Admission Of Patients Research Articles

Critical care unit bed availability and postoperative outcomes: a multinational cohort study.

Critical care beds are a limited resource, yet research indicates that recommendations for postoperative critical care admission based on patient-level risk stratification are not followed. It is unclear how prioritisation decisions are made in real-world settings and the effect of this prioritisation on outcomes. This was a prespecified analysis of an observational cohort study of adult patients undergoing inpatient surgery, conducted in 274 hospitals across the UK and Australasia during 2017. The primary outcome was postoperative morbidity at day 7. Logistic regression models were used to evaluate the relationship between critical care admission and patient and health system factors. The causal effect of critical care admission on outcome was estimated using variation in critical care occupancy as a natural experiment in an instrumental variable analysis. A total of 19,491 patients from 248 hospitals were eligible for analysis, of whom 2107 were directly admitted to critical care postoperatively. Postoperative morbidity occurred in 2829/19,491 (15%) patients. Increasing surgical risk was associated with critical care admission, as was increased availability of critical care beds (odds ratio (95%CI) 1.04 (1.01-1.06), p = 0.002) per available bed; however, the probability of admission varied significantly between hospitals (median odds ratio 3.05). There was no evidence of a difference in postoperative morbidity with critical care admission (odds ratio (95%CI) 0.91 (0.57-1.45), p = 0.710). Postoperative critical care admission is variable and related to bed availability. Statistical methods that adjust for unobserved confounding lowered the estimates of harm previously reported to have been associated with postoperative critical care admission. Our findings provide a rationale for a clinical trial which would evaluate any potential benefits for postoperative critical care admission for patients in whom there is no absolute indication for admission.

Prognostic value of soluble urokinase plasminogen activator receptor (suPAR) in patients admitted with acute heart failure

Abstract Introduction The inflammatory marker, soluble urokinase plasminogen activator receptor (suPAR), has emerged as a promising prognostic biomarker of heart failure (HF). Higher levels of suPAR in plasma are indicative of hospital readmissions and mortality. Currently little is known about suPAR-values upon admission in patients with acute heart failure (AHF). Purpose This study investigates the prevalence of elevated suPAR and prognostic value in patients hospitalized with AHF. Methods In this prospective cohort study, all patients ≥ 18 years old admitted at the Emergency Department at a large University Hospital in Denmark, were consecutively included from March 10, 2020, to March 31, 2022. The follow-up period was 365 days. The biomarker suPAR was measured in all patients upon admission (median time from admission to suPAR measurement was two hours (IQR 3: 3,9-6,9)). Patient data was extracted from the electronic patient record system, and a cardiologist adjudicated whether the patients had AHF. Patients were stratified according to validated cut-off values of suPAR above or below 6 ng/mL. Kaplan-Meier survival analysis and Cox Regression were used to assess the association between suPAR levels and one-year mortality outcomes. Results A total of 408 (5%) AHF patients, from a total population of 6,715, were included in the study. 40 patients were excluded due to missing suPAR-values and the final analysis comprised of 368 AHF patients. Among AHF patients upon admission, the mean suPAR value was 6.2 ng/mL (standard deviation [SD] = 4.8 ng/mL), and non-AHF patients had a mean value of 4.5 ng/mL (SD = 3.1 ng/mL). A suPAR level above 6 ng/mL was significantly associated with mortality (figure 1), log-rank test p-value < 0.0001. Furthermore, Cox regression analysis demonstrated that elevated suPAR levels were independently associated with increased risk of mortality with a hazard ratio (HR): 2.09 (95% CI: 1.59-2.90), p-value < 0.001 after adjusting for potential confounders: age, sex, atrial fibrillation, Chronic Obstructive Pulmonary Disease, and Creatinine levels. Conclusion The inflammatory biomarker suPAR measured upon hospital admission in AHF patients is significantly associated with one-year mortality in patients admitted with AHF. The potential of suPAR as a valuable prognostic marker in AHF is offering clinicians a tool to identify high-risk patients and tailor management strategies, accordingly, thereby improving patient outcomes.Figure 1 - 1 year mortality

National Early Warning Score 2 to Predict ICU Admission of COVID-19 Patients in Bangladeshi Cohort

Objective: To assess the predictive accuracy of the National Early Warning Score 2 (NEWS 2) for early prediction of clinical deterioration (ICU admission) of COVID-19- infected patients in Bangladesh. Methods: Data from 244 patients with COVID-19 infection admitted from July 2021- September 2021, to the Aichi Hospital Ltd, Bangladesh, were retrospectively reviewed. Consecutive adult patients with laboratory-confirmed COVID-19 initially admitted to non- ICU wards were included. Categorical and quantitative variables were expressed as numbers (percentages) and median (interquartile range, IQR). We evaluated the predictive performance of NEWS2 to predict ICU admission by comparing the area under the receiver operating characteristics curve (AUROC) at thresholds 5 and 7 and assessed its association with ICU admission by performing multivariate logistic analyses. STATA conducted all the statistical analyses. Results: Among the included 218 patients, 68 patients were transferred to ICU. The AUROC was 0.96 (Standard error 0.01, 95% confidence interval 0.93-0.98), revealing that NEWS2 at hospital admission was a good predictor of ICU admission. A NEWS2 threshold of 5 had higher sensitivity than a threshold of 7 (72.06% and 29.41%). A point of 7 also had high specificity (99.33% and 63.33%) and a high positive predictive value than a threshold of 5 (95.24% vs. 47.12%). The NEWS2 entries 5 and 7 were related to ICU admission found in multivariate logistic regression analysis. Conclusion: Our results suggest that NEWS2 at hospital admission is a good predictor for ICU admission of COVID-19 patients in Bangladesh. Screening patients at admission with this tool may identify patients at risk of clinical deterioration and help in better management. EWMCJ Vol. 12, No. 1&2, January-July 2024: 60-65

