The patient encounter index: a novel method of measuring clinical workload in a paediatric cardiology service.

Technological advances have led to better patient outcomes and the expansion of clinical services in paediatric cardiology. This expansion creates an ever-growing workload for clinicians, which has led to workflow and staffing issues that need to be addressed. The objective of this study was the development of a novel tool to measure the clinical workload of a paediatric cardiology service in Cape Town, South Africa: The patient encounter index is a tool designed to quantify clinical workload. It is defined as a ratio of the measured duration of clinical work to the total time available for such work. This index was implemented as part of a prospective cross-sectional study design. Clinical workload data were collected over a 10-day period using time-and-motion sampling. Clinicians were contractually expected to spend 50% of their daily workload on patient care. The median patient encounter index for the Western Cape Paediatric Cardiac Service was 0.81 (range 0.19-1.09), reflecting that 81% of total contractual working time was spent on clinical activities. This study describes the development and implementation of a novel tool for clinical workload quantification and describes its application to a busy paediatric cardiology service in Cape Town, South Africa. This tool prospectively quantifies clinical workload which may directly influence patient outcomes. Implementation of this novel tool in the described setting clearly demonstrated the excessive workload of the clinical service and facilitated effective motivation for improved allocation of resources.

Pediatric blood pressures during anesthesia assessed using normalization and principal component analysis techniques.

Expected values for blood pressure are known for both unanesthetized and anesthetized children. The statistics of changes in blood pressure during anesthesia, which may have important diagnostic significance, have not been reported. The purpose of this study was to report the variation in changes in blood pressure in four pediatric age groups, undergoing both cardiac and non-cardiac surgery. An analysis of the changes in blood pressure using normalization and principal component analysis techniques was performed using an existing electronic dataset of intra-arterial pediatric blood pressure values during anesthesia. Cardiac and noncardiac cases were analyzed separately. For 1361 non-cardiac cases, the average systolic blood pressure increased from 55.2 (17.6) mmHg in the first month of life to 85.4 (17.7) mmHg at 5-6 years. For 912 cardiac cases, the average systolic blood pressure increased from 55.7 (16.7) to 71.8 (24.8) mmHg in these cohorts. For non-cardiac cases in the first month, the mean (SD) for change in blood pressure over a 30 s period was 0.00 (8.8), for 5-6 year olds 0.0 (7.4); for cardiac cases, 0.1 (9.2) to - 0.1 (9.2). Variations in systolic blood pressure over a 5-min period were wider: in non-cardiac from 0.1 (12.2) mmHg (first month) to 0.4 (11.5) mmHg (5-6 year old) and from 0.2 (12.5) to 0.4 (14.2) mmHg in cardiac cases. Absolute blood pressures and changes in blood pressure during anesthesia in pediatric cardiac and non-cardiac surgical cases have been analyzed from a population database. Using these values, the quantitative methods of normalization and principal component analysis allow the identification of statistically significant changes.

Anaesthesia monitoring using fuzzy logic.

OBJECTIVE: Humans have a limited ability to accurately and continuously analyse large amount of data. In recent times, there has been a rapid growth in patient monitoring and medical data analysis using smart monitoring systems. Fuzzy logic-based expert systems, which can mimic human thought processes in complex circumstances, have indicated potential to improve clinicians' performance and accurately execute repetitive tasks to which humans are ill-suited. The main goal of this study is to develop a clinically useful diagnostic alarm system based on fuzzy logic for detecting critical events during anaesthesia administration. METHOD: The proposed diagnostic alarm system called fuzzy logic monitoring system (FLMS) is presented. New diagnostic rules and membership functions (MFs) are developed. In addition, fuzzy inference system (FIS), adaptive neuro fuzzy inference system (ANFIS), and clustering techniques are explored for developing the FLMS' diagnostic modules. The performance of FLMS which is based on fuzzy logic expert diagnostic systems is validated through a series of off-line tests. The training and testing data set are selected randomly from 30 sets of patients' data. RESULTS: The accuracy of diagnoses generated by the FLMS was validated by comparing the diagnostic information with the one provided by an anaesthetist for each patient. Kappa-analysis was used for measuring the level of agreement between the anaesthetist's and FLMS's diagnoses. When detecting hypovolaemia, a substantial level of agreement was observed between FLMS and the human expert (the anaesthetist) during surgical procedures. CONCLUSION: The diagnostic alarm system FLMS demonstrated that evidence-based expert diagnostic systems can diagnose hypovolaemia, with a substantial degree of accuracy, in anaesthetized patients and could be useful in delivering decision support to anaesthetists.

