Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context. https://bmjopen.bmj.com/content/6/5/e011585

During the last decade, experimental and clinical studies have demonstrated that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after brain injury (BI). The pathophysiology of these brain–lung interactions are complex and involve neurogenic pulmonary oedema, inflammation, neurodegeneration, neurotransmitters, immune suppression and dysfunction of the autonomic system. The systemic effects of inflammatory mediators in patients with BI create a systemic inflammatory environment that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery and infections. Indeed, previous studies have shown that in the presence of a systemic inflammatory environment, specific neurointensive care interventions—such as MV—may significantly contribute to the development of lung injury, regardless of the underlying mechanisms. Although current knowledge supports protective ventilation in patients with BI, it must be born in mind that ABI-related lung injury has distinct mechanisms that involve complex interactions between the brain and lungs. In this context, the role of extracerebral pathophysiology, especially in the lungs, has often been overlooked, as most physicians focus on intracranial injury and cerebral dysfunction. The present review aims to fill this gap by describing the pathophysiology of complications due to lung injuries in patients with a single ABI, and discusses the possible impact of MV in neurocritical care patients with normal lungs.

Background: Although the proper use of hygiene and personal protective equipment (PPE) is paramount for preventing the spread of diseases such as COVID-19, health care personnel have been shown to use incorrect techniques for donning/doffing of PPE and hand hygiene, leading to a large number of infections among health professionals. Education and training are difficult owing to the social distancing restrictions in place, shortages of PPE and testing material, and lack of evidence on optimal training. Virtual reality (VR) simulation can offer a multisensory, 3-D, fully immersive, and safe training opportunity that addresses these obstacles. Objective: The aim of this study is to explore the short- and long-term effectiveness of a fully immersive VR simulation versus a traditional learning method regarding a COVID-19–related skill set and media-specific variables influencing training outcomes. Methods: This was a prospective, randomized controlled pilot study on medical students (N=29; intervention VR training, n=15, vs control video-based instruction, n=14) to compare the performance of hand disinfection, nasopharyngeal swab taking, and donning/doffing of PPE before and after training and 1 month later as well as variables of media use. Results: Both groups performed significantly better after training, with the effect sustained over one month. After training, the VR group performed significantly better in taking a nasopharyngeal swab, scoring a median of 14 out of 17 points (IQR 13-15) versus 12 out of 17 points (IQR 11-14) in the control group, P=.03. With good immersion and tolerability of the VR simulation, satisfaction was significantly higher in the VR group compared to the control group (median score of User Satisfaction Evaluation Questionnaire 27/30, IQR 23-28, vs 22/30, IQR 20-24, in the control group; P=.01). Conclusions: VR simulation was at least as effective as traditional learning methods in training medical students while providing benefits regarding user satisfaction. These results add to the growing body of evidence that VR is a useful tool for acquiring simple and complex clinical skills.

Background: Diuretics are among the most commonly prescribed medications and, due to their mechanisms of action, electrolyte disorders are common side effects of their use. In the present work we investigated the associations between diuretics being taken and the prevalence of electrolyte disorders on admission as well as the impact of electrolyte disorders on patient outcome. Methods: In this cross sectional analysis, all patients presenting between 1 January 2010 and 31 December 2011 to the emergency room (ER) of the Inselspital, University Hospital Bern, Switzerland were included. Data on diuretic medication, baseline characteristics and laboratory data including electrolytes and renal function parameters were obtained from all patients. A multivariable logistic regression model was performed to assess the impact of factors on electrolyte disorders and patient outcome. Results: A total of 8.5% of patients presenting to the ER used one diuretic, 2.5% two, and 0.4% three or four. In all, 4% had hyponatremia on admission and 12% hypernatremia. Hypokalemia was present in 11% and hyperkalemia in 4%. All forms of dysnatremia and dyskalemia were more common in patients taking diuretics. Loop diuretics were an independent risk factor for hypernatremia and hypokalemia, while thiazide diuretics were associated with the presence of hyponatremia and hypokalemia. In the Cox regression model, all forms of dysnatremia and dyskalemia were independent risk factors for in hospital mortality. Conclusions: Existing diuretic treatment on admission to the ER was associated with an increased prevalence of electrolyte disorders. Diuretic therapy itself and disorders of serum sodium and potassium were risk factors for an adverse outcome.

Nonalcoholic fatty liver disease (NAFLD) emerges as an important global burden and Helicobacter pylori infection (Hp-I) has been suggested as a risk factor of NAFLD, although controversy exists. This retrospective study aimed to investigate a potential impact of active Hp-I on NAFLD severity in morbidly obese patients, subjected to bariatric surgery and gastric biopsy for documentation of Hp-I. Of 64 eligible participants, 15 (23.4%) were diagnosed with active Hp-I, showing higher rates of nonalcoholic steatohepatitis (NASH) than those without Hp-I (86.7% vs. 26.5%, respectively; p < 0.001). Concerning histological lesions, steatosis grade (p = 0.027), ballooning (p < 0.001), lobular inflammation (p = 0.003), and fibrosis stage (p < 0.001) were also more severe in Hp-I positive patients. Likewise, liver function tests, insulin resistance, dyslipidemia, and arterial hypertension were significantly higher in Hp-I positive patients. Hp-I was independently positively associated with NASH (beta = 3.27; p = 0.002), severe NASH (beta = 2.37; p = 0.018), and the presence of fibrosis (beta = 3.86; p = 0.001) in a binary regression model, after adjustment for potential confounders. In conclusion, active Hp-Ι was independently associated with NASH and fibrosis, findings offering potential clinical implication.

A versatile method is reported for the manufacturing of antimicrobial (AM) surgery equipment utilising fused deposition modelling (FDM), three-dimensional (3D) printing and sonochemistry thin-film deposition technology. A surgical retractor was replicated from a commercial polylactic acid (PLA) thermoplastic filament, while a thin layer of silver (Ag) nanoparticles (NPs) was developed via a simple and scalable sonochemical deposition method. The PLA retractor covered with Ag NPs (PLA@Ag) exhibited vigorous AM properties examined by a reduction in Staphylococcus aureus (S. aureus), Pseudomonas aeruginosa (P. aeruginosa) and Escherichia coli (E. coli) bacteria viability (%) experiments at 30, 60 and 120 min duration of contact (p < 0.05). Scanning electron microscopy (SEM) showed the surface morphology of bare PLA and PLA@Ag retractor, revealing a homogeneous and full surface coverage of Ag NPs. X-Ray diffraction (XRD) analysis indicated the crystallinity of Ag nanocoating. Ultraviolent-visible (UV-vis) spectroscopy and transmission electron microscopy (TEM) highlighted the AgNP plasmonic optical responses and average particle size of 31.08 ± 6.68 nm. TEM images of the PLA@Ag crossection demonstrated the thickness of the deposited Ag nanolayer, as well as an observed tendency of AgNPs to penetrate though the outer surface of PLA. The combination of 3D printing and sonochemistry technology could open new avenues in the manufacturing of low-cost and on-demand antimicrobial surgery equipment.