Circulating Angiopoietin-2 (Angpt2) levels predict diagnosis of Chronic Thromboembolic Pulmonary Hypertension (CTEPH)

Abstract Background Vascular remodeling following incomplete thrombus resolution is considered to be a key factor in the progression to chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). Recent data demonstrated that Angpt2, which controls signaling via the Tie2 receptor, could interfere with the normal process of thrombus resolution. Our prior findings have shown that patients presenting with acute PE and having plasma levels of Angt-2 ≥5.5 ng/ml at admission are at a significantly increased risk (93 times higher) of being diagnosed with CTEPH in subsequent assessments. Purpose To externally validate the prognostic performance of Angpt2 for the development of CTEPH. Methods In a prospective cohort study of unselected consecutive all-comers with PE, survivors of the index acute event underwent 3-, 12- and 24-month follow-up with venous blood sampling for subsequent biomarker measurements. Angpt2 was measured on admission using specific enzyme linked immunosorbent assays (ELISA) detecting both the endogenous and the recombinant protein, according to the manufacturer (R&D Systems). Results Overall, 319 patients with acute PE (median age: 62 [IQR, 50-73]; females: 55.2%) were included in the analysis with a median Angpt2 plasma level of 2.6 ng/ml (IQR, 1.8-3.7) (Figure 1). Patients with PE and Angpt-2 plasma levels above the median had more often comorbidities, such as chronic heart failure (24.2% and 11.0.%; p=0.045), chronic kidney disease (33.3% vs 14.0%; p=0.010), or diabetes (27.3% vs. 12.9%; p=0.032). Angpt2 plasma levels correlated with haemodynamic status and parameters indicating severe PE (right ventricle dysfunction, r=0.129 [p=0.021) and troponin, r=0.246 [p<0.001]). In total, post-PE impairment (PPEI) was diagnosed in 33 (10.3%) and CTEPH in four (1.3%) patients during follow-up. Angpt2 plasma levels were higher on admission in patients developing PPEI or CTEPH during follow-up compared to patients without PPEI or CTEPH (PPEI vs non-PPEI: median, 3.2 [2.3-4.1] ng/ml vs. 2.5 [1-3.4] ng/ml, p=0.035; CTEPH vs. non-CTEPH: median, 5.1 [2.9-10.5] ng/ml vs. 2.5 [1.7-3.6] ng/ml, p=0.055). Regarding the diagnosis of CTEPH during follow-up, ROC analysis illustrated an AUC for Angpt2 (0.779 [95% CI 0.56–0.99]; p=0.055]) (Figure 2). By using univariate logistic regression analysis, the calculated predefined Angpt2 cut-off value of ≥5.5 ng/ml was associated with a 9.2-fold increased risk (1.3–67.4, p=0.030) for a diagnosis of CTEPH during follow-up. Conclusion We were able to validate in a different patient cohort the usefulness of Angpt2 as a novel biomarker to identify patients at risk for CTEPH.

EPAS-1 as a potential D-dimer alternative in pulmonary embolism evaluation

Abstract Background and Objectives We aimed in this study was to determine the changes in EPAS-1 levels, which is a biomarker proven to increase with hypoxia, at the time of diagnosis and after treatment in addition to the laboratory parameters and scoring systems examined at the time of admission in patients with pulmonary thromboembolism. Methods Our study included 60 pulmonary embolism patients followed in the Cardiology clinic and 60 control groups with similar demographic characteristics. Laboratory parameters determined at the time of admission were examined. Pulmonary embolism risk and severity scores were applied and EPAS-1 levels were also studied. To determine the response, EPAS-1 levels were checked 3 days later and compared with the control group. Results There was no difference between the two groups in terms of demographic characteristics and comorbidities.EPAS-1 levels were found to be higher at the time of diagnosis compared to the control group ((3.6±1.42/1.57±0.45), p<0.001). It showed a statistically significant positive correlation with PESI severity score and risk score in the patient group. EPAS-1 levels were shown to decline with the treatment of the patients and the tendency to decline was different according to the types of treatment. In patients who died, EPAS-1 levels continued to increase despite treatment (p:0.014). Conclusions Our study is important in that EPAS-1 levels, which are correlated with scoring systems and other laboratory parameters used in pulmonary embolism patients, can be used as a predictive value in the diagnostic process of the disease and play a complementary role in the evaluation of treatment response.

Comparing de novo heart failure and acute decompensated heart failure using a proteomic approach

