First Hour Of Admission Research Articles

High venous to arterial CO2 gap is related to cardiovascular death in cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: None. Background Venous to arterial CO2 gap (CO2gap) is calculated by subtracting partial pressure of arterial CO2 to central venous partial pressure of CO2 (ScvCO2). This marker has been studied in septic shock and indicates hypoperfusion when exceeds 6mmHg. Its kinetics and applicability in cardiogenic shock (CS) are unclear, being mixed/central venous saturation and lactate more commonly used. Purpose The objective of the study is to describe CO2gap kinetics in patients with CS. Secondary objective is to analyze if CO2gap is as marker of prognosis in CS. Methods Prospective observational study that included patients admitted for CS in the Acute Cardiovascular Care Unit of a tertiary hospital. Gasometric samples were obtained at admission, 6, 12, 24 and 48 hours from the onset of shock. In-hospital mortality was registered. Results We included 40 patients with CS during 1 year. Most patients were male (80%), average age was 68 years. There was a high incidence of cardiac arrest (58%), most frequent cause of CS was STEMI (45%), in-hospital mortality was 45%, most cases from non-cardiovascular causes (61%). Refractory shock was frequent (28%). Average lactate peak was 6.02 mmol / L. CO2gap kinetics consisted in a peak at admission (8.8mmHg), a valley 6h (7.7mmHg), new peak at 12h (8.5mmHg) and progressive decrease at at 24 (6.8mmHg) and 48h (5.7 mmHg). Significantly, higher CO2gap values at admission (10.97mmHg vs 8.16mmHg, p = 0.007) was predictor of cardiovascular mortality. Lactate values at 6, 12 and 48 hours were also predictors of cardiovascular mortality, as well as ScvO2 at admission. Conclusions Patients with CS present with high CO2gap values during first hours of admission. The kinetics of this marker consists in two peaks at admission and 12 hours from CS onset, a valley at 6 hours and a progressive decrease at 24 and 48 hours. Its determination at admission is associated with cardiovascular mortality. We suggest the potential benefit of combining this marker, along with lactate and ScvO2 values, to guide management of patients with CS. Abstract Figure. CO2 gap and cardiovascular mortality

Improving Antibiotic Timing in Febrile Neutropenia for Pediatric Oncology Patients with a Central Line.

Background: Febrile neutropenia in pediatric oncology patients is considered a medical emergency. This population is at risk for infection-related complications due to their immunocompromised state. The purpose of this evidence-based quality improvement project was to reduce the time in minutes from admission to antibiotic administration to within 60 min in at least 90% of pediatric oncology patients with a central line presenting with febrile neutropenia. Methods: An order set titled "FAST BREAK-Fever Neutropenia Admission" was created to expedite care during the first hour of admission, including labs, blood cultures, and a one-time STAT dose of intravenous cefepime. Education was provided to all providers and nursing staff on the unit through inservices, handouts, emails, and computer reminders. Results: Within three months from the FAST BREAK order set implementation, compliance for administering antibiotics within 60 min from admission occurred in 100% of admissions. Other outcomes included 100% compliance in provider utilization of the order set, reduction in the average time from admission to antibiotic administration, and cost reduction related to cefepime waste. Discussion: The FAST BREAK order set is now considered the standard of care in the Pediatric Cancer Center at the University of Iowa Stead Family Children's Hospital. Maintaining the expectation of prompt antibiotic administration for febrile neutropenia in pediatric oncology patients with a central line will improve patient care, reduce adverse outcomes in this vulnerable population, and correlate with national guidelines for antibiotic administration in febrile oncology patients.

Association between thiamine deficiency and hyperlactatemia among critically ill patients with diabetes infected by SARS-CoV-2.

