Prehospital point-of-care ultrasound in ruptured abdominal aortic aneurysms-a retrospective cohort study

BACKGROUND

Patients with ruptured abdominal aortic aneurysm (rAAA) require immediate vascular treatment to survive. The use of prehospital point-of-care ultrasound (POCUS) may support clinical assessment, correct diagnosis, appropriate triage and reduce system delay. The aim was to study the process of care and outcome in patients receiving prehospital POCUS versus patients not receiving prehospital POCUS in patients with rAAA, ruptured iliac aneurysm or impending aortic rupture.

METHODS

We performed a retrospective cohort study in patients diagnosed with rAAA in the Central Denmark Region treated by a prehospital critical care physician from 1 January 2017 to 31 December 2021. Performance of prehospital POCUS was extracted from the prehospital electronic health records. System delay was defined as the time from the emergency phone call to the emergency medical service dispatch centre until the start of surgery. Data on patients primary hospital admission to a centre with/without vascular treatment expertise, treatments and complications including death were extracted from electronic health records.

RESULTS

We included 169 patients; prehospital POCUS was performed in 124 patients (73%). Emergency surgical treatment was performed in 71 patients. The overall survival in the POCUS group was 39% versus 16% in the NO POCUS group (hazard ratio (HR) (95% 0.60, 95% CI: 0.41-0.89, p = .011). In the POCUS group 99/124 (80%) were directly admitted to a vascular surgical centre versus 25/45 (56%) in the NO POCUS, RD 24% (95% CI: 8-40)), (p = .002). In the POCUS group, system delay was a median of 142 minutes (interquartile range (IQR) 121-189) and a median of 232 minutes (IQR 166-305) in the NO POCUS group (p = .006). In a multivariable analysis incorporating age, sex, previously known rAAA, and typical clinical symptoms of rAAA, the HR for death was 0.57, 95% CI 0.38-0.86 (p = .008) favouring prehospital POCUS.

CONCLUSIONS

Prehospital POCUS was associated with reduced time to treatment, higher chance of operability and significantly higher 30-day survival in patients with rAAA, ruptured iliac aneurysm or impending rupture of an AAA in this retrospective study. Residual confounding cannot be excluded. This study supports the clinical relevance of prehospital POCUS of the abdominal aorta.

The gold standard program (GSP) for smoking cessation: a cohort study of its effectiveness among smokers with and without cancer

BACKGROUND

Smoking cessation treatment is an important prognostic factor for survival after a cancer diagnosis, especially for tobacco-related cancers. After being diagnosed with lung cancer, approximately 50% of patients continue smoking or frequently relapse after a quit attempt. Given the importance of smoking cessation treatment for cancer survivors, the objective was to compare the effectiveness of a 6-week intensive smoking cessation intervention, the Gold Standard Program (GSP), among cancer survivors compared with smokers without cancer. Second, we compared successful quitting among socioeconomically disadvantaged cancer survivors with that among nondisadvantaged cancer survivors.

MATERIALS AND METHODS

This was a cohort study based on 38,345 smokers from the Danish Smoking Cessation Database (2006-2016). Linkage to the National Patient Register was used to identify cancer survivors undergoing the GSP after being diagnosed with cancer (except nonmelanoma skin cancer). Linkage to the Danish Civil Registration System was used to identify participants who died, went missing, or emigrated before the follow-up. Logistic regression models were applied to evaluate effectiveness.

RESULTS AND CONCLUSION

Six percent (2438) of the included smokers were cancer survivors at the time they undertook the GSP. Their 6-month successful quitting showed no difference compared to that of smokers without cancer, neither before nor after adjustment; 35% versus 37% in crude rates and an aOR of 1.13 (95% CI: 0.97-1.32). Likewise, the results for disadvantaged compared to nondisadvantaged cancer survivors were not significantly different (32% versus 33% and an adjusted aOR of 0.87 (95% CI 0.69-1.11)). Overall, an intensive smoking cessation program seems effective in helping both people without cancer and cancer survivors become successful quitters.

UTI assessment tool for intermittent catheter users: a way to include user perspectives and enhance quality of UTI management

BACKGROUND

Urinary Tract Infections (UTIs) are among the most severe complications for users of intermittent catheterisation (IC), with numerous risk factors contributing to their occurrence. The aim of this study was to develop a tool to assess UTI risk factors among IC users in a systematic way that considers the perspective of the individual user.

METHODS

The Design Thinking Process was used to guide the development of the content and format of the tool. The UTI Risk Factors model by Kennelly et al. was used as a basis for developing the content. Insights on the appropriate content and format were collected via the Coloplast Nurse Advisory Boards and by conducting a qualitative evidence synthesis on user perspectives and practices in relation to UTIs.

