Deaths Associated with Pediatric Hepatitis of Unknown Etiology, United States, October 2021-June 2023.

During October 2021-June 2023, a total of 392 cases of acute hepatitis of unknown etiology in children in the United States were reported to Centers for Disease Control and Prevention as part of national surveillance. We describe demographic and clinical characteristics, including potential involvement of adenovirus in development of acute hepatitis, of 8 fatally ill children who met reporting criteria. The children had diverse courses of illness. Two children were immunocompromised when initially brought for care. Four children tested positive for adenovirus in multiple specimen types, including 2 for whom typing was completed. One adenovirus-positive child had no known underlying conditions, supporting a potential relationship between adenovirus and acute hepatitis in previously healthy children. Our findings emphasize the importance of continued investigation to determine the mechanism of liver injury and appropriate treatment. Testing for adenovirus in similar cases could elucidate the role of the virus.

Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting.

Patients with cirrhosis are prone to developing acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients with cirrhosis and AKI, and to highlight priorities for further research.

A newly developed, easy-to-use prehospital drug-derived score compared with three conventional scores: A prospective multicenter study.

INTRODUCTION: The use of medications by emergency medical services (EMS) is increasing. Conventional scores are time-consuming and therefore difficult to use in an emergency setting. For early decision-making, an easy-to-use score based on the medications administered by the EMS may have prognostic value. The primary objective of this study was to develop the prehospital drug-derived score (PDDS) for 2-day mortality. METHODS: A prospective, multicenter, ambulance-based cohort study was conducted in adults with undifferentiated acute diseases treated by EMS and transferred to the emergency department. Demographic data, prehospital diagnosis data, prehospital medication and variables for the calculation of the National Early Warning Score 2 (NEWS2), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) were collected. The PDDS was developed and validated, establishing three levels of risk of 2-day mortality. The predictive capability of each score was determined by the area under the curve of the receiver operating characteristic curve (AUROC) and compared using the Delong's test (p-value). RESULTS: A total of 6401 patients were included. The PDDS included age and the use of norepinephrine, analgesics, neuromuscular blocking agents, diuretics, antihypertensive agents, tranexamic acid, and bicarbonate. The AUROC of PDDS was .86 (95% CI: .816-.903) versus NEWS2 .866 (95% CI: .822-.911), p = .828; versus REMS .885 (95% CI: .845-.924), p = .311; versus RAPS .886 (95% CI: .846-.926), p = .335, respectively. CONCLUSION: The newly developed easy-to-use prehospital drug-derived PDDS score has an excellent predictive value of early mortality. The PDDS score was comparable to the conventional risk scores and therefore might serve as an alternative score in the prehospital emergency setting.

Impact of non-severe infections on cortisol and thyroid stimulating hormone baseline levels in hospitalized patients: A monocentric cross-sectional study.

Objective. The hormonal balance is dependent on the internal and external stimuli. The baseline cortisol (BC) and thyroid stimulating hormone (TSH) levels have been observed to vary and have a predictive value in critical illness settings. Few reports have studied their variation in non-severe acute illness. The present study aims to describe the variation of BC and TSH levels and to determine the factors influencing BC and TSH levels in patients admitted with non-severe acute illness. Patients and Methods. This is a cross-sectional study of patients admitted to Infectious Diseases and Endocrinology units at the Department of Endocrinology-Diabetology and Internal Medicine at Tahar Sfar University Hospital between March 15th and September 15th, 2020. BC and TSH levels were obtained during the hospitalization. Results. A total of 143 patients were included in this study with 75 presenting with infection. All infections were community-acquired and predominantly non-severe. The BC levels were higher in patients with infection (p=0.004), especially those admitted via the emergency department (p=0.009) with a fever (p=0.015). The BC positively correlated with the temperature (p=0.002, r'=0.350), CRP levels (p=0.002, r'=0.355), neutrophil to lymphocyte ratio (p=0.045, r'=0.235), and SOFA score (p=0.023, r'=0.262). On the other hand, TSH levels were comparable in the presence of infection (p=0.400). TSH levels did not correlate with the fever, the severity of infection, or inflammation biomarkers. Both BC and TSH did not predict unfavorable outcomes in non-severe infected patients. Conclusion. In patients admitted with critical acute infections, the BC levels seem to indicate a relatively more severe infectious state. On the other hand, TSH levels did not show significant variations in these patients.

