Critical Care Admission Research Articles

Emergency and postoperative access to critical and enhanced care: a multicentre prospective observational study.

The ability to admit patients to enhanced or critical care may be limited by bed availability. In a network with low provision of critical and enhanced care beds, we aimed to assess the proportion of patients having surgery with moderate (1%-< 5%) or high (≥ 5%) predicted risk of 30-day postoperative mortality and their postoperative care location. We also aimed to study referral and admission outcomes to critical care. This prospective, 7-day observational study was conducted across 19 acute hospital sites within the South West Critical Care Network. All adult inpatients having a procedure under the care of an anaesthetist (excluding cardiac and obstetric procedures) had a surgical outcome risk tool score calculated retrospectively, and their postoperative destination captured. Synchronously, all critical care referrals, admissions and refusal decisions were captured, along with critical care bed capacity. Of 2222 eligible patients, 1728 (78%) were captured. Retrospective surgical outcome risk tool score calculation revealed 1060 (61%) patients had a low, 418 (24%) a moderate and 250 (15%) a high risk of postoperative mortality. In patients with a moderate predicted risk of postoperative morbidity, 72/418 (17%) received enhanced or critical care and 64/249 (26%) patients with a high predicted risk received critical care. All critical care referral and admission activity was captured; in total, 263/680 (39%) of patients referred were admitted to critical care. Referrals to critical care exceeded the available level 3-equivalent beds on 79% of occasions. These data describe constraints in access to postoperative and emergency enhanced/critical care in the south-west of England. There is poor compliance with national guidance regarding the postoperative care location of patients with a moderate or high risk of postoperative mortality.

Autoimmune Hepatitis and Vitamin D Deficiency: A Nationwide Perspective.

Vitamin D deficiency is linked to worse outcomes in patients with chronic liver diseases (CLD). However, data in patients with autoimmune hepatitis (AIH) remain limited. We aimed to assess the impact of vitamin D deficiency on the outcomes of individuals with AIH. This retrospective cohort study used the TriNetX research network to identify patients with AIH. Patients were matched using propensity score matching and stratified to sufficient vitamin D levels (e.g., 25 (OH) D3 ≥ 30 ng/mL), vitamin D insufficiency (25 (OH) D3: 20-29.9 ng/mL) and vitamin D deficiency (e.g., 25 (OH) D3 < 20 ng/mL). The primary outcome was the all-cause mortality among adult patients with AIH. Secondary outcomes included decompensated liver cirrhosis, acute hepatic failure, liver transplantation (LT), all-cause hospitalizations and all-cause critical care admissions. A total of 1288 AIH patients with vitamin D deficiency were identified and propensity matched with 1288 patients with normal vitamin D levels. Patients with vitamin D deficiency had significantly increased odds for all-cause mortality compared to those with normal levels (adjusted odds ratio (aOR) = 3.2, 95%CI: 2.3-4.48). Patients with vitamin D deficiency were at increased odds of all-cause hospitalizations (aOR = 2.37, 95%CI: 1.97-2.84), critical care unit admissions (aOR = 2.8, 95%CI: 2.21-3.71), decompensated liver cirrhosis (aOR = 2.74, 95%CI: 2.13-3.54), acute hepatic failure (aOR = 3.11, 95%CI: 2.09-4.62) and LT (aOR = 3.47, 95%CI: 1.71-7.04), as compared to those with normal vitamin D levels. This cohort study showed significantly increased odds for all-cause mortality in AIH patients with vitamin D deficiency. Vitamin D deficiency in patients with AIH was associated with increased likelihood of hospitalisation, decompensated liver cirrhosis, acute liver failure and LT.

Role of Sepsis in Obstetric Score (SOS) to identify severe sepsis in pregnant women requiring ICU admission: A prospective observational study

