Unit Admission Research Articles

1308 Investigating the Use of a Novel Pre-Hospital Triage Tool for Acute Abdominal Surgical Emergencies – A Two-Phase Single Centre Cohort Study

Abstract Background Despite the recent improvements in mortality in patients undergoing emergency laparotomy(EL) within the UK, delay to theatre continues to be associated with increased mortality. This study aimed to assess if patients requiring urgent surgical intervention for acute abdominal surgical pathology could be identified in the pre-hospital setting. Method A two-phase, single-centre, cohort study was performed. Phase 1 retrospectively investigated patients who underwent emergency laparotomy between 01/01/2019-31/12/2019 at Leeds Teaching Hospital Trust (LTHT) through the NELA database. Phase 2 prospectively assessed NEWS2 for all patients presenting to LTHT Surgical Admissions Unit with abdominal pain between 01/01/2020-31/01/2020. Results Phase 1: 45 patients were coded through NELA and confirmed through operation note review as undergoing EL for gastrointestinal perforation. 66%(n = 30) were assessed by the ambulance service and 80% (n = 24) had a NEWS2 of 3 or greater. Phase 2: 319 patients were assessed in SAU/ED, of which 69 initially treated by the ambulance service. 30% (n = 21) of these patients had an initial NEWS2 of 3 or above. Sensitivity of a NEWS2 score of >/3 in predicting the need for immediate surgical intervention including EL was 95%(95%CI, 74-99) and specificity was 95% (95%CI, 83-99) with a PPV of 86%(95%CI 67-95) and NPV of 98% (95%CI, 87-99). Conclusions A NEWS2 score of >/3 predicts the need for emergency surgical intervention including laparotomy for gastrointestinal perforation with reasonable sensitivity in this cohort. A pre-hospital triage tool for patients presenting with abdominal pain could utilise NEWS2 as an adjunct to decision-making in an acute abdominal pathway.

1470 Consenting for a Bedside Procedure: A Prospective Observational Analysis of Consenting Practice in the Surgical Emergency Admissions Unit of a District General Hospital

Abstract Aim Consent is necessary to enable patient autonomy, and it is vital that it is voluntary, informed and, where possible, the patient has valid mental capacity to give consent. Recent case law has grown around consent and practice guidance has evolved. This was a prospective observational study investigating the quality of consenting practice for incision and drainage procedures performed within the surgical emergency admissions unit (SEAU) at a district general hospital. Method A prospective study was conducted on consent documentation for a study period from August to September 2020, for patients undergoing bedside incision and drainage (I&D) procedures within the SEAU. Documentation was reviewed and data collected for quality of consent. Further data into the quality of this documentation was also collected; including legibility, risk and benefit discussions, local anaesthetic used, operation note documentation and discussion of the procedure. This was compared against GMC standards. Results Of 20 cases (n = 20), 1 case had written consent and 15 cases had verbal consent documented. 4 cases had no documentation of consent. No cases had benefit documentation, and 4 out of the 20 cases had risks documented. 4 cases had documentation of procedure discussion. 13 cases had an operation note included. Conclusions This study highlights a deviation from recommended practice, and results have been communicated at a departmental level. Recommendations have been offered in an attempt to improve compliance, including the display of posters in the SEAU. We shall re-audit practice within the coming months after these changes have been implemented.