Sex-related differences in clinical characteristics and in-hospital outcomes of patients in acute type A aortic dissection.

OBJECTIVE: The aim of this study was to investigate sex-related differences in the clinical characteristics and hospital outcomes of patients undergoing surgery for acute type A aortic dissection (AAAD). METHODS: This study was a retrospective study. Patients who underwent surgery for AAAD at the Department of Cardiac Surgery, Fujian Medical University Union Hospital, from January 2014 to March 2023 were consecutively included. Data was extracted from electronic medical records. The primary outcome measure was in-hospital mortality, and secondary outcome measures included new-onset postoperative arrhythmia (POA), acute kidney injury (AKI), hepatic dysfunction, neurological complications, gastrointestinal hemorrhage, ICU length of stay, and hospital length of stay. Patients were divided into two groups based on sex, and data analysis was performed using SPSS 25.0 software. RESULTS: A total of 1137 subjects were included, with 863 males (75.9%) and 274 females (24.1%). There were statistically significant differences in age and BMI between the two groups (P < 0.05). There was no statistically significant difference in the incidence of pain at the onset between the two groups, but chest tightness in females was higher than in males (22.6% vs. 13.8%). Regarding primary outcomes, the in-hospital mortality rate was 11.1% for males and 10.6% for females (P = 0.803). There were no statistically significant differences between the groups in ICU days, length of hospitalization, neurological complications, or liver dysfunction (P > 0.05). The rate of POA in females was 4.7%, higher than in males (2.2%), but AKI and gastrointestinal hemorrhage were both higher in males than in females (P < 0.05). Multivariate analysis showed that age, white blood cell (WBC) counts, lactic acid, operation duration and prolonged mechanical ventilation (PMV) increased the risk of in-hospital mortality in male patients. Hypertension, WBC counts, lactic acid, and PMV increased the risk of in-hospital mortality in female patients. CONCLUSION: Despite significant baseline characteristic differences between male and female AAAD patients, there were no significant differences in onset symptoms. The in-hospital mortality rates were similar between male and female patients, but the risk factors for in-hospital mortality differed.

[Fulminant type 1 diabetes mellitus with acute pancreatitis: A case report and literature review].

The objective was to report a relatively rare case of fulminant type 1 diabetes (FT1DM) complicated with acute pancreatitis (AP), to summarize the characteristics as well as experience of diagnosis and treatment, and to explore its pathogenesis. Clinical data of a case of FT1DM complicated with AP in the Department of Endocrinology of our hospital were analyzed retrospectively. A 66-year-old male presented with acute fever and abdominal pain, accompanying with the significantly elevated pancreatic enzymes, and his abdominal CT scan showed exudation around the pancreas. The clinical manifestations mentioned above were consistent with the diagnosis of AP. Five days after onset, the patient developed clinical symptoms, such as obvious thirst, polyuria, polyasthenia and fatigue. Meanwhile, his plasma glucose increased significantly and the diabetic ketoacidosis (DKA) occurred. The patient's fasting and postprandial 2 hours C peptide decreased significantly (all 0.02 µg/L), glycated hemoglobin level was not high (6%), and his islet-related autoantibodies were undetectable. Thus, the patient could be diagnosed with FT1DM. After the treatment of fasting, fluid replacement, anti-infection, somatostatin, anticoagulation and intravenous insulin sequential subcutaneous insulin pump, the patient gained the alleviation of pancreatitis, restoration of oral intake, and relatively stable blood glucose levels. Summarizing the characte-ristics of this case and reviewing the literature, FT1DM complicated with AP was relatively rare in FT1DM. Its common characteristics were described below: (1) Most cases started with AP and the blood glucose elevated within 1 week, or some cases had the simultaneously onset of AP and FT1DM. (2) The clinical course of AP was short and relieved no more than 1 week; Pancreatic imaging could completely return to normal within 1 to 4 weeks after onset. (3) The etiology of AP most was idiopathic; The elevation of pancreatic enzyme level was slight and the recovery was rapidly compared with AP of other etiologies. FT1DM could be complicated with AP, which was different from the physiological manifestations of pancreatic disease in general FT1DM patients. Virus infection mignt be the common cause of AP and FT1DM, and AP might be the early clinical manifestation of some FT1DM. The FT1DM patients developed with abdominal pain was easy to be missed, misdiagnosed and delayed, which should receive more attention in clinic.