Abstract Background Acute heart failure (HF) is defined as new or worsening symptoms of HF and stands as the most common cause of unscheduled hospital admission in patients above the age of 65. Acute HF can be classified into de novo HF (DNHF), defined as no previous history of HF, and acutely decompensated HF (ADHF), defined as worsening symptoms of HF in individuals with a prior diagnosis of HF. Clinically, it is relevant to distinguish ADHF from DNHF as they differ regarding aetiology, comorbidities, mortality, and morbidity. The aim of this study was to compare DNHF and ADHF using a proteomic approach. Method Using a proximity extension assay in a Swedish HF cohort, a total of 324 individuals hospitalized for acute HF underwent proteomic analysis of 92 proteins. The population was categorized into DNHF and ADHF, subsequently comparing normally distributed proteins using an independent samples t-test. Non-normally distributed proteins were compared using the Mann-Whitey U-test. To adjust for multiple testing, Benjamini Hochberg method was applied with a false discovery rate of 5%. Fold change was calculated by subtracting the mean or median protein concentration in ADHF from DNHF. As protein concentrations are expressed on a log2-scale, the difference between the groups equals the fold change. Proteins were considered differentially expressed at a fold change threshold of 1.15. The proteins that met a cut-off, were thereafter analysed with a pathway enrichment analysis using Reactome (only a corrected p-value ≤0.05 was considered significant). Results Complete data was available for n=317 (30.3% women; mean age 74.6) individuals (Table 1). After FDR adjustment, differential protein expression analysis yielded 56 differentially expressed proteins. After applying the fold change threshold, 51 proteins were significantly up regulated in ADHF compared to DNHF and one (Paraoxonase 3) was significantly downregulated. The most prominently up-regulated protein was fatty acid binding protein-4 (FABP4) (fold change 1.68, p <0.001). The largest number of proteins were related to neutrophil degranulation (Figure 1). Conclusion In patients hospitalized for acute HF, we identified several common pathways of the proteins differentially expressed in DNHF compared with ADHF. Neutrophil degranulation was related to the largest number of proteins. The most prominently up regulated protein was FABP4. These findings may inspire future investigation into the different underlying molecular mechanisms in ADHF and DNHF and reveal potentially different targets of treatment between the two conditions.Figure 1.Pathway enrichment analysis

The role of comorbidities for hospital outcome of patients with severe acute pulmonary embolism treated with thrombolytic therapy

Abstract Background The association between the outcome of severe acute pulmonary embolism treated with thrombolytic therapy and the presence of common comorbidities is fairly known. Methodology In this study we investigated the influence of common comorbidities (arterial hypertension, atrial fibrillation, heart failure, coronary disease, diabetes mellitus, active malignant disease, chronic obstructive lung disease, chronic renal failure, anemia and previous stroke) to hospital mortality and the composite of major and clinically relevant non-major bleeding at 7 days from hospital admission in patients with severe acute PE treated with thrombolytic therapy enrolled in the Regional PE Registry from the 4 west-Balkan countries. Univariate and multivariable regression analysis (adjusted to age and the presence of arterial hypotension – systolic blood pressure below 90 mmHg) was used to establish association between comorbidities and hospital outcome of acute PE treated with thrombolysis. Results 2068 patients enrolled with computed tomography pulmonary angiography proven acute, symptomatic PE, and of them 645 patients had features of intermediate-high PE (right ventricle dysfunction with positive biomarkers without severe hypotension) and 283 patients had high-risk PE with arterial hypotension. Of them, 394 (42.5%) were treated with thrombolytic therapy (245 with intermediate-high and 149 with high-risk PE). Overall hospital mortality was 17.0% and the composite of major and clinically relevant non-major bleeding at 7 days was 17.5% (11.2% was major bleeding). Among all tested comorbidities, only 3-staged renal failure (OR 3.56, 95%CI 1.78-7.15, p<0.001 for creatinine clearance 30-59 ml/min compare to clearance ≥ 60 ml/min; and OR 6.01, 95%CI 2.35-15.37, p<0.001 for creatinine clearance <30 ml/min versus ≥ 60 ml/min), and the presence of either paroxysmal or chronic atrial fibrillation had significant higher risk for hospital mortality adjusted to age and the presence of arterial systolic hypotension (OR 2.11, 95% 1.03-4.29, p=0.04). Between all presented comorbidities only the presence of diabetes mellitus type 2 was independently associated with the higher risk for bleeding on thrombolytic therapy OR adjusted to age 2.03, 95%CI 1.126-3.659, p=0.019. Conclusion Creatinine clearance and atrial fibrillation were the independent predictors of hospital death and diabetes mellitus type 2 for bleeding in patients with severe acute PE who were treated with thrombolysis.

Risk and causes of hospital admission in patients with atrial fibrillation on treatment with oral anticoagulants

Abstract Background Atrial fibrillation (AF) is associated with an increased risk of hospitalisation, although the main reasons for hospital admission and the role of antiarrhythmic drugs are not clarified. Objective The aim of our study was to assess the incidence rate and the factors associated with all-cause, cardiovascular and AF-related causes of hospitalisation in patients suffering from AF. Methods This is a prospective single-centre ongoing study (ATHERO-AF cohort) which included 2782 patients affected by non-valvular AF on oral anticoagulants. The primary endpoints were all-cause, cardiovascular and AF-related hospitalisation. Cardiac hospitalizations were defined as (non-AF) arrhythmias, acute coronary syndromes, heart failure (HF), systemic embolism, hypertensive urgency, vascular/cardiac surgery. The AF-related hospitalisation was defined as a recurrence of AF in paroxysmal pattern or as a high-rate symptomatic AF episode in persistent/permanent patterns. Multivariable Cox proportional hazards regression analysis was used to calculate the hazard ratio (HR) with 95% Confidence interval (95%CI) for each factor in relation to risk of hospitalisation. Results Overall, 43.5% of patients were women with a mean age of 74.6±9.1year. Patients were followed for a mean of 31±26.8 months. We registered 1205 (12.1%/year) hospitalisations for any reason, 533 (5.7%/year) for cardiovascular causes and 180 (2.0%/year) were AF-related hospitalisations (Central illustration). Among the anti-arrhythmic drug use, we highlighted that flecainide and propafenone were associated with AF-related hospitalisations in paroxysmal and in persistent/permanent patterns (HR 1.861, 95%CI 1.116-3.101 and HR 1.947, 95%CI 1.069-3.548, respectively). Amiodarone (HR 3.012, 95%CI 1.835-4.943) and verapamil or diltiazem (HR 2.067, 95%CI 1.117-3.825) were associated with an increased risk of AF-related hospitalisations in persistent/permanent AF pattern. Furthermore, cancer was associated (HR 1.802, 95%CI 1.057-3.070) with increased risk of hospitalisation due to AF-related causes. Conversely, beta-blockers and digoxin were not associated with increased risk of hospital admission. Conclusions Hospitalisations of patients with AF are frequent for both cardiovascular and non-cardiovascular causes. Among the AF-related ones, the use of antiarrhythmic drugs emerged as associated with increased risk of hospitalisations, hypothesizing their poor effect in preventing AF episodes. For these reasons, we suggest carefully considering their use, reserving them for symptomatic patients with frequent AF recurrences.Central Illustration

