Higher Admission Rates Research Articles

Future roles of artificial intelligence in early pain management of newborns

The advent of increasingly sophisticated medical technology, surgical interventions, and supportive healthcare measures is raising survival probabilities for babies born premature and/or with life‐threatening health conditions. In the United States, this trend is associated with greater numbers of neonatal surgeries and higher admission rates into neonatal intensive care units (NICU) for newborns at all birth weights. Following surgery, current pain management in NICU relies primarily on narcotics (opioids) such as morphine and fentanyl (about 100 times more potent than morphine) that lead to a number of complications, including prolonged stays in NICU for opioid withdrawal. In this paper, we review current practices and challenges for pain assessment and treatment in NICU and outline ongoing efforts using Artificial Intelligence (AI) to support pain‐ and opioid‐sparing approaches for newborns in the future. A major focus for these next‐generation approaches to NICU‐based pain management is proactive pain mitigation (avoidance) aimed at preventing harm to neonates from both postsurgical pain and opioid withdrawal. AI‐based frameworks can use single or multiple combinations of continuous objective variables, that is, facial and body movements, crying frequencies, and physiological data (vital signs), to make high‐confidence predictions about time‐to‐pain onset following postsurgical sedation. Such predictions would create a therapeutic window prior to pain onset for mitigation with non‐narcotic pharmaceutical and nonpharmaceutical interventions. These emerging AI‐based strategies have the potential to minimize or avoid damage to the neonate's body and psyche from postsurgical pain and opioid withdrawal.

Handgrip strength during admission for COPD exacerbation: impact on further exacerbation risk

BackgroundLow handgrip strength (HGS) is independently associated with a higher exacerbation risk in stable chronic obstructive pulmonary disease (COPD); however, the relationship between HGS while being admitted for COPD exacerbation and further exacerbation risk after discharge remains unclear.MethodsWe enrolled patients admitted for COPD exacerbation between January 2018 and June 2019. HGS tests were done within 3 days after admission. The primary endpoint was exacerbations within 12 months after the index admission, which needed emergency room visits or hospital admission. We analyzed the relationships among demographics, HGS, pulmonary function parameters, and acute exacerbation events.ResultsAmong 43 enrolled patients, 31 (72.1%) participants (HGSw) had HGS weakness (22.1 ± 4.1 kg). The other 12 (27.9%) participants (non-HGSw) had the strength of handgrips 33.7 ± 3.1 kg. HGSw group showed a significantly higher rate of emergency room visits within 6, 9, and 12 months after the index admission than non-HGSw group (0.81 ± 1.30 vs. 0.08 ± 0.29, p = 0.045; 1.26 ± 1.59 vs. 0.17 ± 0.38, P = 0.019; 1.48 ± 1.86 vs. 0.25 ± 0.62, P = 0.027, respectively). There was a trend to have higher admission rate within 9 and 12 months in HGSw group, which did not achieve statistical significance (0.77 ± 1.38 vs. 0.08 ± 0.29, P = 0.064; 0.94 ± 1.56 vs. 0.08 ± 0.29, P = 0.062, respectively).ConclusionsHGS weakness measured upon admission for COPD exacerbation was associated with a higher risk of exacerbation in the next year.Trial registration ClinicalTrials.gov Identifier: NCT04885933.

Gastrointestinal manifestations as early symptoms to diagnose COVID-19 paediatric cases

Background: The international situation surrounding the COVID-19 pandemic is seeing multiple countries battle various waves of the SARS-CoV-2 virus infections, with millions of individuals being infected globally. COVID-19 cases initially involved the immuno-compromised and elderly. As the virus has infected millions globally, the demographic profile of cases has shifted with more children being infected; this increase in younger individuals contracting the infection has resulted in new symptoms with altered manifestations and presentations of the disease in the young. In comparison to the severe symptoms of COVID-19 in adults children present with a more trivial group of symptoms. The majority of children develop mild symptoms or remain asymptomatic. This is in stark contrast to adults who have a higher admission rate with severe symptoms. A sign of great importance and now incidence in pediatric cases with COVID-19 is that of the gastrointestinal tract. The virus has a tropism for the GIT due to the presence of ACE2 receptors, which facilitate the entry of the virus into the cell.
 Conclusion: It is now established that the GIT symptoms form part of a newly recognized multisystem inflammatory syndrome (MIS-C) which occurs as a result and or manifestation of the COVID-19 infection. The innate difficulty in correctly and accurately diagnosing such a case is that the symptoms very close mimic gastroenteritis and acute abdominal pathologies. Therefore, physicians need to be aware of the various manners in which the COVID-19 infection manifests itself in children to diagnose better and isolate the cases.