RESULTS

The literature search identified a total of 3544 articles, out of which 22 met the inclusion criteria. Additionally, three rounds of meetings were conducted with approximately 90 nurses from the Nurse Advisory Boards across Europe. The qualitative evidence synthesis showed that users describe their UTI symptoms in different terms and that personal needs and priorities impact their adherence and catheter selection. Furthermore, some users lack relevant and updated knowledge about IC and UTIs. The nurses described that correct UTI diagnosis is essential. They pointed that they would assess the user's general condition, adherence, technique, and catheter type as potential areas of risk factors and emphasised the importance of adequate support for users. The study resulted in the development of the UTI assessment tool for intermittent catheter users, which comprises three elements: a guide for healthcare professionals, a dialogue board, and a notepad. The tool starts with a confirmation of the UTI incidence, and then assesses risk factors via questions on health, adherence, technique, and catheter, and concludes with a support section.

CONCLUSIONS

The UTI assessment tool for intermittent catheter users is designed to help healthcare professionals assess UTI risk factors in a systematic way, while engaging users and taking their perspective into account. By identifying the relevant risk factors, the use of this tool has the potential to reduce the occurrence of UTIs for the individual IC user.

Plasma neurofilament light chain is associated with mortality after spontaneous intracerebral hemorrhage

Background Neurofilament light chain (NfL) is a neuron-specific biomarker with prognostic ability in several types of central nervous system injuries. This study investigates if plasma NfL (pNfL) is elevated early after spontaneous intracerebral hemorrhage (ICH) and whether such elevation reflects disease severity and day-30 outcome. Methods pNfL was quantified by single molecule array analysis in 103 reference subjects (RS) and in samples from 37 patients with ICH obtained on admission to hospital and at 24-h follow-up. The primary outcome was day-30 mortality. Clinical status on admission was evaluated by standardized scoring systems. Results Median pNfL among RS was 9.6 (interquartile range [IQR] 6.2) pg/mL. Upon admission, ICH patients had pNfL of 19.8 (IQR 30.7) pg/mL increasing to 35.9 (IQR 44.5) pg/mL at 24 h (all, p < 0.001). On admission, pNfL was higher among ICH non-survivors than survivors (119.2 [IQR 152.6] pg/mL vs. 15.7 [IQR 19.6] pg/mL, p < 0.01) and this difference was observed also on 24 h follow-up (195.1 [IQR 73.9] pg/mL vs. 31.3 [IQR 27.8] pg/mL, p < 0.01). The area under the receiver operating characteristic curve (ROC AUC) for discrimination of day-30 mortality was significant on admission (AUC = 0.83, 95% confidence interval [CI]: 0.56-1.0) and increased on 24-h follow-up (AUC = 0.93, 95% CI: 0.84-1.0). The odds ratio (OR) for death, by each quartile increase in pNfL was significant both on admission (OR = 4.52, 95% CI: 1.32-15.48) and after 24-h follow-up (OR = 9.52, 95% CI: 1.26-71.74). Conclusions PNfL is associated with day-30 mortality after spontaneous ICH when early after the ictus.

Plasma Neurofilament Light Chain Is Associated with Poor Functional Outcome and Mortality Rate After Spontaneous Subarachnoid Hemorrhage

The initial clinical status after subarachnoid hemorrhage (SAH) is an important outcome predictor, but the mechanisms behind the early brain injury (EBI) remains incompletely understood. Elevated neurofilament levels in the cerebrospinal fluid at protracted stages after SAH are associated with poor outcome, but the potential association between plasma neurofilament (pNfL) levels during EBI, disease severity on admission, and poor outcome remains unaddressed. Plasma NfL (pNfL) was measured by single molecule array in 44 SAH patients on admission and 24 h after ictus, as well as in 44 controls. Disease severity on admission was assessed by validated scoring systems, and day 30 modified Rankin Scale (mRS) score was registered. Admission levels of pNfL correlated with clinical disease severity scores (rho = 0.43, p < 0.01 and rho = 0.48, p < 0.001) as well as day 30 mRS score (rho = 0.53, p < 0.001). Each quartile increase in pNfL was independently associated with poor functional status (mRS > 4) [odds ratio = 1.98, 95% confidence interval (CI): 1.01-3.88, p = 0.05]. Non-survivors had higher pNfL than survivors; on admission [17.6 pg/mL (IQR 11.4) vs. 8.4 pg/mL (IQR: 8.9), p < 0.01] and 24 h after ictus [29.9 pg/mL (IQR 90.4) vs 7.8 pg/mL (IQR 26.9), p = 0.01]. Each quartile increase in pNfL was independently associated with reduced survival rate [log-rank = 0.02, hazard ratio = 2.29 (95% CI): 1.15-4.57), p = 0.02]. PNfL levels are associated with disease severity during the EBI phase of SAH. Higher pNfL levels during EBI are associated with poor functional outcome on day 30 after ictus and increased mortality rate.