Clinical Features of HIV Arthropathy in Children: A Case Series and Literature Review.

Background: HIV infection has been associated with a non-erosive inflammatory arthritis in children, although few published reports exist. This study describes the clinical, laboratory and imaging features of this noncommunicable disease in a series of HIV-infected children in South Africa. Methods: A database search was conducted to identify HIV-infected children enrolled in a Paediatric Rheumatology service in Cape Town, South Africa between 1 January 2010 and 31 December 2020. Retrospective data were collected from individuals classified with HIV arthropathy, based on a predefined checklist. Demographic, clinical, laboratory, sonographic, therapeutic, and outcomes data were extracted by chart review. Descriptive statistical analysis was performed using R (v4.0.3). Results: Eleven cases of HIV arthropathy were included in the analysis. Cases predominantly presented in older boys with low CD4+ counts. Median age at arthritis onset was 10.3 years (IQR 6.9 - 11.6) and the male-female ratio was 3.0. The median absolute CD4+ count was 389 cells/uL (IQR 322 - 449). The clinical presentation was variable, with both oligoarthritis and polyarthritis being common. Elevated acute phase reactants were the most consistent laboratory feature, with a median ESR of 126 mL/h (IQR 67 - 136) and median CRP of 36 mg/L (IQR 25 - 68). Ultrasonography demonstrated joint effusions and synovial hypertrophy. Response to therapy was slower than has generally been described in adults, with almost all cases requiring more than one immunosuppressive agent. Five children were discharged in established remission after discontinuing immunotherapy, however outcomes data were incomplete for the remaining six cases. Conclusions: In this case series, HIV arthropathy was associated with advanced immunosuppression. Therapeutic modalities included immunomodulators and antiretroviral therapy, which consistently induced disease remission although data were limited by a high rate of attrition. Prospective studies are needed to define and understand this HIV-associated noncommunicable disease.

A multicentre analysis of Clostridium difficile in persons with Cystic Fibrosis demonstrates that carriage may be transient and highly variable with respect to strain and level.

PURPOSE: Clostridium difficile has been reported to occur in the gastrointestinal tract of 50% of Cystic Fibrosis (CF) subjects, however, clinical C. difficile infection (CDI) is a rare occurrence in this cohort despite the presence of toxigenic and hypervirulent ribotypes. Here, we present the first longitudinal, multicentre analysis of C. difficile prevalence among adult CF subjects. METHODOLOGY: Faecal samples were collected from adults with CF (selected based on confirmed Pseudomonas aeruginosa pulmonary colonisation) from Ireland, UK and Belgium as part of the CFMATTERS clinical research trial (grant No. 603038) and from non-CF controls. Faecal samples were collected on enrolment, at three monthly intervals, during pulmonary exacerbation and three months post exacerbation. C. difficile was isolated from faecal samples by ethanol shocking followed by culturing on cycloserine cefoxitin egg yolk agar. Isolates were characterised in terms of ribotype, toxin type and antibiotic susceptibility to antibiotics routinely used in the treatment of CDI (metronidazole and vancomycin) and those implicated in induction of CDI (ciprofloxacin and moxifloxacin). RESULTS: Prevalence of C. difficile among CF subjects in the three sites was similar ranging from 47% to 50% at baseline, while the healthy control cohort had a carriage rate of 7.1%. Including subjects who were positive for C. difficile at any time point there was a higher carriage rate of 71.4%, 66.7% and 63.2% in Ireland, UK, and Belgium, respectively. Ribotyping of 80 isolates from 45 CF persons, over multiple time points revealed 23 distinct ribotypes with two ribotypes (046 and 078) shared by all centres. The proportion of toxigenic isolates varied across the sites, ranging from 66.7% in Ireland to 52.9% in Belgium and 100% in the UK. Antibiotic susceptibility rates to vancomycin, metronidazole, ciprofloxacin and moxifloxacin was 100%, 97.5%, 1.3% and 63.8%, respectively. CONCLUSIONS: This study demonstrates the highest carriage rate of C. difficile to date in a CF cohort. Longitudinal data show that C. difficile can be a transient inhabitant of the CF gut, changing both in terms of strain and excretion rates.

Pediatric systemic lupus erythematosus patients in South Africa have high prevalence and severity of cardiac and vascular manifestations.

