Hoist missions and seasonal influences on air rescue service helicopters: A descriptive study based on three German helicopters (preprint)

Background In the German emergency medical services, 67 rescue helicopters and 12 helicopters for rescue and intensive care transport missions provide their services mostly under visual flight conditions. Of these, 10 helicopters are equipped with a rescue hoist. There is limited data on the frequency of hoist operations, tracer diagnoses, and influences such as weather and vacation periods. This study examines hoist deployment frequencies, tracer diagnostics, and the influence of vacation season at three German helicopter sites.Methods In the period from 01 Feb. 2018 to 31 Dec. 2021, a total of 1340 hoist missions were retrospectively examined descriptively for the helicopters Christoph 15 (n = 196), Christoph 1 (n = 316), and Christoph Murnau (n = 828) using their electronic mission documentation.Results 56.89% of the hoist missions were flown during the summer months, with vacation periods having a small effect on Christoph 1 only. Traumatological diagnoses clearly predominated on all three helicopters, with 75.0% on Christoph 15, 78.8% on Christoph 1, and 52.17% on Christoph Murnau. Among the traumatological indications, extremity trauma (39.29%) was the most frequent, followed by spinal injuries (10.71%), traumatic brain injuries (8.67%), and polytrauma (4.59%). Among internal medicine emergencies, collapse/syncope (5.61%) and cardiovascular arrest (3.06%) were the most common, followed by acute coronary syndromes, anaphylaxis, and hypothermia (2.55% each).Conclusions Despite the predominance of extremity injuries and syncope/collapse, where risk stratification was the primary concern and complex medical care was usually not required, there were also dynamic and complex emergency events, e.g., cardiovascular arrests, traumatic brain injuries, and anaphylaxis. Not even the Covid-19 pandemic led to a significant shift in distribution. Surprisingly, the influence of vacation periods on the frequency of operations was less pronounced even in tourism-oriented regions. For future research, other aspects need to be studied, such as the impact of severe weather on helicopter operations in the context of climate change, as well as personnel strategy (e.g., 3-person vs. 4-person crews).

Coronavirus Disease 2019 Temperature Trajectories Correlate With Hyperinflammatory and Hypercoagulable Subphenotypes.

OBJECTIVES: Body temperature trajectories of infected patients are associated with specific immune profiles and survival. We determined the association between temperature trajectories and distinct manifestations of coronavirus disease 2019. DESIGN: Retrospective observational study. SETTING: Four hospitals within an academic healthcare system from March 2020 to February 2021. PATIENTS: All adult patients hospitalized with coronavirus disease 2019. INTERVENTIONS: Using a validated group-based trajectory model, we classified patients into four previously defined temperature trajectory subphenotypes using oral temperature measurements from the first 72 hours of hospitalization. Clinical characteristics, biomarkers, and outcomes were compared between subphenotypes. MEASUREMENTS AND MAIN RESULTS: The 5,903 hospitalized coronavirus disease 2019 patients were classified into four subphenotypes: hyperthermic slow resolvers (n = 1,452, 25%), hyperthermic fast resolvers (1,469, 25%), normothermics (2,126, 36%), and hypothermics (856, 15%). Hypothermics had abnormal coagulation markers, with the highest d-dimer and fibrin monomers (p < 0.001) and the highest prevalence of cerebrovascular accidents (10%, p = 0.001). The prevalence of venous thromboembolism was significantly different between subphenotypes (p = 0.005), with the highest rate in hypothermics (8.5%) and lowest in hyperthermic slow resolvers (5.1%). Hyperthermic slow resolvers had abnormal inflammatory markers, with the highest C-reactive protein, ferritin, and interleukin-6 (p < 0.001). Hyperthermic slow resolvers had increased odds of mechanical ventilation, vasopressors, and 30-day inpatient mortality (odds ratio, 1.58; 95% CI, 1.13-2.19) compared with hyperthermic fast resolvers. Over the course of the pandemic, we observed a drastic decrease in the prevalence of hyperthermic slow resolvers, from representing 53% of admissions in March 2020 to less than 15% by 2021. We found that dexamethasone use was associated with significant reduction in probability of hyperthermic slow resolvers membership (27% reduction; 95% CI, 23-31%; p < 0.001). CONCLUSIONS: Hypothermics had abnormal coagulation markers, suggesting a hypercoagulable subphenotype. Hyperthermic slow resolvers had elevated inflammatory markers and the highest odds of mortality, suggesting a hyperinflammatory subphenotype. Future work should investigate whether temperature subphenotypes benefit from targeted antithrombotic and anti-inflammatory strategies.