1502 UK National Survey of Huber Needle Availability for Deflation of Gastric Band Balloon in The Acute Setting

Abstract Introduction The laparoscopic gastric band was popularised in the 1990’s. The procedure involves placement of an adjustable band around the proximal stomach, aiming to induce satiety and offering a surgical solution to morbid obesity. Complications such as band slippage and erosion, together with succession by sleeve gastrectomy and gastric bypass which offer more significant weight loss has meant the procedure has gone out of favour. However, their legacy continues with a stream of patients presenting annually with complications, many of whom have travelled abroad for the procedure. The aim of this study was to examine Huber needle availability in acute surgical units nationally. Method All acute general surgical admission units across the UK were identified from the National Emergency Laparotomy Audit database. The senior nurse managing each unit was contacted by telephone and asked three questions; whether their hospital has an elective bariatric service on site, whether they review acute bariatric emergencies and whether the unit stocks Huber needles. Results 151 acute general surgical units were identified across the UK, of which 60% responded. 30/90(33%) have an elective bariatric service on site and 65/90(72%) reviewed acute bariatric patients. 8/90(8.9%) stock Huber needles for the acute deflation of gastric bands. Conclusions Patients presenting acutely with gastric band complications typically need urgent deflation of the gastric band. The Huber needle is a non-coring needle used for gastric band adjustment, preventing damage to the port. The Huber needle is a low-cost item and should be stocked by all acute general surgical units.

1387 Audit of Pregnancy Status Documentation in Emergency Admissions to A Tertiary Colorectal Surgery Unit

Abstract Aim Documenting pregnancy status (PS) is an important component of the medical assessment of all females of reproductive age (FRA), defined as age 16-55 years old when admitted to hospital. This audit aims to determine the rate of documentation of PS amongst FRA admitted to a tertiary colorectal surgical unit via the surgical admissions unit (SAU) or transfer from other departments between 01/10/20 – 13/11/20. Method A complete documentation of PS comprises of results of urine or serum (β-hCG) and relevant gynaecological history (i.e., last menstrual period and any contraceptive use) clearly reported in the admission clerk-in. Patients with presenting complaint excluding abdominal pain, current pregnancy, history of hysterectomy or sterilisation procedures were excluded. Results During the audit duration, 29 FRA were admitted of which 13 (44.8%) were included for analysis. Of patients included, 4/9 (44.4%) and 1/4 (25.0%) admitted via SAU or transferred from other departments respectively had a past colorectal history. 4 (30.8%) had complete documentation of PS of which, 3 (75.0%) were patients transferred from other departments. Conclusions Low rates of documentation of PS especially amongst emergency admissions via SAU, is possibly associated with a narrow differential diagnosis influenced by pre-existing colorectal history. This audit did not look at PS documentation prior to any subsequent surgical intervention. A re-audit following the implementation of a guidance poster in SAU is currently underway.

Diagnostic Yield of 8-Hour Video-EEG in Detecting Psychogenic Non-Epileptic Seizures (PNES)

ABSTRACT To evaluate the diagnostic yield of the first 8 hours of video-EEG (vEEG) monitoring in detecting Psychogenic Non-Epileptic Seizures (PNES) during the Epilepsy Monitoring Unit (EMU) admission. We performed a retrospective chart review of patients ages ≥4 years who were admitted to the EMU between 2011 and 2018 (n = 616). We calculated the proportion of patients diagnosed with PNES within the first 8 hours of EEG recording and studied the associated risk factors for patients diagnosed with PNES and patients with epileptic seizures (ES). Out of the total 616 patients, 24% (149) patients had an EMU diagnosis of PNES. Of these, 44.3% had at least one typical event within the first 8 hours of vEEG monitoring. A higher incidence was seen within the pediatric subgroup (54.8% had an event within 8 hours). A diagnosis of chronic pain disorder was more common with PNES compared to ES (48.3% versus 16.5%, p < 0.001). A suspicion for PNES documented during an office visit was noted in a high proportion of patients (68.5%) who eventually had a PNES event during EMU. Our study suggests that in a well-selected group of patients (such as a high suspicion of PNES during a physician/neurology office visit), an outpatient 8-hour vEEG could open new avenues for a prompt diagnosis. This could especially be beneficial in hospital settings where there is either a lack of an EMU or a delay in admission to the EMU.