Introduction: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Obstetric sepsis is a significant contributor to maternal and perinatal morbidity and mortality, especially in low-income countries. Several scoring systems can help in identifying sepsis and its severity; however, their application in the obstetric population is not well-defined because of the altered physiology of pregnancy. The Sepsis in Obstetrics Score (SOS) is designed specifically for the obstetric population to identify the likelihood of the need for critical care admission for the obstetric population presenting with signs of sepsis. Aim: To determine whether the SOS can be used to identify the severity of sepsis. Materials and Methods: This was a prospective observational time-bound study conducted at Gandhi Hospital, Secunderabad, Hyderabad, Telangana, India over six months from February 2023 to July 2023 on 100 subjects that included pregnant women, postpartum women within six weeks, and postabortal women within two weeks of abortion with suspected obstetric sepsis presenting to Gandhi Hospital. SOS score was calculated for all study participants and grouped into scores of &lt;6 and ≥6. Organ failure was assessed. SOS score was associated with culture positivity, organ involvement, need for critical care support, and the severity of sepsis. Data were analysed using Statistical Packages for Social Sciences (SPSS) software, and appropriate statistical tests were applied; the p-value for significance was set at 0.05. Results: The mean age of the study population was 25.48±5.13 years. Out of 100 women with obstetric sepsis, 50% had severe sepsis, graded by the presence of organ failure. When the cutoff score was considered as 6, SOS score had a sensitivity of 64% and specificity of 84%, a Positive Predictive Value (PPV) of 80.0%, a Negative Predictive Value (NPV) of 70.0%, and a diagnostic accuracy of 74.0% to detecting severe sepsis. Conclusion: The findings emphasised the utility of the SOS score as a valuable tool for assessing the severity of illness, predicting outcomes, and guiding clinical management.

Factors associated with anxiety and depression one year after trauma critical care admission: A multi-centre study.

Recovery after severe injury may be impacted by a range of psychological factors. This multi-site study investigated the prevalence and impact of anxiety and depression at one year after trauma critical care admission. Adult trauma patients admitted to four Level 1 Critical Care Units were prospectively enrolled over 18 months. Survivors were followed-up at one year post discharge using EQ-5D-5L questionnaires. Multivariable logistic regression analysis was used to evaluate factors associated with anxiety and depression at follow up. Of the 657 patients consented and alive at follow-up, 290 questionnaires were completed (44 % response rate). Two-thirds (63 %) reported anxiety or depression (AoD) at follow up, and this was associated with a worse overall health state (EQ-VAS No AoD: 80 vs. AoD: 60, p < 0.0001). Median ISS in both groups was 25 but those with AoD were younger (53 years vs. 60 years, p = 0.033), had previous psychological morbidities (16 % vs. 5 %, p = 0.0056) and longer hospital stays (32 vs. 24 days, p = 0.0027). All physical EQ-5D-5 L domains were worse in the presence of AoD and problems increased as anxiety or depression became more severe. Factors associated with anxiety and depression were younger age (OR 0.98 [95 % CI 0.96-0.99] p = 0.004), previous psychological morbidity (OR 3.30 [95 % CI 1.51-7.40] p = 0.004), penetrating injury (OR 10.10 [95 % CI 1.90 - 44.4] p = 0.007), ongoing pain (OR 1.61 [95 % CI 1.10-2.30] p = 0.003) or difficulties carrying out usual activities (OR 1.40 [95 % CI 1.02-2.29] p = 0.04). Anxiety and depression are significant longer-term impacts after severe injury. Younger age, penetrating injury and psychological comorbidities may be identifiers of longer-term anxiety and depression following trauma critical care. Pain at one-year had a strong association and represents a modifiable target to improve psychological outcomes.

EGS SO13 - Evaluation of Different Surgical Risk Prediction Models in Predicting Morbidity and Mortality in Giant Hiatus and Diaphragmatic Hernia Repairs

Abstract Background Emergency giant hiatus hernia and diaphragmatic hernia repairs are associated with high rates of mortality and morbidity; different studies reported variable outcomes. Accurate risk assessment empowers patients to provide informed consent and also serves as a valuable tool for identifying individuals who may require enhanced postoperative care, such as respiratory support and critical care admission. Various risk prediction tools have been developed to assist clinicians in making decisions to aid in stratifying the risk of surgical management. We aimed to assess the effectiveness of different risk prediction models in predicting mortality and morbidity in this patient cohort. Method Retrospective analysis performed on cases between May, 2010 and January, 2021 in a tertiary adult upper gastro-intestinal centre. The outcomes from the operations were assessed and compared with the predicted morbidity and mortality for different risk prediction models. Including the Surgical Outcome Risk Tool (SORT), the National Emergency Laparotomy Audit (NELA), parsimonious NELA and the American College of Surgeons National Surgical Quality Improvement Programme (ACS-NSQIP). The models were compared using the area under the curve (AUC). Morbidity models included Portsmouth Physiological and Operative Severity Score (P-POSSUM) and the ACS-NSQIP. Morbidity was evaluated by calculating the comprehensive complication index (CCI). Results A total of 108 patients met the criteria and were included in the analysis. Among these 50.9% were females. The median age was 69 (IQR 59-78). The 30-day mortality rate was 6.93% (7 patients), six patients died during the same admission, and one patient died during a re-admission. ACS-NQSIP had the highest predictive power for mortality (AUC = 0.6344), in comparison to NELA (AUC=0.5665), parsimonious NELA (AUC=0.4866) and SORT (AUC = 0.4342). Both ACS-NSQIP and P-POSSUM showed moderate correlation to CCI (rho = 0.489, p&amp;lt;0.001 and 0.446, p&amp;lt;0.001 respectively). Conclusion ACS-NSQIP is a better predictor of both mortality and morbidity in emergency giant hiatus and diaphragmatic hernia repairs when compared to NELA, parsimonious NELA, P-POSSUM and SORT. Interestingly, parsimonious NELA had a lower prediction rate when compared with the older NELA model. ACS-NSQIP may have a role in pre-assessment and consenting of emergency hiatus and diaphragmatic hernia repairs. Multi-centre prospective studies could be used to validate these findings.