Older people in hospitals for the insane in New South Wales, Australia, 1849–1905

Older people had high admission rates to hospitals for the insane in New South Wales, Australia, in the second half of the nineteenth century. The medical casebooks of 226 patients aged 60 years and over admitted to two hospitals for the insane between 1849 and 1905 were examined. Aggressive behaviour (35.4%), suicidal behaviour (23.9%), fears of harm to self (19.9%) and alcohol issues (13.7%) were identified. Physical health factors (35.8%), functional impairment (18.6%) and poor nourishment (8.8%) were noted. Common diagnoses were mania (36.7%), dementia (31.9%) and melancholia (17.7%). Twenty-first-century diagnoses were assigned in nearly 94 per cent of cases with concordance that varied by diagnosis. The majority of admissions had serious mental disorders, with only 29.6 per cent being discharged.

A Challenging Period After Repair: Etiology and Follow-Up Rates of the Patients With Cleft Lip and Palate in Intensive Care Unit.

The perioperative period is quite challenging because of the featured anatomical and clinical properties of the babies with cleft lip and palate (CLP). Therefore follow-up in the intensive care unit (ICU) is a crucial parameter for managing these patients. Although various studies in cleft literature, limited studies have analyzed the ICU admission rate and its etiology in the cleft population. At this point, the present study aims to reveal the etiology and rate of ICU admission of babies with an orofacial cleft to contribute to taking preventive precautions.The rate of primary CLP patients was 69.5% (937 of 1348 patients). Intensive care unit admission rate of primary CLP patients was 6.2% (n = 58). The expected and unexpected ICU admission rate was 4.8% and 1.4%, respectively. Of the patients admitted to the ICU, 53.4% (n = 31) were boys and 46.6% (n = 27) were girls. There was no statistically significant association between gender and ICU admission (P = 0.896). However, the association between cleft type and ICU follow-up was statistically significant (P < 0.001).The findings of the present study reveal the high ICU admission rate of cleft patients within all patients admitted to ICU. Due to many unique statuses of cleft babies, attentive assessment in the preoperative period and determining the postoperative need for ICU follow-up would contribute to preventing postoperative complications.

Characteristics and Outcomes of Pediatric Patients With a Ventricular Assist Device Presenting to the Emergency Department.

A growing number of children receive support from left ventricular assist devices (LVADs) in the outpatient setting. Unexpected complications of LVAD support occur that require emergent management, and no studies examine how pediatric LVAD patients present to the emergency department (ED). The goals of this study were (1) to describe frequency of visits, clinical characteristics, adverse events, and outcomes of LVAD-supported children treated in ED settings and (2) to evaluate for associations between specified patient outcomes and ED care location. This was a retrospective cohort study of children in a single-center outpatient VAD program who presented to several EDs during a 10-year period. We defined adverse events according to the Advanced Cardiac Therapies Improving Outcomes Network registry guidelines. Secondary analysis evaluated for associations between specified patient outcomes (adverse events, hospitalizations, intensive care unit admissions) and ED care location (institutional vs other ED). Of 104 subjects with LVAD implantations during the study period, 30 (28.8%) transitioned to outpatient care. Among subjects in the outpatient VAD program, 24 (80%) of 30 had 54 visits to various EDs over 141.9 patient-months. The median age at time of ED visit was 13.5 years (range, 7.2-17.9 years). The median number of visits per subject was 1 (range, 0-6). The most common complaints on arrival to the ED were vomiting or abdominal pain (16.7%), fever (15.3%), and headache (13.9%). Seventeen adverse events occurred during 14 (25.9%) of 54 ED visits. The most common adverse events were major infection (33.3%) and right heart failure (16.7%). Hospital admission resulted from 41 (75.9%) of 54 ED visits, including 17 (41.5%) of 41 to a cardiovascular intensive care unit. Care at a nonspecialty ED was associated with a higher rate of hospitalization (93.8% vs 68.4%, P = 0.049). During the study period, 4 subjects (13.3%) died, including 1 patient on destination therapy, 1 with multisystem organ failure due to cardiogenic shock, and 2 with hemorrhagic stroke. No patient died while in the ED. Among subjects in a single outpatient pediatric VAD program presenting to the ED, the most common complaints were abdominal pain/vomiting, fever, and headache. The most common adverse events were major infection and right heart failure. Subjects had a high rate of ED utilization and hospital admission.

Hospital admission for symptoms exacerbation in 2,075 infants suffering from recurrent asthma-like symptoms: (EISL-3 South America).

