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ABSTRACTBackgroundThe implementation and clinical impact of machine learning–based early warning systems for patient deterioration in hospitals have not been well described. We sought to describe the implementation and evaluation of a multifaceted, real-time, machine learning–based early warning system for patient deterioration used in the general internal medicine (GIM) unit of an academic medical centre. MethodsIn this nonrandomized, controlled study, we evaluated the association between the implementation of a machine learning–based early warning system and clinical outcomes. We used propensity score–based overlap weighting to compare patients in the GIM unit during the intervention period (Nov. 1, 2020, to June 1, 2022) to those admitted during the pre-intervention period (Nov. 1, 2016, to June 1, 2020). In a difference-indifferences analysis, we compared patients in the GIM unit with those in the cardiology, respirology, and nephrology units who did not receive the intervention. We retrospectively calculated system predictions for each patient in the control cohorts, although alerts were sent to clinicians only during the intervention period for patients in GIM. The primary outcome was non-palliative in-hospital death. ResultsThe study included 13 649 patient admissions in GIM and 8470 patient admissions in subspecialty units. Non-palliative deaths were significantly lower in the intervention period than the pre-intervention period among patients in GIM (1.6% v. 2.1%; adjusted relative risk [RR] 0.74, 95% confidence interval [CI] 0.55–1.00) but not in the subspecialty cohorts (1.9% v. 2.1%; adjusted RR 0.89, 95% CI 0.63–1.28). Among high-risk patients in GIM for whom the system triggered at least 1 alert, the proportion of non-palliative deaths was 7.1% in the intervention period, compared with 10.3% in the pre-intervention period (adjusted RR 0.69, 95% CI 0.46–1.02), with no meaningful difference in subspecialty cohorts (10.4% v. 10.6%; adjusted RR 0.98, 95% CI 0.60–1.59). In the difference-indifferences analysis, the adjusted relative risk reduction for non-palliative death in GIM was 0.79 (95% CI 0.50–1.24). InterpretationImplementing a machine learning–based early warning system in the GIM unit was associated with lower risk of non-palliative death than in the pre-intervention period. Machine learning–based early warning systems are promising technologies for improving clinical outcomes.

Although the induction of behavioural unconsciousness during sleep and general anaesthesia has been shown to involve overlapping brain mechanisms, sleep involves cyclic fluctuations between different brain states known as active (paradoxical or rapid eye movement: REM) and quiet (slow-wave or non-REM: nREM) stages whereas commonly used general anaesthetics induce a unitary slow-wave brain state. Long-duration, multi-site forebrain field recordings were performed in urethane-anaesthetized rats. A spontaneous and rhythmic alternation of brain state between activated and deactivated electroencephalographic (EEG) patterns was observed. Individual states and their transitions resembled the REM/nREM cycle of natural sleep in their EEG components, evolution, and time frame ( approximately 11 minute period). Other physiological variables such as muscular tone, respiration rate, and cardiac frequency also covaried with forebrain state in a manner identical to sleep. The brain mechanisms of state alternations under urethane also closely overlapped those of natural sleep in their sensitivity to cholinergic pharmacological agents and dependence upon activity in the basal forebrain nuclei that are the major source of forebrain acetylcholine. Lastly, stimulation of brainstem regions thought to pace state alternations in sleep transiently disrupted state alternations under urethane. Our results suggest that urethane promotes a condition of behavioural unconsciousness that closely mimics the full spectrum of natural sleep. The use of urethane anaesthesia as a model system will facilitate mechanistic studies into sleep-like brain states and their alternations. In addition, it could also be exploited as a tool for the discovery of new molecular targets that are designed to promote sleep without compromising state alternations.

Background Emphysematous cystitis is a well-described life threatening complication of urinary tract infection, most commonly seen in patients with diabetes and typically caused by gas forming bacterial or fungal pathogens. Pneumorrhachis is the rare finding of gas within the spinal canal, most commonly reported in the context of cerebrospinal fluid leakage secondary to trauma or spinal instrumentation. To our knowledge there is only one other reported case of pneumorrhachis in the setting of emphysematous cystitis. Case presentation This is a single case report of pneumorrhachis in the setting of emphysematous cystitis. An 82-year-old Asian female patient originally from East Asia, with no prior medical history besides hypertension, presented to hospital with a chief complaint of acute on chronic neck pain and functional decline. Examination revealed nonspecific neurosensory deficits and suprapubic tenderness. Laboratory investigations demonstrated leukocytosis and extended-spectrum beta-lactamase containing Escherichia coli bacteremia and bacteriuria. Computed tomography showed emphysematous cystitis with widespread gas within the cervical and lumbar spinal canal, as well as multiple gas-containing soft tissue collections in the bilateral psoas muscles and paraspinal soft tissues. Despite prompt antimicrobial therapy the patient passed away within 48 hours from septic shock. Conclusions Our case adds to a growing body of literature showing that the spread of air to distant sites, including the spine, may be a poor prognostic indicator in patients with gangrenous intraabdominal infections. This report highlights the importance of recognizing the causes and presentation of pneumorrhachis to facilitate early diagnosis and treatment of potentially life threatening and treatable causes.