BackgroundThe present study aims to verify the association between diabetes and thiamine deficiency in critically ill patients infected by severe acute respiratory syndrome coronavirus 2.MethodsThis is a descriptive cross‐sectional study, whose demographic, anthropometric, and laboratory data (arterial lactate, bicarbonate, and plasma thiamine) were obtained in the first hours of admission to the intensive care unit. Patients with diabetes were compared with individuals without diabetes, and the correlation was performed between thiamine and lactate levels. Thiamine levels <28 μg/L were considered as thiamine deficiency.ResultsOverall, 270 patients met the inclusion criteria; 51.1% were men, and the median age was 74 years (66.8‐81). The median value of thiamine was 54.0 μg/L (38‐72.3), and 15.6% had thiamine deficiency. Among patients with diabetes, 26.3% had thiamine deficiency, and 69.3% had hyperlactatemia. There was an association between thiamine deficiency and diabetes (odds ratio 4.28; 95% CI, 2.08‐8.81; P < .001). There was a strong negative correlation between thiamine and arterial lactate in patients with diabetes (r = −0.711, P < .001) and a moderate negative correlation in critically ill patients without diabetes (r = −0.489, P < .001).ConclusionsThe prevalence of thiamine deficiency in critically ill patients due to coronavirus disease 2019 is higher in patients with diabetes. There is a negative correlation between thiamine and arterial lactate levels, which is higher in people with diabetes.

Comparative analysis of laboratory data of patients suffering from SARS-CoV-2-induced pneumonia and bacterial pneumonia

Comparative analysis of laboratory data of 46 patients suffering from pneumonia caused by SARS-CoV-2 and 12 patients - pneumonia of bacterial etiology is given. It was established that in patients with COVID-19 compared to patients with bacterial pneumonia, the level of direct bilirubin is 84% more, and thrombocrit is three times more, which can indicate intravascular hemolysis and activation of the hemostasis system. Sex differences in laboratory indicators in patients with COVID-19, which go beyond the known limits of the physiological norm, were not detected. However, in men, hematocrit, hemoglobin, and plasma creatinine values were statistically higher than in women, but the amount of C-reactive protein in women was 5 times greater. However, these laboratory measures in COVID-19 have low prognostic significance. Therefore, conventional laboratory measures do not reveal clinic-critical differences in bacterial pneumonia and pneumonia caused by SARS-CoV-2. When conducting multifactorial analysis, it turned out that the laboratory indicators of patients suffering from bacterial pneumonia are not clustered and it is impossible to form predictor models from them. While laboratory indicators of patients suffering from pneumonia caused by COVID-19 form a directed pathogenetic response of the body as a whole, which causes multi-branch associated changes in homeostasis. Unfortunately, the amount of data available to us did not allow a qualitative discriminant analysis, which, with a very large amount of data, could lead to discriminant equations that are resistant to random emissions. This would allow, according to the available key individual laboratory indicators, to identify patients suffering from COVID-19 in the early stages already in the first hours of admission to the clinic.

Incidence and predictors of mortality among children admitted to the pediatric intensive care unit at the University of Gondar comprehensive specialised hospital, northwest Ethiopia: a prospective observational cohort study

ObjectiveTo determine the incidence and predictors of mortality among children admitted to the paediatric intensive care unit (PICU) at the University of Gondar comprehensive specialised hospital, northwest Ethiopia.DesignA single-centre prospective...

Early Surgery in Trauma Patients Is a Key Performance Indicator of Outcome—A Case Series Analysis

We analyzed one feasible timeline of critical surgery within the first hour of admission as a possible intervention, which could be applied in existing trauma systems in Low and middle-income countries (LMIC), and may improve trauma care outcomes. Retrospective analysis of a prospectively maintained data registry under project named TITCO (Towards Improved Trauma Care Outcome) was done at a level one trauma center in India from October 2013 to September 2015. All admitted patients who underwent critical surgery within the first hour of admission were analyzed. These patients were divided in two groups depending upon primary presentation or referred from other facility. Statistical analysis was done between these two groups to compare outcome. Sixty-one (57.6%) patients were directly admitted, whereas forty-five (42.4%) were transferred from other hospitals. The median time from injury to presentation for primary patients was 50 min with interquartile range (IQR) of 40. In referred patient median time gap between the injury to our center (not referring center) was 230 min with IQR of 350. This difference was statistically significant. Both the groups were comparable in terms of injury severity measured by ISS. Major outcome indicators in the form of median ICU and total stay, as well as mortality, were not significantly different. We propose that critical surgery within the first hour of presentation might be a useful hospital-based key performance indicator even in the existing trauma systems in LMIC to improve the outcome of injured patients.

Clinical outcome of severe sepsis and septic shock in critically ill children.