Contrary to what happens in children and adults, the prevalence and the factors related to hospitalisation for asthma/wheezing in infants with recurrent asthma-like symptoms are poorly known. This study is part of the International Study of Wheezing in infants Phase 3; 2,079 infants (aged 12-18 months) with recurrent asthma-like symptoms, from 11 South American centres, were studied to determine the prevalence and the associated factors for wheezing exacerbation admission. Descriptive statistics and multivariate logistic regression were employed for analysis. The prevalence of admission for wheezing was 29.7% (95% CI 27.7-31.6) and was significantly associated to severe wheezing episodes (OR: 3.89; 95% CI: 2.93-5.18, p < 0.001), physician-diagnosed asthma (OR: 1.79; 95% CI: 1.33-2.41, p < 0.0001), use of inhaled corticosteroids (OR: 1.78; 95%CI: 1.38-2.29, p < 0.0001), maternal tobacco smoking during pregnancy (OR: 1.69; 95% CI: 1.19-2.39, p = 0.003) and onset of wheezing in the first trimester of life (OR: 1.30; 95% CI: 1.02-1.66, p = 0.038). Breast feeding ≥4 months (OR: 0.72; 95% CI: 0.54-0.96, p = 0.004), maternal high educational level (>12 years) (OR: 0.66; 95% CI: 0.51-0.85, p = 0.001) and total monthly household income ≥US$ 3,000 (OR: 0.34; 95% CI: 0.18-0.67, p = 0.002), were protective factors. Infants with recurrent asthma-like symptoms have a high rate of admissions. Tobacco smoking in pregnancy, viral respiratory illness in the first trimester of life and severe progression were risks for admissions. Improving medical management to prevent severe exacerbations, prolonging the postnatal period at home longer than 3 months, favouring breastfeeding and avoiding smoking during pregnancy may have a preventive role for admissions in infants with recurrent asthma-like symptoms.

Spirituality, moral injury and mental health among Chinese health professionals.

Moral injury has been found to be prevalent among healthcare professionals during the COVID-19 public health crisis. The present study examines the relationship between spirituality, moral injury, and mental health among physicians and nurses in mainland China during the COVID-19 pandemic. An online cross-sectional study was conducted involving 3006 physicians and nurses in mainland China, where the COVID-19 pandemic has caused high rates of hospital admission and death. The Moral Injury Symptoms Scale-Health Professional was administered, along with measures of mental health and spirituality. Hierarchical linear regression modelling was used to examine the mediating and moderating role of moral injury in the relationship between spirituality and mental health. Spirituality was positively correlated with moral injury (β = 2.41, P < 0.01), depressive symptoms (β = 0.74, P < 0.01) and anxiety symptoms (β = 0.65, P < 0.01) after controlling sociodemographic variables. Moral injury significantly mediated the relationship between spirituality and both depression and anxiety, explaining 60% (0.46/0.76) of the total association between spirituality and depression and 58% (0.38/0.65) of the association with anxiety. No moderating effect of moral injury was found on the spirituality-mental health relationship. Although they were the findings of a cross-sectional study, these results suggest that concern over transgressing moral values during the pandemic may have been a driving factor for negative mental health symptoms among Chinese health professionals for whom spirituality was somewhat important. Future longitudinal studies are needed to determine the causal nature of these relationships.

Prevalence of Venous Thromboembolism in Cancer Patients in the Emergency Department and Associated Healthcare Resource Utilization and Expenditure in the United States