MS O01 - HPB Outcomes following Cholecystostomy Insertion for Acute Cholecystitis: A National Registry-based Study

Abstract Background Acute cholecystitis (AC) is a commonly encountered surgical emergency. In cases of severe AC or cholangitis, or in patients with significant comorbidities, percutaneous cholecystostomy (PC) may be employed. International data suggest PC is associated with significantly worse patient outcomes, but limited data exist in the Irish context. Method All patients with AC presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics including age, co-morbidities, length of stay/LOS, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. All patients managed with PC were identified, and their outcomes compared to patients managed without PC. Results In total, 20,886 patients were admitted with AC. 975 (5%) patients underwent PC and 19,911 patients (95%) were managed without percutaneous cholecystostomy. In comparison to non-cholecystostomy cohort, the PC cohort was older (median 72 v 58 years, p&amp;lt;0.001), less likely to be female (39% v 57% p&amp;lt;0.001), had proportionally longer LOS (&amp;lt;0.001), higher mortality rates (&amp;lt;0.001), were more likely to be admitted to critical care (&amp;lt;0.001), and more likely to be re-admitted to hospital within 30 days (&amp;lt;0.001). Conclusion Cholecystostomy insertion occurs in older patients with more comorbidities. These patients have higher in-hospital mortality rates, higher rates of critical care admission, longer LOS, and increased 30-day readmission rates.

OGC SO01 - Patients undergoing major upper gastrointestinal resection admitted to an enhanced peri-operative care facility: Two years of outcomes

Abstract Background The Author's Trust has set up an Enhanced Peri-Operative Care facility (EPOC) to provide a higher level of monitoring in the immediate postoperative period, for certain patients undergoing elective major surgical procedures. Patients receive a nursing ratio of 2:1, invasive blood pressure monitoring, and epidural and peripheral vasopressor infusions if required, for one day before being discharged to the ward. This service, in carefully selected patients, can remove the need for critical care admission, which patients undergoing major upper gastrointestinal (UGI) resection previously required. We believe this to be a novel pathway in the UK for major UGI resections. Method Between November 2021 to November 2023, 170 major UGI resections (oesophagectomies and gastrectomies [including total and subtotal]) were performed. 82 of these cases (48%) were admitted to EPOC, instead of the Critical Care Department (CCD). The primary project outcome consisted of the proportion of EPOC cases being successfully discharged to the ward by the end of day one. Patients failing to meet the requirements for safe EPOC discharge were transferred to the CCD. Secondary outcomes included total admission length, need for escalation to critical care after discharge from EPOC and patient deaths. Results 78% of cases admitted to EPOC after major UGI resection were able to be discharged to the ward by the end of day one. The total admission length of these cases was 11.5 days. 4.6% of patients discharged to the ward from EPOC later developed complications and needed to be transferred to the CCD. 96% of patients were discharged home. Three patients died. Conclusion The Trust has been sending major UGI resection cases to EPOC for over two years. This is the first project looking at the combined outcomes. The first year was audited in 2022 and results were used to support pathway expansion, with an increased number of patients admitted in year two. The results support the notion that when patients are selected correctly they can be cared for safely in an EPOC setting, relieving pressure on the CCD and reducing the likelihood of cancellation due to critical care capacity, improving the efficiency of the UGI surgical service.

Reported roles of care partners in a specialized weaning centre-perspectives of patients, care partners, and health care providers.

