Translating the COVID-19 epidemiological situation into policies and measures: the Belgian experience

The COVID-19 pandemic led to sustained surveillance efforts, which made unprecedented volumes and types of data available. In Belgium, these data were used to conduct a targeted and regular assessment of the epidemiological situation. In addition, management tools were developed, incorporating key indicators and thresholds, to define risk levels and offer guidance to policy makers. Categorizing risk into various levels provided a stable framework to monitor the COVID-19 epidemiological situation and allowed for clear communication to authorities. Although translating risk levels into specific public health measures has remained challenging, this experience was foundational for future evaluation of the situation for respiratory infections in general, which, in Belgium, is now based on a management tool combining different data sources.

Immunovirological and environmental screening reveals actionable risk factors for fatal COVID-19 during post-vaccination nursing home outbreaks

Coronavirus Disease 2019 (COVID-19) vaccination has resulted in excellent protection against fatal disease, including in older adults. However, risk factors for post-vaccination fatal COVID-19 are largely unknown. We comprehensively studied three large nursing home outbreaks (20-35% fatal cases among residents) by combining severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) aerosol monitoring, whole-genome phylogenetic analysis and immunovirological profiling of nasal mucosa by digital nCounter transcriptomics. Phylogenetic investigations indicated that each outbreak stemmed from a single introduction event, although with different variants (Delta, Gamma and Mu). SARS-CoV-2 was detected in aerosol samples up to 52 d after the initial infection. Combining demographic, immune and viral parameters, the best predictive models for mortality comprised IFNB1 or age, viral ORF7a and ACE2 receptor transcripts. Comparison with published pre-vaccine fatal COVID-19 transcriptomic and genomic signatures uncovered a unique IRF3 low/IRF7 high immune signature in post-vaccine fatal COVID-19 outbreaks. A multi-layered strategy, including environmental sampling, immunomonitoring and early antiviral therapy, should be considered to prevent post-vaccination COVID-19 mortality in nursing homes.

A determination of the current causes of hyperkalaemia and whether they have changed over the past 25 years

OBJECTIVE

Hyperkalaemia is a potentially lethal electrolyte disorder. The objective of this study was to determine if the causes of hyperkalaemia-related visits to the emergency department (ED) have changed since 25 years.

METHODS

All patients presenting to the ED with hyperkalaemia between January 2009 and August 2011 were included in this retrospective, single-centre study. Patients were divided into one of these three categories: mild (5·2≤ K(+)<5·8 mEq/l), moderate (5·8≤K(+)<7·0 mEq/l) or severe hyperkalaemia (K(+)≥7·0 mEq/l). The causes of hyperkalaemia were divided into three groups: renal failure (RF), potassium-increasing drugs (PIDs) or others.

RESULTS

Overall, 139 patients with hyperkalaemia were included in the study (mean K(+) of 6·2 mEq/l): 35% with mild, 49% with moderate and 16% with severe hyperkalaemia. Eighty-three per cent of patients (n = 115) had RF with creatinine levels ≥1·25 mg/dl or estimated glomerular filtration rate (eGFR) levels ≤60 ml/min/1·73 m(2). Serum potassium levels were significantly related with creatinine and eGFR values (P<0·001). The severity of hyperkalaemia was significantly related with creatinine levels ≥1·25 mg/dl (P = 0·002) and eGFR values ≤60 ml/min/1·73 m(2) (P = 0·005). Seventy-five per cent of patients (n = 105) were taking PIDs. Potassium levels were significantly related with PIDs (P<0·001), in particularly spironolactone (P = 0·001) and angiotensin-converting enzyme inhibitors (P = 0·008). The category 'others' included 7% of patients (n = 10).

CONCLUSIONS

RF (83%) and PIDs (75%) remain common causes of hyperkalaemia. Hyperkalaemia is significantly related with four variables: creatinine levels, spironolactone, ACEIs and beta-blocker intake. The causes of hyperkalaemia have not changed in recent years.