Acute renal injury among seriously ill Iraqi children: risk factors, management, and outcome.

OBJECTIVE: To determine the frequency of acute kidney injury in seriously ill young patients, and to find out the risk factors linked to renal impairment. METHODS: The cross-sectional study was conducted from June 1 to December 1, 2019, at the Central Child Teaching Hospital, Baghdad, Iraq, and comprised patients of either gender aged from >28 days to <18 years who presented to the emergency department with any critical acute illness who had to undergo hospitalisation. Kidney Disease Improving Global Outcomes criterion was used to identify patients having acute kidney injury. Such patients were followed up during their hospitalisation and their follow-up data was collected daily till discharge... Data was analysed using SPSS 25. RESULTS: of the 485 critically ill paediatric patients, 113(23.3%) had acute kidney injury; 57(50.9%) females and 56(49.1%) males. The overall mean age was 18.68±25.8 months (range: 1.5-120 months). There were 46(40.7%) patients with stage 3 disease. The incidence of acute kidney disease was not significantly associated with either age or gender (p>0.05). Diarrhoea and vomiting were the only complaints that had a significant association with acute kidney injury (p=0.001). Sagwa was consumed by 40(8.2%) cases, and 35(87.5%) of them developed acute kidney injury (p=0.001). Ventilator was used in 12(10.6%) cases, Of the total 65(13.4) cases of mortality, 21(18.6%) had acute kidney injury compared to 44(11.8%) of the rest (p=0.014). CONCLUSIONS: Acute renal impairment was found to be prevalent in seriously ill paediatric patients and was linked to increased mortality. Sagwa poisoning, diarrhoea and vomiting as presenting complaints had a significant association with acute kidney disease in such patients.

Variation in general practice referral rate to acute medicine services and association with hospital admission. A retrospective observational study.

BACKGROUND: Variation in general practice (GP) referral rates to outpatient services is well described however variance in rates of referral to acute medical units is lacking. OBJECTIVE: To investigate variance in GP referral rate for acute medical assessment and subsequent need for hospital admission. METHODS: A retrospective cohort study of acute medical referrals from 88 GPs in Lothian, Scotland between 2017 and 2020 was performed using practice population size, age, deprivation, care home residence, and distance from hospital as explanatory variables. Patient-level analysis of demography, deprivation, comorbidity, and acuity markers was subsequently performed on referred and clinically assessed acute medical patients (n = 42,424) to examine how practice referral behaviour reflects clinical need for inpatient hospital care. RESULTS: Variance in GP referral rates for acute medical assessment was high (2.53-fold variation 1st vs. 4th quartile) and incompletely explained by increasing age and deprivation (adjusted R2 0.67, P < 0.001) such that significant variance remained after correction for confounders (2.15-fold). Patients from the highest referring quartile were significantly less likely to require hospital admission than those from the third, second, or lowest referring quartiles (adjusted odds ratio 1.28 [1.21-1.36, P < 0.001]; 1.30 [1.23-1.37, P < 0.001]; 1.53 [1.42-1.65, P < 0.001]). CONCLUSIONS: High variation in GP practice referral rate for acute medical assessment is incompletely explained by practice population socioeconomic factors and negatively associates with need for urgent inpatient care. Identifying modifiable factors influencing referral rate may provide opportunities to facilitate community-based care and reduce congestion on acute unscheduled care pathways.

