Clinical decision support tools for paediatric sepsis in resource-poor settings: an international qualitative study.

OBJECTIVE: New paediatric sepsis criteria are being developed by an international task force. However, it remains unknown what type of clinical decision support (CDS) tools will be most useful for dissemination of those criteria in resource-poor settings. We sought to design effective CDS tools by identifying the paediatric sepsis-related decisional needs of multidisciplinary clinicians and health system administrators in resource-poor settings. DESIGN: Semistructured qualitative focus groups and interviews with 35 clinicians (8 nurses, 27 physicians) and 5 administrators at health systems that regularly provide care for children with sepsis, April-May 2022. SETTING: Health systems in Africa, Asia and Latin America, where sepsis has a large impact on child health and healthcare resources may be limited. PARTICIPANTS: Participants had a mean age of 45 years, a mean of 15 years of experience, and were 45% female. RESULTS: Emergent themes were related to the decisional needs of clinicians caring for children with sepsis and to the needs of health system administrators as they make decisions about which CDS tools to implement. Themes included variation across regions and institutions in infectious aetiologies of sepsis and available clinical resources, the need for CDS tools to be flexible and customisable in order for implementation to be successful, and proposed features and format of an ideal paediatric sepsis CDS tool. CONCLUSION: Findings from this study will directly contribute to the design and implementation of CDS tools to increase the uptake and impact of the new paediatric sepsis criteria in resource-poor settings.

Leveraging Data Science and Novel Technologies to Develop and Implement Precision Medicine Strategies in Critical Care.

Precision medicine aims to identify treatments that are most likely to result in favorable outcomes for subgroups of patients with similar clinical and biological characteristics. The gaps for the development and implementation of precision medicine strategies in the critical care setting are many, but the advent of data science and multi-omics approaches, combined with the rich data ecosystem in the intensive care unit, offer unprecedented opportunities to realize the promise of precision critical care. In this article, the authors review the data-driven and technology-based approaches being leveraged to discover and implement precision medicine strategies in the critical care setting.

Pediatric Critical Care in the Twenty-first Century and Beyond.

Pediatric critical care addresses prevention, diagnosis, and treatment of organ dysfunction in the setting of increasingly complex patients, therapies, and environments. Soon burgeoning data science will enable all aspects of intensive care: driving facilitated diagnostics, empowering a learning health-care environment, promoting continuous advancement of care, and informing the continuum of critical care outside the intensive care unit preceding and following critical illness/injury. Although novel technology will progressively objectify personalized critical care, humanism, practiced at the bedside, defines the essence of pediatric critical care now and in the future.

Prediction of recovery from multiple organ dysfunction syndrome in pediatric sepsis patients.

MOTIVATION: Sepsis is a leading cause of death and disability in children globally, accounting for ∼3 million childhood deaths per year. In pediatric sepsis patients, the multiple organ dysfunction syndrome (MODS) is considered a significant risk factor for adverse clinical outcomes characterized by high mortality and morbidity in the pediatric intensive care unit. The recent rapidly growing availability of electronic health records (EHRs) has allowed researchers to vastly develop data-driven approaches like machine learning in healthcare and achieved great successes. However, effective machine learning models which could make the accurate early prediction of the recovery in pediatric sepsis patients from MODS to a mild state and thus assist the clinicians in the decision-making process is still lacking. RESULTS: This study develops a machine learning-based approach to predict the recovery from MODS to zero or single organ dysfunction by 1 week in advance in the Swiss Pediatric Sepsis Study cohort of children with blood-culture confirmed bacteremia. Our model achieves internal validation performance on the SPSS cohort with an area under the receiver operating characteristic (AUROC) of 79.1% and area under the precision-recall curve (AUPRC) of 73.6%, and it was also externally validated on another pediatric sepsis patients cohort collected in the USA, yielding an AUROC of 76.4% and AUPRC of 72.4%. These results indicate that our model has the potential to be included into the EHRs system and contribute to patient assessment and triage in pediatric sepsis patient care. AVAILABILITY AND IMPLEMENTATION: Code available at https://github.com/BorgwardtLab/MODS-recovery. The data underlying this article is not publicly available for the privacy of individuals that participated in the study. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

Estudio ADENI-UCI: Análisis de las decisiones de no ingreso en UCI como medida de limitación de los tratamientos de soporte vital / ADENI-UCI Study: Analysis of non-income decisions in ICU as a measure of limitation of life support treatments