OP03.05: Mental wellbeing among pregnant and postpartum women during the COVID‐19 pandemic: a large international survey

To assess the mental well-being of pregnant and postpartum women during the COVID-19 pandemic. A cross-sectional, web-based international survey was carried out between May 15 and October 15, 2020. The survey was available in English, Spanish, Italian and Russian and promoted through social media and health care professionals. The questions evaluated sociodemographic characteristics, medical and obstetric history, COVID-19 symptoms and infection. The World Health Organization well-being index (WHO-5) was used to assess mental health status. Pregnant and postpartum women up to 12 months postpartum who were older than 18 years of age were eligible. Women were classified as having a low (WHO-5 ≦52) or high (WHO-5 > 52) mental well-being. Multivariate linear regression was used to identify factors associated with low mental well-being. A total of 4221 patients provided valid surveys for analysis (3324 pregnant and 897 postpartum women). The mean (±SD) WHO-5 scores for pregnant and postpartum women were 54.3 ± 20.3 and 54.7 ± 21, respectively. Low mental well-being was observed in 42% and 40% of pregnant and postpartum women respectively. Factors associated with low mental well-being included residence in a South American country (p < 0.001), being a single mother (p < 0.001), smoking (p < 0.001), having a respiratory or a psychiatric disorder (p = 0.02 and 0.03 respectively), multiparity (p < 0.001), the presence of symptoms like difficulty breathing (p = 0.02), diarrhoea (p = 0.04) and muscle pain (p < 0.001), and the pandemic period (p < 0.001). The second and third trimesters of pregnancy and the postpartum period were associated with higher mental well-being compared to the first trimester (p < 0.001). A history of hospital admission, pneumonia, or intensive care unit admission due to COVID-19 infection was not associated with worse mental well-being score. Sociodemographic characteristics, and not the SARS-COV-2 infection, were the determinants of mental well-being among pregnant and postpartum women during the COVID-19 pandemic.

Self-assessment

A 11-day old male baby is admitted into the Paediatric Admission Unit following the advice of the GP who on examination found that the baby had yellow sclera. The baby presented with a 3-day history of pale stools and dark urine. There had been no history of large vomits and the parents report that he has been wetting his nappies as usual. The patient had a traumatic birth with PROM and required a brief resuscitation. Both mother and baby recovered well from the birth. During the paediatric assessment his airway was patent, breathing was normal, he was pink and warm with a capillary refill time of 2–3s, he was alert and active and apyrexial with no rashes. On examination, his neurological function appeared normal and there were no abnormalities in the exam of his respiratory and his cardio-vascular systems. The abdomen was soft and non-tender with normal bowels sounds, genitalia and a patent anus. However, the liver appeared enlarged and palpable 5cm below the costal margin.

High mean arterial pressure target to improve sepsis-associated acute kidney injury in patients with prior hypertension: a feasibility study

BackgroundThe optimal mean arterial pressure (MAP) in cases of septic shock is still a matter of debate in patients with prior hypertension. An MAP between 75 and 85 mmHg can improve glomerular filtration rate (GFR) but its effect on tubular function is unknown. We assessed the effects of high MAP level on glomerular and tubular renal function in two intensive care units of a teaching hospital. Inclusion criteria were patients with a history of chronic hypertension and developing AKI in the first 24 h of septic shock. Data were collected during two 6 h periods of MAP regimen administered consecutively after haemodynamic stabilisation in an order depending on the patient's admission unit: a high-target period (80–85 mmHg) and a low-target period (65–70 mmHg). The primary endpoint was the creatinine clearance (CrCl) calculated from urine and serum samples at the end of each MAP period by the UV/P formula.Results26 patients were included. Higher urine output (+0.2 (95%:0, 0.4) mL/kg/h; P = 0.04), urine sodium (+6 (95% CI 0.2, 13) mmol/L; P = 0.04) and lower serum creatinine (− 10 (95% CI − 17, − 3) µmol/L; P = 0.03) were observed during the high-MAP period as compared to the low-MAP period, resulting in a higher CrCl (+25 (95% CI 11, 39) mL/mn; P = 0.002). The urine creatinine, urine–plasma creatinine ratio, urine osmolality, fractional excretion of sodium and urea showed no significant variation. The KDIGO stage at inclusion only interacted with serum creatinine variation and low level of sodium excretion at inclusion did not interact with these results.ConclusionsIn the early stage of sepsis-associated AKI, a high-MAP target in patients with a history of hypertension was associated with a higher CrCl, but did not affect the kidneys' ability to concentrate urine, which may reflect no effect on tubular function.