Managing the populations need for urgent medical care is challenge in many healthcare systems and overcrowding of urgent medical services negatively affects patient experience and can affect timely treatment. In the United Kingdom, the primary sources of patients attending for acute medical care are self-attendance to the hospital or by way of referral by a primary care physician (general practitioner). These data for the first time demonstrate high variation in referral rates for acute medical assessment between general practices which is incompletely explained by factors such as the age, deprivation, distance to the hospital or care home residence status of the care home population. Analysis of over 40,000 of these referrals for urgent medical care was subsequently undertaken to further investigate this variation. After adjusting for important clinical factors, patients referred from "high referring" practices were over 50% less likely to require inpatient hospital care than patients from lower referring practices. This suggests that the threshold for referral varies greatly between individual primary care clinicians, practices, or practice populations and many of these patients may have been suitable for less urgent community-based care. Identification of modifiable factors that account for this unexplained variation may facilitate community-based care and improve patient experience by reducing unnecessary attendance and congestion in already busy emergency care services.

Acute Sarcopenia.

Sarcopenia is currently understood as an organ insufficiency. However, the distinction of acute and chronic sarcopenia as different categories, which makes sense in this conceptual framework, is still evolving. The first set of modern definitions of sarcopenia only considered chronic sarcopenia. However, research showed that function in acute care settings differs from the loss that evolves slowly over months or years, and this fact is starting to permeate modern definitions. The updated version of the EWGSOP definition identifies acute and chronic sarcopenia as subcategories. Different studies have reported rates of incident sarcopenia in hospitalised older patients around 15-20%, which adds to the prevalent sarcopenia present on admission. Diagnosing sarcopenia in acute settings carries specific challenges related to the patients, the acute condition, and limitations in the use of diagnostic tests for muscle mass, muscle strength, and physical performance. Prevention and management of acute sarcopenia rely on exercise during admission, but the quality of evidence is still low. Nutritional intervention and drugs may have a role, but more research is needed.

Incorporating COVID-19 into Acute Febrile Illness Surveillance Systems, Belize, Kenya, Ethiopia, Peru, and Liberia, 2020-2021.

Existing acute febrile illness (AFI) surveillance systems can be leveraged to identify and characterize emerging pathogens, such as SARS-CoV-2, which causes COVID-19. The US Centers for Disease Control and Prevention collaborated with ministries of health and implementing partners in Belize, Ethiopia, Kenya, Liberia, and Peru to adapt AFI surveillance systems to generate COVID-19 response information. Staff at sentinel sites collected epidemiologic data from persons meeting AFI criteria and specimens for SARS-CoV-2 testing. A total of 5,501 patients with AFI were enrolled during March 2020-October 2021; >69% underwent SARS-CoV-2 testing. Percentage positivity for SARS-CoV-2 ranged from 4% (87/2,151, Kenya) to 19% (22/115, Ethiopia). We show SARS-CoV-2 testing was successfully integrated into AFI surveillance in 5 low- to middle-income countries to detect COVID-19 within AFI care-seeking populations. AFI surveillance systems can be used to build capacity to detect and respond to both emerging and endemic infectious disease threats.

Effect of Electrical Muscle Stimulation on the Reduction of Muscle Volume Loss in Acute Heart Failure Patients.

Electrical muscle stimulation (EMS) is expected to be considered as an add-on therapy for the usual rehabilitation of patients with chronic heart failure (HF). However, it remains unclear whether EMS can reduce muscle volume loss in patients with acute HF (AHF) immediately after hospitalization. Therefore, the aim of this study was to investigate if EMS could reduce the lower-limb muscle volume loss in patients with AHF. In this single-center, retrospective, observational study, lower-limb skeletal muscle volume, quadriceps muscle layer thickness, and clinical events (worsening HF or kidney function) were evaluated in 45 patients with AHF (mean age, 77.4 ± 11.6 years, 31 males). All patients underwent EMS on the right leg, in addition to usual rehabilitation, for 20 minutes per day, 5 days per week, for 2 weeks. A two-factor (time × leg) analysis of variance was performed to compare the difference between the right leg (usual rehabilitation and EMS) and left leg (usual rehabilitation only). The skeletal muscle mass decreased by 11.6% ± 19.7% from baseline in the right leg and by 20.4% ± 16.1% in the left leg (interaction; F = 4.54, P = 0.036). The quadriceps muscle layer thickness decreased by 10.2% ± 7.1% from baseline in the right leg and by 13.5% ± 6.0% in the left leg (interaction; F = 10.50, P = 0.002). No clinical events were related to EMS. Results showed that EMS combined with usual rehabilitation for patients with AHF has the potential to inhibit muscle volume loss.

