A Crohn’s Disease Patient with Extraintestinal Manifestations: A Case Report

Crohn’s disease (CD) is a chronic debilitating inflammatory disease which mostly affect gastrointestinal tract, but due to its unique features, CD enables to affect extraintestinal organs. Pathophysiology of extraintestinal manifestations is still debatable as many experts propose immune-related hypotheses. It is still unpredictable which manifestation precedes another as studies ongoing. Diagnosing CD is difficult since no gold standards available, therefore clinicians must combine history taking, diagnostic modalities, and a good clinical judgement to diagnose CD. Treatment for CD is not only to treat disease activity, but also to prevent complications to preserve patients’ quality of life.

Prospective comparison of AMB, GAP AND START scores and triage nurse clinical judgement for predicting admission from an ED: a single-centre prospective study

BackgroundIt is postulated that early determination of the need for admission can improve flow through EDs. There are several scoring systems which have been developed for predicting patient admission at triage, although they have not been directly compared. In addition, it is not known if these scoring systems perform better than clinical judgement. Therefore, the aim of this study was to validate existing tools in predicting hospital admission during triage and then compare them with the clinical judgement of triage nurses.MethodsTo conduct this prospective, single-centre observational study, we enrolled consecutive adult patients who presented between 30 September 2019 and 25 October 2019 at the ED of a large teaching hospital in Milan, Italy. For each patient, triage nurses recorded all of the variables needed to perform Ambulatory (AMB), Glasgow Admission Prediction (GAP) and Sydney Triage to Admission Risk Tool (START) scoring. The probability of admission was estimated by the triage nurses using clinical judgement and expressed as a percentage from 0 to 100 with intervals of 5. Nurse estimates were dichotomised for analysis, with ≥50% likelihood being a prediction of admission. Receiver operating characteristic curves were generated for accuracy of the predictions. Area under the curve (AUC) with 95% CI for each of the scores and for the nursing judgements was also calculated.ResultsA total of 1710 patients (844 men; median age, 54 years (IQR: 34–75)) and 35 nurses (15 men; median age, 37 years (IQR: 33–48)) were included in this study. Among these patients, 310 (18%) were admitted to hospital from the ED. AUC values for AMB, GAP and START scores were 0.77 (95% CI: 0.74 to 0.79), 0.72 (95% CI: 0.69 to 0.75) and 0.61 (95% CI: 0.58 to 0.64), respectively. The AUC for nurse clinical judgement was 0.86 (95% CI: 0.84 to 0.89).ConclusionAMB, GAP and START scores provided moderate accuracy in predicting patient admission. However, all of the scores were significantly worse than the clinical judgement of the triage nurses.

Preoperative Management of Diabetic Patients, an Overview

Glycemic control is critical in the perioperative setting, especially in diabetic patients. The consequences of surgical tension and anesthesia on blood sugar levels are distinct, and should be considered in order to maintain optimal glycemic control. Each stage of surgery presents its own set of challenges in terms of keeping glucose levels within the target range. Furthermore, there are some surgical conditions that necessitate specific glucose management protocols. Authors hope to highlight the most crucial factors to consider when developing a perioperative diabetic regimen, while still allowing for specific adjustments based on sound clinical judgement. Overall, by carefully managing glycemic control in perioperative patients, we may be able to reduce morbidity and mortality while improving surgical outcomes.

Standardised Holographic Patients: An Evaluation of Their Role in Developing Clinical Reasoning Skills

In 2019, two standardised holographic patients viewed through a mixed-reality (MR) HoloLens headset were used in a structured learning activity to develop clinical reasoning skills among second-year nursing students (N=99, 94%). Quantitative results indicated that all students felt that being able to closely view holographic patients enhanced their learning experience. Qualitative results showed that the best feature of the MR technology was being able to clinically assess the patient in a safe facilitated environment. Further analysis revealed that students were at the ‘beginning’ or ‘developing’ skill level of the vpLCJR. These findings confirm that using standardized holographic patients offers a dynamic and effective experience for students and helps students to develop clinical reasoning and judgement skills. The technology also allows educators to determine a student’s development of clinical judgement skills and tailor learning experiences to further develop these skills.

341 Observational multicentre study on effectiveness and tolerability of Alirocumab in real world, the OMERO study: interim data from the first 699 patients

Aims OMERO is a prospective study, aimed to assess the long-term effectiveness, tolerability, and safety of alirocumab, a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9-i), in the real life in Italy. The study is planned to include 800 patients, from 40 Italian sites, treated with alirocumab on top of standard lipid lowering therapy. Methods and results This analysis concerns 699 (out of 800) patients with all data available: 65.5% male; mean age 60.6 ± 11.09 years; 29.6% with HeFH in primary prevention; 70.4% in secondary prevention (with/without HeFH). Before ALI administration, 461 patients (66%) were treated with statins while 231 (33%) reported statin intolerance, that resulted in the statin discontinuation. Mean baseline LDL-C was 161.5 ± (53.07) mg/dl. Based on clinical judgement, ALI was initially prescribed at 75 mg Q2W dosing regimen in 60.80% of participants, whereas the remainder received 150 mg Q2W. At V1 57 patients (89.06%) switch from 75 mg Q2W to 150 mg Q2W and 7 patients (10.94%) from 150 mg Q2W to 75 mg Q2W. LDL-C level reduction from baseline (before ALI administration) to 6 months from the study enrolment (V1), was −45% (V1: mean LDL-C was 73.5 ± 45.70 mg/dl). LDL-C levels at V1 by participant category are shown in Figure 1. The rate of patients with at least one adverse event was 25.6% (of which SAE 7.4%); the rate of patients with at least one related adverse reaction to treatment was 3.8% none of them were serious. Conclusions OMERO confirmed in clinical practice the results observed in trials: a significant reduction of LDL-C was observed with ALI 75/150 mg Q2W in participants at high CV risk with or without HeFH. ALI was generally well tolerated.