The impact of comorbidities and their stacking on short- and long-term prognosis of patients over 50 with community-acquired pneumonia

BackgroundThe prognosis of patients hospitalized with community-acquired pneumonia (CAP) with regards to intensive care unit (ICU) admission, short- and long-term mortality is correlated with patient’s comorbidities. For patients hospitalized for CAP, including P-CAP, we assessed the prognostic impact of comorbidities known as at-risk (AR) or high-risk (HR) of pneumococcal CAP (P-CAP), and of the number of combined comorbidities.MethodsData on hospitalizations for CAP among the French 50+ population were extracted from the 2014 French Information Systems Medicalization Program (PMSI), an exhaustive national hospital discharge database maintained by the French Technical Agency of Information on Hospitalization (ATIH). Their admission diagnosis, comorbidities (nature, risk type and number), other characteristics, and their subsequent hospital stays within the year following their hospitalization for CAP were analyzed. Logistic regression models were used to assess the associations between ICU transfer, short- and 1-year in-hospital mortality and all covariates.ResultsFrom 182,858 patients, 149,555 patients aged ≥ 50 years (nonagenarians 17.8%) were hospitalized for CAP in 2014, including 8270 with P-CAP. Overall, 33.8% and 90.5% had ≥ 1 HR and ≥ 1 AR comorbidity, respectively. Cardiac diseases were the most frequent AR comorbidity (all CAP: 77.4%). Transfer in ICU occurred for 5.4% of CAP patients and 19.4% for P-CAP. Short-term and 1-year in-hospital mortality rates were 10.9% and 23% of CAP patients, respectively, significantly lower for P-CAP patients: 9.2% and 19.8% (HR 0.88 [95% CI 0.84–0.93], p < .0001). Both terms of mortality increased mostly with age, and with the number of comorbidities and combination of AR and HR comorbidities, in addition of specific comorbidities.ConclusionsNot only specific comorbidities, but also the number of combined comorbidities and the combination of AR and HR comorbidities may impact the outcome of hospitalized CAP and P-CAP patients.

Machine learning techniques to predict different levels of hospital care of CoVid-19

In this study, we analyze the capability of several state of the art machine learning methods to predict whether patients diagnosed with CoVid-19 (CoronaVirus disease 2019) will need different levels of hospital care assistance (regular hospital admission or intensive care unit admission), during the course of their illness, using only demographic and clinical data. For this research, a data set of 10,454 patients from 14 hospitals in Galicia (Spain) was used. Each patient is characterized by 833 variables, two of which are age and gender and the other are records of diseases or conditions in their medical history. In addition, for each patient, his/her history of hospital or intensive care unit (ICU) admissions due to CoVid-19 is available. This clinical history will serve to label each patient and thus being able to assess the predictions of the model. Our aim is to identify which model delivers the best accuracies for both hospital and ICU admissions only using demographic variables and some structured clinical data, as well as identifying which of those are more relevant in both cases. The results obtained in the experimental study show that the best models are those based on oversampling as a preprocessing phase to balance the distribution of classes. Using these models and all the available features, we achieved an area under the curve (AUC) of 76.1% and 80.4% for predicting the need of hospital and ICU admissions, respectively. Furthermore, feature selection and oversampling techniques were applied and it has been experimentally verified that the relevant variables for the classification are age and gender, since only using these two features the performance of the models is not degraded for the two mentioned prediction problems.