Influence of blood pressure targets on inflammation and associations between inflammatory markers and vasopressor usage after cardiac arrest - a substudy of a randomized clinical trial

Abstract Background Following resuscitation from cardiac arrest, a profound systemic inflammatory response may develop. In observational studies of critically ill patients an association between levels of inflammation and vasopressor usage has been found. Higher levels of inflammation may lead to higher vasopressor needs due to vasoplegia and cardiac dysfunction, however, catecholamines, including vasopressors also have immune modulatory effects. In the Blood Pressure and Oxygenation Targets in Post resuscitation Care (BOX) trial patients were randomized to a high or low blood pressure target, and vasopressor usage was increased in the high blood pressure target group. Therefore, the inflammatory response evoked by cardiac arrest, may have been altered by differences in vasopressor usage according to blood pressure target in this trial. Purpose To determine if differences in vasopressor and inotropy usage associated with randomization to a high compared to a low blood pressure target affects the inflammatory response after OHCA, and to investigate the association between inflammation and vasopressor and inotropy usage. Methods In the BOX trial, comatose OHCA patients with a presumed cardiac etiology were randomized to a blinded intervention of either a high (77mmHg) or a low blood pressure target (63mmHg). The inflammatory markers of leukocytes and CRP were measured at 0, 24, 48, and 72 hours. The average Vasoactive-Inotropic Score (VIS) was determined during initial 72 hours. The associations between average CRP, leukocytes, and VIS during initial 72 hours were determined by Spearman’s correlation analysis. Results The BOX trial included 789 resuscitated comatose OHCA patients, and 788 patients had at least 1 measurement of leukocytes and CRP. The median age was 64 (IQR 54-73), females constituted 19%, 1 year mortality was 36%. There was no difference in leukocytes and CRP at admission between the high and low blood pressure target groups (Figure 1). Leukocytes were slightly higher at 24 hours (p<0.01) in the high blood pressure target group, but no group differences were found at 48 and 72 hours, and CRP levels did not differ at 24, 48, or 72 hours. The average VIS was 19 (11-32) and 11 (5-19), p<0.01, in the two groups, with VIS being consistently higher at all timepoints beyond ICU admission (all p<0.01, data not shown) in patients with a high blood pressure target. Both average CRP and leukocytes were weakly correlated with average VIS at 0-72 hours for both blood pressure targets, r=0.17 and r=0.20, respectively for a high target (both p<0.01), and r=0.17 and r=0.20, respectively for a low target (both p<0.01). Conclusions In conclusion, increased vasopressor and inotropy usage in this randomized, blinded study of blood pressure targets after OHCA, did not lead to clinically relevant changes in inflammation. Inflammatory markers and VIS were correlated to a similar degree for both blood pressure targets.Figure 1, LeukocytesFigure 2, CRP

An analysis of the virtual cardio-oncology research initiative (VICORI) resource: bleeding risk among cancer patients beyond 1-year post-myocardial infarction

Abstract Introduction Cardiovascular disease (CVD) and cancer are common causes of morbidity and mortality. Advancements in treatment strategies for both diseases have resulted in a growing population who live with both conditions. Myocardial infarction (MI) represents approximately 20% of all CVD admissions in cancer patients and 10% of patients who present with an acute MI have cancer. Managing MI patients with cancer require careful balancing of their ischaemic and bleeding risks. While dual antiplatelet therapy (DAPT) increases a patient’s bleeding risk, cancer patients are at further increased risk due to a range of direct and indirect cancer effects. While our recent studies demonstrated an increased bleeding risk in cancer patients in the 1st year after MI (the period of intensive APT), it is currently not known if this risk is sustained beyond this period. VICORI is the world’s first whole-country cardio-oncology research platform, linking data from the National Cancer Registration and Analysis Service, National Institute for Cardiovascular Outcomes Research and Hospital Episode Statistics [1]. We investigated the risk of bleeding among MI patients in the 2nd year post-MI, where a large majority of patients would have completed a course of DAPT, stratified by the presence or absence of cancer. Methods In this retrospective observational study, we investigated the risk of bleeding following an MI between 2006-2019, in patients with and without cancer. Cancer was defined as a diagnosis of cancer in the 1-year preceding MI. Patients who lived past the 1st year after MI were followed-up from 12 to 24 months after their MI. We used inverse probability weighting based on propensity scores to produce a balanced cohort of patients with and without cancer. Cox proportional hazard and flexible parametric modelling were used to investigate cancer as a predictor of bleeding. Subgroup analyses were performed on stent status, MI and cancer type. Results Of 506280 patients presenting with MI, 5666 (1.1%) had cancer while 500614 (98.9%) did not. Prostate (n=1377), colorectal (n=1024), lung (n=490), breast (n=448) and bladder (n=334) cancers were among the most common types of cancers. The rate (hazard) of bleeding in MI was higher in patients with cancer in the 2nd year post-MI (HR:1.42, 95%CI 1.29-1.56) compared to those without. From the flexible parametric survival analysis, the risk of bleeding in cancer patients in the 2nd year post-MI was lower compared to the 1st year but remained statistically significant compared to non-cancer patients. Conclusion In this large real-world study, cancer patients have a persistent, increased bleeding risk beyond the 1-year post-MI period, compared to those without cancer, and this risk differed by type of cancer. Further work is needed to identify specific patient characteristics in each patient sub-group which alters one’s ischaemic or bleeding risk so they can be balanced favourably with personalised strategies.

