Discreet Values of Shock Index Pediatric Age-Adjusted (SIPA) to Predict Intervention in Children With Blunt Organ Injuries.

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Correction: Yau et al. Risk Factors for Early Return Visits to the Emergency Department in Patients Presenting with Nonspecific Abdominal Pain and the Use of Computed Tomography Scan. Healthcare 2021, 9, 1470

Massive blood loss that develops during surgery is a common cause of life-threatening conditions and deaths in patients of any age. 
This study aimed to analyze domestic and foreign publications that present methods for determining the volume of intraoperative blood loss. 
The literature sources were searched in PubMed, Scopus, Web of Science, MEDLINE, eLibrary, and Russian Science Citation Index databases. The search was conducted in Russian and English using the following keywords: intraoperative blood loss, severity of blood loss, methods for assessing blood loss, direct methods, and indirect methods. The literature review included five articles from PubMed, nine from Scopus, six from Web of Science, two from MEDLINE, six from eLibrary, and four from Russian Science Citation Index. 
Massive blood loss is understood as a one-time loss according to some authors of 30% and according to others of 50% of the volume of the circulating blood or blood loss equal in volume to 23 mL/kg/min. Risk factors for the development of intraoperative complications such as massive blood loss are, in addition to surgical interventions, the features of surgical intervention, i.e., size of the incision, surgical duration, and anesthesia, which can increase blood loss. The intensity and degree of blood loss are very important in determining the indications for transfusion of blood components, replenishing the volume of circulating blood, and determining indications for intraoperative hemostasis, both medical and surgical. In neonates and young children, the risk of dangerous intraoperative blood loss is associated with anatomical and physiological features, i.e., a small volume of circulating blood and insufficiently mature compensatory mechanisms. In older children, a high risk of massive blood loss is associated with comorbidities, features of hemostasis, and use of drugs that slow down the blood coagulation process. 
To date, several methods are available for assessing intraoperative blood loss, but only a few are used in routine clinical practice. Each method has advantages and disadvantages. One of the main disadvantages is the complexity of the mechanisms for assessing blood loss, for example, weighing surgical materials or the patient before and after surgery, determining hemoglobin in the liquid after soaking the used surgical materials, and calculating indices using formulas. Most often, the assessment of blood loss is conducted according to the clinical picture (pallor of the skin and mucous membranes, weak pulse, lowering blood pressure, etc.). 
The results of the literature analysis showed insufficient research on determining the volume of intraoperative blood loss in pediatric practice, as evidenced by the small number of published scientific papers and the complete absence of randomized trials. Thus, further study of this problem is necessary.

Intraoperative methods for assessing blood loss: A review

Importance
Emergency department (ED) visitation is common for the treatment of hidradenitis suppurativa (HS), whereas dermatology outpatient care is low. The reasons underlying this differential follow-up have not been elucidated.


Objective
To assess the interventions and patient factors associated with ED return following an initial ED visit for HS.


Design, Setting, and Participants
This retrospective cohort study used data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases (trademark symbols retained per database owner requirement). An HS cohort was formed from patients who had 2 or more claims for HS during the study period of 2010 to 2019 and with at least 1 ED visit for their HS or a defined proxy. Data were analyzed from November 2021 to May 2022.


Exposures
Factors analyzed included those associated with the ED visit and patient characteristics.


Main Outcomes and Measures
Primary outcomes were return to the ED or dermatology outpatient follow-up for HS or related proxy within 30 or 180 days of index ED visit.


Results
This retrospective cohort study included 20 269 patients with HS (median [IQR] age, 32 [25-41] years; 16 804 [82.9%] female patients), of which 7455 (36.8%) had commercial insurance and 12 814 (63.2%) had Medicaid. A total of 9737 (48.0%) patients had incision and drainage performed at the index ED visit, 14 725 (72.6%) received an oral antibiotic prescription, and 9913 (48.9%) received an opioid medication prescription. A total of 3484 (17.2%) patients had at least 1 return ED visit for HS or proxy within 30 days, in contrast with 483 (2.4%) who had a dermatology visit (P < .001). Likewise, 6893 (34.0%) patients had a return ED visit for HS or proxy within 180 days, as opposed to 1374 (6.8%) with a dermatology visit (P < .001). Patients with Medicaid and patients who had an opioid prescribed were more likely to return to the ED for treatment of their disease (odds ratio [OR], 1.48; 95% CI, 1.38-1.58; and OR, 1.48; 95% CI, 1.39-1.58, respectively, within 180 days) and, conversely, less likely to have dermatology follow-up (OR, 0.16; 95% CI, 0.14-0.18; and OR, 0.81; 95% CI, 0.71-0.91, respectively, within 180 days).


Conclusions and Relevance
This cohort study suggests that many patients with HS frequent the ED for their disease but are not subsequently seen in the dermatology clinic for ongoing care. The findings in this study raise the opportunity for cross-specialty interventions that could be implemented to better connect patients with HS to longitudinal care.

Factors Associated With Dermatologic Follow-up vs Emergency Department Return in Patients With Hidradenitis Suppurativa After an Initial Emergency Department Visit.

Point-of-care ultrasonography (POCUS) has become the most popular modality of testing for physicians in recent years and is used for improving the quality of care and increasing patient safety. However, POCUS is not always acceptable to all physicians. To address the benefits and importance of POCUS, numerous studies have examined the use of POCUS in clinical practice and even medical education. This article aims to highlight the effects of POCUS as an extension of the physical examination, and we present a case to address the reasons it should be performed. For a man experiencing abdominal pain immediately after his feeding jejunostomy tube was changed, there was high suspicion of small-bowel volvulus after a “whirlpool sign” was observed during the POCUS, whereby mesenteric vessels presented in a whirling or spiral shape. This impression was subsequently confirmed by computed tomography. Small-bowel volvulus is a rare complication of changing a feeding jejunostomy tube. The images submitted here add to the sparse evidence from the literature on the use of POCUS as an extension of the physical examination for evaluating abdominal pain. POCUS can be used after taking the patient’s history and conducting a physical examination. The observation of a whirlpool sign may indicate the presence of a volvulus that is life-threatening.