Care partners are individuals chosen by a person with an illness to support their care during hospitalization. Patients with persistent critical illness have longer than average critical care admission and often other conditions including dysphagia, communication vulnerability, severe physical deconditioning, the need for an artificial airway, and difficulty weaning from invasive mechanical ventilation. Family presence has been identified as important for patients experiencing persistent critical illness in specialized weaning centers. Despite this, the role of care partners in clinical settings for patients with persistent critical illness has not been fully characterized, particularly from the perspectives of patients, care partners, and health care providers. The aim of this study was to gain insights into the roles of care partners during persistent critical illness from the perspectives of patients, care partners, and health care providers. We used qualitative descriptive methodology including semi-structured interviews and content analysis. Interviews were audio recorded and transcribed verbatim. Included participants (n = 30) were patient survivors (n = 7), care partners of patient survivors (n = 9), and professionally diverse health care providers (n = 14) of adult patients with persistent critical illness from two specialized units in one community academic hospital in Toronto, Canada. Participants across all groups described care partner roles that included physical, mental health, cognitive, social, and spiritual support of the patient, including the perceived role of safeguarding the multiple dimensions of care for the patient who is experiencing persistent critical care in specialized care settings. The results of this study are being used to co-design, implement, and evaluate a sustainable care partner program that is acceptable, appropriate, and feasible to implement in clinical settings where the care of patients with persistent critical illness occurs. Consolidated criteria for reporting qualitative studies (COREQ).

Critical care admissions and outcomes in pregnant and postpartum women: a systematic review.

To synthesise evidence for the incidence of intensive care unit (ICU) admission, characteristics and mortality of pregnant and postpartum women with a focus on differences between high-income countries (HICs) and low-middle-income countries (LMICs) and report changes in reported findings since the last review by Pollock et al. (2010). We searched Ovid Medline, EMBASE, and CINAHL (2010-2023), following best practice guidelines for abstract screening for large-evidence systematic reviews. Patient and study characteristics of extracted studies were analysed descriptively. Multivariable meta-regression analysis, employing mixed-effects models, was conducted for assessing ICU admission and mortality. Studies reviewed by Pollock et al. were included to perform an overall analysis, including each study period and geographic region in a model. Seventy-one eligible studies reported data on 111,601 women admitted to ICU, with 41,291,168 deliveries reported in 65 studies. Fifty-six studies were retrospective. Case definitions, admission criteria, and causes of mortality reported were heterogeneous. The pooled ICU admission rate was 1.6% (95% confidence interval [CI] 1.28-1.99; I2 = 99.8%), 0.4% (95% CI 0.32-0.48, I2 = 99.9%) in HICs versus 2.8% (95% CI 0.65-6.4, I2 = 99.9%) in LMICs (p < 0.0001). The pooled ICU mortality rate among 140,780 admissions reported in 63 studies was 6.5% (95% CI 5.2-7.9; I2 = 98.7%), with mortality in HICs 1.4% (95% CI 0.8-2.1, I2 = 98.04%) lower than LMICs 12.4% (95% CI 8.1-17.5, I2 = 98.9%) (p < 0.0001). Multivariable meta-regression analysis found a significant association between the ICU admission rates (p = 0.0001) and mortality (p = 0.0003) with geographic region (HIC vs LMIC). Compared to the earlier study of Pollock et al. in 2010, there was an increase in reported studies (71 vs 40 in Pollock et al. study) and reported admissions (111,601 vs 7887 Pollock et al. study), particularly from LMICs'. Mortality for critically ill peripartum women is substantial and the gap in reported ICU admissions and mortality for critically ill peripartum women between HIC and LMICs remains unacceptably high. The reports are often small and heterogeneous using many case definitions. Reporting standards focusing on critical care processes and outcomes and large multinational prospective studies are necessary to better understand and mitigate maternal and child health challenges as sustainable development goals in LMICs and HICs.