BackgroundVenous thromboembolism (VTE) is one of the leading causes of morbidity and mortality in cancer patients. We investigated VTE prevalence in cancer patients in the emergency department (ED) setting, associated utilization of health care resources and costs.MethodsThe Agency for Healthcare Research and Quality sponsored Nationwide Emergency Department Sample (NEDS) database was used to identify cancer patients and ED utilizations in 2006-12. The NEDS database captures 20% of US ED visits. Cancer types (solid tumor, lymphoma, leukemia, multiple myeloma) and acute venous thromboembolism [VTE, which includes deep vein thrombosis (DVT) and/or pulmonary embolism (PE)] were identified by ICD-9 codes. CPT procedure codes were used to identify any use of computed tomography pulmonary angiography (CTPA), CT chest with contrast (CTC), duplex ultrasound of the veins (DUS), or ventilation-perfusion (VQ) scan. Descriptive statistics were used to present the VTE prevalence, use of imaging study, admission rates and costs incurred. Chi-square test were used to compare death/admission rate and chi-square test for trend was used for trend analysis. Multivariable logistic regression modeling was used to explore the association between VTE diagnosis and hospital admission or death during hospital course after baseline characteristics adjustment.ResultsThere were 6,330,322 ED visits by cancer patients in our study, which represented 3.2 % of total ED visits from 2006-2012 in the NEDS database. Over the study period, 1.6% of patients received either CTPA, CTC, DUS, or V/Q scan during their ED visits (CTPA: 0.56%; CTC: 0.47%; DUS: 0.62%; V/Q: 0.02%). The use of imaging studies had increased from 0.92 to 2.35 per 100 ED visits (Figure 1, p-value for trend<.0001) over time. The overall VTE rate was 2.35 (95% CI: 2.34-2.37) per 100 ED visits [Table 1, DVT: 1.34 (95% CI: 1.33-1.35) per 100 ED visits; PE: 1.30 (95% CI: 1.29-1.31) per 100 ED visits]. Patients with pancreatic cancer had the highest rate (5.84 per 100 ER visits), followed by lung (3.51 per 100 ER visits) and stomach cancers (3.09 per 100 ER visits) (Figure 2). Patients with thyroid, head and neck and prostate cancers had the lowest rates. Cancer patients with VTE had a higher rate of death in the ED (6.5% vs 4% of those without VTE, p-value<.0001) and a higher rate of admission (92% vs 61% of those without VTE, p-value< .0001). From 2006-2012, the total median hospital cost of cancer patients with VTE increased from $26,069 to $34,254 and were consistently higher than those without VTE (costs: $19,013 to $26,768, Table 2). In the subgroup of patients with solid tumor cancer (N=5,349,246), VTE diagnosis was independently associated with higher odds of admission (adjusted odds ratio (AOR):6.7, 95% CI: 6.56-6.84, p-value< .0001) and hospital death (AOR: 1.24, 95% CI: 1.21-1.27, p-value< .0001) after adjusting for age, cancer types, and metastatic status.ConclusionsVTE diagnosed in the ED was associated with higher rate of mortality, hospital admissions, and healthcare-associated costs. Imaging studies for VTE are increasingly frequent, suggesting increased awareness by ED providers. Future clinical trials are warranted to investigate the cost-effectiveness of outpatient VTE prophylaxis among cancer patients in order to reduce VTE-associated burden. [Display omitted] DisclosuresKhorana:Halozyme: Consultancy, Honoraria; Janssen Scientific Affairs, LLC: Consultancy, Honoraria, Research Funding; Sanofi: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Amgen: Consultancy, Research Funding; Leo: Consultancy, Honoraria, Research Funding.

A Multicenter Retrospective Review of Outcomes of Diffuse Large B Cell Lymphoma (DLBCL) in the Elderly Treated with RCHOP in Australia

▪BackgroundThe outcome of DLBCL in the elderly is well described in clinical trials with reported 2-year OS of 60-80%. However less well reported are aspects of care of elderly DLBCL patients treated outside the trial context, including rates of completion of induction chemotherapy and detailed reasons for dose delays and reductions and their effect on outcomes including remission rates and progression free survival (PFS). Here we describe an Australian experience of management of elderly DLBCL patients treated at 3 large institutions.MethodsThis is a multi-center, retrospective analysis of consecutive patients aged >=60, with DLBCL, planned to receive rituximab-chemotherapy . The standard regimens included 3 cycles (early stage disease) or 6 cycles (advanced) RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone) followed by two rituximab doses in fit patients; R-miniCHOP for unfit and R-CE(etoposide)OP for patients with cardiacdysfunction. Disease response was PET-based. Patient data including included baseline characteristics, histology, clinical parameters, comorbidities, treatment outcomes and toxicity were extracted from hospital medical records. The primary endpoint was PFS; secondary endpoints included overall survival (OS), overall response rate and toxicity and rates of dose delays, dose reductions, hospital admission and completion of planned treatment. Descriptive statistics were used in the analysis.Results227 patients were evaluated from 2012-2017. Table 1 shows baseline characteristics and treatment. Median age was 73 years (range 60-97). Major comorbidities were present in 126 (55%) patients, with ischaemic heart disease (24%), diabetes (21%) and renal impairment (15%) the most common. Impaired cardiac function (EF<55%) was present in 25 (11%) of cases. G-CSF was used in 57 (25%) patients for primary prophylaxis and 20 (9%) patients post febrile neutropenia. Dose reductions occurred in 114 patients (50%): 59 (26%) upfront, 85 (38%) from cycle 2 onwards and 30 (13%) requiring both. Fifty-four patients (24%) had more than one dose reduction during treatment and 40 (18%) had dose delays. Only 19 (8%) patients did not receive all planned cycles of R-chemotherapy. Hospital admission was required in 167 (74%) cases. The median number of admissions was 4 (range 0-16) with a median inpatient duration of 7 days (range 1-83). Sixteen patients were admitted to ICU and 36 had limitations place to their resuscitation orders due to admission related morbidity . Of the evaluable patients (one center) for toxicity (n=98) the most common (12, 5%) grade 3-4 non-haematological toxicity was hepatic (ALT>2xULN), see table 2. Complete remission (CR) on PET following completion of treatment was achieved in 161 cases (71%) and was not impacted by dose reduction/delay (CR of 71% in these cases). Radiotherapy was administered in 56 (25%) patients, predominantly for initial bulky disease (48%) or for residual disease (40%). Median follow-up was 33 months. Two year PFS 69% was (95% CI 63-76%), OS 78% (95% CI 73-84%), see figures 1 and 2 for survival curves. The impact of dose reduction, dose delay and major co-morbidities on survival are under assessment and will be presented at the meeting.DiscussionIn our cohort, DLBCL in the elderly presented frequently as advanced stage, with high rates of B symptoms and extranodal disease. Clinically-relevant comorbidities were present in the majority of patients. Despite >90% of patients completing the planned number of treatment cycles, toxicity was significant with a high rate of hospital admission and dose reductions. In this real world setting, CR rates and survival were reassuringly comparable with published trial data. Elderly DLBCL patients with significant comorbidities have similar survival to the published data but close monitoring and early intervention for toxicity is needed. [Display omitted] DisclosuresHawkes:Roche: Other: Travel expenses; Bristol-Myers Squibb: Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Roche: Other: Travel expenses, Research Funding; Merck Sharpe Dohme: Research Funding; Takeda: Other: Travel expenses; Celgene: Research Funding; Merck Serono: Research Funding. Grigg:Takeda: Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees, Other: Travel expenses; Merck Sharpe Dohme: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees, Other: Travel expenses. Cheah:BMS: Membership on an entity's Board of Directors or advisory committees, Other: Conference travel expenses; Janssen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Speakers Bureau; Gilead: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Roche: Research Funding, Speakers Bureau; Celgene: Research Funding; Abbvie: Research Funding; Amgen: Other: Conference travel expenses.