Information concerning the clinical outcome of severe sepsis and septic shock among the burden of tropical infections in children is limited, particularly in low-income settings. We conducted a prospective consecutive cohort study in all children aged 1 month to 16 years needing paediatric intensive care between 1 January 2017 and 31 December 2018. Demographic details, presenting symptoms and duration, associated co-morbidity and organ dysfunction were recorded. Clinical and laboratory parameters discriminating between survivors and non-survivors were evaluated. Most presented with respiratory or central nervous system derangement along with cardiovascular dysfunction. Haematological involvement was almost invariably found on diagnostic evaluation. Those children with ≥3 systems involved had higher odds of mortality. Dengue was seen in half the patients, being the commonest tropical infection. Not surprisingly, non-survivors were younger, had rapid progression of illness and needed ventilation more often within the first hour of admission. However, in multivariable regression analysis, only procalcitonin levels were associated with increased risk of mortality. We conclude that that tropical infections causing severe sepsis and septic shock are an important cause of mortality. There are, however, no clinical parameters which differentiate reliably between survivors and non-survivors.

Caracterización de pacientes con enfermedad cerebrovascular isquémica aguda

Introducción: dada la alta mortalidad asociada con la enfermedad cerebrovascular, es necesario conocer las características clínicas, factores de riesgo, causas del evento, tiempos de atención y tratamiento de los pacientes para implementar medidas que mejoren la detección y su tratamiento. Objetivo: caracterizar a los pacientes adultos hospitalizados con diagnóstico de enfermedad cerebrovascular isquémica atendidos en el Hospital de San José de Bogotá entre el 1 de junio de 2017 y 31 de mayo de 2018. Metodología: estudio descriptivo de corte transversal. Se incluyeron mayores de 18 años con diagnóstico de enfermedad cerebrovascular isquémica. La información se recolectó de las historias clínicas y se empleó estadística descriptiva para analizar los datos. Resultados: se incluyeron 160 pacientes. El tiempo de evolución tuvo una mediana de 9.9 horas, 85% de ellos ingresaron sin alteración de la conciencia y severidad leve. El tiempo puerta a imagen tuvo una mediana de 36 minutos y el de puerta a trombolisis de 72.5 minutos. Se realizaron neuroimágenes en la primera hora de ingreso a 65%, procedimientos de recanalización endovenosa a 13%, de arritmia cardíaca a 96% y de vasos carotídeos a 93%; 82.4% recibió terapia antiagregante y 76% lograron una marcha superior a 10 metros en el momento del egreso. Discusión y conclusiones: se requiere la realización de mejorías en los tiempos de atención para alcanzar las pautas establecidas en las guías internacionales actuales.

Performance and Analysis of Pediatric Index of Mortality 3 Score in a Pediatric ICU in Latifa Hospital, Dubai, UAE

Introduction: The pediatric index of mortality (PIM) 3 is one of several severity scoring systems used for predicting the outcome of patients admitted to pediatric intensive care units (PICUs) based on data collected within the first hour of admission. It avoids potential bias from the effects of treatment after admission and offers practical utility in assigning children to clinical trials soon after PICU admission. PIM 3 is an updated version of PIM 2 for predicting mortality in the PICU. It provides an international standard based on a large contemporary dataset for the comparison of risk-adjusted mortality among children admitted to intensive care. Objective: The aim was to evaluate the performance of the PIM 3 score in predicting mortality in a tertiary care PICU. Materials and Methods: This was a cohort observational study conducted at a tertiary care PICU from January 2016 to October 2018. All patients between 1 month and 15 years of age who were admitted in the PICU in Latifa Hospital were included. PIM 3 scoring was done for all the patients. All data were extracted from the computerized ICU registry database. Scores were calculated using the PIM 3 calculator application. Data were entered into Microsoft Excel 2013 and analyzed using SPSS v24.0. We analyzed the association between PIM 3 score and mortality. The performance of PIM 3 score was assessed by calibration and discrimination. Calibration evaluated PIM 3 at different risks of mortality and was assessed by standardized mortality ratio (SMR) and Pearson’s χ² goodness-of-fit test. SMR was calculated to a mean probability of death and the ratio of observed-to-expected death rates. Discrimination evaluated how well PIM distinguished between patients who survived and died and was assessed using the area under the curve (AUC) with a 95% confidence interval (CI) from the receiver-operating characteristics plot. Results: A total of 583 patients were included in the study, 46 of whom (7.9%) died. The overall SMR was 0.53. SMR was 0.33 and 0.72 in the p < 14.3% and p > 14.3% group, respectively. The expected mortality rate based on PIM 3 score was 9.2 and 37.5% in the p < 14.3% and p > 14.3% group, respectively. Conclusion: The PIM 3 was used to predict mortality in PICU patients in Latifa Hospital, Dubai. The overall accumulated expected mortality was 87.081 (5%) compared to the observed mortality of 46 (7.9%) and SMR of 0.53. PIM 3 had acceptable discrimination ability with an AUC of 0.78 (95% CI 0.69–0.87).