IntroductionCystic fibrosis (CF) is a life-limiting genetic disorder estimated to affect more than 160 000 individuals and their families worldwide. People living with CF commonly experience significant physical and emotional symptom burdens, disruptions to social roles and complex treatment decision making. While palliative care (PC) interventions have been shown to relieve many such burdens in other serious illnesses, no rigorous evidence exists for palliative care in CF. Thus, this study aims to compare the effect of specialist palliative care plus usual CF care vs usual CF care alone on patient quality of life.Methods and analysisThis is a five-site, two-arm, partially masked, randomised superiority clinical trial. 264 adults with CF will be randomly assigned to usual CF care or usual CF care plus a longitudinal palliative care intervention delivered by a palliative care specialist. The trial’s primary outcome is patient quality of life (measured with the Functional Assessment of Chronic Illness Therapy-Palliative care instrument). Secondary outcomes include symptom burden, satisfaction with care and healthcare utilisation. Outcomes will be measured at 12 months (primary endpoint) and 15 months (secondary endpoint). In addition, we will conduct qualitative interviews with patient participants, caregivers, and palliative care and CF care team members to explore perceptions of the intervention’s impact and barriers and facilitators to dissemination.Ethics and disseminationHuman subjects research ethics approval was obtained from all participating sites, and all study participants gave informed consent. We will publish the results of this trial in a peer-reviewed journal.Trial registration numberISRCTN53323164.

The transfer of patients from the intensive care unit (ICU) to the general medical ward is high risk for adverse events and health care provider dissatisfaction. We aimed to identify perceived practices, and what information is important to communicate during an ICU transfer. This study used a self-administered questionnaire that surveyed physicians in 2 different hospitals. These physicians provide care in either the ICU or the general medical ward. Responses were evaluated with Likert scales and frequencies. A total of 121 physicians (54% response rate) completed the survey. Current practice most often includes written chart and telephone communication. Most providers (63.3%) believed that the current process is inadequate. Surprises are common (79% of respondents); and reported adverse events include medication errors (60.4%), aspiration (49.5%), and decreased level of consciousness requiring intervention (44.6%). The use of an ICU transfer tool is one potential mechanism of improving this process of care, and providers reported several items that may be useful. Providers reported the current process of transferring patients from the ICU to the general medical ward as inadequate. We highlight data that physicians feel is important to communicate at the time of transfer.

A 69-year-old woman presented to the emergency department with a 3-day history of progressively worsening abdominal distention and pain. She was taking dexamethasone for cerebral edema associated with glioblastoma multiforme.

Bedside point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. At present, no consensus exists for what POCUS curriculum is appropriate for internal medicine residency training programs. This document details the consensus-based recommendations by the Canadian Internal Medicine Ultrasound (CIMUS) group, comprising 39 members, representing 14 institutions across Canada. Guiding principles for selecting curricular content were determined a priori. Consensus was defined as agreement by at least 80% of the members on POCUS applications deemed appropriate for teaching and assessment of trainees in the core (internal medicine postgraduate years [PGY] 1–3) and expanded (general internal medicine PGY 4–5) training programs. We recommend four POCUS applications for the core PGY 1–3 curriculum (inferior vena cava, lung B lines, pleural effusion, and abdominal free fluid) and three ultrasound-guided procedures (central venous catheterization, thoracentesis, and paracentesis). For the expanded PGY 4–5 curriculum, we recommend an additional seven applications (internal jugular vein, lung consolidation, pneumothorax, knee effusion, gross left ventricular systolic function, pericardial effusion, and right ventricular strain) and four ultrasound-guided procedures (knee arthrocentesis, arterial line insertion, arterial blood gas sampling, and peripheral venous catheterization). These recommendations will provide a framework for training programs at a national level.

Ultrasonography helps to ensure safe and successful insertion of an arterial catheter. This video demonstrates the use of ultrasound guidance for radial arterial catheterization in adults with the over-the-needle approach in the transverse and longitudinal planes. The Use of Compression to Differentiate Artery from Vein. The radial artery (Panel A, yellow arrow) is shown in the transverse orientation along with associated veins (white arrows). The application of light pressure with the ultrasound probe results in the collapse of the veins but not the artery, which can still be visualized (Panel B, arrow).