Predicting severe outcomes using national early warning score (NEWS) in patients identified by a rapid response system: a retrospective cohort study

There are insufficient data in managing patients at high risk of deterioration. We aimed to investigate that national early warning score (NEWS) could predict severe outcomes in patients identified by a rapid response system (RRS), focusing on the patient’s age. We conducted a retrospective cohort study from June 2019 to December 2020. Outcomes were unplanned intensive care unit (ICU) admission, ICU mortality, and in-hospital mortality. We analyzed the predictive ability of NEWS using receiver operating characteristics (ROC) curve and the effect of NEWS parameters using multivariable logistic regression. A total of 2,814 RRS activations were obtained. The predictive ability of NEWS for unplanned ICU admission and in-hospital mortality was fair but was poor for ICU mortality. The predictive ability of NEWS showed no differences between patients aged 80 years or older and under 80 years. However, body temperature affected in-hospital mortality for patients aged 80 years or older, and the inverse effect on unplanned ICU admission was observed. The NEWS showed fair predictive ability for unplanned ICU admission and in-hospital mortality among patients identified by the RRS. The different presentations of patients 80 years or older should be considered in implementing the RRS.

Circulating extracellular vesicles during pregnancy in women with type 1 diabetes: a secondary analysis of the CONCEPTT trial

BackgroundExtracellular vesicles are membrane vesicles that are released into the extracellular environment and accumulate in the circulation in vascular disease. We aimed to quantify circulating extracellular vesicles in pregnant women with type 1 diabetes and to examine associations between extracellular vesicle levels, continuous glucose measures, and pregnancy outcomes.MethodsWe used plasma samples from the Continuous Glucose Monitoring in Women with Type 1 Diabetes in Pregnancy Trial study and quantified circulating extracellular vesicles by flow cytometry (n = 163). Relationships with clinical variables were assessed by repeated measures correlation. Logistic regression was used to assess associations between elevated extracellular vesicle levels and pregnancy outcomes.ResultsPlatelet extracellular vesicle levels were inversely associated with glucose time above range and glycaemic variability measures (P < 0.05). A weak positive association was observed between endothelial extracellular vesicles and mean amplitude of glycemic excursion (P < 0.05). In a univariate logistic regression model, high baseline endothelial extracellular vesicles was associated with increased risk of neonatal intensive care unit (NICU) admission (OR: 2.06, 1.03–4.10), and respiratory distress requiring ventilation (OR: 4.98, 1.04–23.92). After adjusting for HbA1c and blood pressure the relationship for NICU admission persisted and an association with hyperbilirubinemia was seen (OR: 2.56, 1.10–5.94). Elevated platelet extracellular vesicles were associated with an increased risk of NICU admission (OR: 2.18, 1.04–4.57), and hyperbilirubinemia (OR: 2.61, 1.11–6.12) after adjusting for HbA1c and blood pressure.ConclusionsHigh levels of extracellular vesicles in early pregnancy were associated with adverse neonatal outcomes. Assessment of extracellular vesicles may represent a novel approach to personalized care in type 1 diabetes pregnancy.

CT-Based Risk Stratification for Intensive Care Need and Survival in COVID-19 Patients-A Simple Solution.

We evaluated a simple semi-quantitative (SSQ) method for determining pulmonary involvement in computed tomography (CT) scans of COVID-19 patients. The extent of lung involvement in the first available CT was assessed with the SSQ method and subjectively. We identified risk factors for the need of invasive ventilation, intensive care unit (ICU) admission and for time to death after infection. Additionally, the diagnostic performance of both methods was evaluated. With the SSQ method, a 10% increase in the affected lung area was found to significantly increase the risk for need of ICU treatment with an odds ratio (OR) of 1.68 and for invasive ventilation with an OR of 1.35. Male sex, age, and pre-existing chronic lung disease were also associated with higher risks. A larger affected lung area was associated with a higher instantaneous risk of dying (hazard ratio (HR) of 1.11) independently of other risk factors. SSQ measurement was slightly superior to the subjective approach with an AUC of 73.5% for need of ICU treatment and 72.7% for invasive ventilation. SSQ assessment of the affected lung in the first available CT scans of COVID-19 patients may support early identification of those with higher risks for need of ICU treatment, invasive ventilation, or death.