Cardiopulmonary resuscitation in special circumstances.

Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts.

Association of hypothermia with increased mortality rate in SARS-CoV-2 infection.

OBJECTIVE: Patients were observed to have variable temperatures. The objective of this study was to identify whether hypothermia in a patient infected with SARS-CoV-2 was associated with a higher than expected mortality. METHODS: In total, 331 charts from patients hospitalized with SARS-CoV-2 between March 9 and April 20, 2020 were reviewed. RESULTS: The probability of death was 2.06 times higher for those with hypothermia than for those without (95% CI 1.25-3.38)]. In ventilated patients, there were 32 deaths. Of these, 75% had been hypothermic. In a prior review of 10 000 non-SARS-CoV-2 patients with sepsis, the mortality rate in patients with hypothermia was 47%. A review of previous studies demonstrated a range of expected mortality rates in patients with ventilator-dependent respiratory failure and sepsis. In comparison, our study showed that within a group of critically ill patients with SARS-CoV-2 and hypothermia, the mortality rate exceeded those rates. CONCLUSION: Our review showed a significant association between hypothermia and death (p = 0.0033). Predictors of mortality in SARS-CoV-2 disease can expedite earlier aggressive care. Additionally, in areas with limited resources or overburdened healthcare systems, where there may be a need for resource allocation management, information about mortality risk may be helpful.

Longitudinal Trends in Bleeding Complications on Extracorporeal Life Support (ECLS) Over the Past Two Decades – ELSO Registry Analysis (preprint)

Background: The use of extracorporeal life support (ECLS) has increased worldwide over the last decade including for new emerging indications like extracorporeal cardiopulmonary resuscitation, trauma, and COVID-19. Bleeding complications remain feared and frequent, with high morbidity and increased mortality. Yet, data about trends, and in-hospital outcomes, have been poorly investigated.Methods: The Extracorporeal Life Support Organization (ELSO) Registry database was explored for patients who received veno-venous (V-V) and veno-arterial (V-A) ECLS between the years 2000 and 2020. Trends in bleeding complications and mortality were analyzed. Bleeding complications were classified according to site (gastro-intestinal, cannulation site, surgical site, pulmonary, tamponade and central nervous system) and analyzed separately. Multivariable analysis was performed to identify risk factors for bleeding complications.Results: ELSO database analysis included 53.644 patients with single ECLS runs, mean age 51.4± 15.9 years, 33.859 (64.5%) male. Study cohort included 19.748 patients cannulated for V-V ECLS and 30.696 patients for V-A ECLS. Bleeding complications were reported in 14.786 patients (27.6%) and occurred more often in V-A-modalities compared to V-V modalities (30.0% versus 21.9%, p<0.001). Patients with a bleeding complication had a lower hospital survival in the V-V ECLS (49.6% versus 66.6%, p<0.001) and V-A ECLS subgroup (33.9 versus 44.9%, p<0.001). Bleeding complications in V-V ECLS and V-A ECLS have been decreasing over the past two decades with coefficient of -1.124; P<0.001 and -1.661; P<0.001, respectively. Cannulation site bleeding and surgical site bleeding rates showed the highest negative trend in both V-V and V-A ECLS patients. No change in mortality rates over time in V-V or V-A ECLS patients (coef.: -0.147; P=0.442 and coef.: -0.195; P=0.139) was observed. For V-V ECLS supported patients, multivariate regression revealed the following independent association with bleeding: advanced age, ECLS duration, surgical cannulation, pre-ECLS support with cardiopulmonary bypass, renal replacement therapy, prone positioning, vasodilatory and anti-hypotensive agents. For V-A ECLS supported patients, predictors for bleeding included: female gender, ECLS duration, pre-ECLS arrest or bridge to transplant, therapeutic hypothermia, surgical cannulation and pre-ECLS support with cardiopulmonary bypass, ventricular assist devices, cardiac pacemakers, vasodilatory and anti-hypotensive agents.Conclusions: The steady decrease in particular cannulation and surgical site related bleeding complications over the past 20 years suggests advances in equipment development (membrane and tubes surfaces) as well as better understanding of anticoagulation management. However, the high incidence of bleeding and association with hospital mortality reinforces the need for studies to understand bleeding complications more thoroughly during ECLS.Funding Information: No funding.Declaration of Interests: Prof. Dr. Lorusso is a consultant for Medtronic, Getinge and LivaNova and medical advisory board member for EUROSETS, all unrelated to this work; all honoraria to the university for research funding. Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). Dr. Tonna received speaker fees and travel compensation from LivaNova and Philips Healthcare, unrelated to this work. Prof. Ten Cate received research support from Bayer and Pfizer, is a consultant for Alveron and stockholder with Coagulation Profile; all unrelated to this work. Prof Zoe McQuilten is supported by an Australian National Health and Medical Council (NHMRC) Investigator Grant.Other authors have no conflict of interest to declare.Ethics Approval Statement: Each institution participating in ELSO Registry approves data reported to the registry through their local institutional review board. This study involved only analysis of pre-existing de-identified data from an international registry, and as such no ethics approval was required. Similarly, no patient consent was required.