England's rate of involuntary psychiatric admission is double that of the Republic of Ireland: Why? A consideration of some possible causes.

Involuntary psychiatric admission or 'sectioning' is a serious event with clear implications for the right to liberty, among other rights. Rates of involuntary admission vary considerably across jurisdictions. The rate of involuntary admission in England is approximately double that in the Republic of Ireland. Why? This paper examines potential explanations for this difference, including the prevalence of mental disorder in the two jurisdictions, factors relating to mental health legislation, differing levels of police involvement in care-pathways, funding and resources, and attitudes to risk among the public and professionals. Overall, it appears that the relatively high rate of involuntary admission in England might be attributable to the role of perceived risk in shaping mental health law in England but not Ireland, the broader definition of 'mental disorder' in the Mental Health Act, 1983 in England, broader legal criteria for involuntary admission in the 1983 Act, differences in the operational definitions of 'voluntary patient' between the two jurisdictions and, possibly, increased involvement of police in pathways to care in England and differences in relation to different ethnic groups. The relatively higher number of inpatient beds in England could be a cause or a consequence of higher rates of involuntary admission. Future research could usefully focus on other factors that are also likely relevant: issues relating to social care, substance misuse, availability of alternative treatment options in the community and various other factors that are, as yet, unknown. The potential impact of risk aversion among mental health professionals and others merits particular attention.

Estimated Cost-effectiveness of Solar-Powered Oxygen Delivery for Pneumonia in Young Children in Low-Resource Settings

Pneumonia is the leading cause of childhood mortality worldwide. Severe pneumonia associated with hypoxemia requires oxygen therapy; however, access remains unreliable in low- and middle-income countries. Solar-powered oxygen delivery (solar-powered O2) has been shown to be a safe and effective technology for delivering medical oxygen. Examining the cost-effectiveness of this innovation is critical for guiding implementation in low-resource settings. To determine the cost-effectiveness of solar-powered O2 for treating children in low-resource settings with severe pneumonia who require oxygen therapy. An economic evaluation study of solar-powered O2 was conducted from January 12, 2020, to February 27, 2021, in compliance with the World Health Organization Choosing Interventions That Are Cost-Effective (WHO-CHOICE) guidelines. Using existing literature, plausible ranges for component costs of solar-powered O2 were determined in order to calculate the expected total cost of implementation. The costs of implementing solar-powered O2 at a single health facility in low- and middle-income countries was analyzed for pediatric patients younger than 5 years who required supplemental oxygen. Treatment with solar-powered O2. The incremental cost-effectiveness ratio (ICER) of solar-powered O2 was calculated as the additional cost per disability-adjusted life-year (DALY) saved. Sensitivity of the ICER to uncertainties of input parameters was assessed through univariate and probabilistic sensitivity analyses. The ICER of solar-powered O2 was estimated to be $20 (US dollars) per DALY saved (95% CI, $2.83-$206) relative to the null case (no oxygen). Costs of solar-powered O2 were alternatively quantified as $26 per patient treated and $542 per life saved. Univariate sensitivity analysis found that the ICER was most sensitive to the volume of pediatric pneumonia admissions and the case fatality rate. The ICER was insensitive to component costs of solar-powered O2 systems. In secondary analyses, solar-powered O2 was cost-effective relative to grid-powered concentrators (ICER $140 per DALY saved) and cost-saving relative to fuel generator-powered concentrators (cost saving of $7120). The results of this economic evaluation suggest that solar-powered O2 is a cost-effective solution for treating hypoxemia in young children in low- and middle-income countries, relative to no oxygen. Future implementation should prioritize sites with high rates of pediatric pneumonia admissions and mortality. This study provides economic support for expansion of solar-powered O2 and further assessment of its efficacy and mortality benefit.

