The broad spectrum of COVID-like patients initially negative at RT-PCR testing: a cohort study

Background Patients that arrive in the emergency department (ED) with COVID-19-like syndromes testing negative at the first RT-PCR represent a clinical challenge because of the lack of evidence about their management available in the literature. Our first aim was to quantify the proportion of patients testing negative at the first RT-PCR performed in our Emergency Department (ED) that were confirmed as having COVID-19 at the end of hospitalization by clinical judgment or by any subsequent microbiological testing. Secondly, we wanted to identify which variables that were available in the first assessment (ED variables) would have been useful in predicting patients, who at the end of the hospital stay were confirmed as having COVID-19 (false-negative at the first RT-PCR). Methods We retrospectively collected data of 115 negative patients from2020, March 1st to 2020, May 15th. Three experts revised patients’ charts collecting information on the whole hospital stay and defining patients as COVID-19 or NOT-COVID-19. We compared ED variables in the two groups by univariate analysis and logistic regression. Results We classified 66 patients as COVID-19 and identified the other 49 as having a differential diagnosis (NOT-COVID), with a concordance between the three experts of 0.77 (95% confidence interval (95%CI) 0.66- 0.73). Only 15% of patients tested positive to a subsequent RT-PCR test, accounting for 25% of the clinically suspected. Having fever (odds ratio (OR) 3.32, (95%CI 0.97-12.31), p = 0.06), showing a typical pattern at the first lung ultrasound (OR 6.09, (95%CI 0.87-54.65), p = 0.08) or computed tomography scan (OR 4.18, (95%CI 1.11-17.86), p = 0.04) were associated with a higher probability of having COVID-19. Conclusions In patients admitted to ED with COVID-19 symptoms and negative RT-PCR a comprehensive clinical evaluation integrated with lung ultrasound and computed tomography could help to detect COVID-19 patients with a false negative RT-PCR result.

Nursing Education Innovations and Obstacles During COVID-19

The COVID-19 pandemic created a paradigm shift in the way educators employ active learning strategies. In this chapter, the authors discuss how engaging and innovative learning strategies were developed to teach baccalaureate-level nursing students during the COVID-19 pandemic. The initial focus is on the teaching and learning strategies created for first-semester students who are developing foundational nursing skills and concepts. The discussion transitions to complex strategies developed for fourth-semester students, solidifying critical thinking and clinical judgment skills. Highlighted are active learning strategies used in the classroom, skills lab, and simulated clinical environment. These promote clinical judgment and present practical direction for adapting technology to provide an engaging learning environment. Throughout the chapter, the authors use several strategies to showcase how a nursing program responded to COVID-19 restrictions, including active learning and technology strategies, and how they can be applied across a curriculum using varying levels of technology.

Impaired knowledge in individuals with heart failure: a middle range nursing theory

ABSTRACT Objective: To develop a middle range nursing theory of impaired knowledge in individuals with heart failure. Methods: Descriptive study of the cross type developed through the theoretical-causal validity method, which used six steps for theory building: Definition of the construction approach; Definition of theoretical-conceptual models; Definition of main concepts; Development of a pictorial scheme; Construction of propositions; and Establishment of causal relations and evidence for practice. Results: Twenty-four articles were found, which identified two attributes, eight antecedents, and seven consequences, which gave rise to the pictogram, which schematized the concepts by relating them to cardiac physiology. Finally, 11 propositions and four causal relationships were created. Conclusion: The constructed theory enables a targeted driving of nurses’ clinical judgment regarding impaired knowledge in individuals with heart failure, culminating in individualized interventions to improve quality of life.

Plasmapheresis: Is it a potential alternative treatment for chronic urticaria?

Background Chronic urticaria is a common disease. Plasmapheresis is an alternative treatment that can be appropriate for patients who are resistant to treatment with 2nd generation antihistamines or for whom treatment with omalizumab is unsuitable. Objective To investigate the effect of plasmapheresis treatment in chronic urticaria. Methods A retrospective analysis was performed based on the data of 98 patients suffering from refractory chronic urticaria who received plasmapheresis as an alternative treatment in Vilnius University’s Hospital Santaros Clinics from 2000 to 2020. The efficiency of the treatment was evaluated by clinical judgment. Results 58.2% of the patients exhibited a complete or significant response; of these, 37.8% had temporary relief of symptoms and 20.4% achieved disease remission; 41.8% showed no response to the plasmapheresis. Men (34.8%) had a tendency to achieve disease remission more often than women (16%) (p < 0.05). One patient did not finish the plasmapheresis treatment due to the symptoms’ exacerbation and treatment with omalizumab was initiated. Conclusion Plasmapheresis is a safe and effective alternative treatment when traditional treatment is unavailable or does not relieve symptoms completely. Our data showed that plasmapheresis was effective in more than half of our patients.