Bluish vomiting: a rare clinical presentation of poisoning

Bluish vomiting is a symptom of poisoning that is rarely seen in Western emergency departments. Consequently, physicians are not aware of the diagnosis, complications, and treatment of this unusual form of intoxication. In this article, we report a case of bluish vomiting that occurred after an accidental ingestion of copper sulphate. In the discussion, we review three life-threatening causes of bluish vomiting (copper sulphate, boric acid, and paraquat ingestion), and we discuss their respective clinical manifestations, specificities, complications, and management therapies.

Assessing clinical reasoning using a script concordance test with electrocardiogram in an emergency medicine clerkship rotation

Objectives

Script concordance tests (SCTs) can be used to assess clinical reasoning, especially in situations of uncertainty, by comparing the responses of examinees with those of emergency physicians. The examinee's answers are scored based on the level of agreement with responses provided by a panel of experts. Emergency physicians are frequently uncertain in the interpretation of ECGs. Thus, the aim of this study was to validate an SCT combined with an ECG.

Methods

An SCT-ECG was developed. The test was administered to medical students, residents and emergency physicians. Scoring was based on data from a panel of 12 emergency physicians. The statistical analyses assessed the internal reliability of the SCT (Cronbach's α) and its ability to discriminate between the different groups (ANOVA followed by Tukey's post hoc test).

Results

The SCT-ECG was administered to 21 medical students, 19 residents and 12 emergency physicians. The internal reliability was satisfactory (Cronbach's α=0.80). Statistically significant differences were found between the groups (F0.271=21.07; p<0.0001). Moreover, significant differences (post hoc test) were detected between students and residents (p<0.001), students and experts (p<0.001), and residents and experts (p=0.017).

Conclusions

This SCT-ECG is a valid tool to assess clinical reasoning in a context of uncertainty due to its high internal reliability and its ability to discriminate between different levels of expertise.

Evaluation of clinical reasoning in basic emergencies using a script concordance test

OBJECTIVES

To develop and assess the reliability of a script concordance test (SCT) to evaluate pharmacy students' clinical reasoning when facing basic emergency situations.

DESIGN

A first aid course was designed that consisted of 8 weekly instructional sessions (4 on internal medicine, including life threatening situations; 2 on pediatrics; and 2 on trauma) in which the instructor presented case studies in a small-group format. In the first and final sessions of the course, a practice SCT was administered to familiarize students with the test format.

ASSESSMENT

A 66-question SCT examination was administered to the 68 third-year pharmacy students enrolled in the first aid course. The students' mean score was 68.5% ± 9.8% and panel members' mean score was 86.5% ± 4.2%. Twenty students were selected randomly to complete a course survey and 85% indicated they were satisfied with using the SCT.

CONCLUSIONS

A first aid SCT was found to be both a practical and reliable testing instrument for assessing the clinical reasoning of pharmacy students in basic emergency situations.

Sulfonylurea-induced hypoglycaemia: use of octreotide

Sulfonylurea compounds are commonly used to treat type 2 diabetes mellitus. The case of an old alcoholic addicted diabetic patient treated with gliquidone developing recurrent and prolonged hypoglycaemias refractory to dextrose administration is related. According to the emergency literature, the use of octreotide in sulfonyurea-induced hypoglycaemia refractory to dextrose administration is related to overdoses of SUA. Use of octreotide with our patient allowed stabilization of the glycaemia.

Increasing cause of cough among adults

Cough is a frequent reason for ED consultation. When one considers the epidemiological data, whooping cough must be considered in the differential of subacute cough. Clinical symptomatology is slightly different in the adult and unvaccinated child. An infection by Bordetella pertussis should be suspected when the history shows a persistent cough for more than 1 week in conjunction with other clinical elements. Several methods are available to establish a diagnosis: culture, PCR and bacterial serology. An early diagnosis will allow effective treatment, limit the transmission to unvaccinated infants, reduce complications and prevent extensive and expensive check-ups for chronic cough.

Severe hiccups and intravenous lidocaine

We report the case of a patient in whom the use of intravenous Lidocaine to treat incapacitating hiccups was a success. Intravenous lidocaine should be considered as an alternative treatment for severe hiccups when classical medications are ineffective or produce side effects.