Management of patients presenting with low back pain to a private hospital emergency department in Melbourne, Australia.

Recent studies suggest many patients with non-specific low back pain presenting to public hospital EDs receive low-value care. The primary aim was to describe management of patients presenting with low back pain to the ED of a private hospital in Melbourne, Australia, and received a final ED diagnosis of non-specific low back pain. We also determined predictors of hospital admission. Retrospective review of patients who presented with low back pain and received a final ED diagnosis of non-specific low back pain to Cabrini Malvern ED in 2015. Demographics, lumbar spinal imaging, pathology tests and medications were extracted from hospital records. Multivariate logistic regression was used to determine independent predictors of hospital admission. Four hundred and fifty presentations were included (60% female); 238 (52.9%) were admitted to hospital. One hundred and seventy-seven (39.3%) patients received lumbar spine imaging. Two hundred and eighty (62.2%) patients had pathology tests and 391 (86.9%) received medications, which included opioids (n = 298, 66.2%), paracetamol (n = 219, 48.7%), NSAIDs (n = 161, 35.8%), benzodiazepines (n = 118, 26.2%) and pregabalin (n = 26, 5.8%). Predictors of hospital admission included older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02-1.05), arrival by ambulance (OR 2.03, 95% CI 1.06-3.90) and receipt of pathology tests (OR 3.32, 95% CI 2.01-5.49) or computed tomography scans (OR 1.86, 95% CI 1.12-3.11). We observed high rates of imaging, pathology tests and hospital admissions compared with previous public hospital studies, while medication use was similar. Implementation of strategies to optimise evidence-based ED care is needed to reduce low-value care and improve patient outcomes.

Announcing the Lancet Psychiatry Commission on Psychoses in Global Context

Psychoses affect more than 20 million people worldwide1 and are associated with substantial impoverishment,2 premature mortality,3 stigma,4 and human rights violations.5,6 In high-income countries, for example, social outcomes for those with psychoses are poor and include high levels of unemployment, poverty, and homelessness in the decades after the initial contact with mental health services.2 In addition, there are marked inequities in outcomes and involvement with services by ethnic group (eg, high rates of compulsory admissions among Black populations in several countries).

Comprehensive hospital-based regional survey of anaphylaxis in Japanese children: Time trends of triggers and adrenaline use

BackgroundSince few studies have analyzed time trends in pediatric anaphylaxis, including triggers and adrenaline usage, this study aimed to reveal these issues in a comprehensive analysis of pediatric anaphylaxis cases. MethodsThe Aichi Medical Association performed a comprehensive survey of pediatric anaphylaxis cases aged under 15 years from 87 secondary and 25 tertiary emergency care hospitals in Aichi Prefecture (population 7.5 million), Japan. ResultsBetween April 2016 and March 2020, 3423 cases of anaphylaxis were identified. Food items were the most frequent trigger (73%), followed by exercise after food ingestion (4.3%), and drugs (2.2%). Egg (19%) and milk (17%) specifically were the most frequent among food triggers, while the largest proportional increase was observed in tree nuts from 6.0% in 2017 to 15% in 2019. Overall, 1647 (48%) cases were admitted to the hospital, of which 26 (0.8%) were admitted to the intensive care unit. Drug-induced anaphylaxis was associated with the highest admission rate (71%). Of the 2493 food-induced anaphylaxis cases, 1107 (44%) were treated with adrenaline. Among them, 343 cases included previously prescribed adrenaline auto-injectors (AAI), with 225 (66%) usages prior to hospital arrival. There was no significant difference in the admission rate between the cases in which AAIs were used and those with adrenaline administered in the hospital (68% and 72%, respectively). ConclusionsThe proportion of tree nuts in food-induced anaphylaxis increased significantly. Although prehospital AAI use has become widespread, it was not associated with lower admission rate compared to in-hospital adrenaline usage.

Impact of parents' education on variation in hospital admissions for children: a population-based cohort study

ObjectivesTo assess the impact of parental educational level on hospital admissions for children, and to evaluate whether differences in parents' educational level can explain geographic variation in admission rates.DesignNational cohort...