BACKGROUND: Pediatric onset of systemic lupus erythematosus (SLE) is associated with major organ involvement, and African patients tend to develop more aggressive disease than patients of European descent. Although cardiovascular involvement is common in pediatric SLE, there are few published reports on the subject. This study describes the frequency and characteristics of cardiac and vascular manifestations of pediatric SLE in a multi-ethnic South African cohort. METHODS: Demographic, clinical, and echocardiographic data were collected from pediatric SLE patients at two centers in Cape Town, South Africa. At the time of investigation, this cohort consisted of 93 participants diagnosed with SLE according to international classification criteria prior to the age of 19. Individuals with cardiac and/or vascular involvement were identified by retrospective chart review. Cardiac manifestations were defined as presence of pericardial effusion, myocarditis, cardiomyopathy, cardiac failure, Libman-Sacks endocarditis, myocardial infarction, and arrhythmia. Vascular manifestations included deep vein thrombosis, pulmonary embolism, sinus thrombosis, stroke, critical limb ischemia, cerebral vasculitis and systemic vasculitis. Statistical analysis was performed using R (v3.4.1). RESULTS: Cardiac and vascular involvement was present in 47% of the cohort. Previous studies have reported prevalence of 5%-50%. Demographic features of those with cardiac/vascular involvement did not differ from the overall cohort. Echocardiographic data were available for 23 participants. The most common cardiac manifestations were pericardial effusion (n = 24) and cardiac failure (n = 8), while the most common vascular manifestations were cerebral vasculitis (n = 9), stroke (n = 7), and pulmonary embolism (n = 7). Cardiovascular manifestations were frequently severe; one third of pericardial effusion cases required intervention, including three cases of cardiac tamponade. Cardiac and vascular involvement conferred an increased risk of mortality (31.1% versus 10.4%). CONCLUSIONS: Cardiac and vascular involvement were highly prevalent in this South African cohort. The mortality rate was high, and severe manifestations were frequent. Prospective research is needed to improve knowledge of pediatric SLE in Africa and to improve outcomes for this high-risk population.

Epidemiology of nontuberculous mycobacteria (NTM) amongst individuals with cystic fibrosis (CF).

BACKGROUND: Infection by nontuberculous mycobacteria (NTM) in patients with cystic fibrosis (CF) is often associated with significant morbidity. Limited, conflicting results are published regarding risk factors for pulmonary NTM disease. We analysed factors potentially associated with NTM in a large population of European patients with CF. METHODS: We investigated associations between presence of NTM and various factors for patients registered in the European Cystic Fibrosis Society Patient Registry. RESULTS: 374 (2.75%) of 13,593 patients studied had at least one positive NTM culture within the study year. Age- and FEV1-adjusted odds of NTM infection was more than 2.5 times higher (95%CI: 1.79; 3.60) in patients infected by Stenotrophomonas maltophilia than in patients not infected (p<0.0001), 2.36 times higher (95%CI: 1.80;3.08) in patients with ABPA than without (p<0.0001), 1.79 times higher (95%CI: 1.34; 2.38) in patients who use bronchodilators than in patients who don't (p<0.0001), 1.49 times higher (95%CI: 1.18; 1.89) in patients who use inhaled antibiotics than in patients who don't (p=0.001), and 1.30 times higher (95%CI: 1.02; 1.66) in patients who use rhDNase than in patients who don't (p=0.032). CONCLUSIONS: NTM-positive cultures in individuals with CF are associated with distinct clinical variables. Improved data collection identifying risk factors for NTM infection will allow more focused screening strategies, and influence therapeutic choices and infection control measures in high-risk patients.

The qualitative detection of decreases in cardiac output.

BACKGROUND: Cardiac output is a major factor in the maintenance of physiological homeostasis and is difficult to measure with accuracy. This study describes an evidence-based technique, based on physiological changes, which may indicate small changes in cardiac output that cannot be measured by current techniques. METHOD: Synchronous changes in blood pressure, heart rate, pulse amplitude and end-tidal carbon dioxide are analysed using runs analysis and a normalisation technique. An evidence-based algorithm was used to detect possible changes in cardiac output and data extracts from 31 consenting patients are presented as examples. RESULTS: The decrease in end-tidal carbon dioxide, during steady state ventilation, was greater in those events notified as hypovolaemia associated with a fall in cardiac output than those events notified as hypovolaemia alone. The difference in end-tidal carbon dioxide between the two groups was -0.25 kPa (CI -0.42 to -0.09) p<0.003. DISCUSSION: Runs analysis can detect trends in EtCO2 that during steady state ventilation may indicate a decrease in cardiac output. It is a safe technique; no additional hardware is required and the generated alerts only notify the clinician of the possibility of an adverse change. Determination of the rate of clinically significant false positives and negatives requires further work.

