Background: Acute stroke patients are usually transported to the nearest hospital regardless of their required level of care. This can lead to increased pressure on emergency departments and treatment delay. Objective: The aim of the study was to explore the benefit of a mobile stroke unit (MSU) in the UK National Health Service (NHS) for reduction of hospital admissions. Methods: Prospective cohort audit observation with dispatch of the MSU in the East of England Ambulance Service area in Southend-on-Sea was conducted. Emergency patients categorized as code stroke and headache were included from June 5, 2018, to December 18, 2018. Rate of avoided admission to the accident and emergency (A&E) department, rate of admission directly to target ward, and stroke management metrics were assessed. Results: In 116 MSU-treated patients, the following diagnoses were made: acute stroke, n = 33 (28.4%); transient ischaemic attacks, n = 13 (11.2%); stroke mimics, n = 32 (27.6%); and other conditions, n = 38 (32.8%). Pre-hospital thrombolysis was administered to 8 of 28 (28.6%) ischaemic stroke patients. Pre-hospital diagnosis avoided hospital admission for 29 (25.0%) patients. As hospital treatment was indicated, 35 (30.2%) patients were directly triaged to the stroke unit, 1 patient (0.9%) even directly to the catheter laboratory. Thus, only 50 (43.1%) patients required transfer to the A&E department. Moreover, the MSU enabled thrombolysis with a median dispatch-to-needle time of 42 min (interquartile range, 40–60). Conclusion: This first deployment of an MSU in the UK NHS demonstrated improved triage decision-making for or against hospital admission and admission to the appropriate target ward, thereby reducing pressure on strained A&E departments.

Our study shows lower frequency of morbidity in JIA; probably related to a better healthcare system facilitating early diagnosis and treatment in this part of the country.

Objective: To evaluate serial ferritin levels measured in the initial 72 h of admission as a biomarker for new and progressive multi organ dysfunction syndrome (NPMODS) and mortality (unfavorable outcomes) in critically ill children with sepsis due to tropical infections.Material and Methods: In this prospective observational study from a tertiary care teaching hospital in India, children 3 month to 12 years with a diagnosis of acute febrile illness and any two features suggesting tropical infections [cytopenia (platelet count <1,00,000/cu.mm, total leucocyte count <4,000/cu.mm), hepatomegaly and/or splenomegaly, lymphadenopathy, systemic signs (rash, edema), respiratory distress, and encephalopathy not accounted by localized infection] were eligible for inclusion. Children with known or suspected disorder of iron metabolism were excluded. Primary outcome was to determine the association of serial ferritin levels with mortality and NPMODS. Secondary outcomes included estimation of the prevalence of hyperferritinemia and comparison of risk prediction scores with serial ferritin measurement in predicting unfavorable outcomes.Measurements and Main Results: In the 202 children enrolled, diagnosis could be established in 133 (65.8%) children. Scrub typhus and dengue were the most common infections. Median (IQR) ferritin measured at admission (n = 183) and on day 3 (n = 120) of hospital stay were 798 (378, 3,205) μg/L and 429 (213,680) μg/L, respectively. Majority (n = 180, 89.1%) had MODS at admission defined as per International pediatric sepsis consensus conference. NPMODS occurred in 47 (23.3%) children of whom 37 (18.3%) died. Children with three or less organ dysfunctions had lower mortality. Neither admission ferritin values nor the percentage change over 72 h was different between children with favorable and unfavorable outcomes. Pediatric Risk of Mortality (PRISM-III) and daily Pediatric Logistic Organ Dysfunction score (dPELOD2 score) were significantly different in those with unfavorable outcomes. Admission ferritin levels and percentage change in 72 h had poor discriminatory power for mortality with AUC of 0.53 (0.53, 0.67) and 0.50 (0.50, 0.64), respectively. dPELOD2 had the best discriminatory power for mortality with AUC of 0.89 (0.89, 0.95).Conclusions: Serial ferritin estimation predicted neither organ dysfunction nor mortality in pediatric sepsis with tropical infections. dPELOD-2 and PRISM-III predicted unfavorable outcomes better than ferritin. The current diagnostic criteria for MODS overestimated organ dysfunctions in tropical infections and hence may need modification with further validation in this epidemiological cohort.