Sickle cell disease and COVID-19: Susceptibility and severity.

We surveyed published papers and an international sickle cell disease (SCD) registry to detect susceptibility and clinical course of coronavirus disease 2019 (COVID‐19) in SCD patients. COVID‐19 presentation was mild in children and moderate in many SCD adults. Regarding increased comorbidities with age, it seems severe COVID‐19 to be more common in older SCD patients. Although the overall outcome of COVID‐19 was favorable in SCD children, a high rate of pediatric intensive care unit admission should be considered in managing these patients. To explain COVID‐19 outcome in SCD patients, the possible benefits of hydroxyurea therapy could be considered. The obtained results should be interpreted, considering low cases from sub‐Saharan people, younger age of SCD patients compared to general population, a bias toward registry of the more severe form of disease, the effect of pre‐existing comorbidities with multisystem organ damage, and the role of health socio‐economic determinants.

P531 SARS-CoV-2 infection in Elderly patients with Inflammatory Bowel Disease with or without immunosuppressants during the first year of the pandemic. An observational, descriptive, cohort study

BackgroundOlder age has been confirmed as a risk factor for severe clinical presentation of SARS-CoV-2 disease (COVID-19). The prevalence of confirmed SARS-CoV-2 infection in Catalonia among people over 60 years is 6.6%. Biological agents have not been associated with a higher incidence nor a worse prognosis of COVID-19. However, the role of immunosuppressants (IMS) on this issue is still to be elucidated. Moreover, there are scarce data related about COVID-19 in inflammatory bowel disease (IBD) patients under IMS, and none focusing in elderly IBD. Our aim was to describe and to compare the incidence and severity of COVID-19 in patients over 65 years of age with IBD, particularly in relation to the use of IMS.MethodsWe performed a retrospective cohort study including IBD patients over 65 years since January 2020, from two referral centres in the Barcelona metropolitan area (Catalonia, Spain). Patients were grouped in two cohorts regarding the use or not of IMS (thiopurines or methotrexate). Patients on biological treatment were excluded. We identified those cases with confirmed infection with SARS-CoV-2 (positive PCR) during the period from 1st of March 2020 (the beginning of the pandemic in Catalonia) to 1st March 2021 (the beginning of vaccination in the elderly). Demographic data, IBD comorbidities, concomitant non-IBD related treatments, and SARS-CoV-2 infection outcomes were recorded.ResultsFour-hundred and eighteen elderly IBD patients were included. The median age was 74 years (IQR 69–78), 52% were male; 70% had ulcerative colitis, 28% Crohn’s disease and 2% IBD unclassified, 62% had arterial hypertension, 22% diabetes mellitus, 22% cardiovascular disease, 15% chronic obstructive pulmonary disease, 10% chronic renal disease, 5% were active smokers. There were no differences regarding comorbidities and non-IBD treatments between the two study groups. From the whole cohort, 89 (21.3%) patients were on IMS (86 with thiopurines, 3 with methotrexate). The median time on IMS was 121 months (IQR 60–162). During the study period, 32 patients (7.7%) had confirmed SARS-CoV-2 infection (7 of whom were on IST; 7.6% not on IMS vs. 7.9% on IMS, P=0.933). Seventeen (53%) patients required hospital admittance (4% not IMS vs. 4.5% on IMS; P=0.818); 4 of them developed COVID-19 related complications (3 patients not on IMS vs. 1 on IMS), and 7 (22%) patients died (6 not on IMS vs. 1 patient on IMS).ConclusionThe rate of SARS-CoV-2 infection among elderly IBD patients is quite similar to that reported in the elderly background population. In elderly IBD patients, SARS-CoV-2 infection was associated with a high admission rate and mortality, regardless of the use of IMS.

Initial report on hospitalized cancer patients with COVID-19 from the National Cancer Institute (NCI) COVID-19 in Cancer Patients Study (NCCAPS).