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Point-of-Care Ultrasonography as an Extension of the Physical Examination for Abdominal Pain in the Emergency Department: The Diagnosis of Small-Bowel Volvulus as a Rare Complication after Changing the Feeding Jejunostomy Tube

Risk Factors for Early Return Visits to the Emergency Department in Patients Presenting with Nonspecific Abdominal Pain and the Use of Computed Tomography Scan.

Background: The shock index, pediatric age-adjusted (SIPA), defined as the maximum normal heart rate divided by the minimum normal systolic blood pressure by age, can help predict the risk of morbidity and mortality after pediatric trauma. This study investigated whether the SIPA can be used as an early index of prognosis for non-traumatic children visiting the pediatric emergency department (ED) and were directly admitted to the intensive care unit (ICU). We hypothesized that an increase in SIPA values in the first 24 h of ICU admission would correlate with mortality and adverse outcomes. Methods: This multicenter retrospective study enrolled non-traumatic patients aged 1-17 years who presented to the pediatric ED and were directly admitted to the ICU from January 1, 2016, to December 31, 2018, in Taiwan. The SIPA value was calculated at the time of arrival at the ED and 24 h after ICU admission. Cutoffs included SIPA values >1.2 (patient age: 1-6), >1.0 (patient age: 7-12), and >0.9 (patient age: 12-17). The utility of the SIPA and the trends in the SIPA during the first 24 h of ICU admission were analyzed to predict outcomes. Results: In total, 1,732 patients were included. Of these, 1,050 (60.6%) were under 6 years old, and the median Pediatric Risk of Mortality score was 7 (5-10). In total, 4.7% of the patients died, 12.9% received mechanical ventilator (MV) support, and 11.1% received inotropic support. The SIPA value at 24 h after admission was associated with increased mortality [odds ratio (OR): 4.366, 95% confidence interval (CI): 2.392-7.969, p < 0.001], MV support (OR: 1.826, 95% CI: 1.322-2.521, p < 0.001), inotropic support (OR: 2.306, 95% CI: 1.599-3.326, p < 0.001), and a long hospital length of stay (HLOS) (2.903 days, 95% CI: 1.734-4.271, p < 0.001). Persistent abnormal SIPA value was associated with increased mortality (OR: 2.799, 95% CI: 1.566-5.001, p = 0.001), MV support (OR: 1.457, 95% CI: 1.015-2.092, p = 0.041), inotropic support (OR: 1.875, 95% CI: 1.287-2.833, p = 0.001), and a long HLOS (3.2 days, 95% CI: 1.9-4.6, p < 0.001). Patients with abnormal to normal SIPA values were associated with decreased mortality (OR: 0.258, 95% CI: 0.106-0.627, p = 0.003), while patients with normal to abnormal SIPA values were associated with increased mortality (OR: 3.055, 95% CI: 1.472-5.930, p = 0.002). Conclusions: In non-traumatic children admitted to the ICU from the ED, increased SIPA values at 24 h after ICU admission predicted high mortality and bad outcomes. Monitoring the trends in the SIPA could help with prognostication and optimize early management.

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Shock Index, Pediatric Age-Adjusted Predicts Morbidity and Mortality in Children Admitted to the Intensive Care Unit.

BACKGROUND
Machine learning models have demonstrated superior performance in predicting invasive bacterial infection (IBI) in febrile infants compared to commonly used risk stratification criteria in recent studies. However, the black-box nature of these models can make them difficult to apply in clinical practice. In this study, we developed and validated an explainable deep learning model that can predict IBI in febrile infants ≤ 60 days of age visiting the emergency department.


METHODS
We conducted a retrospective study of febrile infants aged ≤ 60 days who presented to the pediatric emergency department of a medical center in Taiwan between January 1, 2011 and December 31, 2019. Patients with uncertain test results and complex chronic health conditions were excluded. IBI was defined as the growth of a pathogen in the blood or cerebrospinal fluid. We used a deep neural network to develop a predictive model for IBI and compared its performance to the IBI score and step-by-step approach. The SHapley Additive Explanations (SHAP) technique was used to explain the model's predictions at different levels.


RESULTS
Our study included 1847 patients, 53 (2.7%) of whom had IBI. The deep learning model performed similarly to the IBI score and step-by-step approach in terms of sensitivity and negative predictive value, but provided better specificity (54%), positive predictive value (5%), and area under the receiver-operating characteristic curve (0.87). SHapley Additive exPlanations identified five influential predictive variables (absolute neutrophil count, body temperature, heart rate, age, and C-reactive protein).


CONCLUSION
We have developed an explainable deep learning model that can predict IBI in febrile infants aged 0-60 days. The model not only performs better than previous scoring systems, but also provides insight into how it arrives at its predictions through individual features and cases.

Ying Yang

Papers

Risk Factors for Early Return Visits to the Emergency Department in Patients Presenting with Nonspecific Abdominal Pain and the Use of Computed Tomography Scan.

Shock Index, Pediatric Age-Adjusted Predicts Morbidity and Mortality in Children Admitted to the Intensive Care Unit.

Correction: Yau et al. Risk Factors for Early Return Visits to the Emergency Department in Patients Presenting with Nonspecific Abdominal Pain and the Use of Computed Tomography Scan. Healthcare 2021, 9, 1470

Explainable deep learning model to predict invasive bacterial infection in febrile young infants: A retrospective study