Neurological manifestations in people living with HIV/AIDS in the late cART era: a prospective observational study at a tertiary healthcare center in São Paulo, Brazil

Background:The aim of this study was to evaluate the frequency, spectrum, in-hospital mortality rate, and factors associated with death in people living with HIV/AIDS (PLWHA) presenting with neurological diseases from a middle-income country, as well as estimate its one-year global death rate. Methods:This prospective observational cohort study was conducted at a Brazilian tertiary health center between January and July 2017. HIV-infected patients above 18 years of age who were admitted due to neurological complaints were consecutively included. A standardized neurological examination and patient and/or medical assistant interviews were performed weekly until the patient’s discharge or death. The diagnostic and therapeutic management of the included cases followed institutional routines. Results:A total of 105 (13.2%) patients were included among the 791 hospitalized PLWHA. The median age was 42.8 [34-51] years, and 61% were men. The median CD4+ lymphocyte cell count was 70 (27-160) cells/mm3, and 90% of patients were experienced in combined antiretroviral therapy. The main diseases were cerebral toxoplasmosis (36%), cryptococcal meningitis (14%), and tuberculous meningitis (8%). Cytomegalovirus causing encephalitis, polyradiculopathy, and/or retinitis was the third most frequent pathogen (12%). Moreover, concomitant neurological infections occurred in 14% of the patients, and immune reconstitution inflammatory syndrome-related diseases occurred in 6% of them. In-hospital mortality rate was 12%, and multivariate analysis showed that altered level of consciousness (P = 0.04; OR: 22.7, CI 95%: 2.6-195.1) and intensive care unit (ICU) admission (P = 0.014; OR: 6.2, CI 95%: 1.4-26.7) were associated with death. The one-year global mortality rate was 31%. Conclusion:In this study, opportunistic neurological diseases were predominant. Cytomegalovirus was a frequent etiological agent, and neurological concomitant diseases were common. ICU admission and altered levels of consciousness were associated with death. Although in-hospital mortality was relatively low, the one-year global death rate was higher.

Evaluation of the Initial General Ward Early Warning Score and ICU Admission, Hospital Length of Stay and Mortality.

IntroductionDespite widespread implementation of the Early Warning Score (EWS) in hospitals, its effect on patient outcomes remains mostly unknown. We aimed to evaluate associations between the initial EWS and in-hospital mortality, intensive care unit (ICU) admission, and hospital length of stay (LOS).MethodsWe performed a retrospective cohort study of adult patients admitted to a general hospital ward between July 1, 2014–December 31, 2017. Data were obtained from electronic health records (EHR). The primary outcome was in-hospital mortality. Secondary outcomes were ICU admission and hospital LOS. We categorized patients into three risk groups (low, medium or high risk of clinical deterioration) based on EWS. Descriptive analyses were used.ResultsAfter applying inclusion and exclusion criteria, we included 53,180 patients for analysis. We found that the initial (low- vs high-risk) EWS was associated with an increased in-hospital mortality (1.5% vs 25.3%, P <0.001), an increased ICU admission rate (3.1% vs 17.6%, P <0.001), and an extended hospital LOS (4.0 days vs 8.0 days, P <0.001).ConclusionOur findings suggest that an initial high-risk EWS in patients admitted to a general hospital ward was associated with an increased risk of in-hospital mortality, ICU admission, and prolonged hospital LOS. Close monitoring and precise documentation of the EWS in the EHR may facilitate predicting poor outcomes in individual hospitalized patients and help to identify patients for whom timely and adequate management may improve outcomes.

Associations between remote patient monitoring programme responsiveness and clinical outcomes for patients with COVID-19

ObjectiveTo assess whether engagement in a COVID-19 remote patient monitoring (RPM) programme or telemedicine programme improves patient outcomes.MethodsThis is a retrospective cohort study analysing patient responsiveness to our RPM survey...