Early coronary revascularization among stable patients with non-ST-segment elevation acute coronary syndromes: the role of diabetes and age

Abstract Background Diabetes mellitus affects 10-30% patients hospitalized with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and two-fold higher mortality risk compared to non-diabetics. Despite higher post-PCI complications in diabetic patients, guidelines advise early invasive NSTE-ACS treatment for all, based expert opinion, and limited evidence. Purpose To investigate the impact of an early coronary revascularization (<24 hours) compared with initial conservative strategy on clinical outcomes in diabetic patients with NSTE-ACS who are in stable condition at hospital admission. Methods The ISACS-TC database was queried for a sample of diabetic and nondiabetic patients with diagnosis of NSTE-ACS. Patients with cardiac arrest, hemodynamic instability, and serious ventricular arrhythmias were excluded. The characteristics between groups were adjusted using logistic regression and inverse probability of treatment weighting models. Primary outcome measure was all cause 30-day mortality. Risk ratios (RRs) and odds ratios (ORs) with their 95% CIs were employed. Results Of the 7,589 NSTE-ACS patients identified, 2,343 were diabetics. The data show a notable reduction in mortality for the elderly undergoing early revascularization compared to those receiving an initial conservative strategy both in the diabetic (3.3% versus 6.7%; RR: 0.48; 95% CI: 0.28-0.80) and nondiabetic patients (2.7% versus 4.7%: RR: 0.57; 95% CI: 0.36-0.90). In multivariate analyses, diabetes was a strong independent predictor of mortality in the elderly (OR: 1.43; 95% CI: 1.03-1.99), but not in the younger patients OR: 1.04; 95% CI: 0.53-2.06). Conclusions Early coronary revascularization does not lead to any survival advantage within 30 days from admission in young NSTE-ACS patients who present to hospital in stable conditions with and without diabetes. An early invasive management strategy may be best reserved for the elderly. Factors beyond revascularization are of considerable importance for outcome in elderly diabetic subjects with NSTE-ACS.

1.N. Scientific session: Child injuries monitoring and reporting: Challenges and technological developments

Abstract Globally, more than 1,600 children and adolescents below the age of 19-years die every day from preventable injuries. Road traffic injuries, drowning and self-harm represent leading causes of death and injury among children and adolescents (WHO 2021; WHO Regional Office for Europe, 2021; Unicef, 2021). Most unintentional injuries in early childhood occur at home and children from less advantaged backgrounds are exposed to more hazardous home environments due to overcrowding or unsafe structures over which parents often have limited control (WHO, 2020). According to the IDB data analysis approximately 15% of home injuries could have been prevented by improved product safety and parental education. The COVID-19 pandemic and the conflict in Ukraine have created a complex and challenging situation for children and adolescents in the region, increasing their vulnerability and compromising their well-being. To efficiently prevent child injuries, one must account for a complex interplay between human factors as well as physical and socio-cultural environments. Multiple determinants of child injury cannot be addressed by the health sector alone, this is why a whole-of-government and a whole-of-society approaches are required. Schools have a crucial role to play for promoting the well-being of children and serve as a platform to increase access to health services. However, EU countries are still missing intersectoral collaboration and strong information systems to enable efficient response to the problem. Data on child injuries are still inconsistently collected in Europe due to substantial differences in coding systems, variation between injury mechanisms, different general policies pertaining to the admission of patients, and legal policies on reporting requirements. EU-wide networks such as the Eurosafe study (IDB network) collecting information on child injuries, are scarce. Likewise, access to healthcare services and support systems are unevenly distributed, particularly in underserved communities. Building country capacity in collecting, analysing and increasing the use of child injury data for decision making at global, regional, and national levels, is critical. Adequate epidemiological data on the burden of child injuries are necessary to allow governments prioritize areas for intervention and maximize the impact of their resources. Utilizing evidence-based tools and procedures and promoting intersectoral collaboration is vital. The workshop aims to discuss trends and inequalities of injury burden and present efficient measures and latest developments in monitoring and reporting child injuries across EU countries. The workshop will further discuss the methodological challenges in collecting and analysing data on child injuries. Evidence-informed tools for sharing health information and improved measurements of injury burden that are feasible and usable in both research and clinical contexts will be presented and success stories will be presented. Key messages • There is an EU-wide need for epidemiological data on the burden of child injuries. • Validated tools, well-designed injury data management systems and standard data collection procedures are missing.