Malaria in the Republic of Ireland; A retrospective review of the clinical epidemiology of malaria between 2016 and 2020

ObjectivesMalaria is a parasitic infection that continues to present significant morbidity and mortality figures throughout the world. In the Republic of Ireland (Ireland), malaria is an imported infection linked most frequently to travel routes from West Africa. There is a paucity of data on the clinical epidemiology and hospital service utilization of malaria in non-endemic setting to inform physician practice. This study aims to fill that gap, providing a clinical context to the national picture of both adult and pediatric cases. MethodsA retrospective review of data from all public Irish hospitals was performed from 2016 to 2020, inclusive. Ethical approval was granted following review by the Social Research Ethics Committee (SREC) of University College Cork. Results and ConclusionsDuring the study period, there were 337 cases of malaria presenting to Irish hospitals, 15.1% (51/337) in the pediatric age category. Presentations occurred nationwide with a predictable seasonality. The majority (77.45%; 261/337) were Plasmodium falciparum and 6% (20/337) required critical care admission. Interestingly, females had a higher likelihood of admission to critical care (odds ratio 2.75, 95% confidence interval 1.1-6.86). The COVID-19 pandemic saw a 78% reduction in malaria presentations in 2020. A total of 1,166 bed days were utilized by cases of malaria.

Renal transplantation in older adults: retrospective cohort study to examine the impact of the new 2019 kidney offering scheme on older adult transplant recipients.

In 2019, a new kidney offering scheme was launched in the United Kingdom, aiming to better match estimated patient survival and graft life expectancy. The scheme's impact on older patients undergoing kidney transplantation (KT) is unknown. This study aims to compare the outcomes of older adult KT recipients before and after introduction of the 2019 scheme. A retrospective observational cohort study of older adults who underwent KT was undertaken. Group 1 were transplanted between 1 September 2017 and 31 August 2019 (2006 allocation scheme) and group 2 between 1 September 2019 and 31 August 2021 (2019 offering scheme). An older adult was any person ≥60 years old at the time of KT. Univariable binary logistic regression analysis was performed to determine odds ratios (OR) and 95% confidence intervals (CI). There were 107 older adult deceased donor KT recipients, 62 from group 1 and 45 from group 2. Median age at transplantation was 68 (interquartile range [IQR] 62-71) and 67 (IQR 64-73) years, respectively. Univariable analysis showed that re-intervention (OR 6.486, 95% CI 1.306-32.216, p = 0.022) and critical care admission (OR 5.619, 95% CI 1.448-21.812, p = 0.013) were significantly more likely in group 2. Group 2 recipients were significantly more likely to have a level 4 human leucocyte antigen (HLA) mismatch (OR 4.667, 95% CI 1.640-13.275, p = 0.004) and to have undergone previous KT (OR 4.691, 95% CI 1.385-15.893, p = 0.013). The introduction of the 2019 offering scheme was associated with re-intervention and critical care admission for older KT recipients. We also observed less-favourable HLA matches but more KT in difficult-to-match groups.

The trends and outcomes of inflammatory bowel disease surgery during the COVID-19 pandemic: A retrospective propensity score-matched analysis from a multi-institutional research network.

The coronavirus disease 2019 (COVID-19) pandemic has affected the management of inflammatory bowel disease (IBD) patients. Elective operations and surveillance endoscopies were postponed for IBD patients to preserve healthcare resources and to prevent the spread of COVID-19. This study aimed to describe the trends and outcomes of IBD surgery during the pandemic. This was a retrospective propensity score-matched analysis using data extracted from TriNetX, a multi-institutional research database. IBD patients admitted for surgery were identified between March 2019 to February 2020 (prepandemic) and March 2020 to February 2023 (pandemic). The monthly volume of IBD surgical procedures was compared during the pandemic to the prepandemic period. After matching, the risk of adverse outcomes following IBD surgery was compared between the 3 years of the pandemic compared to the prepandemic cohort. There was a reduction in both elective and emergency IBD operations during the pandemic. These trends were not significant. After matching, the risks of returning to theaters and hospital readmission were comparable across the 3 years of the pandemic. In the first and second years of the pandemic, elective patients were at a greater risk of mortality (risk ratio [RR], 2; 95% confidence interval [CI], 1.160-3.448 and RR, 1.778; 95% CI, 1.003-3.150, respectively) and the emergency cohort had a higher risk of critical care admission (RR, 1.759; 95% CI, 1.126-2.747 and RR, 1.742; 95% CI, 1.131-2.682, respectively). Our study highlights the impact of the COVID-19 pandemic on the management of IBD patients undergoing surgery. These results provide insights into the management of IBD surgery during times of crisis and can help guide decision-making and resource allocation for IBD patients requiring surgical intervention.

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.