Epidemiology of burn patients admitted in the Netherlands: a nationwide registry study investigating incidence rates and hospital admission from 2014 to 2018

PurposeThe aim of this study was to gain insight into the epidemiology of burn patients admitted to a hospital without a burn center or referred to a burn center.MethodsThis retrospective, nationwide, cohort study included patients with burns or inhalation trauma, admitted between 2014 and 2018, from a national trauma registry. The primary outcome measure was admission to a hospital with or without a burn center. Secondary outcome measures were patient and injury characteristics, Intensive Care Unit (ICU) admission and length of stay, and hospital length of stay (HLOS).ResultsOf the 5524 included patients, 2787 (50.4%) were treated at a non-burn center, 1745 (31.6%) were subsequently transferred to a burn center, and 992 (18.0%) were primarily presented and treated at a burn center. The annual number of patients decreased from 1199 to 1055 (− 12.4%). At all admission locations, a clear incidence peak was observed in children ≤ 4 years and in patients of ≥ 80 years. The number of ICU admissions for the entire population increased from 201 to 233 (33.0%). The mean HLOS for the entire population was 8 (SD 14) days per patient. This number remained stable over the years in all groups.ConclusionHalf of all burn patients were admitted in a non-burn center and the other half in a burn center. The number and incidence rate of patients admitted with burns or inhalation trauma decreased over time. An increased incidence rate was found in children and elderly. The number of patients admitted to the ICU increased, whereas mean hospital length of stay remained stable.

Obstetric A&E unit admission and hospitalization for obstetrical management during COVID-19 pandemic in a third-level hospital of southern Italy

BackgroundThe COronaVIrus Disease 2019 (COVID-19) has spread in Italy since February 2020, inducing the government to call for lockdown of any activity, apart primary needs, during the months March–May 2020. During the lockdown, a reduction of admissions and hospitalizations for ischemic diseases was noticed. Purpose of this study was to observe if there has been the same reduction trend in Accident & Emergency (A&E) unit admissions also for obstetric-gynecological conditions.MethodsMedical records and electronic clinical databases were searched for all patients who were admitted to the obstetric A&E department or hospitalized at the Gynecology and Obstetrics Unit of University hospital of Naples Federico II, during the quarter March–May in the years 2019 and 2020. The mean ± standard deviation (SD) of monthly admission to the obstetric A&E department and hospitalization of the year 2020 was compared with that of the year 2019, using the unpaired T test with α error set to 0.05 and 95% confidence intervals (95% CI).ResultsAdmissions were 1483 in the year 2020 and 1786 in 2019. Of total, 1225 (37.5%) women were hospitalized: 583 in the year 2020, 642 in 2019. Mean ± SD of patients monthly admitted to our obstetric A&E department was 494 ± 33.7 in the year 2020, and 595.3 ± 30.9 in 2019, with a mean difference of − 101.3 (95% CI − 103.5 to − 99.1; p < 0.0001). Mean ± SD of patients monthly hospitalized to our department was 194 ± 19.1 in the year 2020, 213.7 ± 4.7 in 2019, with a mean difference of − 19.7 (95% CI − 23.8 to − 15.6; p < 0.0001).ConclusionA significant decrease in the mean of monthly admissions and hospitalizations during the COVID-19 pandemic when compared to the previous year was found also for obstetric–gynecological conditions. Further studies are necessary to assess COVID-19 impact and to take the most appropriate countermeasures.