Objetivo: Analizar las variables asociadas a las decisiones de rechazo al ingreso en una Unidad de Cuidados Intensivos (UCI) como medida de limitación de tratamiento de soporte vital. Diseño: Prospectivo, multicéntrico. Ámbito: Sesenta y dos UCI de España entre febrero de 2018 y marzo de 2019. Pacientes: Mayores de 18 años a los que se les negó el ingreso a una UCI como medida de limitación de tratamiento de soporte vital. Intervenciones: Ninguna. Variables de interés principals: Comorbilidades de los pacientes, situación funcional previa medida por la escala KNAUS y Karnosfky; escalas pronósticas de Lee y Charlson; gravedad del enfermo medida por las escalas APACHE II y SOFA, motivo que justifica la toma de la decisión, persona a la cual es trasmitida la información; fecha de alta o fallecimiento intrahospitalario, destino al alta hospitalaria. Resultados: Se registraron un total de 2.312 decisiones de no ingreso como medida de limitación del tratamiento de soporte vital (LTSV), de las cuales se analizaron 2.284. El principal motivo de consulta fue la insuficiencia respiratoria (1.080 [47,29%]). La pobre calidad de vida estimada de los enfermos (1.417 [62,04%]), la presencia de una enfermedad crónica grave (1.367 [59,85%]) y la limitación funcional previa de los pacientes (1.270 [55,60%]) fueron los principales motivos esgrimidos para denegar el ingreso. La tasa de mortalidad intrahospitalaria fue del 60,33%. La futilidad del tratamiento se constató como factor de riesgo asociado a mortalidad (OR: 3,23; IC 95%: 2,62-3,99). Conclusiones: Las decisiones para limitar el ingreso en UCI como medida de LTSV se basan en los mismos motivos que las decisiones tomadas dentro de la UCI. La futilidad valorada por el intensivista se relaciona adecuadamente con el resultado final de muerte (AU)

Objective: To analyze the variables associated with ICU refusal decisions as a life support treatment limitation measure. Design: Prospective, multicentrico. Scope: 62 ICU from Spain between February 2018 and March 2019. Patients: Over 18 years of age who were denied entry into ICU as a life support treatment limitation measure. Interventions: None. Main interest variables: Patient comorities, functional situation as measured by the KNAUS and Karnosfky scale; predicted scales of Lee and Charlson; severity of the sick person measured by the APACHE II and SOFA scales, which justifies the decision-making, a person to whom the information is transmitted; date of discharge or in-hospital death, destination for hospital discharge. Results: A total of 2312 non-income decisions were recorded as an LTSV measure of which 2284 were analyzed. The main reason for consultation was respiratory failure (1080 [47.29%]). The poor estimated quality of life of the sick (1417 [62.04%]), the presence of a severe chronic disease (1367 [59.85%]) and the prior functional limitation of patients (1270 [55.60%]) were the main reasons for denying admission. The in-hospital mortality rate was 60.33%. The futility of treatment was found as a risk factor associated with mortality (OR: 3.23; IC95%: 2.62-3.99). Conclusions: Decisions to limit ICU entry as an LTSV measure are based on the same reasons as decisions made within the ICU. The futility valued by the intensivist is adequately related to the final result of death (AU)

ADENI-UCI study: Analysis of non-income decisions in ICU as a measure of limitation of life support treatments.

OBJECTIVE: To analyze the variables associated with ICU refusal decisions as a life support treatment limitation measure. DESIGN: Prospective, multicentrico. SCOPE: 62 ICU from Spain between February 2018 and March 2019. PATIENTS: Over 18 years of age who were denied entry into ICU as a life support treatment limitation measure. INTERVENTIONS: None. MAIN INTEREST VARIABLES: Patient comorities, functional situation as measured by the KNAUS and Karnosfky scale; predicted scales of Lee and Charlson; severity of the sick person measured by the APACHE II and SOFA scales, which justifies the decision-making, a person to whom the information is transmitted; date of discharge or in-hospital death, destination for hospital discharge. RESULTS: A total of 2312 non-income decisions were recorded as an LTSV measure of which 2284 were analyzed. The main reason for consultation was respiratory failure (1080 [47.29%]). The poor estimated quality of life of the sick (1417 [62.04%]), the presence of a severe chronic disease (1367 [59.85%]) and the prior functional limitation of patients (1270 [55.60%]) were the main reasons for denying admission. The in-hospital mortality rate was 60.33%. The futility of treatment was found as a risk factor associated with mortality (OR: 3.23; IC95%: 2.62-3.99). CONCLUSIONS: Decisions to limit ICU entry as an LTSV measure are based on the same reasons as decisions made within the ICU. The futility valued by the intensivist is adequately related to the final result of death.

ADENI-UCI Study: Analysis of non-income decisions in ICU as a measure of limitation of life support treatments. / Estudio ADENI-UCI: Análisis de las decisiones de no ingreso en UCI como medida de limitación de los tratamientos de soporte vital.