Inequalities in severe COVID-19 outcomes in Wales, UK

ObjectiveResearch evidence shows that COVID-19 has disproportionately affected people from more deprived backgrounds. In Wales (UK), there is strong evidence of a socioeconomic gradient in total hospitalisations, critical care admissions and deaths. This study focussed on a cohort of the Welsh population using anonymised individual-level linked population-scale data in the SAIL Databank. ApproachThis analysis examines the impact of confounding/mediating factors on severe health outcomes. We used logistic regression, considering the Welsh Index of Multiple Deprivation (WIMD) 2019 as a predictor, to investigate how the coefficient for WIMD is changed when other variables (such as comorbidities, smoking status, Body Mass Index) are added, aiming to understand whether inequalities are mediated by observed characteristics or related to other unobserved factors. ResultsInitial findings show that age-standardised rates of hospital admissions, Intensive Care Unit (ICU) admissions and deaths were roughly twice as high in the most deprived vs least deprived WIMD quintile in Wales. We estimated Years of Life Lost per 1,000 due to COVID-19 as 28.9, with variation between WIMD quintiles of 38.4 for the most deprived and 22.2 for the least deprived. The project also produced regression formulas to evaluate the contribution of the different confounding factors. ConclusionThis study built on existing research findings and further explored the potential reasons for known socioeconomic inequalities in relation to COVID-19 outcomes. Insights from this study have broadened the knowledge around the impact of mediating factors and may contribute to future pandemic preparedness and the formation of future policies.

WP5.13 - National Emergency Laparotomy (NELA) critical care admissions: A cohort study

Abstract Aims NELA is committed to enhancing quality of peri-operative care of patients undergoing emergency laparotomy. NELA emphasizes importance of identifying high risk patients, who are associated with significant morbidity &amp; mortality. Critical care allows close monitoring, organ (basic/advanced) support. Aim of study is to review the NELA critical care patients. Methods Cohort study of NELA patients that received post-operative ITU care (direct/indirect admission) at single centre. Descriptive demography, and outcomes were evaluated. NELA parsimonious risk &amp; CCMDS ITU scores used. NELA patient that did not require ITU care were controls. Results NELA critical care (n = 400) NELA non critical care (n = 466) Mann Whitney U (p value) Deaths (n) - (n) Age(yrs) 71.8 64.0 &amp;lt; 0.0001 Sex(M:F) 173 : 227 220 : 246 NS ASA 3 2 &amp;lt; 0.0001 BMI(kg/m2) 26.3 25.0 NS Lap(n) 67 168 Open(n) 333 293 Op time(mins) 131.0 109.4 &amp;lt; 0.0001 LOS(days) 18 9.5 &amp;lt; 0.0001 Deaths 30 day 50 25 60 day 66 37 90 day 73 40 Lactate(mmol/L) 2.4 1.8 &amp;lt;0.01 WCC(x109/L) 13.0 11.8 &amp;lt;0.05 CRP(mg/L) 90.1 56.6 &amp;lt;0.0001 Physiological-score 25.6 19.8 &amp;lt;0.0001 Operative-severity-score 17.9 15.9 &amp;lt;0.0001 Prepossum-score 21.6 7.5 &amp;lt;0.0001 PPmortality-score 11.9 4.9 &amp;lt;0.0001 PPmorbidity-score 77.3 55.7 &amp;lt;0.0001 Survival Rate (%) 1styear 75.4 86.2 5thyear 53.8 70.8 Logrank 10thyear 41.1 58.7 p&amp;lt;0.0001 Conclusion NELA critical care patients had poorer survival rates in our study. Theatre return or indirect critical care transfers can adversely affect survival. These patients were older, frail, multiple co-morbid status. NELA parsimonious mortality risk score &amp;gt;5% should encourage consultant level supervision, mortality risk score &amp;gt;10% should encourage direct critical care involvement.

Evaluating current acute aortic syndrome pathways: Collaborative Acute Aortic Syndrome Project (CAASP)