Coronary-artery bypass surgery and the brain: persisting concerns.

Mortality after coronary-artery bypass surgery (CABS) has fallen steadily over recent years. Concern remains, however, about the effect of this surgery on the brain. The problem of brain damage after CABS is multifactorial, involving microembolism, disturbed perfusion, metabolic derangement, and inflammatory responses. Microemboli numbers have been linked to the likelihood of neuropsychological deterioration after surgery. Risk factors for cerebral changes after CABS include older age, gender, neurological disease, diabetes, and calcification of the aorta. These risk factors are important because, in comparison with the early 1990s, patients undergoing CABS are now older and tend to have a greater number of comorbid conditions. Changes in surgical technique, such as the introduction of arterial-line filters and membrane oxygenators, have led to a reduction of both microemboli and neuropsychological disturbance. However, the problem persists, prompting further studies on surgical technique and neuroprotective strategies.

Acute neuropsychological changes in hemodialysis and peritoneal dialysis patients.

This study examined the impact of different dialysis treatments on the neuropsychological (NP) functioning of 145 end-stage renal disease patients. Hemodialysis (HD) and peritoneal dialysis (PD) patients were administered an NP test battery and measures of mood on 2 consecutive days (pre- and 24 hr postdialysis). Biochemistry was assessed at each session. Results indicated significant improvements in NP functioning (attention, concentration, verbal and visual memory, and psychomotor speed) in HD patients 24 hr postdialysis. No such fluctuations were found in PD patients. Although biochemical changes were found in the HD patients at the same time points, these were not consistently related to the NP changes.

Cognitive change 5 years after coronary artery bypass surgery.

A longitudinal study of cognitive function after coronary artery bypass surgery examined 107 participants using 11 tests, preoperatively and at 6 days, 8 weeks, and 5 years after surgery. The overall neuropsychological (NP) change score declined at 6 days, showed some recovery at 8 weeks, and declined again at 5 years. The number of microemboli recorded during surgery, postoperative short-term cognitive change, and degree of recovery at 8 weeks were identified as predictors of change in NP score to 5 years. This suggests that even over a 5-year period, operative damage is detectable. Patients' vulnerability to short-term deterioration and resilience or ability to recover over a few weeks from operative cerebral insult are important processes of unknown mechanisms.

Radiation-induced meningiomas: clinical, pathological, cytokinetic, and cytogenetic characteristics.

OBJECT: Radiation-induced meningiomas are known to occur after high- and low-dose cranial radiation therapy. The goal of this study was to discern the distinguishing findings and characteristics of radiation-induced meningiomas. METHODS: The records of 16 patients (seven men and nine women) who fulfilled the criteria for radiation-induced meningiomas were retrospectively reviewed. Clinical, histopathological, cytokinetic, and cytogenetic findings as well as the patients' outcome were analyzed. The mean age of the patients was 38.8 years and the mean tumor latency was 26.5 years. Five patients had multiple meningiomas in the irradiated field. The recurrence rate was 100% after the initial resection; 62% of patients had a second recurrence and 17% had a third recurrence. Thirty-eight percent of patients had atypical or malignant histopathological findings. The presence of progesterone receptors and low proliferation indices in these patients did not correlate with benign tumor behavior. Cytogenetic analysis showed multiple clonal aberrations in all tumors studied. The most frequent aberrations were found on chromosomes 1p, 6q, and 22. Derivative, lost, or additional chromosome 1p was found in 89% of cases and loss or deletion on chromosome 6 was found in 67%. CONCLUSIONS: The age of patients at presentation with meningioma and the latency period of radiation-induced meningiomas are dose related. These tumors are more aggressive and are certain to recur, have a higher histopathological grade, and are associated with complex cytogenetic aberrations particularly involving 1p and 6q.

The effect of leucocyte-depleting arterial line filters on cerebral microemboli and neuropsychological outcome following coronary artery bypass surgery.