Changes in the Lectin Pathway Following Intracerebral or Spontaneous Subarachnoid Hemorrhage

Previous research indicates that the complement system is activated after occurrence of intracerebral hemorrhage (ICH) and spontaneous subarachnoid hemorrhage (SAH). The role of the lectin pathway (LP) of the complement system in this activation has only scarcely been investigated. The aim of this study was to determine the plasma concentration of the LP proteins in patients with ICH or SAH at admission compared to healthy individuals. Secondly, ICH and SAH patients were followed during the initial 24 h of disease, to investigate changes in LP protein concentrations during the critical acute phase. This prospective, observational study included 30 ICH and 33 SAH patients. EDTA plasma samples were collected at admission, 6 and 24 h after symptom onset. Time-resolved immuno-flourometric assays (TRIFMA) were used to measure all proteins of the LP in patient samples and in samples from age- and gender-matched healthy individuals. Compared to healthy individuals, ICH and SAH patients had increased levels of H-ficolin (p = 0.04, p = 0.03), M-ficolin (both p < 0.0001), and MAp44 (both p = 0.01) at admission. M-ficolin, H-ficolin, CL-L1, MASP-1, MASP-3, and MAp44 decreased significantly in both ICH and SAH patients during the initial 24 h after symptom onset. In conclusion, we observed significant differences in lectin pathway protein concentrations between patients with ICH or SAH and healthy individuals. Significant dynamics in lectin pathway protein levels were demonstrated during the initial 24 h after symptom onset. This indicates a potential role of the LP proteins during the acute phase of SAH and ICH.

Coagulation Profile after Spontaneous Intracerebral Hemorrhage: A Cohort Study

BACKGROUND

Intracerebral hemorrhage (ICH) causes death or disability and the incidence increases with age. Knowledge of acute hemostatic function in patients with ICH without anticoagulant and antiplatelet therapy is sparse. Increased knowledge of the coagulation profile in the acute phase of ICH could improve acute treatment and recovery. We investigated coagulation at admission and changes in coagulation during the first 24hours after symptom onset.

METHODS

Enrolled were 41 ICH patients without anticoagulant or antiplatelet therapy admitted to Aarhus University Hospital, Denmark. Blood samples were collected at admission, 6, and 24hours after symptom onset. Thromboelastometry (ROTEM), thrombin generation, and thrombin-antithrombin (TAT) complex were analyzed. Clinical outcome was evaluated using the National Institute of Health Stroke Scale, the Modified Rankin Score, and mortality.

RESULTS

At admission, compared with healthy individuals, ICH patients had increased maximum clot firmness (EXTEM P < .0001; INTEM P < .0001; FIBTEM P < .0001), increased platelet maximum clot elasticity (P < .0001) in ROTEM, higher peak thrombin (P < .0001) and endogenous thrombin potential (P = .01) in thrombin generation, and elevated TAT complex levels. During 24hours after significantly, while thrombin generation showed decreased peak thrombin (P < .0001) and endogenous thrombin potential (P < .0001). Coagulation test results did not differ between patients when stratified according to clinical outcome.

CONCLUSIONS

ICH patients without anticoagulant or antiplatelet therapy demonstrated activated coagulation at admission and within 24hours after symptom onset.

[There is a need for further studies exploring the sleep in patients during intensive care unit admission]

We have been reviewing the literature on sleep in intensive care unit (ICU) patients, concluding that lack of normal sleep is a common problem. Polysomnography studies have demonstrated sleep deprivation and fragmentation. Delirium commonly coincides with sleep deprivation and shares the same symptoms. Mechanically ventilated patients have traditionally been sedated, making sleep scoring unreliable. There is a need for further studies exploring the relationship between circadian rhythm disturbance, sleep disorders, delirium and sedation in ICU patients.

[Sublingual haematoma as a result of dysregulated peroral anticoagulant therapy]

We describe a case of spontaneous sublingual haematoma secondary to warfarin toxicity, leading to impending airway obstruction. The case was handled with the administration of vitamin K and fresh frozen plasma, and without invasive airway handling. Furthermore, we discuss the presentation of the condition and the signs of impending airway obstruction. Preferred management includes a safe airway and reversion of coagulopathy. The prognosis is good when treatment is prompt and correct.

[Takotsubo stress cardiomyopathy with mural thrombosis]

Takotsubo-cardiomyopathy is a stress-related acute cardiac disorder characterized by reversible systolic ballooning and hypokinesia of the distal part of the left ventricle, cardiac symptoms, and ECG-changes, but no coronary artery stenosis, and no other causable disease. In the present case, heart disease was suspected because of tachycardia and dyspnoea which continued after treatment for severe asthma. A mural thrombosis was an extraordinary finding in this otherwise typical case.