Using ICD-10 Diagnostic Codes to Identify ‘Missing’ Paediatric Patients During Nationwide COVID-19 Lockdown in Oxfordshire, UK (preprint)

Objective: To identify diagnoses which were ‘missing’ amongst paediatric inpatients during the UK’s first national lockdown, compared with the same period over the past five years. Study design A retrospective observational cohort study of all children (0-15 years) attending for urgent care across Oxfordshire, during the first UK lockdown in 2020, compared to matched dates in 2015-2019. This covers two paediatric hospitals providing secondary care, one with tertiary services. Main outcomes: Changes in numbers of patients attending and inpatient diagnoses (using ICD-10 classification) during the first 2020 lockdown, compared with the previous five years. Results: Total ED attendances (n=4030) and hospital admissions (n=1416) during the first UK lockdown were reduced by 56.8% and 59.4%, respectively, compared to attendances/admissions in 2015-2019 (5-year mean n=7446.8 and n=2491.6, respectively). Proportions of patients admitted from ED and length of stay were similar in lockdown to 2015-2019. Significantly greater numbers of neoplasms were diagnosed during lockdown than the same period in 2015-2019 (p= 0.0123). 80% of diagnoses ‘missing’ during lockdown were categorised as infectious diseases or their sequelae, whilst 20% were non-specific pains/aches/malaise and accidental injury/poisonings. Conclusions: Using standardised ICD-10 codes as a measure of diagnostic activity between years; ‘missing’ diagnoses can be identified. Our findings may suggest parents are supervising infectious illness at home or had anxieties about hospital attendance, with self-limited low-morbidity disease. Prospective studies should establish if parents/carers are adequately supported in caring for their children at home, and that access and referral pathways are appropriate where children have concerning clinical features.

Was the COVID-19 pandemic associated with a change in the pace of self-inflicted injury deaths?: A time series analysis of suicide and accidental injury mortality data (preprint)

The COVID-19 pandemic struck in the context of growing self-inflicted injury rates and appears to have increased nation-wide levels of distress. This study describes mortality trends in Maryland during the first six months of the pandemic and adds to the current literature by accounting for characteristics of pre-pandemic mortality trends and by distinguishing differences in mortality trends based on cause (e.g., overdose) and manner (e.g., suicidal) of death. We obtained data for all unnatural deaths in Maryland from January 2003 to August 2020 from the Maryland Office of the Chief Medical Examiner. We grouped decedents based on cause and manner of death (e.g., suicidal poisoning). We used ARIMA, exponential smoothing, and/or seasonal time series modeling to project the expected rate of self-inflicted mortality during March through August 2020. We compared expected mortality rates based on these self-inflicted injury models to the observed during the pandemic period mortality to investigate the hypothesis that self-inflicted injury deaths would increase at a more rapid pace than observed prior to the pandemic. The models forecasting accidental overdose deaths fit the data well (model R2 = .90, model BIC = 3.77). There were more deaths by accidental poisoning and fewer deaths by accidental falls in March and May 2020 than predicted by pre-COVID-19 models. Most self-inflicted suicidal and accidental injury deaths appear to continue to occur at the same rate during the early months of the pandemic. This research is limited by its use a limited dataset that captured mortality in one state for six months. This study may not capture longer-term effects of the COVID-19 pandemic or the association between the pandemic and rarer events (e.g., firearm deaths.) Additionally, this study does not account for the disproportionate impact of the COVID-19 pandemic on people of color who are dying by suicide at a faster rate than their White counterparts in Maryland during the pandemic.