Improving cooperation between Hospital and the Community Mental Health Services of Nicosia

Abstract In order to accelerate psychiatric reform in Cyprus we took advantage of JA Implemental during the pilot implementation of Belgium best practices on facilitating the transfer of mental patients from mental hospital to the community mental health services. A multidisciplinary network has been organized between Athalassa Mental Hospital, that is the only mental hospital in the Republic of Cyprus performing 700 patients admissions yearly, and the Community Services of sector 1 and sector 2 of Nicosia Community Mental Services. The network meets regularly in order to facilitate therapeutic culture change in the direction of increasing the percentage of hospital patients that are motivated and prepared to be voluntarily moved for care by the community multidisciplinary teams. This is going to facilitate discharges from hospital, decrease duration of hospitalizations, decrease the frequency of hospitalizations and revolving door readmissions. This increased cooperation is being built on the basis of administrational procedures and clinical protocols that are based on multidisciplinary consensus. The evaluation starts multidisciplinarily in the hospital. A liaison community mental nurse takes part I the evaluation and motivation of the patients before the discharge from the hospital. A written informed consent process takes place in the hospital for the voluntary admission in the community mental health care setting. Also an effort is being made for early written referrals and appointments for community psychiatrist, psychologist, social worker and occupational therapist. This pilot action plan is going to increase cooperation of the mental hospital with the community mental health services, to decrease stigmatization and reform therapeutic culture to the direction of treatment in the community and recovery approach, according to Belgium best practices included in the JA Implemental project.

Early improvement in left ventricular microvascular flow post sonothrombolysis is associated with better left ventricular systolic function in st elevation myocardial infarction patients

Abstract Background/Introduction Acute coronary syndromes are the main cause of death worldwide and the timely application of proper therapy is critical for patient outcome. However, even when state of the art treatment is implemented, significant no-reflow phenomenon may occur. In this scenario, sonothrombolysis, which consists of a continuous infusion of an ultrasound-enhancing agent associated with high-energy intermittent ultrasound impulses, may restore cardiac microcirculation and improve left ventricular (LV) systolic function. Purpose We aimed to evaluate LV segmental microvascular flow, LV mechanics and function in patients with ST-elevation myocardial infarction (STEMI) after sonothrombolysis therapy and evaluate whether an early (immediately post percutaneous coronary intervention – PCI or PCI+Sonothrombolysis) improvement in myocardial microvascular flow could predict better LV systolic function at 1-month. Methods STEMI patients receiving conventional treatment (PCI with or without previous fibrinolytic therapy) were randomized to sonothrombolysis (therapy group - TG) or conventional treatment (control group - CG). This study included 143 patients (interim analysis) who compose the HUBBLE I databank (High-intensity Ultrasonic impulses and microbuBBles to Limit the Extent of acute myocardial infarction I) and were randomized from two clinical trials (NCT04732091 and NCT02410330): CG, N=74 and TG, N=69 patients. There were 25 patients treated previously with fibrinolytic therapy (14 in CG and 11 in TG) and the percentage of left anterior descending artery as culprit vessel was similar between groups (59 vs. 54%, P=0.482). Sonothrombolysis was initiated after patient admission to the emergency room and continued after PCI for a total of 50 minutes. Echocardiography was carried out immediately after PCI or PCI+Sonothrombolysis and at 1-month for assessing LV ejection fraction (LVEF) and perfusion score index (PSI) in contrasted imaging and global longitudinal strain (GLS) in 2D imaging, that was presented in [module]. Results Demographic characteristics, cardiovascular risk factors and echocardiographic variables immediately after PCI or PCI+Sonothrombolysis were similar between groups (P>0.05). At 1-month follow up, TG presented higher LVEF (46.4±10.5 vs. 50.9±11.1%, P=0.018) and GLS (13.0±3.6 vs. 14.9±4.3%, P=0.008) and lower PSI (1.56±0.4 vs. 1.39±0.3, P=0.007) and number of segments with perfusion defects (5.8±3.7 vs. 4.6±3.3, P=0.050) compared with CG. There was a negative correlation between early PSI and 1-month LVEF (r=-0.701, p<0.0001). Conclusions The preliminary data indicates that sonothrombolysis can be an effective adjuvant treatment in STEMI patients previously treated or not with fibrinolytic therapy, contributing to a better myocardial microvascular flow and LV systolic performance. Early myocardial microvascular reperfusion improvement can predict whether cardiac function will improve in this setting.

Public Health Benefits of Applying Evidence-Based Best Practices in Managing Patients Hospitalized for COVID-19.

As COVID-19-related mortality remains a concern, optimal management of patients hospitalized for COVID-19 continues to evolve. We developed a population model based on real-world evidence to quantify the clinical impact of increased utilization of remdesivir, the effectiveness of which has been well established in hospitalized patients with COVID-19. The PINC AI healthcare database records for patients hospitalized for COVID-19 from January to December 2023 were stratified by those treated with or without remdesivir ("RDV" and "No RDV") and by supplemental oxygen requirements: no supplemental oxygen charges (NSOc), low-flow oxygen (LFO), and high-flow oxygen/non-invasive ventilation (HFO/NIV). Key vulnerable subgroups such as elderly and immunocompromised patients were also evaluated. The model applied previously published hazard ratios (HRs) to 28-day in-hospital mortality incidence to determine the number of potential lives saved if additional "No RDV" patients had been treated with remdesivir upon hospital admission. Of 84,810 hospitalizations for COVID-19 in 2023, 13,233 "No RDV" patients were similar in terms of characteristics and clinical presentation to the "RDV" patients. The model predicted that initiation of remdesivir in these patients could have saved 231 lives. Projected nationally, this translates to >800 potential lives saved (95% CI: 469-1,126). Eighty-nine percent of potential lives saved were elderly and 19% were immunocompromised individuals. Seventy-one percent were among NSOc or LFO patients. This public health model underscores the value of initiating remdesivir upon admission in patients hospitalized for COVID-19, in accordance with evidence-based best practices, to minimize lives lost due to SARS-CoV-2 infection.