Imaging in patients with suspected acute heart failure: timeline approach position statement on behalf of the Heart Failure Association of the European Society of Cardiology.

Acute heart failure is one of the main diagnostic and therapeutic challenges in clinical practice due to a non-specific clinical manifestation and the urgent need for timely and tailored management at the same time. In this position statement, the Heart Failure Association aims to systematize the use of various imaging methods in accordance with the timeline of acute heart failure care proposed in the recent guidelines of the European Society of Cardiology. During the first hours of admission the point-of-care focused cardiac and lung ultrasound examination is an invaluable tool for rapid differential diagnosis of acute dyspnoea, which is highly feasible and relatively easy to learn. Several portable and stationary imaging modalities are being increasingly used for the evaluation of cardiac structure and function, haemodynamic and volume status, precipitating myocardial ischaemia or valvular abnormalities, and systemic and pulmonary congestion. This paper emphasizes the central role of the full echocardiographic examination in the identification of heart failure aetiology, severity of cardiac dysfunction, indications for specific heart failure therapy, and risk stratification. Correct evaluation of cardiac filling pressures and accurate prognostication may help to prevent unscheduled short-term readmission. Alternative advanced imaging modalities should be considered to assist patient management in the pre- and post-discharge phase, including cardiac magnetic resonance, computed tomography, nuclear studies, and coronary angiography. The Heart Failure Association addresses this paper to the wide spectrum of acute care and heart failure specialists, highlighting the value of all available imaging techniques at specific stages and in common clinical scenarios of acute heart failure.

Prognostic scoring systems in pediatric ICUs: Pediatric Risk of Mortality III versus Pediatric Index of Mortality 2

Background Estimations of disease severity and probability of death are important elements in determining the prognosis of patients in pediatric ICU (PICU), and a more accurate prognostic assessment can lead to more appropriate monitoring, proper management, and family counseling. Objective The aim of the study was to compare the performance of the PRISM III (Pediatric Risk of Mortality III) and the PIM2 (Pediatric Index of Mortality 2) scores at PICU and to investigate the relation between scores and mortality. Patients and methods A prospective observational cohort study was conducted at PICU, Menoufia University Hospital, Egypt, during the period of February to October 2017. The study was approved by the Ethical Committee of Menoufia University Hospital. A total of 50 patients were included during the study period. Within the first hour of admission, PIM2 and PRISM III scores were applied. Patients were followed up for outcome, measured in the form of survivors and nonsurvivors. Results A total 50 patients were included, of whom 35 were survivors and 15 were nonsurvivors. Most survivors and nonsurvivors were females, but there was no statistical significant influence on outcome. The area under the receiver operating characteristic curve was 0.937 (0.863–1.000) for PRISM III and 0.870 (0.759–0.99) for PIM2. There was a positive correlation between the two scores on the day of admission. Conclusion Both PRISM III and PIM2 scores have a good discriminatory performance. PRISM III has better discrimination ability on admission in comparison with PIM2.

Variation in the use of Fontan fenestration in the current surgical era

Fontan fenestration reduces chest tube duration and shortens post-operative length of stay but is not universally performed. Using a large national database, we sought to describe current use of the Fontan fenestration, including factors associated with placement.The Virtual Pediatric System database was queried to identify patients with the Society of Thoracic Surgery code for a Fontan procedure during their admission from January 2009 until June 2016. Those undergoing a fenestrated Fontan were compared to those undergoing a non-fenestrated Fontan.Of the 1695 patients, 1084 (64%) had a fenestration placed. There was variation between centers with the range of fenestration placement being 8 to 100%. Those with a fenestration placed had lower weight, despite similar age, and were more likely to have a single right ventricle. Those with a fenestration had lower systolic blood pressure and greater need for mechanical ventilation within the first hour of admission to the intensive care unit after Fontan.Most patients still have a fenestration placed at the time of Fontan but this varies markedly by center. Fenestration placement is more common in higher risk patients including those with a systemic right ventricle. Further study is necessary to determine specific patient populations that benefit from fenestration placement at the time of Fontan.