OBJECTIVE: To analyze the variables associated with ICU refusal decisions as a life support treatment limitation measure. DESIGN: Prospective, multicentrico SCOPE: 62 ICU from Spain between February 2018 and March 2019. PATIENTS: Over 18 years of age who were denied entry into ICU as a life support treatment limitation measure. INTERVENTIONS: None. MAIN INTEREST VARIABLES: Patient comorities, functional situation as measured by the KNAUS and Karnosfky scale; predicted scales of Lee and Charlson; severity of the sick person measured by the APACHE II and SOFA scales, which justifies the decision-making, a person to whom the information is transmitted; date of discharge or in-hospital death, destination for hospital discharge. RESULTS: A total of 2312 non-income decisions were recorded as an LTSV measure of which 2284 were analyzed. The main reason for consultation was respiratory failure (1080 [47.29%]). The poor estimated quality of life of the sick (1417 [62.04%]), the presence of a severe chronic disease (1367 [59.85%]) and the prior functional limitation of patients (1270 [55.60%]) were the main reasons for denying admission. The in-hospital mortality rate was 60.33%. The futility of treatment was found as a risk factor associated with mortality (OR: 3.23; IC95%: 2.62-3.99). CONCLUSIONS: Decisions to limit ICU entry as an LTSV measure are based on the same reasons as decisions made within the ICU. The futility valued by the intensivist is adequately related to the final result of death.

Sorovares e perfil de suscetibilidade a antimicrobianos em Salmonella spp. isoladas de produtos de origem suína / Serovars and antimicrobial susceptibility of Salmonella spp. product isolated from swine

Foi analisado um total de 1824 cepas de Salmonella, isoladas de alimentos de origem suína, no período de janeiro/2005 a junho/2010. As cepas, provenientes de diferentes regiões do país, foram recebidas pelo Labent/IOC/FIocruz para caracterização antigênica conclusiva. Foram identificados 41 sorovares, destacando-se: Typhimurium, Derby, Enteritidis, Panama, Infantis e Anatum. Aspectos bacteriológicos e epidemiológicos relacionados a esses sorovares foram discutidos. O teste de suscetibilidade aos antimicrobianos foi realizado em 357 amostras, 257 (72%) foram resistentes a uma ou mais drogas, e destas, 31,9% mostraram-se multirresistentes. A variedade de sorovares observada neste estudo confirma o papel dos suínos na cadeia alimentar como importantes reservatórios de Salmonella, agravado ainda pelo elevado percentual de cepas resistentes a um ou mais antimicrobianos, alertando para uma condição de risco à saúde pública.

We analyzed a total of 1824 strains of Salmonella isolated from swine-origin foods from January/2005 to June/2010. The strains from different regions of the country were received by Labent/IOC/FIOCRUZ for conclusive antigenic characterization. We identified 41 serovars, of which these stood out: Typhimurium, Derby, Enteritidis, Panama, Infantis and Anatum. Bacteriological and epidemiological aspects related to these serovars were discussed. The antimicrobial susceptibility test was performed on 357 samples, 257 (72%) were resistant to one or more of these drugs and 31,9% were multiresistant. A variety of serovars were identified reinforcing the swine as an important reservoir of Salmonella in the food chain. The high rates of antimicrobial resistance obtained in this evaluation may represent a risk condition to human health.

Insertion of self-expanding metal stent for treatment of malignant obstruction in a pregnant woman.

Colorectal cancer (CRC) is the second most frequent cancer both in incidence and mortality in women, especially in those over 60 years of age. Diagnosis in women at gestational age is rare, so its incidence during pregnancy is low. However, an increase in its diagnosis is expected during the next years because of the raise in the average age of pregnancy.In most cases, the diagnosis is delayed because symptoms related to CRC can be attributed to pregnancy itself. Up to 30 % of CRC cases may present as an intestinal obstruction. In this situation, the main objective is to solve the clinical emergency in the safest way for mother and fetus, together with performing an accurate diagnostic approach to offer the best possible therapeutic management knowing the limitations and difficulties related to pregnancy. The self-expanding metallic stent (SEMS) can be particularly useful in colon obstruction in a pregnant patient with CRC because it allows solving the acute condition providing time to perform a more accurate staging study and to prepare the patient for surgery, thus reducing both post-surgical morbidity and mortality.We report on the case of a patient who early in the second trimester of pregnancy presented with an acute colonic obstruction due to CRC which was successfully managed with the placement of a self-expanding metal stent.

British Association for Sexual Health and HIV: framework for guideline development and assessment.

This article has been prepared by the Clinical Effectiveness Group (CEG) of the British Association for Sexual Health and HIV (BASHH) to specify the methodology BASHH requires for guideline development and the process of guideline evaluation by the CEG. This replaces the specifications for the development of UK guidelines on the management of sexually transmitted infections and closely related conditions previously published in this journal in 2004 and updated in 2005.