Optimal fluid resuscitation targets in septic patients with acutely decompensated heart failure

BackgroundTo determine the optimal fluid resuscitation volume in septic patients with acutely decompensated heart failure (ADHF).MethodsSeptic patients with ADHF were identified from a tertiary urban medical center. The generalized additive models were used to explore the association between fluid resuscitation volume and endpoints, and the initial 3 h fluid resuscitation volume was divided into four groups according to this model: < 10 mL/kg group, ≥ 10 to ≤ 15 mL/kg group, > 15 to ≤ 20 mL/kg group, and > 20 mL/kg group. Logistic and Cox regression models were employed to explore the association between resuscitation volume and primary endpoint, in-hospital mortality, as well as secondary endpoints including 30-day mortality, 1-year mortality, invasive ventilation, and ICU admission.ResultsA total of 598 septic patients with a well-documented history of HF were enrolled in the study; 405 patients (68.8%) had sepsis-induced hypoperfusion. Patients with NYHA functional class III and IV were 494 (83.9%) and 22 (3.74%), respectively. Resuscitation volumes above 20 mL/kg (OR 3.19, 95% CI 1.31–8.15) or below 10 mL/kg (OR 2.33, 95% CI 1.14–5.20) significantly increased the risk of in-hospital mortality in septic patients, while resuscitation volumes between 15 and 20 mL/kg were not associated with the risk of in-hospital death in septic patients (OR 1.79, 95% CI 0.68–4.81). In the multivariable Cox models, the effect of resuscitation volume on 30-day and 1-year mortality in septic patients was similar to the effect on in-hospital mortality. Resuscitation volume exceeds 15 mL/kg significantly increased the risk of tracheal intubation, while fluid resuscitation volume was not associated with ICU admission in the septic patients. In septic patients with hypoperfusion, these fluid resuscitation volumes have similar effects on patient outcomes. This association was consistent across the three subgroups with worsened cardiac function, as well as in sensitivity analyses.ConclusionsOur study observed that an initial fluid resuscitation volume of 10–15 mL/kg in the first 3 h was optimal for early resuscitation in septic patients with ADHF, particularly those with worsened cardiac function. These results need to be confirmed in randomized controlled trials with larger sample sizes.

Construction of Survival Nomogram for Ventilator-Associated Pneumonia Patients: Based on MIMIC Database.

Objective: To construct and validate a predictive nomogram model for the survival of patients with ventilator-associated pneumonia (VAP) to enhance prediction of 28-day survival rate in critically ill patients with VAP. Methods: A total of 1,438 intensive care unit (ICU) patients with VAP were screened through Medical Information Mart for Intensive Care (MIMIC)-IV. On the basis of multi-variable Cox regression analysis data, nomogram performance in predicting survival status of patients with VAP at ICU admission for 7, 14, and 28 days was evaluated using the C-index and area under the curve (AUC). Calibration and decision curve analysis curves were generated to assess clinical value and effectiveness of model, and risk stratification was performed for patients with VAP. Result: Through stepwise regression screening of uni-variable and multi-variable Cox regression models, independent prognostic factors for predicting nomogram were determined, including age, race, body temperature, Sequential Organ Failure Assessment score, anion gap, bicarbonate concentration, partial pressure of carbon dioxide, mean corpuscular hemoglobin, and liver disease. The model had C-index values of 0.748 and 0.628 in the train and test sets, respectively. The receiver operating characteristic curve showed that nomogram had better performance in predicting 28-day survival status in the train set (AUC = 0.74), whereas it decreased in the test set (AUC = 0.66). Calibration and decision curve analysis curve results suggested that nomogram had favorable predictive performance and clinical efficacy. Kaplan-Meier curves showed significant differences in survival between low, medium, and high-risk groups in the total set and training set (log-rank p < 0.05), further validating the effectiveness of the model. Conclusion: The VAP patient admission ICU 7, 14, and 28-day survival prediction nomogram was constructed, contributing to risk stratification and decision-making for such patients. The model is expected to play a positive role in supporting personalized treatment and management of VAP.

Effects of sarcopenia and nutritional status on surgical outcomes for metastatic spinal tumors: In the perspective of peri-operative complications and performance improvement.

With the advancement of cancer treatment, appropriate treatment for musculoskeletal problems is becoming more important as it extends the patient's lifespan and improves the quality of life. In surgical treatment for metastatic spine tumors (MST), various efforts are being considered to obtain a good prognosis. The purposes of this study are to analyze prognostic factors for postoperative ambulation and perioperative complications in patients surgically treated for MST with neurologic symptoms. Seventy five cases of patients who underwent surgery for MST with neurologic symptoms were enrolled between December 2016 and January 2023. Postoperative ambulatory function and medical complications were assessed for each patient in this study. The endpoint of ambulatory function was defined as the best function among entire periods of follow-up outpatient visits. We defined the improvement of ambulatory function as improvement in Eastern Cooperative Oncology Group (ECOG) scale. For complications, we applied complication classification system for orthopaedic surgery. Perioperative complications were defined as those requiring changes of treatment compared with routine postoperative treatment during patient's admission. Confirmed complications included expire, delirium, urinary tract infection (UTI), pneumonia, sepsis, bacteremia, acute kidney injury (AKI), chylothorax. Prognostic factors were collected and analyzed for relationship by logistic regression. Of the 75 cases, postoperatively 42 (56%) cases of patients were improved in Nurick grade, 36 (48%) cases of patients in ECOG performance. And 21 (28%) cases of patients were treated in intensive care unit (ICU) and 15 (20%) cases of patients suffered from major perioperative complications. Regression analysis showed that clinical factors such as ECOG, psoas muscle index (PMI) and prognostic nutritional index (PNI) were related to the improvement of ambulatory function and incidence of perioperative complications. On multivariate analysis, improvement of ambulatory function was associated with PMI (p = 0.014) and incidence of perioperative complications was associated with PNI (p = 0.045). Preoperative nutritional status and sarcopenia are related factors in the outcome of surgical treatment for MST, and preoperative efforts to improve these may be a way to obtain better clinical results.