The diagnosis of growth hormone deficiency remains a judgment call – and that is good

The diagnosis of GHD still does not reflect evidence-based and generally accepted practice, and reliance on growth hormone stimulation testing (GST) leads to a high rate of false positive diagnosis of idiopathic isolated GHD (IIGHD). While searching for more definitive indicators of GHD is attractive, it should not distract from currently available steps to reduce erroneous IIGHD diagnoses. This paper describes opportunities to improve the accuracy of the GST which include: 1) meticulous selection of candidates for GST, since a low prevalence of GHD among short children in general is a major factor undermining the test’s diagnostic accuracy; 2) departure from traditional pass/fail diagnostic GH cutoffs towards, instead, formulation of diagnoses along a continuum that spans actual GHD -> provisional GHD -> not GHD; 3) response to the provisional diagnosis of IIGHD based on GST with additional post-test observation or alternative growth-promoting interventions rather than immediate hGH treatment; 4) re-examination and often correction of a prior IIGHD diagnosis with the onset of puberty. Modern medicine is increasingly offering diagnostic tests that aim to eliminate the need for provisional diagnoses. But a pitfall of such a “definitive” test for GHD would be the temptation to respond to its results definitively. Given the nuances, variations, and fluctuations in GH axis function over time, children evaluated for growth concerns are still best served by clinical judgment that combines thoroughness, patience, flexibility, and healthy skepticism into the diagnosis of GHD.

Self-care deficit versus the potential to improve self-care: explanation of the nurse's clinical judgments

Background: people who become functionally dependent due to serious illness and/or the worsening of a chronic illness have different recovery paths. The attribution of the nursing diagnosis of self-care deficit versus potential to improve self-care requires, on the part of the nurse, a rigorous clinical judgment, for which a set of diagnostic activities is necessary. Objectives: the present study sought to identify the assumptions used by expert nurses when formulating the clinical judgment of self-care deficit versus the potential to improve self-care Methodology: qualitative design. Data were generated in two focus group meetings that included eleven nurses experienced in caring for persons with functional dependence and self-care defict. Previously prepared structured questions were used to facilitate discussion. The focus group meetings were recorded in audio and transcribed. Inductive content analysis was used to identify emerging themes. The checklist Consolidated Criteria for Reporting Qualitative Research (COREQ) was also used. Results: nurses` decision-making depends: the factors of influencing the potential to improve self-care abilities of a person with functional dependence, the domain of influence of these factors, and three fundamental aspects to consider when evaluating a person with functional dependence. Conclusions: the absence of recovery potential can rarely be deduced. People without cognitive impairment or with mild cognitive impairment present highest potential for recovery.

Practice patterns in the management of myasthenia gravis: a cross-sectional survey of neurologists in the United States

Background: Management of myasthenia gravis (MG), a rare immunoglobulin G autoantibody–mediated neuromuscular junction disorder, is driven by physician experience. To gain insight into current practices and physician needs, neurologists’ use of guidelines and disease activity evaluations to manage MG was assessed. Methods: In November and December of 2020, a quantitative, cross-sectional, 51-item, online survey–based study was used to collect data from 100 community neurologists, from 31 US states, who treat MG. Differences across ratio variables were analyzed via Chi-square and t tests, at a significance level of P<0.05. Results: Of respondents, 76% reported using clinical judgment rather than guidelines to inform treatment decisions, and only 29% reported awareness of the updated 2020 International Consensus Guidance for Management of Myasthenia Gravis. Treatment patterns reported include use of prednisone-equivalent corticosteroid doses ≤10 mg/day for ≥6 months (76% of respondents). When corticosteroids are contraindicated or after failure of an initial nonsteroidal immunosuppressant therapy (NSIST), immunoglobulin therapy is the respondents’ preferred initial treatment in patients with acetylcholine receptor antibody–positive generalized MG (vs a second NSIST). Respondents expressed interest in more guidance on crisis management, initiating/titrating maintenance medications, and managing patients with comorbidities. Conclusions: Respondents to this survey reported varied approaches to MG management and, in some clinical settings, heavier reliance on clinical judgment than on available consensus-based guidance. Also observed was potential underutilization of NSISTs in patients for whom corticosteroids are contraindicated, with reliance, instead, on immunoglobulin.