Selective retina therapy (SRT) in patients with therapy refractory persistent acute central serous chorioretinopathy (CSC): 3 months functional and morphological results.

PURPOSE: Central serous chorioretinopathy (CSC) is a disease presenting with detachment of the neurosensory retina and characteristic focal leakage on fluorescein angiography. The spontaneous remission rate is 84% within 6 months. In this study, the efficacy of selective retina therapy (SRT) was examined in patients with therapy refractory persistent acute CSC defined by symptoms for at least 6 months and persistent subretinal fluid (SRF) despite eplerenone therapy. MATERIAL AND METHODS: This is a prospective, monocentric observational study in 17 eyes (16 patients, mean age 42 years, 2 female). SRT was performed with the approved R:GEN laser (Lutronic, South Korea), a micropulsed 527-nm Nd:YLF laser device, with a train of 30 pulses of 1.7 µs at 100-Hz repetition rate at the point of focal leakage determined by fluorescein angiography (FA) at baseline (BSL). Visits on BSL, week 4 (wk4), and week 12 (wk12) included best corrected visual acuity (BCVA, logMar), central retinal thickness (CRT) on spectral domain optical coherence tomography (SD-OCT), and FA. Statistical analysis was performed by pair-by-pair comparisons of multiple observations in each case with Bonferroni correction for multiple testing. (IBM SPSS Statistics 25®). RESULTS: Mean CRT at BSL was 387.69 ± 110.4 µm. CRT significantly decreased by 106.31 µm in wk4 (95%-KI: 21.42-191.2; p = 0.01), by 133.63 µm in wk12 (95%-KI: 50.22-217.03; p = 0.001) and by 133.81 µm (95%-KI: 48.88-218.75; p = 0.001) compared to BSL. Treatment success defined as complete resolution of SRF occurred at wk4 in 7/17 eyes (35.3%) and at wk12 in 10/17 eyes (58.8%). Re-SRT was performed in 7/17 eyes (41.2%) after an average of 107.14 ± 96.59 days. Treatment success after Re-SRT was observed in 4/6 eyes (66.6%, 12 weeks after Re-SRT). Mean BCVA did not change significantly from BSL to any later timepoint after adjusting for multiple testing. Notably, eyes with treatment success showed better BCVA at all timepoints and gained more letters compared to failures. CONCLUSION: Single or repetitive SRT may be an effective and safe treatment in 2 of 3 patients suffering from acute persistent CSC after 6 months of symptoms or more. We observed complete resolution of SRF in around 60% of eyes 12 weeks after first SRT treatment and also 12 weeks after Re-SRT treatment in eyes with persistent or recurrent SRF. Results on the long-term course after SRT are still pending.

Core Domains for Research on Hospital Inactivity in Acutely Ill Older Adults: A Delphi Consensus Study.

OBJECTIVE: To identify core domains for research studies of physical activity and sedentary behavior during hospitalization for older adults with an acute medical illness. DESIGN: A 4-Round Delphi consensus process. Round 1 invited responses to open-ended questions to generate items for the core domains research. In rounds 2-4, participants were invited to use a Likert scale (1-9) to rate the importance of each core domain for research studies of physical activity and/or sedentary behavior in hospitalized older adults with an acute medical illness. SETTING: Online surveys. PARTICIPANTS: A total of 49 participants were invited to each round (international researchers, clinicians, policy makers and patients). Response rates across rounds 1-4 were 94%, 88%, 83% and 81%, respectively. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Consensus was defined a priori as ≥70% of respondents rating an item as "critical" (score≥7) and ≤15% of respondents rating an item as "not important" (score≤3). RESULTS: In round 2, a total of 9 of 25 core domains reached consensus agreement (physical functioning, general, role functioning, emotional functioning, global quality of life, hospital, psychiatric, cognitive functioning, carer burden). In round 3, an additional 8 reached consensus (adverse events, perceived health status, musculoskeletal, social functioning, vascular, cardiac, mortality, economic). Round 4 participants provided further review and a final rating of all 17 core domains that met consensus in previous rounds. Four core domains were rated as "critically important" to evaluate: physical functioning, social functioning, emotional functioning, and hospital outcomes. CONCLUSIONS: This preliminary work provides international and expert consensus-based core domains for development toward a core-outcome set for research, with the ultimate goal of fostering consistency in outcomes and reporting to accelerate research on effective strategies to address physical activity and/or sedentary behavior in older adults while hospitalized.