Background: ASPECTS (Alberta Stroke Program Early CT Score) is a validated scoring system for assessment of early ischemic change (EIC) on CT head scans, which can be used to guide patient management and improve diagnostic accuracy. Detection of EIC can be challenging particularly for less experienced clinicians. e-ASPECTS software uses machine learning algorithms to support physicians in detecting EIC, which can be quantified using the ASPECTS score. Hypothesis: e-ASPECTS shortens time for CT scan assessment and improves agreement with reference standard ASPECTS when compared to blinded assessment. Methods: 26 clinicians (including 11 radiologists, 6 junior and 7 consultant stroke physicians, and 2 non-specialist physicians) independently scored 2560 ASPECTS regions from 64 patients for signs of EIC on non-contrast CT brain scans. These were acquired within 4.5 hours of stroke onset. A familiarization training set of 5 patients was used prior to scoring. Images were randomized to manual or software assistance. After two weeks images were rescored using the alternative method. Scorers were blinded to clinical symptoms. Reference standard scores were defined by an independent neuroradiologist with information on clinical symptoms, access to 24h follow-up, and with CT perfusion or MRI scans when available. Results: Mean NIHSS was 11. Mean time to score scans fell by 34% (45s, 2:12 to 1:27, mm:ss) using e-ASPECTS assistance. Rater agreement with ground truth was greatest in the radiologist cohort, but performance improved across all clinician categories using e-APSECTS assistance (radiology kappa: 0.26 to 0.38). Sensitivity to EIC improved by a factor of two across all clinician groups using e-ASPECTS assistance, and this was most marked for less experienced physicians. Conclusion: In acute ischemic stroke e-ASPECTS assisted analysis increased accuracy and reduced time for detection of EIC. Routine assistance of non-contrast CT interpretation has the potential to reduce treatment times and improve accuracy across clinicians and sites.

Background Hyperferritinemia is increasingly associated with mortality in sepsis. Studies estimating the prevalence of hyperferritinemia in pediatric scrub typhus are limited. Methods This was a secondary analysis of a prospective observational study (FERRIS) from a tertiary care teaching hospital in North India where 72 children with confirmed scrub typhus, 4 (5.5%) PCR positive, 55 (76.4%)-IgM ELISA positive, and 13 (18.1%)-both PCR and ELISA positive, were analyzed. Serum ferritin was measured in 62 children to identify the prevalence of hyperferritinemia and determine its association with mortality. Results Hyperferritinemia (> 500 μg/L) was seen in 72.6% [n = 45] children; 26 (41.9%) were mild (500–2000 μg/L), 13 (21%) were moderate (2000–10,000 μg/L), and 6 (9.7%) were severe (> 10,000 μg/L). Early presentation to hospital (≤ 7 days of febrile illness) had more survivors than late presentation (> 7 days). Non-survivors had significantly higher PRISM III, PELOD-2, hyperlactatemia, hypoalbuminemia, organ dysfunction, need for mechanical ventilation, and need of RRT. Ferritin had poor sensitivity and specificity in predicting survival with AUC of 0.56. Organ dysfunction and risk scores as PRISM III, PELOD 2, and VIS at admission were better predictors with AUC (95% CI) of 0.72 (0.56, 0.89), 0.77 (0.63, 0.92), and 0.90 (0.78, 1.0) respectively. Conclusions Hyperferritinemia is common in scrub typhus but it did not predict survival. Organ dysfunction and risk scores were better predictors of mortality than ferritin.

No abstract

Background: Hyperferritinemia is increasingly associated with mortality in sepsis. Studies estimating the prevalence of hyperferritinemia in pediatric scrub typhus is limited.Methods: We conducted a prospective observational study from a tertiary care teaching hospital in North India where 72 children with confirmed scrub typhus;17(24%)-PCR positive, 68(94%)-IgM ELISA positive and 13(18%)-both PCR and ELISA positive. Serum ferritin was measured in 62 children to identify the prevalence of hyperferritinemia and determine its association with mortality. Results: Hyperferritinemia (>500µg/L) was seen in 72.6% [n=45] children; 26(42%) were mild (500-2000µg/L), 13(21%) were moderate (2000-10000µg/L) and 6(9.7%) were severe (>10000µg/L). A biphasic pattern of hyperferritinemia was seen with two peaks when plotted against duration since symptoms onset; one between 2 and 3 days (early onset hyperferritinemia) and second peak between 12 and14 days (late onset hyperferritinemia). Early onset hyperferritinemia had more survivors than late onset hyperferritinemia. Non survivors had significantly higher PRISM III, PELOD-2, hyperlactatemia, hypoalbuminemia, organ dysfunction, need for mechanical ventilation and need of RRT. Ferritin had poor sensitivity and specificity in predicting survival with AUC of 0.56. Organ dysfunction and risk scores as PRISM III, PELOD 2 and VIS at admission were better predictors with AUC(95%CI) of 0.72(0.56,0.89), 0.77(0.63,0.92) and 0.90(0.78,1.0) respectively.Conclusions: Hyperferritinemia is common in scrub typhus. A distinct biphasic response was observed with worse outcome in late onset hyperferritinemia. Organ dysfunction and risk scores were better predictors of mortality than ferritin.