Abstract Background Diagnosis of acute aortic syndrome is challenging and associated with high perihospital mortality rates. The study aim was to evaluate current pathways and understand the chronology of acute aortic syndrome patient care. Method Consecutive patients with acute aortic syndrome imaging diagnosis between 1 January 2018 and 1 June 2021 were identified using a predetermined search strategy and followed up for 6 months through retrospective case note review. The UK National Interventional Radiology Trainee Research and Vascular and Endovascular Research Network co-ordinated the study. Results From 15 UK sites, 620 patients were enrolled. The median age was 67 (range 25–98) years, 62.0% were male and 92.9% Caucasian. Type-A dissection (41.8%) was most common, followed by type-B (34.5%); 41.2% had complicated acute aortic syndrome. Mode of presentation included emergency ambulance (80.2%), self-presentation (16.2%), and primary care referral (3.6%). Time (median (i.q.r.)) to hospital presentation was 3.1 (1.8–8.6) h and decreased by sudden onset chest pain but increased with migratory pain or hypertension. Time from hospital presentation to imaging diagnosis was 3.2 (1.3–6.5) h and increased by family history of aortic disease and decreased by concurrent ischaemic limb. Time from diagnosis to treatment was 2 (1.0–4.3) h with interhospital transfer causing delay. Management included conservative (60.2%), open surgery (32.2%), endovascular (4.8%), hybrid (1.4%) and palliative (1.4%). Factors associated with a higher mortality rate at 30 days and 6 months were acute aortic syndrome type, complicated disease, no critical care admission and age more than 70 years (P &amp;lt; 0.05). Conclusions This study presents a longitudinal data set linking time-based delays to diagnosis and treatment with clinical outcomes. It can be used to prioritize research strategies to streamline patient care.

Real-world data of in-hospital administration of alglucosidase alfa in French patients with Pompe disease: results from the National Claims Database.

Pompe disease is caused by a rare biallelic mutation in the GAA gene resulting in acid α-glucosidase deficiency and glycogen accumulation. We analyzed hospital admissions associated with the administration of Myozyme®, utilizing the French hospital discharge database, known in France as the Programme de Médicalisation des Systèmes d'Information (PMSI), which comprehensively captures all hospital activity within the country. In this observational study, we examined hospitalization records from April 4, 2012, to December 31, 2019, within the PMSI database, focusing on admissions where Myozyme® was administered. We particularly investigated the incidence of critical care admissions and adverse events (AEs) related to Myozyme®. From 2012 to 2019, approximately 26,714 hospital stays involving Myozyme® administration were recorded for 239 patients. Most (96.6%) of these were outpatient stays, with only 3.2% in critical care. Furthermore, hospitalizations without critical care needs increased from 96% in 2012 to 99% in 2019. Of the patients receiving at least one infusion, 997 critical care admissions were recorded, with 781 (78.3%) occurring concurrent with or the day after the Myozyme® treatment without directly correlating to adverse effects of enzyme therapy. The analysis of the French hospital discharge database indicated that Myozyme® was associated with a low incidence of AEs and complications in a hospital context, supporting the consideration of its safe use in home-infusion settings.

Using NHS Data to Monitor Trends in the Occurrence of Severe, Food-Induced Allergic Reactions Work Package 1

People with food allergies may experience food allergic reactions due to accidental exposure. These reactions are commonly categorised as non-severe, fatal food anaphylaxis and near-fatal food anaphylaxis. Non-severe allergic reactions to food are more common with an incidence of up to 1,000 times greater than fatal food-related anaphylaxis. However, obtaining accurate data relating to the circumstances under which these reactions occurred is challenging under the current diagnosis coding system used in the National Health Service (NHS). This project addressed two key questions: 1. What are the trends in the occurrence of food hypersensitivity (FHS) reactions and their consequences in terms of healthcare encounters (both to hospital and primary care)? 2. What are the circumstances surrounding severe, life-threatening reactions to food? Approach The researchers used existing NHS datasets (relating to Hospital Admissions, Accident &amp; Emergency visits, Critical Care admissions and Primary care visits) to evaluate healthcare encounters due to food hypersensitivity over the study period. Patient pathways through the healthcare system were also assessed by linking these different datasets. Key Results • Food-induced anaphylaxis represented 29.4% of reported anaphylaxis. admissions, and increased significantly from 1.23 to 4.02 admissions per 100,000 population per annum over the study period. • However, despite an annual increase of 5.7% in hospitalisation for food-induced anaphylaxis between 1998 and 2018, the case fatality rate (proportion of hospital admissions associated with a fatal outcome) more than halved, from 0.7% in 1998 to less than 0.3% in 2018. • 152 deaths were identified during the study period where the cause was very likely to have been food-induced anaphylaxis. • At least 86 (46%) fatalities were triggered by peanut or tree nuts. • Cows’ milk was reported to be the most common cause of fatal anaphylaxis in children aged under 16 years. • Using data from England for the period 2008-2018, the prevalence of food allergy ranged from 4% in preschool-aged children (under 5 years), 1-2% in school-aged children and young people (5 to 20 years) and 0.9% in adults. Although the same methods were used throughout the study period, the statistics presented may be prone to limitations such as miscoding and incomplete datasets. • Prescription of adrenaline auto-injector devices (AAI) are an important risk management intervention in people at risk of food-induced anaphylaxis. However, there is significant under-prescribing of AAI. Data showed that 40% of individuals with prior food-induced anaphylaxis were not prescribed AAI and at least 59% did not have AAI on repeat prescription. • Most healthcare visits for food allergy occurred in general practice. Less than 3% of individuals with a diagnosis of food allergy attended Accident and Emergency during the study period, 2008-2018. Therefore, using hospital data in isolation to analyse patterns of health service utilisation with respect to FHS may not provide a comprehensive overview.