The Real-World Effect of Early Screening for Palliative Care Criteria in a Medical ICU: An Instrumental Variable Analysis.

Early identification of ICU patients likely to benefit from specialist palliative care could reduce the time such patients spend in the ICU receiving care inconsistent with their goals. To evaluate the real-world effects of early screening for palliative care criteria in a medical ICU. We performed a retrospective cohort study in adults admitted to the ICU using a causal inference approach with instrumental variable analysis. The intervention consisted of screening ICU admissions for palliative care trigger conditions, and if present, offering specialist palliative care consultation which could be accepted/declined by the ICU. We evaluated specialist palliative care use in pre- and post-implementation cohorts from the year before/after screening implementation began (October 2022). In the post-implementation cohort, we compared use of specialist palliative care in those who received early screening versus not. We then estimated the effect of early screening on the primary outcome of days to do-not-resuscitate (DNR) code status or ICU discharge, with death without a DNR order placed at the 99th percentile of the days to DNR or ICU discharge distribution. Secondary outcomes included: DNR order, ICU/hospital lengths of stay, hospice discharge, and mortality metrics. To address unmeasured confounding, we used two-stage least-squares instrumental variables analysis. The instrument, which predicts early screening, comprised weekend vs. weekday admission and number of patients meeting palliative care criteria on a patient's ICU days 1 and 2. Amongst 1282 post-implementation admissions, 626 (45%) received early screening, and 398 (28%) received specialty palliative consultation. Early receipt of specialist palliative care was higher in patients who received early screening vs. not (17% vs 1% , p<0.001), and overall use of specialty palliative care was higher post- vs. pre-screening implementation (28 vs. 15%, p<0.001). In the post-implementation cohort, there were no statistically significant effects of early screening on the primary outcome of days to DNR or ICU discharge (15% relative increase, 95% CI [-11% to +48%]) or other secondary outcomes. Despite significantly increased specialty palliative care consultation there was no evidence that early screening for palliative care criteria affected time to DNR/ICU discharge or other secondary outcomes.

06 Eating disorder toolkit 2023: Standards of practice in the primary care setting

Abstract Background Throughout the COVID 19 pandemic, physicians across Canada began to see a 'shadow pandemic' unfold as new diagnosis of eating disorders and hospital admissions for patients with medically unstable eating disorders increased exponentially. As these rates remain high, specialists stressed the importance of the role primary care physicians play in the early recognition, assessment, and diagnosis of eating disorders as a way to improve prognosis. Further, the high volume of patients has resulted in the need to manage patients in the community or engage in collaborative care between the eating disorder specialist and primary care physician. This Eating Disorder Toolkit was created as a knowledge mobilization resource to provide primary care and community providers with Standards of Practice and improve care for eating disorder patients. Objectives 1. Provide an updated and easily readable evidence-based reference tool for PCPs 2. Clarify PCPs role in working with, monitoring, and treating EDs in a shared care model 3. Strive for early diagnosis and connection to care for improved prognosis and decreased morbidity 4. Highlight unique considerations for specific populations 5. Align with the upcoming Eating Disorders Pathway project Design/Methods The first edition of the ED Toolkit was reviewed and based on feedback sought and provided by key partners including PCPs already using the Toolkit, areas of improvement were identified. These included formatting to improve accessibility in the primary care setting, updating the guidelines, and including unique considerations for specific populations. A literature review of current guidelines and practices internationally was completed. Experienced paediatric and adult ED specialists reviewed the material to ensure it was appropriate for clinical practice. Key partners contacted for feedback and collaboration included the Provincial ED Steering Committee, Provincial ED Pathway Project Committee, UBC Continuing Professional Development, and Primary Care physicians. This ensured the resource was meeting PCPs identified needs and was usable in the primary care setting. Edits were made to reflect the feedback received. Finally, the resource was reviewed to ensure alignment with the upcoming Provincial ED Pathway Project. Results The Eating Disorder Toolkit 2023: Standards of Practice in the Primary Care Setting is now available and has been distributed widely across British Columbia. In addition, Kelty Mental Health and Compass, leading resource hubs in the province, host the live document on their sites. Finally, the toolkit is also provided to any health providers upon request to their regional ED clinic. While we have not formally studied the outcome of this resources, anecdotal reports via email and verbal feedback from nurse practitioners, paediatricians, and ED specialists across the province has been positive. Conclusion Eating disorders are complex illnesses associated with significant medical and psychiatric complications. Early recognition and management improves prognosis. Community providers play a crucial role in recognizing and managing these patients, however many do not have expertise in this area. It is hoped that this resource will support PCPs in managing ED patients in British Columbia and there may be a potential scope for use across Canada with adaptations to local guidelines and resources.