INTRODUCTION: The purpose of this study was to assess the application of the early warning score system (EWS-S) and gauge physician awareness, perceptions of necessity and attitudes regarding these tools based on previously experienced unnoticed clinical deterioration (CDET). METHODS: A cross-sectional survey was carried out via an online questionnaire at a large 3,500-bed Class 3A general hospital in China. A total of 299 physicians of adult general wards were asked to answer a translated questionnaire that was localised from the original version. Demographic profiles of patients were included as well as three other sections assessing awareness of CDET/EWS-S and gauging attitudes towards and perceptions of the necessity of EWS-S at our hospital. RESULTS: A high level of physician awareness of the CDET problem was observed. Most physicians knew about the existence of a systematic assessment tool for clinical application. Physicians with previous experience in reanimation, unplanned transfer to intensive care unit (UTICU) and/or death tended to consider EWS-S necessary in attentive and well-trained staff (p < 0.05). Physicians who had previous experience with UTICU were more likely to recommend implementing EWS-S in their wards compared with those without such experience (p < 0.05). CONCLUSION Most physicians have positive attitudes towards EWS-S. However, their awareness should be further heightened. Physicians who had previous experience with CDET/UTICU were more likely to employ EWS-S in their clinical practices. To better facilitate the implementation of EWS-S in Chinese hospitals, existing facilities, policy supports, standardised managements and the development of information systems should be strengthened.
Adult ; Attitude ; Clinical Deterioration ; Cross-Sectional Studies ; Early Warning Score ; Humans ; Physicians

Objective: To assess the performance of prognostic models in predicting mortality or clinical deterioration among patients with COVID-19, both hospitalized and non-hospitalized Methods: We conducted a systematic review of the literature until March 8, 2021. We included models for the prediction of mortality or clinical deterioration in COVID-19 with external validation. We used the Prediction model Risk Of Bias ASsessment Tool (PROBAST) and the GRADEpro Guideline Development Tool (GDT) to assess the evidence obtained. Results: We reviewed 33 cohort studies. Two studies had a low risk of bias, four unclear risks, and 27 with a high risk of bias due to participant selection and analysis. For the outcome of mortality, the QCOVID model had excellent prediction with high certainty of evidence but was specific for use in England. The COVID Outcome Prediction in the Emergency Department (COPE) model, the 4C Mortality Score, the Age, BUN, number of comorbidities, CRP, SpO2/FiO2 ratio, platelet count, heart rate (ABC2-SPH) risk score, the Confusion Urea Respiration Blood Pressure (CURB-65) severity score, the Rapid Emergency Medicine Score (REMS), and the Risk Stratification in the Emergency Department in Acutely Ill Older Patients (RISE UP) score had fair to good prediction of death among inpatients, while the quick Sepsis-related Organ Failure Assessment (qSOFA) score had poor to fair prediction. The certainty of evidence for these models was very low to low. For the outcome of clinical deterioration, the 4C Deterioration Score had fair prediction, the National Early Warning Score 2 (NEWS2) score poor to good, and the Modified Early Warning Score (MEWS) had poor prediction. The certainty of evidence for these three models was also very low to low. None of these models had been validated in the Philippine setting. Conclusion The QCOVID, COPE, ABC2-SPH, 4C, CURB-65, REMS, RISE-UP models for prediction of mortality and the 4C Deterioration and NEWS2 models for prediction of clinical deterioration are potentially useful but need to be validated among patients with COVID-19 of varying severity in the Philippine setting.
COVID-19 ; Mortality ; Clinical Deterioration

INTRODUCTION: Dural arteriovenous fistulae (DAVF) are relatively rare lesions that are composed of abnormal connections between dural arteries and usually adjacent cortical veins. Their true incidence is unknown. 1 Diagnosis is oftentimes difficult because the clinical and radiological findings are similar with the much more frequent spinal DAVFs.8 We report a case of DAVF with an even more rarely seen venous drainage into the perimedullary veins.

CASE: A 37-year-old, female, Filipino presented with progressive motor weakness of all extremities for 3 years. Initial neuroimaging studies of the brain and spinal cord were interpreted as normal despite progressive clinical deterioration. A cranial angiogram was then done which showed a DAVF at the right cerebellar dura mainly supplied by the branches of the right ECA. Several stages of coil and nBCA glue embolization were done on the supplying arterial branches but the patient failed to improve clinically. The patient was referred to our institution's Neuroendovascular Team and review of all previous studies done showed multiple proximal branches of the right BCA forming a low flow extracranial dural fistula with bilateral perimedullary veins. This was exacerbated by continuous recruitment of arterial feeders due to failure of previous embolization procedures.

DISCUSSIONS: Intracranial DAVFs with spinal perimedullary venous drainage are rare lesions and only a relatively small number of cases have been reported.8,10-15The pathophysiologic mechanism of the progressive spinal cord deficits is due to spinal cord venous hypertension and secondary cord swelling.8 Fistulas localized in the intracranial dura mater can give rise to congestion of the spinal venous system via the anastomotic channels between the veins of the posterior cranial fossa and the spinal perimedullary veins.15 Our patient had extensive spinal venous drainage descending to the thoracic spinal cord from the onset and thereby underwent progressive myelopathy. Because the fistula was low flow in character, motor symptoms were very gradual. Our patient presented with symptoms suggestive of spinal rather than intracranial origin. The diagnostic and subsequent therapeutic delays resulted in a never-ending and perpetually recruiting supply to the fistula which was responsible for the persistent neurologic deficit in our patient. Although these vascular lesions are rare, it is crucial that the diagnosis not be delayed for better neurologic outcome. It is imperative that cerebral and spinal angiography be performed without delay.

CONCLUSIONS: In patients who present with clinical symptoms of spinal cord syndrome who possess an MRI picture of vascular myelopathy and who exhibit negative spinal angiography, a four-vessel cerebral angiography should be undertaken, aiming at the recognition of an intracranial DAVF. Cerebral and spinal angiography without delay must be performed to instigate endovascular or surgical intervention for good neurologic outcome. Good outcome means complete cessation of the myelopathy

Human ; Female ; Adult (a Person 19-44 Years Of Age) ; Adhesives ; Cranial Fossa, Posterior ; Cerebral Angiography ; Incidence ; Clinical Deterioration ; Central Nervous System Vascular Malformations ; Spinal Cord Diseases ; Dura Mater ; Magnetic Resonance Imaging ; Arteries ; Brain ; Hypertension ; Fistula ; Drainage