Admission Hyperoxia Is a Risk Factor for Mortality in Pediatric Intensive Care.

To determine whether the association between hyperoxia and increased risk-adjusted mortality in adult intensive care patients is also observed in a pediatric intensive care population. Single-center retrospective analysis of admissions to ICU over a 5-year period commencing January 1, 2012, examining the relationship between PaO2 measured within the first hour of admission and risk-adjusted mortality. Standardized mortality rates were calculated using the Pediatric Index of Mortality-3, and patients were grouped into 50 mm Hg (6.67 kPa) PaO2 bands to assess the relationship between initial PaO2 and risk-adjusted mortality. Tertiary PICU with 17 beds and 1,100 annual admissions located in metropolitan Sydney, Australia. A total of 1,447 patients 0-18 years old with PaO2 recorded at admission to the ICU. None. There were 5,176 patients admitted to the ICU during the study period and 1,447 (28%) with PaO2 recorded at admission. A U-shaped relationship between raw mortality and admission PaO2 was observed, with lowest mortality (2.3% and 2.6%, respectively) observed in the 101-150 (13.5-20.0 kPa) and 151-200 mm Hg (20.1-26.7 kPa) bands and the highest mortality observed in patients with PaO2 less than 50 mm Hg (6.67 kPa) with mortality of 5.3%, or greater than 350 mm Hg (46.7 kPa) with mortality of 18.2%. Hyperoxia at admission was associated with an increase in risk-adjusted mortality, with polynomial regression indicating a strong correlation between PaO2 band and risk-adjusted outcome (r = 0.845). When included in a multivariate model that included the Pediatric Index of Mortality-3 variables, the odds ratio for hyperoxia (defined as PaO2 > 250 mm Hg [33.3 kPa]) predicting death was 2.66 (p = 0.047). In this single-center study, hyperoxia at admission to the PICU was highly correlated with increased risk-adjusted mortality. Further investigation of these observations in a large multicenter cohort is warranted.

Treatment of severe bronchiolitis: A survey of Canadian pediatric intensivists.

To describe management practices and the factors guiding admission and treatment decisions for viral bronchiolitis across Canadian pediatric intensive care units (PICUs). Cross-sectional survey. Canadian PICUs. Pediatric intensivists. A survey using two case scenarios (non-intubated vs intubated patients) was developed using focus groups and a literature review. We analyzed our results using descriptive statistics and multivariate logistic regression. Our response rate was 55% (57/103). Regarding bronchiolitis management, 75% (42/56) of respondents would use inhaled therapies, with nebulized epinephrine (33/56, 59%) and salbutamol (20/56, 36%) being the most common. Antibiotic use within the first hour of admission to PICU almost doubled in frequency (36% vs 71%) in patients who required mechanical ventilation (p 0.0004). High flow nasal cannula (HFNC; 32/56, 57%) and continuous positive airway pressure (CPAP; 16/56, 29%) were the preferred modes of non-invasive ventilation (NIV). The management of severe viral bronchiolitis is similar across Canadian PICUs. The use of NIV, inhaled treatments, and antibiotics is frequent, which differs from the recommendations made by published guidelines. Canadian pediatric intensivists use homogeneous PICU admission criteria based on patients' characteristics and severity of the clinical picture. Clinical practice guidelines for children with viral bronchiolitis should address the management of patients with severe clinical disease.

Sim-sepsis: improving sepsis treatment in the emergency department?