Bridging the impactibility gap in population health management: a systematic review

ObjectivesAssess whether impactibility modelling is being used to refine risk stratification for preventive health interventions.DesignSystematic review.SettingPrimary and secondary healthcare populations.PapersArticles published from 2010 to 2020 on the use or implementation of impactibility modelling in population health management, reported with the terms ‘intervenability’, ‘amenability’, and ‘propensity to succeed’ (PTS) and associated with the themes ‘care sensitivity’, ‘characteristic responders’, ‘needs gap’, ‘case finding’, ‘patient selection’ and ‘risk stratification’.InterventionsQualitative synthesis to identify themes for approaches to impactibility modelling.ResultsOf 1244 records identified, 20 were eligible for inclusion. Identified themes were ‘health conditions amenable to care’ (n=6), ‘PTS modelling’ (n=8) and ‘comparison or combination with clinical judgement’ (n=6). For the theme ‘health conditions amenable to care’, changes in practice did not reduce admissions, particularly for ambulatory care sensitive conditions, and sometimes increased them, with implementation noted as a possible issue. For ‘PTS modelling’, high costs and needs did not necessarily equate to high impactibility and targeting a larger number of individuals with disorders associated with lower costs had more potential. PTS modelling seemed to improve accuracy in care planning, estimation of cost savings, engagement and/or care quality. The ‘comparison or combination with clinical judgement’ theme suggested that models can reach reasonable to good discriminatory power to detect impactable patients. For instance, a model used to identify patients appropriate for proactive multimorbid care management showed good concordance with physicians (c-statistic 0.75). Another model employing electronic health record scores reached 65% concordance with nurse and physician decisions when referring elderly hospitalised patients to a readmission prevention programme. However, healthcare professionals consider much wider information that might improve or impede the likelihood of treatment impact, suggesting that complementary use of models might be optimum.ConclusionsThe efficiency and equity of targeted preventive care guided by risk stratification could be augmented and personalised by impactibility modelling.

The Impact of Standard in-Patients Exposure on Clinical Judgement among Undergraduate Nursing Students at SNC Lahore

Background: Clinical judgment skills development of nursing professional is essential and vital during clinical education. This quasi experimental study hasevaluated the impact of standardizedIn-patient’s exposure on clinical judgment among under graduate nursing students using observational measures. Method: A single group of undergraduate students was recruited with purposive sampling at College of Nursing, Shalamar Hospital Lahore, Pakistan and Tanner’s clinical rubric model was used. A total 78 under graduate nursing students accomplished in five In-patients exposure within 45 clinical hours. Two Clinical Nursing Instructors were hired to evaluate the outcome of nursing students; clinical judgment at the end of each standardized in-patient exposure session. The inter-rater reliability ranged 0.830 to 0.90 for the session. Results: Clinical judgment outcome were improved from first in-patient exposure to last patient exposure compared with pre and post data of clinical judgement of patient second, third, fourth and fifth. The debriefing method was helpful for the undergraduate nursing students to improve their critical thinking. The undergraduate nursing students confessed that in-patient exposure has not only uplifted their clinical experience but also strengthened the critical thinking in emergency situation and improve the ability to notice, interpret, and respond suitably. The clinical nursing faculty also highlighted and valued the newly learned knowledge and commented that exposure of In-patients to under graduate nursing students is essential for clinical skills preparation. Conclusion: Standardized In-patient exposure has potential to support the undergraduate nursing student for the development of clinical judgement. No doubt, the clinical instructor has enhanced nursing professional’s intrinsic motivation but standardized in-patient presented a true picture, while learning to complete assessment skills.A difference may exist between high fidelity simulator and standardized in-patient exposure among undergraduate nursing students, so further research can explore this phenomenology. Key words:Nursing students, Clinical Judgment, Standardized in-patients, Nursing professionals.

A Case of Restrictive Lung Disease Masquerading as Sars-Cov-2 Pneumonia: The Complexity of Integrating Lung Ultrasound in Clinical Management

This report aims to highlight the importance of integrating the lung ultrasound findings in the clinical judgement, and to integrate its findings, exemplified in this patient, thought to have COVID-19 bilateral pneumonia, and turn out to have an infectious spondylodiscitis and secondary, a restrictive lung disease.As ultrasound devices become increasingly portable and affordable, the future potential of lung ultrasound relies on a not lesser degree of clinical skills acquisition.