6566 Background: Hospitalized cancer patients (pts) with COVID-19 have a severe disease course and high mortality. Pts with lung cancer, hematologic malignancies and metastatic disease may be at higher risk. Detailed prospective inpatient data may help to identify those at greatest risk for poor outcomes. Methods: NCCAPS is a longitudinal study aiming to accrue 2,000 cancer pts undergoing treatment for hematologic malignancy or solid tumor with COVID-19. For pts’ first COVID-19 hospitalization, clinical data, research blood specimens and imaging are collected, and additional clinical data are collected during subsequent hospitalizations. Results: As of Jan. 22, 2021, among 757 enrolled adult patients from 204 sites, 124 (16.3%) reported at least one hospitalization for COVID-19, and discharge data was available for 98 hospitalizations in 88 patients. The median age was 67 (range 21-93, 1Q:56, 3Q:72), 35/88 (40%) were female. The most common malignancies in hospitalized adult pts were lymphoma (18.2%), lung cancer (15.9%) and multiple myeloma (10.2%). The most common presenting symptoms were shortness of breath (65%), fatigue/malaise (64%), and fever (49%). 8/88 (9%) pts were neutropenic (ANC &lt; 1000) at presentation; 17/88 (19%) were thrombocytopenic. Median length of stay was 6.5 days (range 1-41, 1Q:4, 3Q:12). Among those hospitalized, 20/88 (22.7%) received care in the ICU or high dependency unit, with a median ICU stay of 7 days (range 1-22, 1Q:2.5, 3Q:9.5); of those admitted to the ICU, 25% (5/20) received invasive mechanical ventilation. Of those in whom inpatient medications were recorded (n = 63), 63% received corticosteroids, 46% received remdesivir, and 14% received convalescent plasma. One pt received bamlanivimab and 2 patients received tocilizumab. Most (46/63; 73%) received anticoagulation, primarily prophylactic low molecular weight heparin; 11/63 (17%) received therapeutic dose anticoagulation. Inpatient D-dimer values were recorded in 43 inpatients, 26 of whom had multiple measurements. 16/98 hospitalizations ended with death (16%). Conclusions: Preliminary analysis of NCCAPS data reveals that inpatient hospital admission is common among oncology patients with COVID-19 and mortality rates appear high within this cohort. Hematologic malignancies and lung cancer are the most common underlying diagnoses in patients requiring hospitalization. Corticosteroids and anti-coagulation were the most commonly used therapies. Despite high rates of ICU admission, invasive mechanical ventilation may be instituted less often in an oncology cohort. These observations may inform decisions about vaccine policy and decisions to limit life sustaining treatment. Clinical trial information: NCT04387656.

Outcomes of immune checkpoint inhibitor-mediated colitis: Multicenter cohort study.

2643 Background: Immune checkpoint inhibitor (ICI)-mediated colitis (IMC) is a common and serious adverse event. Although small series have described the clinical presentation of IMC, large multicenter series that integrate clinical, endoscopic, and histologic findings are lacking. Methods: We retrospectively assessed patients who received ICI and had endoscopically confirmed IMC from 2010 to 2019. IMC was graded based on the CTCAE version 5.0 criteria. Multivariate logistic regression analyses were conducted to assess factors associated with recurrence of IMC symptoms and long duration of corticosteroids use (&gt; 70 days). Results: 675 patients were included. 387 patients were males (57%). Median age was 63 years. Melanoma was the most common cancer type (327; 48%). Most (365; 54%) patients received CTLA-4 inhibitor ICI, as monotherapy or in combination with PD-(L)1. Median time from ICI therapy to IMC was 62 days. IMC was grade 2 in 335 (50%) patients, Grade 3 in 181 (27%), and grade 4 in 16 (3%). 155 (23%) patients had mucosal ulceration on endoscopy, 91 of them had severe features (deep, large, or multiple ulcers); 336 (50%) patients had non-ulcerative inflammation. The rest had normal endoscopic findings with histologic inflammation. Most patients were admitted to the hospital for management of IMC (405; 60%) and 16 (3%) needed ICU-level of care. Treatment included corticosteroids in 577 (85%) patients (median duration 52 days), TNF inhibitor in 245 (36%), and vedolizumab in 90 (13%). 202 (32%) patients had recurrent IMC after resolution of symptoms. On multivariate logistic regression, factors associated with IMC recurrence and long (&gt; 70 days) duration of corticosteroid therapy were grade of IMC ( p = 0.049), treatment with infliximab or vedolizumab ( p = 0.044), presence of mucosal ulceration ( p = 0.034 ), or features of active histologic inflammation ( p = 0.076). Of note, patients with mucosal ulceration received infliximab or vedolizumab more frequently ( p &lt; 0.001). For patients with grade 2 IMC, mucosal inflammation on endoscopy and delay in performing endoscopy with time from IMC onset to endoscopy more than a month were associated with IMC recurrence and longer duration of corticosteroid use ( p = 0.029 and p &lt; 0.001, respectively). 16 (3%) patients had colonic perforation, 7 of them underwent surgical resection. No IMC-related death occurred. Conclusions: IMC is a clinically significant adverse event that can lead to premature termination of ICI therapy with high rates of hospital admission. Rarely, it results in colonic perforation requiring surgical intervention and ICU admission. Our data suggest that there is a utility of endoscopic and histologic evaluation in the prediction of worse outcomes from IMC. This finding is particularly important for grade 2 IMC as current guidelines do not recommend endoscopic evaluation for this group.