Sepsis is a time-critical medical emergency that is estimated to account for 37 000 deaths annually in the UK. It is an adverse systemic host response to infection that can lead to multiple organ failure and death where timely administration of specific clinical interventions reduces mortality.1 Despite internationally focused awareness campaigns and clinician-friendly bundles of care, compliance with all six steps (sepsis 6) within the first hour of admission remains poor.2 Simulation-based education (SBE) uses high-fidelity-guided patient experiences to develop learnt behaviours for unexpected critical incidents. While SBE has been shown to improve participant satisfaction and knowledge, there is limited evidence that demonstrates a change in participants’ behaviour and patient outcome. Such evidence is key as it demonstrates translation of learning into practice. Our study, assessing the effectiveness of an in-house SBE programme using the Kirkpatrick learning evaluation model3 in a cohort of emergency department (ED) physicians, indicates such a change may be achievable. Using a locally written sepsis teaching programme, participants attended two didactic seminar sessions covering the fundamentals of sepsis management and human factors. Focused multiple choice and short answer pre-seminar and post-seminar assessment were completed by attendees (Kirkpatrick level …

Observational study of dermatological manifestations in patients admitted to a tertiary poison center in Iran

Background/aim: Acute unintentional and deliberate poisoning by medications and chemicals is a frequent emergency, especially in Iran. This study aimed to evaluate the frequency and character of skin findings occurring in patients with acute intentional and aunintentional poisoning. Materials and methods: This prospective observational study was performed at the Loghman Hakim Hospital Poison Center over a period of 6 months from April 2016 to September 2016. Data including patient demographics, cause of poisoning, and level of consciousness were collected. Pediatric patients (under the age of 13) and patients who died in the first hours of admission were excluded from the study. Results: The most common cause of toxicity-related admission in our patients was methadone overdose. The most common skin finding in these patients was xerosis. According to our results, there was an association between tramadol poisoning and self-induced lesions. Shin hyperpigmentation was found to be significantly more frequent in patients with lead poisoning. Conclusion: Further study is recommended to shed light on the possible association of drug poisoning and skin lesions.

Performance of PRISM score III in predicting the outcome of patients admitted in tertiary care pediatric intensive care unit (P.I.C.U.): A pilot study

Introduction: P.I.C.U is a unit that provides care to the critically ill patients with purpose of reducing the rate of mortality and morbidity. Various scoring systems are used to assess and compare the standards of care of different P.I.C.U.s. Among them, PRISM III scoring has shown promising results, especially in developing countries. In Pakistan, these studies are fewer in numbers with conflicting results in different hospital settings (private and public sector). Since our hospital is also a tertiary care hospital, we planned a pilot study to evaluate PRISM III score in our P.I.C.U. Objective: To evaluate the performance of PRISM III score in predicting the outcome of patients admitted in P.I.C.U of tertiary care hospital of Karachi. Method: PRISM III is Pediatric Risk of Mortality Scoring system consisting of clinical assessment (Glasgow Coma Scale, pupillary reflex, temperature, heart rate, systolic blood pressure) and lab parameters (arterial blood gas, urea, nitrogen, creatnine, blood sugar, potassium, white cell count, platelets, PT/APTT). It is a cross-sectional study and data was collected from admitted patients in P.I.C.U, Unit II of Abbasi Shaheed Hospital during 1st October to 31st December 2016. PRISM score is being calculated from all the patients within 24 hours of admission. Result: Total of 70 patients of which 51(72%) survived and 19(27%) expired. 49 were males and 21 females. Age range of non-survivors was 2 to 18 months. Duration of PI.C.U stay was 72 hours for survivors. Patients who were referred, had malnutrition, depressed mental status, deranged renal functions and required mechanical ventilation during first hour of admission had poor outcome. Out of 19 non-survivors, PRISM III predicted mortality in 15 patients (78.9%). Conclusion: High total PRISM III score was significantly associated with poor outcome i.e. death in this pilot study. Thus PRISM III score was found to be a valid predictor of outcome in our P.I.C.U. There is no conflict of interest keywords: P.I.C.U, Mortality, PRISM III score, Outcome.

