Acute Medicine最新文献

This case report describes an atypical small bowel obstruction in a 71- years old cannabis user and how point-of-care of ultrasound (PoCUS) helped to its management by further orientating the physician toward the bowel obstruction etiology, namely intussusception. Intussusception is the invagination of an intestinal segment into the adjacent segment. The acute clinical presentation of intussusception often has non-specific symptoms, and the diagnosis can be challenging. While the most common etiology is neoplasm, intussusception also occurs in bowel motility disorder such as after cannabis use. Although this case report illustrates intussusception PoCUS findings, these should nevertheless be integrated into the clinical picture and CT-scan should remain the gold standard complementary examination in case of a suspected bowel obstruction.

Acute Intermittent Porphyria (AIP) can be a challenging diagnosis to make, due to its rarity in actual practice and presenting symptoms often being attributed to more common conditions. This is particularly the case, since many patients will likely present to acute and general hospitals where the diagnosis may often not be considered. However, it remains pivotal to diagnose the condition as early as possible to prevent significant morbidity and even death. Here we present an unexpected case of AIP, illustrating the diagnostic delay that is commonly seen with the condition and yet emphasise the importance of its detection to commence urgent treatment.

Background: Chatbots hold great potential to serve as support tool in diagnosis and clinical decision process. In this study, we aimed to evaluate the accuracy of chatbots in diagnosing pulmonary embolism (PE). Furthermore, we assessed their performance in determining the PE severity.

Method: 65 case reports meeting our inclusion criteria were selected for this study. Two emergency medicine (EM) physicians crafted clinical vignettes and introduced them to the Bard, Bing, and ChatGPT-3.5 with asking the top 10 diagnoses. After obtaining all differential diagnoses lists, vignettes enriched with supplemental data redirected to the chatbots with asking the severity of PE.

Results: ChatGPT-3.5, Bing, and Bard listed PE within the top 10 diagnoses list with accuracy rates of 92.3%, 92.3%, and 87.6%, respectively. For the top 3 diagnoses, Bard achieved 75.4% accuracy, while ChatGPT and Bing both had 67.7%. As the top diagnosis, Bard, ChatGPT-3.5, and Bing were accurate in 56.9%, 47.7% and 30.8% cases, respectively. Significant differences between Bard and both Bing (p=0.000) and ChatGPT (p=0.007) were noted in this group. Massive PEs were correctly identified with over 85% success rate. Overclassification rates for Bard, ChatGPT-3.5 and Bing at 38.5%, 23.3% and 20%, respectively. Misclassification rates were highest in submassive group.

Conclusion: Although chatbots aren't intended for diagnosis, their high level of diagnostic accuracy and success rate in identifying massive PE underscore the promising potential of chatbots as clinical decision support tool. However, further research with larger patient datasets is required to validate and refine their performance in real-world clinical settings.

Aim: To investigate the additional value of geriatric parameters such as physical impairment to the quick Sequential Organ Failure Assessment (qSOFA) tool for predicting clinical deterioration in older ED patients with a suspected infection and to validate the final prediction model.

Methods: Post-hoc multivariable regression analysis from a prospective observational cohort study of adult patients visiting the ED of a university hospital to develop a prediction model. External validation of the prediction model was performed using the prospective data-biobank Acutelines.

Results: In older patients, qSOFA (OR 1.47 (95% CI 1.12-1.95)) and physical impairment (OR 1.84 (95% CI 1.20-2.82)) were independently associated with clinical deterioration within 72 hours. This resulted in a prediction model with an area under the curve of 0.62 (95% CI 0.56-0.68) in the derivation cohort, and of 0.62 (95% CI 0.56-0.68) in the validation cohort. Calibration of the model was poor.

Conclusion: In older ED patients with a suspected infection, not only disease severity scores, but also presence of physical impairment is independently associated with clinical deterioration.

Background: The prevalence of acute pulmonary embolism (PE) among patients hospitalized with pneumonia and its association with adverse outcomes remain uncertain.

Methods: Data from the US National Inpatient Sample between 2016 to 2020 was used to determine the proportion of patients with chief diagnosis of pneumonia that had concomitant PE and to examine the relationship between PE and in-hospital outcomes such as mortality, mechanical ventilation, thrombolysis, length of stay (LoS), and inpatient costs.

