P=0.003). The performance of Ca²⁺ or fibrinogen was not significantly different (area under the curve [AUC]=0.79 [95% CI, 0.75-0.83] vs AUC=0.86 [95% CI, 0.82-0.9]; P=0.09). The addition of Ca²⁺ to fibrinogen improved the model, leading to AUC of 0.9 (95% CI, 0.86-0.93), P=0.03.

CONCLUSIONS

Ca²⁺ level at the time of diagnosis of PPH was associated with risk of severe bleeding. Ca²⁺ monitoring may facilitate identification and treatment of high-risk patients.

Return to training in the COVID-19 era: The physiological effects of face masks during exercise

COVID-19 outbreak has a profound impact on almost every aspect of life. Universal masking is recommended as a means of source control. Routinely exercising in a safe environment is an important strategy for healthy living during this crisis. As sports clubs and public spaces may serve a source of viral transmission, masking may become an integral part of physical activity. This study aimed to assess the physiological effects of wearing surgical masks and N95 respirators during short-term strenuous workout. This was a multiple cross-over trial of healthy volunteers. Using a standard cycle ergometry ramp protocol, each subject performed a maximal exercise test without a mask, with a surgical mask, and with an N95 respirator. Physiological parameters and time to exhaustion were compared. Each subject served his own control. Sixteen male volunteers (mean age and BMI of 34 ± 4 years and 28.72 ± 3.78 kg/m² , respectively) completed the protocol. Heart rate, respiratory rate, blood pressure, oxygen saturation, and time to exhaustion did not differ significantly. Exercising with N95 mask was associated with a significant increase in end-tidal carbon dioxide (EtCO₂ ) levels. The differences were more prominent as the load increased, reaching 8 mm Hg at exhaustion (none vs N95, P = .001). In conclusion, in healthy subjects, short-term moderate-strenuous aerobic physical activity with a mask is feasible, safe, and associated with only minor changes in physiological parameters, particularly a mild increase in EtCO₂ . Subjects suffering from lung diseases should have a cautious evaluation before attempting physical activity with any mask.

Quantum Backaction on kg-Scale Mirrors: Observation of Radiation Pressure Noise in the Advanced Virgo Detector

The quantum radiation pressure and the quantum shot noise in laser-interferometric gravitational wave detectors constitute a macroscopic manifestation of the Heisenberg inequality. If quantum shot noise can be easily observed, the observation of quantum radiation pressure noise has been elusive, so far, due to the technical noise competing with quantum effects. Here, we discuss the evidence of quantum radiation pressure noise in the Advanced Virgo gravitational wave detector. In our experiment, we inject squeezed vacuum states of light into the interferometer in order to manipulate the quantum backaction on the 42 kg mirrors and observe the corresponding quantum noise driven displacement at frequencies between 30 and 70 Hz. The experimental data, obtained in various interferometer configurations, is tested against the Advanced Virgo detector quantum noise model which confirmed the measured magnitude of quantum radiation pressure noise.

Applying Gamification to the Library Orientation

By providing an overview of library services as well as the building layout, the library orientation can help newcomers make optimal use of the library. The benefits of this outreach can be curtailed, however, by the significant staffing required to offer in-person tours. One academic library overcame this issue by turning to user experience research and gamification to provide an individualized online library orientation for four specific user groups: undergraduate students, graduate students, faculty, and community members. The library surveyed 167 users to investigate preferences regarding orientation format, as well as likelihood of future library use as a result of the gamified orientation format. Results demonstrated a preference for the gamified experience among undergraduate students as compared to other surveyed groups.

Exploring the views of undocumented migrant women on access to maternity services in the UK

Background

Migrant women face inequalities in access to health-care services and are known to experience poorer maternal and child outcomes than women born in the UK. The development of more restrictive health policies in the UK and Europe, including being denied or charged for healthcare at maternity services, may be exacerbating these outcomes, particularly among undocumented migrant women without permission to reside. We investigated undocumented migrant women's experiences of accessing maternity services in the UK and their impact on health outcomes.

Methods

We did semi-structured in-depth qualitative interviews with a purposive sample of migrant women (born outside the UK) who were aged 18 and over, and had experiences of pregnancy in the UK whilst undocumented. Participants were recruited through the Doctors of the World UK clinic. Interviews were transcribed and analysed using thematic analysis.

Results

We did interviews with 20 undocumented women (age range 31-40 years; mainly from Africa and Asia). Among participants, of whom 13 were pregnant at the time of interview, 10 (50%) first accessed antenatal care late (after the national target of 13 weeks). Women described an ongoing cycle of precariousness, defined by their legal status, social isolation, and poor economic status. Women reported receiving bills of up to £11,500 for maternity services (range £3,072 to £11.500). The impact of their experiences meant that they were deterred from seeking timely health care and were reluctant to present to health services, with women reporting fear and loss of trust in the health system.

Conclusions

These women's narratives illustrated the potential deterrent and detrimental impact of increasingly restrictive health policies on women's access to care and their health. UK and European health policies must be equitable, non-discriminatory, and better align with our commitments to promote universal health coverage among all individual residing in the region.

Key messages

Increasingly restrictive health policies may have a deterrent and detrimental impact on migrant women’s access to health care. Undocumented migrant women in the UK reported fear and loss of trust in the health system.