[Application of Rotarex mechanical thrombectomy system in acute lower limb ischemia].

OBJECTIVE: To evaluate the effectiveness and safety of Rotarex mechanical thrombectomy system in treating acute lower limb ischemia. METHODS: From December 2017 to December 2019, the clinical data of 23 acute lower limb ischemia cases treated with Rotarex mechanical thrombectomy system were retrospectively analyzed. There were 14 males and 9 females from 53- to 84-year-old patients and the mean age was (69.1±9.1) years. Duration of symptoms was 6 hours to 14 days (median time 7 days). In the study, 8 acute thromboembolism cases and 15 acute thrombosis cases were included (In which, there was one thromboangiitis obliterans case and two in-stent restenosis cases). In 5 cases, the lesions were located above the groin; in 16 cases, the lesions were located below the groin, and in the other 2 cases, the lesions were located both above and below the groin. All the cases were treated with Rotarex mechanical thrombectomy system. When residual stenosis was greater than 50%, percutaneous transluminal angioplasty (PTA) was used, and stent was used only when it was necessary. Heparin was used 24 h after the procedure, and after that, antiplatelet agents were used in acute thrombosis cases, and oral anti-coagulants were used in acute thromboembolism cases. Doppler ultrasonography was taken during the follow-up. RESULTS: In all the 23 cases, there were 22 successful cases and 1 unsuccessful case, the mean procedure time was (68.2±15.6) min. Percutaneous transluminal angioplasty was used in 18 cases, 7 of which were implanted stents (3 stents were implanted in iliac artery and 4 in superficial femoral artery). There were 3 procedure related complications. The first one was arterial wall injury which resulted in contrast medium extravazation, and in this case, we solved it with prolonged balloon inflation. The second one was distal embolism. We took out the thrombus with guiding catheter. The last one was acute occlusion in a stent, and thrombectomy was applied urgently, and the result was good. Mean hospital stay were (3.6±1.7) days. The ankle brachial index (ABI) increased from 0.25±0.10 to 0.85±0.16 after treatment (t=12.901, P < 0.001). All the patients were followed up for 4.0-28.0 months, and the median time was 12.0 months. One patient stopped antiplatelet agents, which resulted in acute thrombosis 2 months later. Another percutaneous mechanical thrombectomy and PTA were taken. In the failed case, the patient suffered amputation above the knee 3 months later and in another case, the patient died of heart failure 8 months after the procedure. Two target lesion restenosis occurred during the follow-up. Because the patients' symptom was not sever, no procedure was taken. CONCLUSION: Percutaneous mechanical thrombectomy using Rotarex catheter is safe and effective in treating acute lower limb ischemia. For one side, it can restore blood flow to the affected limbs quickly, and for the other, it has the characteristics of minimally invasive and good repeatability. So it should be considered that this me-thod can be widely used for acute lower limb ischemia.

Break in the Stroke Chain of Survival due to COVID-19.