Outcomes of different steroid dosing regimens in critical Covid-19 pneumonia at a Kenyan hospital: A retrospective cohort study.

Among therapeutic options for severe and critical COVID- 19 infection, dexamethasone six milligrams once daily for ten days has demonstrated mortality benefit and is guideline recommended at this dose. In practice, variable doses of steroids have been used, especially in critical care settings. Our study aimed to determine the pattern of steroid dosing and outcomes in terms of critical care mortality, occurrence of dysglycaemias, and occurrence of superadded infections in patients with critical COVID-19. A retrospective cohort study was carried out on all eligible patients admitted to the Aga Khan University Hospital, Nairobi, with critical COVID-19 between 1st March 2020 and 31st December 2021. The intervention of interest was corticosteroids quantified as the average daily dose in milligrams of dexamethasone. A steroid dose of six milligrams once a day was compared to high dose steroid dosing, which was defined as any dose greater than this. The primary outcome measure was ICU mortality and secondary outcomes included occurrence of dysglycaemias, superadded infections and duration of critical care admission. The study included 288 patients. The median age was 61.2 years (IQR: 49.7, 72.5), with 71.2% of patients being male. The most common comorbidities were diabetes mellitus (60.7%), hypertension (58%), and heart disease (12.2%). The average oxygen saturation and C-reactive protein at admission were 82% [IQR: 70.0-89.0]and 113.0 [IQR: 54.0-186.0], respectively. Fifty-eight percent of patients received a standard dose (6mg) of steroids. The mortality rate was higher in the high-dose group compared to the standard-dose group; however, the difference was not statistically significant (47.9% vs 43.7% p = 0.549). The two most common steroid associated adverse effects were uncomplicated hyperglycemia (62.2%) and superimposed bacterial pneumonia (20.1%). The high-dose group had a higher incidence of uncomplicated hyperglycemia compared to the standard-dose group (63.6% vs 61.1%). However, the incidence of diabetic ketoacidosis was lower in the high dose group (0.6% vs 6.6%). Oxygen saturation at admission was associated with survival where it was lower among non-survivor patients with critical COVID-19. The study found that high-dose steroids in the treatment of critically ill patients with COVID-19 pneumonia did not confer any mortality benefit and were associated with an increased risk of dysglycemia and superimposed infections.

Clinical Presentation of Enterovirus D68 in a Swiss Pediatric University Center.

Enterovirus D68 (EV-D68) is responsible for millions of infections. In the last decade, there has been an increase in the number of children requiring hospital or critical care admission due to severe respiratory illness. Nevertheless, the epidemiological and clinical importance of EV-D68 infections remains unclear. We aimed to determine the local prevalence of EV-D68 infection in pediatric patients and to characterize its clinical presentation and disease burden compared with non-EV-D68 enterovirus and human rhinovirus (RV) infections. We performed a retrospective single-center study of children presenting with respiratory symptoms and positive respiratory panel polymerase chain reaction for EV/RV from November 2018 to December 2019. We tested EV/RV positive specimens with an EV-D68-specific polymerase chain reaction to discriminate EV-D68, non-EV-D68 and RV and compared their respective clinical presentation, outcomes and treatment. We identified 224 patients (median age 21 months), of which 16 (7%) were EV-D68 positive. They presented with cough (88%), wheezing (62%) and dyspnea (75%). EV-D68 infection had an odds ratio regarding pediatric respiratory severity-score of 11.6 relative to non-EV-D68 [confidence intervals (CI): 3.51-41.14], and of 9.9 (CI: 3.75-27.95) relative to RV. The fitted logistic regression showed that the odds of intensive care were 5 times more likely with EV-D68 than RV infection (CI: 1.32-19.28; P = 0.001). Patients with EV-D68 infections were more likely to receive medical support in the form of supplementary oxygen, antibiotics and steroids. EV-D68 infection is associated with higher morbidity and a higher likelihood of intensive care treatment than non-EV-D68 and RV infections.