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14

Background Patients admitted to hospital outside normal working hours suffer higher complication and mortality rates than patients admitted at times when the hospital is fully operational. This ‘weekend effect’ is well described but poorly understood. It is not clear whether or not the effect extends to other out-of-hours periods, or how far excess mortality for out-of-hours admissions reflects a different presenting population with higher severity of illness and how much is explained by poorer availability and quality of services. Objectives We aimed to assess (1) the costs and benefits of introducing 7-day services, (2) whether or not mortality rates are elevated during all out-of-hours periods, (3) whether or not selection of more severely ill patients for admission out of hours explains elevated mortality rates and (4) whether or not mortality rates out of hours are related to staffing levels. Methods We conducted a series of retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. For the national studies, we analysed emergency admissions to all 140 non-specialist acute hospital trusts in England between April 2013 and February 2014 (over 12 million accident and emergency attendances and 4.5 million emergency admissions). For the single trust, we analysed emergency admissions between April 2004 and March 2014 (240,000 admissions). Deaths within 30 days of attendance or admission were compared for normal working hours and out-of-hours periods. Results We found that, in addition to elevated mortality for weekend admissions, mortality rates are also elevated for patients admitted during night-time periods. Elevated mortality was reduced for stroke patients in a large acute trust when more – and more experienced – nursing staff were present during the first hour of admission. Nationally, we found that excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes when we accounted for severity of patient illness. We also found that the estimated cost of implementing 7-day services exceeds the maximum amount that the National Institute for Health and Care Excellence would recommend the NHS should spend on eradicating excess mortality at weekends. Limitations Our results depend on the accuracy and completeness of data recording by hospital staff. If accuracy of recording is related to time of patient admission, our results may be biased. Results based on data from a single trust should be treated as indicative. Conclusions In addressing variations in patient outcomes across the week, a more nuanced approach, extending services for key specialties over critical periods – rather than implementing whole-system changes – is likely to be the most cost-effective. Future work Future research should aim to develop and use appropriate measures of severity of illness to facilitate meaningful analysis of variations in patient outcomes, and to identify candidate specialties and critical periods for which extending services is likely to be cost-effective. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Mean Platelet Volume as a Marker of Intraventricular Hemorrhage in Very Premature Infants

Background: Since the intraventricular hemorrhage (IVH) is still a serious problem in premature infants associated with poor neurodevelopmental outcomes, there is a need for an accessible tool in order to identify these at high risk neonates. Objectives: To determine if high mean platelet volume (MPV) within 24 hours of birth can identify preterm infants prone to IVH as a simple accessible test. Methods: One hundred premature infants with gestational age (GA) of < 34 weeks with respiratory distress syndrome (RDS) were eligible in this study and were divided into two groups based on the diagnosis of IVH. Measurements of MPV and platelet counts were performed during the first hours of admission and on the third day of life. Elevated MPV was defined as a value of ≥ 11 fL. Results: Seventy four percent of infants with IVH had an MPV of more than 11 fL compared to twenty six percent in infants without IVH (Crude OR: 10.71, 95%CI: 4.26 to 26.90, P < 0.001). Multivariate logistic regression analysis of selected variables demonstrated that MPV (Adjusted OR: 10.68, 95%CI: 3.20 to 35.59, P < 0.001) and GA (Adjusted OR: 0.54, 95%CI: 0.40 to 0.74, P < 0.001) were related to the occurrence of IVH. Conclusions: High MPV within 24 hours of birth can be determined as a simple available laboratory test for identifying NICU-admitted premature infants at risk of IVH.

Electrocardiogram Abnormality Associated with Methadone Overdose.

A 19-year-old male patient presented to the Emergency Department at Hazrat-e Ali Asghar Hospital, Shiraz, Iran, in May 2015 four hours after ingesting 200 mg of methadone in a suicide attempt. His past medical and family history were negative for any hereditary diseases. He had a history of opium addiction but had been abstinent for the preceding six months; he had previously been prescribed 40 mg of methadone per day as treatment for his opiate dependence. On examination, the patient was conscious, well-oriented and had stable vital signs. Laboratory tests and arterial blood gas analysis were within normal limits. A 12-lead electrocardiogram (ECG) was performed [Figure 1A]. Although the ECG initially seemed normal, further inspection revealed that the QTc interval in the patient was approximately 500 milliseconds (ms). Moreover, the PR interval exceeded 200 ms and a small deflection after the T wave (known as the U wave) was detected. Interestingly, another ECG performed 48 hours later, just before the patient was discharged, revealed the complete normalisation of these abnormalities without the administration of antiarrhythmic agents [Figure 1B]. Figure 1A & B: 12-lead electrocardiograms (ECGs) in a patient with methadone intoxication (A) within the first hour of admission showing T (black arrowheads) and U (white arrowheads) waves and (B) 48 hours later. Note the complete normalisation of the abnormalities ...