OBJECTIVES: A randomised clinical trial sought evidence as to whether leucocyte-depleting (LD) arterial line filters added a further degree of neuroprotection in patients undergoing elective coronary artery bypass graft (CABG) surgery. METHODS: One hundred and ninety-two patients were randomised to the use of a Pall Leukoguard-6 LD filter or either an Avecor Affinity or Pall Autovent-6 control filter. Cerebral microemboli during surgery were recorded by transcranial Doppler (TCD) monitor over the right middle cerebral artery. Evidence of cerebral impairment was obtained by comparing patients' performance in a neuropsychological (NP) test battery (nine tests) administered 6-8 weeks post-operatively with their pre-operative scores. RESULTS: The groups proved well balanced in pre-operative variables. During cardiopulmonary bypass (CPB) the median number and range of microemboli was 15 (3-180) in the LD group compared to 67 (5-846) and 55 (2-773) for the Avecor and AV6 groups, respectively (P<0.0001). One hundred and sixty-two patients completed all the NP tests. The LD group showed better post-operative performance in all but one of the nine tests although the difference in a total change score just failed to reach significance (P=0.07 one-tailed t-test). CONCLUSIONS: LD filtration during CABG reduced the number of cerebral microemboli recorded by TCD and showed a strong trend towards improving NP performance post-operatively. These findings suggest that the use of such filters in CABG surgery may offer increased neuroprotection.

Fuzzy logic based anaesthesia monitoring systems for the detection of absolute hypovolaemia.

Anaesthesia monitoring involves critical diagnostic tasks carried out amongst lots of distractions. Computers are capable of handling large amounts of data at high speed and therefore decision support systems and expert systems are now capable of processing many signals simultaneously in real time. We have developed two fuzzy logic based anaesthesia monitoring systems; a real time smart anaesthesia alarm system (RT-SAAM) and fuzzy logic monitoring system-2 (FLMS-2), an updated version of FLMS for the detection of absolute hypovolaemia. This paper presents the design aspects of these two systems which employ fuzzy logic techniques to detect absolute hypovolaemia, and compares their performances in terms of usability and acceptability. The interpretation of these two systems of absolute hypovolaemia was compared with clinicians' assessments using Kappa analysis, RT-SAAM K=0.62, FLMS-2 K=0.75; an improvement in performance by FLMS-2.

Two open access, high-quality datasets from anesthetic records.

OBJECTIVE: To provide a set of high-quality time-series physiologic and event data from anesthetic cases formatted in an easy-to-use structure. MATERIALS AND METHODS: With ethics committee approval, data from surgical operations under general anesthesia were collected, including physiologic data, drug administrations, events, and clinicians' comments. These data were de-identified, formatted in a combined CSV/XML structure and made publicly available. RESULTS: Two separate datasets were collected containing physiologic time-series data and time-stamped events for 34 patients. For 20 patients, the data included 400 physiologic signals collected over 20 h, 274 events, and 597 drug administrations. For 14 patients, the data included 23 physiologic signals collected over 69 h, with 286 time stamped comments. DISCUSSION: Data reuse potentially saves significant time and financial costs. However, there are few high-quality repositories for accessible physiologic data and clinical interventions from surgical cases. De-identifying records assists with overcoming problems of privacy and storing the data in a format which is easily manipulated with computing resources facilitates access by the wider research community. It is hoped that additional high-quality data will be added. Future work includes developing tools to explore and visualize the data more efficiently, and establishing quality control measures. CONCLUSION: An approach to collecting and storing high-quality datasets from surgical operations under anesthesia such that they can be easily accessed by others for use in research has been demonstrated.

Detection and classification of hypovolaemia during anaesthesia.

In recent years, there has been a rapid growth in patient monitoring and medical data analysis using decision support systems, smart alarm monitoring, expert systems and many other computer aided protocols. The main goal of this study was to enhance the developed diagnostic alarm system for detecting critical events during anaesthesia. The proposed diagnostic alarm system is called Fuzzy logic monitoring system-2 (FLMS-2). The performance of the system was validated through a series of off-line tests. When detecting hypovolaemia a substantial level of agreement was observed between FLMS-2 and the human expert and it is shown that system has a better performance with sensitivity of 94%, specificity of 90% and predictability of 72%.

A fuzzy logic-based system for anaesthesia monitoring.

In recent years there has been a rapid growth in patient monitoring and medical data analysis using a number of computer-aided systems based on expert systems, fuzzy logic and many other intelligent techniques. Fuzzy logic-based expert systems have shown potential to improve clinician performance by imitating human thought processes in complex circumstances and accurately executing repetitive tasks to which humans are ill-suited. The main goal of this study was to develop a clinically useful diagnostic alarm system for detecting critical events during anaesthesia administration. The proposed diagnostic alarm system called Fuzzy logic monitoring system (FLMS) is presented. The performance of the system was validated through a series of off-line tests. When detecting hypovolaemia a substantial level of agreement was observed between FLMS and the human expert (the anaesthetist) during surgical procedures.