BACKGROUND AND PURPOSE: Emergency measures to treat patients with coronavirus disease 2019 (COVID-19) and contain the outbreak is the main priority in each of our hospitals; however, these measures are likely to result in collateral damage among patients with other acute diseases. Here, we investigate whether the COVID-19 pandemic affects acute stroke care through interruptions in the stroke chain of survival. METHODS: A descriptive analysis of acute stroke care activity before and after the COVID-19 outbreak is given for a stroke network in southern Europe. To quantify the impact of the pandemic, the number of stroke code activations, ambulance transfers, consultations through telestroke, stroke unit admissions, and reperfusion therapy times and rates are described in temporal relationship with the rising number of COVID-19 cases in the region. RESULTS: Following confinement of the population, our stroke unit activity decreased sharply, with a 25% reduction in admitted cases (mean number of 58 cases every 15 days in previous months to 44 cases in the 15 days after the outbreak, P<0.001). Consultations to the telestroke network declined from 25 every 15 days before the outbreak to 7 after the outbreak (P<0.001). The increasing trend in the prehospital diagnosis of stroke activated by 911 calls stopped abruptly in the region, regressing to 2019 levels. The mean number of stroke codes dispatched to hospitals decreased (78% versus 57%, P<0.001). Time of arrival from symptoms onset to stroke units was delayed >30 minutes, reperfusion therapy cases fell, and door-to-needle time started 16 minutes later than usual. CONCLUSIONS: The COVID-19 pandemic is disruptive for acute stroke pathways. Bottlenecks in the access and delivery of patients to our secured stroke centers are among the main challenges. It is critical to encourage patients to continue seeking emergency care if experiencing acute stroke symptoms and to ensure that emergency professionals continue to use stroke code activation and telestroke networks.

Acute pancreatitis: 31-Year trends in incidence and mortality - A Danish population-based cohort study.

BACKGROUND: Objectives: Increasing incidence rates and declining mortality rates have made acute pancreatitis a common cause of hospitalization. We aimed to examine 31-year trends in first-time hospitalization for acute pancreatitis, the subsequent short-term and long-term mortality, and the prognostic impacts of age, sex, and comorbidity. METHODS: In this nationwide Danish population-based cohort study of 47,711 incident cases, we computed the annual sex-specific age-standardized incidence rates of acute pancreatitis for 1988-2018. Among patients with incident hospitalization for acute pancreatitis, we computed sex-specific 30-day and 31-365-day mortality rates, stratified them, and performed proportional-hazards regression to estimate mortality rate ratios adjusted for sex, age, and comorbidity, measured by Charlson Comorbidity Index categories. RESULTS: From 1988 to 2018, the standardized incidence rate of acute pancreatitis per 100,000 person-years increased by 29% for men (28.8-37.0%) and by 148% for women (15.7-38.9%). Among patients with pancreatitis, the 30-day mortality declined from 10.0% in those diagnosed in 1988-1992 to 6.3% for those diagnosed in 2013-2017. The corresponding 31-365 day mortality increased from 5.5% to 6.0%. In comparing periods 1988-1992 and 2013-17, the adjusted 30-day mortality rate ratio was 0.36 (95% confidence interval: 0.32-0.41) and the adjusted 31-365 day mortality rate ratio was 0.64 (95% confidence interval: 0.56-0.74). Comorbidity was a strong predictor of mortality among patients with pancreatitis. CONCLUSIONS: Over the 31 years of observations, annual rates of acute pancreatitis more than doubled among women, converging with those among men. The comorbidity burden was a strong prognostic factor for short and long-term mortality. Treatments for acute pancreatitis should focus on existing comorbidities.

Prevalence and Outcomes of Web-Based Health Information Seeking for Acute Symptoms: Cross-Sectional Study.

BACKGROUND: The literature indicates that Web-based health information seeking is mostly used for seeking information on well-established diseases. However, only a few studies report health information seeking in the absence of a doctor's visit and in the context of acute symptoms. OBJECTIVE: This survey aimed to estimate the prevalence of Web-based health information seeking for acute symptoms and the impact of such information on symptom management and health service utilization. METHODS: This was a cross-sectional study of a convenience sample of 287 Lebanese adults (with a response rate of 18.5% [54/291]) conducted between December 2016 and June 2017. The survey was answered by participants online or through phone-based interviews. RESULTS: A total of 64.3% of the participants (178/277) reported checking the internet for health information when they had an acute symptom. The rate of those who sought to use Web-based health information first when experiencing acute symptom(s) in the past 12 months was 19.2% (25/130). In addition, 50% (9/18) visited the doctor because of the obtained information, and the rest self-medicated or sought a pharmacist's advice; the majority (18/24, 75%) improved within 3-4 days. CONCLUSIONS: Higher education level and trust in Web-based medical information were two major predictors of Web-based health information seeking for acute symptoms. Seeking Web-based health information first for acute symptoms is common and may lead to self-management by avoiding a visit to the physician. Physicians should encourage their patients to discuss Web-based health information and guide them toward trusted online websites.