Left behind: the state of universal health coverage in Europe

Background

Barriers to access healthcare and lack of data undermine Universal Health Coverage (UHC) in Europe, despite the region's clear commitment to the Sustainable Development Goals and UHC. Current indicators measuring unmet healthcare needs in the European Union (EU) often exclude more marginalised groups, further rendering their health needs invisible and the data to inform policy flawed. For effective evaluation of UHC, comprehensive data on the health of these groups is needed.

Methods

We conducted an evaluation of humanitarian healthcare provision of people attending Médecins du Monde (MdM) programmes in seven countries in Europe (Belgium, France, Germany, Luxembourg, Sweden, Switzerland, and the United Kingdom). MdM is a humanitarian organisation, providing care to those excluded from mainstream healthcare services. We describe the characteristics of MdM service users, their determinants of health and healthcare access.

Results

A total of 29,359 people were seen between January 2017 and December 2018. Nearly all were migrants (97.2%, 21,591/22,136), with 66.3% (11,690/17,629) of people reported not having a right or permission to reside in the country they presented in. A majority were living below the poverty line (92.6%, 7,660/8,268), residing in insecure housing (44.3%, 8,895/20,097) or living as street homeless or in emergency shelters (20.4%, 4,107/20,097). Most people reported having no healthcare coverage (81.7%, 14,848/18,164). When asked about barriers to accessing healthcare, 20.8% of responses reported economic barriers (3,960/19,020) and 14.3% reported a lack of knowledge of health system/entitlements (2,718/19,020).

Conclusions

This humanitarian service evaluation highlights the intersecting vulnerabilities and barriers to access healthcare for people excluded from mainstream healthcare systems across Europe. Our findings provide a unique insight into the extent of unmet healthcare needs of migrants and other marginalised populations.

Key messages

UHC requires comprehensive data on the population groups who are many times left without access to health services and who are often excluded from national data collection and research. A majority of MdM service users do not have healthcare coverage and experience multiple and intersecting barriers to access healthcare across Europe.

Technological Developments and Strategic Management for Overcoming the COVID-19 Challenge within the Hospital Setting in Israel

The coronavirus disease 2019 (COVID-19) pandemic has remarkably challenged health care organizations and societies. A key strategy for confronting the disease implications on individuals and communities was based on harnessing multidisciplinary efforts to develop technologies for mitigating the disease spread and its deleterious clinical implications. One of the main challenging characteristics of COVID-19 is the provision of medical care to patients with a highly infective disease mandating the use of isolation measures. Such care is complicated by the need for complex critical care, dynamic treatment guidelines, and a vague knowledge regarding the disease's pathophysiology. A second key component of this challenge was the overwhelming surge in patient burden and the relative lack of trained staff and medical equipment which required rapid re-organization of large systems and augmenting health care efficiencies to unprecedented levels. In contrast to the risk management strategies employed to mitigate other serious threats and the billions of dollars that are invested in reducing these risks annually by governments around the world, no such preparation has been shown to be of effect during the current COVID-19 pandemic. Unmet needs were identified within the newly opened COVID-19 departments together with the urgent need for reliable information for effective decision-making at the state level.This review article describes the early research and development response in Israel under the scope of in-hospital patient care, such as non-contact sensing of patients' vital signs, and how it could potentially be weaved into a practical big picture at the hospital or national level using a strategic management system. At this stage, some of the described technologies are still in developmental or clinical evidence generation phases with respect to COVID-19 settings. While waiting for future publications describing the results of the ongoing evidence generation efforts, one should be aware of this trend as these emerging tools have the potential to further benefit patients as well as caregivers and health care systems beyond the scope of the current pandemic as well as confronting future surges in the number of cases.

Injuries associated with the use of ejection seats: a systematic review, meta-analysis and the experience of the Israeli Air Force, 1990-2019

INTRODUCTION

All modern military jet aircraft are equipped with rocket-assisted ejection systems. Jet aircraft operate in the majority of the conflict regions throughout the world, and in nearly all modern countries during peacetime. Civilian and military emergency services may be called upon to treat aircrews that have ejected and should be familiar with the common injury patterns associated with aircraft ejection.

METHODS

A systematic review and meta-analysis of the literature were undertaken using the preferred reporting for systematic reviews and meta-analyses (PRISMA) methodology. Peer-reviewed journal and conference papers published between 1 January 1971 and 15 June 2019 were included. Our primary outcomes of interest were mortality and major injury rates. The I² test was used to assess heterogeneity among the included studies, and data were pooled under random effects models. In addition, all ejection cases in the Israeli Air Force (IAF) between 1990 and 2019 were studied. The data were manually extracted from the accident records and the electronic medical records system.

RESULTS

We identified 14 studies that included 1710 aircrew ejections. Heterogeneity was high (I²>75%). Pooled mean mortality and major injury rates were 10.5% (95% CI 6.8-14.8%) and 29.8% (95% CI 20.1-40.6%), respectively. The major injuries included spinal fractures (61.6%), extremity trauma (27.3%), and head trauma (8.9%). During the IAF study period, a total of 37 aircrew ejected from 26 IAF aircraft. The fatality rate was 5.4% and 18.9% suffered major injuries.

CONCLUSIONS

Although ejection is lifesaving, it is associated with unique injury patterns that should be addressed during clinical evaluation. Because of their high prevalence, spinal precautions are paramount until spinal injury can be ruled out, generally by advanced imaging. Looking forward, injury patterns will continue to evolve in parallel with improving ejection seat systems.