Gastrointestinal bleeding in critically ill immunocompromised patients

BackgroundAcute gastrointestinal bleeding (GIB) may be a severe condition in immunocompromised patients and may require intensive care unit (ICU) admission. We aimed to describe the clinical spectrum of critically ill immunocompromised patients with GIB and identify risk factors associated with mortality and severe GIB defined by hemorrhagic shock, hyperlactatemia and/or the transfusion of more than 5 red blood cells units. Finally, we compared this cohort with a control population of non-immunocompromised admitted in ICU for GIB.ResultsRetrospective study in 3 centers including immunocompromised patients with GIB admitted in ICU from January, 1st 2010 to December, 31rd 2019. Risk factors for mortality and severe GIB were assessed by logistic regression. Immunocompromised patients were matched with a control group of patients admitted in ICU with GIB. A total of 292 patients were analyzed in the study, including 141 immunocompromised patients (compared to a control group of 151 patients). Among immunocompromised patients, upper GIB was more frequent (73%) than lower GIB (27%). By multivariate analysis, severe GIB was associated with male gender (OR 4.48, CI95% 1.75–11.42, p = 0.00), upper GIB (OR 2.88, CI95% 1.11–7.46, p = 0.03) and digestive malignant infiltration (OR 5.85, CI95% 1.45–23.56, p = 0.01). Conversely, proton pump inhibitor treatment before hospitalization was significantly associated with decreased risk of severe GIB (OR 0.25, IC95% 0.10–0.65, p < 0.01). Fifty-four patients (38%) died within 90 days. By multivariate analysis, mortality was associated with hemorrhagic shock (OR 2.91, IC95% 1.33–6.38, p = 0 .01), upper GIB (OR 4.33, CI95% 1.50–12.47, p = 0.01), and long-term corticosteroid therapy before admission (OR 2.98, CI95% 1.32–6.71, p = 0.01). Albuminemia (per 5 g/l increase) was associated with lower mortality (OR 0.54, IC95% 0.35–0.84, p = 0.01). After matching with a control group of non-immunocompromised patients, severity of bleeding was increased in immunocompromised patients, but mortality was not different between the 2 groups.ConclusionMortality is high in immunocompromised patients with GIB in ICU, especially in patients receiving long term corticosteroids. Mortality of GIB is not different from mortality of non-immunocompromised patients in ICU. The prophylactic administration of proton pump inhibitors should be considered in this population.

Early-Phase Urine Output and Severe-Stage Progression of Oliguric Acute Kidney Injury in Critical Care.

Background: The relationship between urine output (UO) and severe-stage progression in the early phase of acute kidney injury (AKI) remains unclear. This study aimed to investigate the relationship between early-phase UO6−12h [UO within 6 h after diagnosis of stage 1 AKI by Kidney Disease: Improving Global Outcomes (KDIGO) UO criteria] and severe-stage progression of AKI and to identify a reference value of early-phase UO6−12h for guiding initial therapy in critical care.Methods: Adult patients with UO < 0.5 ml/kg/h for the first 6 h after intensive care unit (ICU) admission (meeting stage 1 AKI by UO) and UO6−12h ≥ 0.5 ml/kg/h were identified from the Medical Information Mart for Intensive Care (MIMIC) III database. The primary outcome was progression to stage 2/3 AKI by UO. After other variables were adjusted through multivariate analysis, generalized additive model (GAM) was used to visualize the relationship between early-phase UO6−12h and progression to stage 2/3 AKI by UO. A two-piecewise linear regression model was employed to identify the inflection point of early-phase UO6−12h above which progression risk significantly leveled off. Sensitivity and subgroup analyses were performed to assess the robustness of our findings.Results: Of 2,984 individuals, 1,870 (62.7%) with KDIGO stage 1 UO criteria progressed to stage 2/3 AKI. In the multivariate analysis, early-phase UO6−12h showed a significant association with progression to stage 2/3 AKI by UO (odds ratio, 0.40; 95% confidence interval, 0.34–0.46; p < 0.001). There was a non-linear relationship between early-phase UO6−12h and progression of AKI. Early-phase UO6−12h of 1.1 ml/kg/h was identified as the inflection point, above which progression risk significantly leveled off (p = 0.780). Patients with early-phase UO6−12h ≥ 1.1 ml/kg/h had significantly shorter length of ICU stay (3.82 vs. 4.17 days, p < 0.001) and hospital stay (9.28 vs. 10.43 days, p < 0.001) and lower 30-day mortality (11.05 vs. 18.42%, p < 0.001). The robustness of our findings was confirmed by sensitivity and subgroup analyses.Conclusions: Among early-stage AKI patients in critical care, there was a non-linear relationship between early-phase UO6−12h and progression of AKI. Early-phase UO6−12h of 1.1 ml/kg/h was the inflection point above which progression risk significantly leveled off.