Results: A total of 13,956,485 patients with a diagnosis of pneumonia were included and 2.6% had a concomitant diagnosis of PE. The median LoS for patients with PE was 7 days, compared to 5 days for those without PE. The median hospitalization cost was higher for patients with a diagnosis of PE compared to those without PE ($16,917 vs. $10,656). The strongest factors associated with a diagnosis of PE were other venous thromboembolism (Odds Ratio (OR) 11.65, 95%CI 11.42-11.88, p<0.001), arterial thrombosis (OR 2.64, 95%CI 2.40-2.89, p<0.001), previous venous thromboembolism (OR 1.72, 95%CI 1.68-1.77, p<0.001), cardiac arrest (OR 1.69, 95%CI 1.62-1.77, p<0.001) and cancer (OR 1.45, 95%CI 1.42-1.48, p<0.001). Co-diagnosis of PE was associated with greater in-hospital mortality (OR 1.50, 95%CI 1.46-1.54), mechanical ventilation (OR 1.12, 95%CI 1.10-1.15), thrombolysis use (OR 6.69, 95%CI 6.31-7.09), and major bleeding (OR 1.48, 95%CI 1.39-1.57).

Conclusions: A diagnosis of PE occurs in 2.6% of patients hospitalized with a principal diagnosis of pneumonia. Having concomitant PE was associated with greater risks of in-hospital mortality, increased use of mechanical ventilation and thrombolysis, extended hospital stay, and higher inpatient costs.

Identification, escalation and clinical review of the deteriorating patient is essential for a safe and effective hospital. We present a deteriorating patient pathway developed within our electronic patient record, including implementation of a digital escalation and senior review process, triggered from a logic algorithm and vital signs. The pathway is activated by an average 43 patients per day with median mortality of 13.3%. Our Trust has seen a significant improvement in escalation and senior review and increased use of treatment escalation plans. The pathway has facilitated a cultural shift in the Trust towards the deteriorating patient. The new pathway is transferrable to both other digital Trusts as well as maternity and paediatric practice.

Background: This study explored changes in short-term mortality during a national reconfiguration of emergency care starting in 2007.

Methods: Unplanned hospital contacts at emergency departments across Denmark from 2007 to 2016. The reconfiguration was a natural experiment, resulting in individual timelines for each hospital. The outcome was in-hospital and 30-day mortality.

Results: Individual patient-level data included 9,745,603 unplanned hospital contacts from 2007 to 2016 at 20 hospitals with emergency departments. We observed a sharp downwards shift in in-hospital mortality and 30-day mortality in three hospitals in relation to the reconfiguration.

Conclusion: This nationwide study identified three hospitals where the reconfiguration was closely associated with reduced in-hospital and 30-day mortality. In contrast, no major effects were identified for the remaining hospitals.

Background: Defensive medicine (DM) has been increasingly studied in recent years. This study aims to investigate the understanding of DM and the motives for practicing DM among emergency physicians.

Methods: Focus group interviews.

Results: Themes identified: The understanding of DM, DM is a matter of self-confidence, DM or tests to ensure diagnosis and patient flow, DM due to confounding by availability, DM due to guidelines, Patient-initiated DM, Fear of complaints, DM in an emergency department setting.

Conclusion: This study shows that emergency physicians perform an abundance of diagnostic tests and investigations but only categorize few of them as DM. The many flow-mediating tests based on guidelines may, however, mask activities that individual physicians would possibly find defensive, if it was up to them to decide based on pure and simple anamnesis and clinical findings. It might be argued that flow optimization has overruled medical clinical reasoning in some ways, thereby introducing an inclination to conduct DM.

Emergency departments are under year-round pressure, driven by high hospital bed occupancy and compounded by increasing attendances and admissions. In 2023, 1.5 million people waited 12 hours or more for a bed. Long waits are associated with increased mortality and there is a disproportionate impact on people living in more deprived areas. Addressing this problem begins with unity of purpose and vision, such that we all view emergency department performance as our responsibility, whatever our place in the healthcare system.

NHS urgent and emergency care (UEC) remains under immense and unsustainable pressure. This is increasingly causing harm to patients and emotional trauma to the staff striving to deliver basic standards of care.