Pitfalls in acute febrile illness diagnosis: Interobserver agreement of signs and symptoms during a dengue outbreak.

AIMS AND OBJECTIVES: To compare and evaluate interobserver (nurses and physicians) agreement for dengue clinical signs and symptoms, including the World Health Organization diagnostic algorithm. BACKGROUND: Agreement of clinical history defines the capacity of the examiner to measure a given clinical parameter in a reproducible and consistent manner, which is prerequisite for diagnosis validity. Nurses play a major role in the triage and care of dengue patients in many countries. STUDY DESIGN: This is a sub-study on interobserver agreement performed as part of a cross-sectional diagnostic accuracy study for acute febrile illness (AFI) using the checklist STARD. METHODS: A previously validated semi-structured sign and symptom standardised questionnaire for AFI was independently administered to 374 patients by physician and nurse pairs. The interobserver agreement was estimated using kappa statistics. RESULTS: For a set of 27 signs and symptoms, we found six interobserver discrepancies (examiner detected red eyes, lethargy, exanthema, dyspnoea, bleeding and myalgia) as identified by regular and moderate kappa indexes. Four signs (patient observed red eyes, cough, diarrhoea and vomiting) and one symptom (earache) had near-perfect agreement. Most signs and symptoms showed substantial agreement. The WHO (Dengue guidelines for diagnosis, treatment, prevention and control: new edition, World Health Organization, 2009) clinical criteria for dengue comprise a group of symptoms known as "pains and aches." Interobserver agreement for abdominal pain, retro-orbital pain and arthralgia exceed that found for headache and myalgia. CONCLUSIONS: During a dengue outbreak, the interobserver agreement for most of the signs and symptoms used to assess AFI was substantial. RELEVANCE TO CLINICAL PRACTICE: This result suggests good potential applicability of the tool by health professionals following training. A well-trained health professional is qualified to apply the standardised questionnaire to evaluate suspected dengue cases during outbreaks.

[Acute appendicitis after bone grafting from the right anterior iliac crest-difficult differential diagnosis]. / Akute Appendizitis nach Knochenentnahme am rechten Beckenkamm ­ erschwerte Differenzialdiagnostik.

To fill bony defects, an iliac crest bone graft is often used. Typical complications are hematoma, nerve injuries, infection or donor site related pain. This article reports the case of a young patient with acute appendicitis after bone grafting from the right iliac crest. Because of the preceding operation, the correct diagnosis was difficult and was only possible by a differentiated clinical examination followed by machine-aided diagnosis.

[Inpatient equivalent treatment : A new form of care also in gerontopsychiatry]. / Stationsäquivalente Behandlung : Eine neue Versorgungsform auch in der Gerontopsychiatrie.

Since 2018, following a revision of the German Social Code Book V (SGB V), it has been possible for psychiatric hospitals to provide inpatient outreach treatment in the domestic environment of psychiatric patients. Special structural features and documentation requirements must be observed. In addition to a member of the medical and nursing professions, the treatment team must include at least one member of a third professional group (e.g. occupational therapy, social work, physiotherapy). The reimbursement of services is negotiated between the respective medical institution and the health insurance companies and includes regionally divergent billing on the basis of lump sums, per minute worked or mixed models. From a psychiatric psychotherapeutic point of view the treatment of gerontopsychiatric patients in their living environment and thus in their social context offers many advantages. A prerequisite for the success of this approach is a multiprofessional treatment team that is also experienced in somatic illnesses and logistically highly flexible. Under the conditions of the corona pandemic special challenges arise from the prohibition of visiting nursing homes and the risk of infection for patients and members of the treatment team associated with outreach work.