What Can Online Personal Statements Tell Us? Insights about Physicians’ Personality Traits and Clinical Performance (preprint)

Individuals are encouraged to present themselves on various online platforms in the era of social media. These online self-expressions help readers understand and assess individuals' personality traits. In this study, we use physicians’ personal statements that are posted on an online physician review platform to examine the impact of physicians’ personality traits on their clinical performance. We extract 2,019 physicians' personal traits from the unstructured physician-generated content using the Linguistic Inquiry and Word Count dictionary. To address non-random matching between patients and physicians, we adopt a quasi-random setting to study patients who arrived at emergency departments with accidental injuries in Florida. Our analyses show that being treated by physicians with higher openness scores leads to lower in-hospital mortality rates, lower lab test costs, and shorter lengths of stay (LOS). In contrast, physicians with higher conscientiousness scores tend to incur more lab test costs without significantly improving patient outcomes. Moreover, agreeable physicians are more likely to help patients save lab test costs because of empathy. Further, incorporating these personality traits into an optimization problem of ED scheduling, our counterfactual analysis shows an average of 11.4%, 18.4% and 17.8% reduction in in-hospital mortality rates, lab test expenditures and LOS, respectively. As our study suggests that physicians' personality traits indeed affect their clinical performance, future healthcare management should take physicians' personalities into consideration, especially when physicians are in shortage during the pandemics like COVID-19.

Clinical Features of Pregnant Women and Neonates with COVID-19 in Wuhan: a paired comparison study (preprint)

Background Our study aimed to find symptoms unique in pregnancy and to help the early diagnosis in pregnant women and to evaluate the impact of COVID-19 in postpartum women and their newborns.Methods Clinical data were reviewed and collected for 11 pregnant women with laboratory-confirmed COVID-19 who were consecutively admitted to Zhongnan Hospital of Wuhan University and Women and Children’s Hospital of Hubei Province, from Jan 26 to Feb 26, 2020.Results All the confirmed women didn’t have any exposure history and their early symptoms were mildly elevated temperate and fatigue. The chest CT scans of confirmed women can be atypical manifestations, such as bilateral pleural effusions and slightly increased densities. Eight of eleven confirmed women did not feel anything unusual until abnormalities were found on chest CT scans on admission screening test. All three groups had elevated white blood cell count, neutrophil count and lactate dehydrogenase, and reduced total protein.The infection did not increase the risk for premature delivery, premature rupture of membrane, or comorbidities in pregnancy.Conclusions Pregnant women were often asymptomatic and accidentally detected abnormalities on chest CT scan on admission which emphasize the importance of CT scan in prevalent areas of the COVID-19. Even after the laboratory confirmation, the manifestation of the CT scan could be atypical, which alerted the necessity of protection for healthcare workers. The COVID-19 did not increase the risk of complications in pregnant women and their neonates.Trial registration: This case series was approved by the institutional ethics board of Zhongnan Hospital of Wuhan University (No. 2020020) and Women and Children’s Hospital of Hubei Province(NO. LW035).

Detecting SARS-CoV-2 at point of care: Preliminary data comparing Loop-mediated isothermal amplification (LAMP) to PCR (preprint)

Background: The need for a fast and reliable test for COVID-19 is paramount in managing the current pandemic. A cost effective and efficient diagnostic tool as near to the point of care (PoC) as possible would be a game changer in current testing. We tested reverse transcription loop mediated isothermal amplification (RT-LAMP), a method which can produce results in under 30 minutes, alongside standard methods in a real-life clinical setting. Methods: This service improvement project piloted a research RT-LAMP method on nasal and pharyngeal swabs on 21 residents in an NHS Category 1 care home, with two index COVID-19 cases, and compared it to multiplex tandem reverse transcription polymerase chain reaction (RT-PCR). We calculated the sensitivity, specificity, positive and negative predictive values of a single RT-LAMP swab compared to RT-PCR, as per STARD guidelines. We also recorded vital signs of patients to correlate clinical and laboratory information. Findings: The novel method accurately detected 8/10 PCR positive cases and identified a further 3 positive cases. Eight further cases were negative using both methods. Using repeated RT-PCR as a 'gold standard', the sensitivity and specificity of the novel test were 80% and 73% respectively. Positive predictive value (PPV) was 73% and negative predictive value (NPV) was 83%. We also observed hypothermia to be a significant early clinical sign in a number of COVID-19 patients in this setting. Interpretation: RT-LAMP testing for SARS-CoV-2 was found to be promising, fast, easy to use and to work equivalently to RT-PCR methods. Definitive studies to evaluate this method in larger cohorts are underway. RT-LAMP has the potential to transform COVID-19 detection, bringing rapid and accurate testing to the point of care. This method could be deployed in mobile testing units in the community, care homes and hospitals to detect disease early and prevent spread.